Cardiovascular Exam

Hi my name is ______, Im a second year medical student. What is your name? Its very nice to meet you. Mr./Mrs. ______ Ive been asked to come in and check your pulse and blood pressure. Is that ok with you? Ok if there is any discomfort at any time please let me know and Ill try my best to alleviate the discomfort.

I. Inspection
Inspect with the patient in supine position with the arms at their sides Inspect from the foot of the bed, then on the right side of the patient Inspect the patients body from their periphery in towards their heart Palpate for pitting edema o Mr./Mrs. _____ Im just going to be pressing into your legs

and feet, just let me know if there is any pain at all

o Note: when palpating for pitting edema, the doctor should be looking at the patients face for any signs of tenderness o Press firmly but gently with thumb for > 5 seconds bilaterally over: The dorsum of foot Posterior to medial malleolus Over the shins Inspect the patients eye o Can you please look up for me? o Pull down underneath the patients eye to be able to inspect the conjunctival sac for signs of anemia o Can you please look down for me? o Pull up on the eyelids to be able to inspect the sclera for jaundice Inspect the patients tongue o Can you please open your mouth for me? o Checking for glossitis o Can you please lift up your tongue for me? o Checking for central cyanosis Inspect the patients fingers o Bring up the patients fingers to eye level to check for clubbing and splinter hemorrhages o Capillary refill: pinch the patients fingers/nails for a second and look to see the blood flow back into the nails

Upon initial inspection the patient is not in any distress, there is no pitting edema, no signs of anemia and jaundice. There are no signs of

glossitis and central cyanosis. There is no clubbing, splinter hemorrhages, and capillary refill is normal

II. Pulses
Inspect arm/hand for masses scars or lesions

Mr./Mrs. _____ Im going to be checking your pulse now

Palpate the right radial pulse with the pads of your index and middle finger on the patients lateral flexor surface of wrist for one minute. You are palpating for: o Rate beats per minute o Rhythm o Volume o Character o Palpate for tone of vessel wall (should not be palpable): with the middle finger of your right hand occlude the radial artery and then with the index finger of the same hand palpate for the radial artery

With the patient in supine position, the right radial artery is 72 beats per minute, with regular rhythm, normal volume and character. The right radial artery was not palpable.
Palpate the following bilaterally except for the carotid. Check to see that all the pulses are present bilaterally, no differences in the rate, rhythm, volume, and character. For this part of the exam you should only have to check the pulses for a few seconds (5-10). Radial: lateral to tendon of flexor carpi radialis

Mr./Mrs. _____ can you go ahead and flex your arm for me against my hand

Brachial: medial to the biceps tendon (by giving resistance as the patient tries to flex their arm the biceps tendon should become visible)

Mr./ Mrs. _____ can you turn your head to the side please... ok, now the turn to the other side... thanks
Carotid: between the trachea and the SCM, sternoidcleidomastoid muscle (check one side at a time)

Mr/Mrs._____ Im going to be checking for your pulses in the groin area and Im going to be palpating for some landmarks first
Femoral: distal to the inguinal ligament (ASIS, anterior superior iliac spine and symphysis pubis) **Radial-Femoral Delay**: o Palpate radial and femoral pulses simultaneously (you may want to check for this at this point since the femoral artery has already been palpated) o Positive sign is if the pulses are not felt simultaneously.

Mr/Mrs. _____ can you slide your legs up for me please, Im going to check your pulse under your knee...thanks. Ok you can go ahead and bring your legs back down.

Popliteal: lateral to the semimembranosus tendon (from medial to lateral, semitendinosus, semimembranosus, and biceps femoris) Dorsalis pedis: between the 1st and 2nd metatarsals Posterior tibial: posterior to the medial malleolus **Water-Hammer**: o Do you get dizzy when you sit up...ok, then can you please sit up

for me please.

o Ask the patient to sit up o Go ahead and relax your arm for me please. Im going to be

raising your arm over your head.

o Palpate radial pulse the lift off the artery until you can barely feel it; then quickly move patients arm over their head **Allens Test**: o Check for patency (occlusion) of ulnar artery before puncturing the radial artery for blood samples o Can you make a fist for me? o Take the patients hand using both your hands and compress both the radial and ulnar arteries firmly between your thumb and fingers as they are making a fist (palm up). o Go ahead and open your hand now and relax your hand a bit. o The patients hand should be pale and the hand should be positioned in a slightly flexed position. o Release pressure over the ulnar artery (this is checking for patency in the radial artery); note time until color returns. o Can you make a fist for me again?. o Take the patients hand using both your hands and compress both the radial and ulnar arteries firmly between your thumb and fingers as they are making a fist (palm up). o Go ahead and open your hand now and relax your hand a bit. o The patients hand should be pale and the hand should be positioned in a slightly flexed position.

All pulses are present and bilateral. There was no Radial-femoral delay noted. Water-Hammer test was negative, and Allens test showed patency of both ulnar and radial arteries.

o Release pressure over the radial artery (this is checking for patency in the ulnar artery); note time until color returns.

III. Blood Pressure

The patients arm has to be exposed up to the shoulder

Im going to take your blood pressure right now Have you ever had your blood pressure taken before? Do you remember what it was the last time you had your blood pressure taken? Did you have any coffee/tea today? How long ago? Did you exercise today? Do you smoke?
Inspect the arm

Upon inspection, no masses, scars, lesions, tearing or interferences in the cubital fossa are noted
Measure cuff: bladder width should be approximately 40% of upper arm circumference and length should be approximately 80%. Confirm the presence of the brachial pulse (1 cm proximal and medial to cubital fossa) and palpate the vascular tone for patency Position patients hand in your armpit hands free support Center the bladder over the brachial artery, approximately 2.5 cm above the antecubital fossa; secure snugly.

Youre going to feel some pressure

Determine target inflation level (estimating the systolic) o Palpate radial pulse o Inflate cuff until radial pulse in non palpable (palpable systolic) o Target level is then palpable systolic + 30mmHg o Use this target from subsequent inflation to prevent discomfort from unnecessarily high cuff pressures; also avoids auscultory gap Deflate cuff to 0 mmHg Place bell over the brachial artery, inflate cuff to target inflation level then deflate at a rate about 2 mmHg per second and listen for Korotkoff sounds To confirm disappearance of sounds, listen as pressure falls 10-20 mmHg past 5th Korotkoff sound, then deflate cuff rapidly to zero Report both systolic and diastolic level to the nearest 2 mmHg (even numbers), where measured, patients position

The patients blood pressure was 120/80 in the right brachial artery with the patient sitting

The first reading is the point where you hear the first sound and the second reading is the point where you hear the last sound (4th) minus 2 mmHg. So in the case where the blood pressure is 120/80 mmHg the last sound heard (4th) is 82 mmHg. Offer to take BP twice and repeat in left arm

IV. Venous System

Jugular Venous Pressure o Determination of right atrial pressure o Position patient with the bed elevated 30 degrees, adjust angle to maximize visibility of the jugular venous pulsation; ask patient to turn head slightly away from the side being checked o Arbitrarily the sternal angle is 5 cm above the center of the right atrium (vertical height doesnt change whether the patient is lying down or inclined) Inspection o Look for any masses, scars, or lesions, varicose veins, caput medusa o Upon inspection, no masses, scars, or lesions noted. No

varicose veins noted

Locate internal jugular (between bellies of sternoidcleidomastoid muscle) or external jugular vein (post to post belly of sternoidcleidomastoid muscle) o Use tangential lighting and valsalva maneuver if necessary to locate the highest point where venous pulse can be seen o Confirm it is the venous pulse Measure highest point (vertical height) of pulsation from the sternal angle o Place ruler on the sternal angle in the vertical position o Place a straight edge up or down so that its lower edge rests at the highest point of pulsation o Read vertical distance between the sternal angle and the lower edge of the straight edge (to the nearest cm above sternal angle) o If the highest point of pulsation lies below the sternal angle: Place the straight edge on the sternal angle in the horizontal position Place long end of ruler at highest point of pulsation and perpendicular to straight edge Read the vertical distance between the end of the ruler and the straight edge (cms below the sternal angle)

The JVP is 3 cms above the sternal angle or 8 cm above the right atrium
Offer to execute and observe: o **Hepato-jugular reflux**:

Im going to be pressing into your stomach now

Lightly press on abdomen and observe the JVP

The Hepato-jugular reflux and the Kussmaul sign are negative.

Normally it should see it distend for a quick second, but in abnormal it should stay distended longer because the heart cant compensate the extra blood due to right-sided heart failure. o **Kussmaul sign**: Note the JVP as the patient inspires. Normally it should go in. You breath in there is a pooling of blood effect to the heart but in the abnormal (positive) it distends due to the backing up of blood caused by right-sided heart failure.

Cardiovascular Exam Secondaries

I. Inspection Head Temperature Sclera for jaundice, yellowish discoloration of the skin and sclera with bilirubin levels greater than 2.5 mg/dL. Conjunctiva for anemia: blood loss, iron deficiency, folate/B12 deficiency, hemolysis, infections, sickle cell, thalassemia, DIC; associated with pallor, carotid bruits, Water-hammer, cyanosis, slow capillary refill Tongue for glossitis: o Causes: iron deficiency anemia, vitamin deficiency (vitamin C, niacin B3, riboflavin B2, folate, cobalamin B12) o Signs and symptoms: painful tongue, red, smooth, and no filiform papillae Underneath tongue for central cyanosis: bluish discoloration of the skin with reduced Hb; d/t CO anemia, RL shunts, vasoconstriction, polycythemia, pulmonary pathology; having central cyanosis implies peripheral cyanosis, but peripheral cyanosis can exist without central cyanosis Chest symmetry Pectus excavatum: depressed sternum/funnel chest that may cause murmur. Compresses the heart and great vessels causing murmurs. Pectus carnatum: in kids with asthma, may be caused by cardiomegaly. Pigeon chest/ children breast deformity. Sternum is displaced anteriorly, costal cartilages are depressed. Palms Temperature, moisture, pallor, jaundice, xanthomas, lesions Nails

Clubbing: (tips of the fingers appear round and bulbous) angle between plate and proximal fold >180 degrees, spongy (spongy, feels like the nail is floating) nail bed; due to RL shunts, infective endocarditis, bronchogenic carcinoma, Crohns disease and ulcerative colitis, liver cirrhosis, TB, chronic bronchitis, anemia, empyema Capillary refill (normal is 1-2 seconds): peripheral vasculature disorders (diabetes mellitus, vasculitis) Splinter hemorrhages: Subacute bacterial endocarditisis the most common cause. Splinter hemorrhages appear as narrow red to reddish brown hemorrhages beneath the nails. They run in the direction of nail growth. The hemorrhages are caused by microscopic clots that damage the small capillaries under the nails. Legs Pitting edema: + depression due to pressure of thumb fluid moved into vascular system, therefore skin takes longer to return to normal; veins distended; Scale: +1 to +4 (worst) o Chronic venous insufficiency: CHF, liver disease, nephrotic syndrome, IVC obstruction; bilateral, thick skin, ulcers o Orthostatic: prolonged sitting or standing; bilateral Non-pitting edema: no pitting because fluid doesnt move into vascular system; veins are not distended. Causes: 7

o Lymphedema: lymphatic obstruction; often bilateral; thick skin o Lipedema: fat deposition in legs; not true edema; bilateral Pulses Radial pulse Rate: <60 = bradycardia; >100 = tachycardia o with caffeine, smoking, exercise, inspiration, hyperthyroidism, fever, anemia, severe lung disease, shock, sinus tachycardia, ventricular and supraventricular tachycardia o with trained athlete, exhalation, 2nd/3rd degree heart block, early stages of MI, vagal tone Rhythm: o Regularly irregular (heart block, atrial flutter) o Irregular Regular Atrial (supraventricular) premature contractions o Aberrant P waves o S1 differs in intensity and S2 Ventricular premature contradictions o Aberrant QRS and T o Early beat with split sounds Sinus arrhythmia o Normal cyclical heart rate variation: with inspiration; with expiration Irregular Atrial fibrillation/flutter o No P waves o Ventricular rhythm is totally irregular, S1 varies with intensity; Rx: digitalis/quinidine o Complication: stagnant blood clot embolization Volume o Normal: full o Increase: fever, anemia, hyperthyroidism, pheochromocytoma, aortic fistula o Decreased: hypovolemia (diuretic, emesis, diarrhea, hemorrhage), left ventricular failure Character o Normal: nonbounding, brisk upstroke o Bisferiens: double systolic peak due to aortic regurgiation with or without aortic stenosis, hypertrophic CM o Pulsus Alterans: pulse amplitude regularly alternates due to left ventricular failure, heart swinging in pericardial sac o Pulsus parvus: weak upstroke due to stroke volume, hypovolemia, left ventricular failure, aortic or mitral stenosis o Pulsus tardus: slow rising pulse due to aortic stenosis o Paradoxical pulse: exaggerated inspiratory fall in systolic blood pressure (>10mmHg less than expiratory systolic blood pressure) due to cardiac tamponade, constrictive pericarditis, obstructive lung disease 8

o Small, weak pulse: upstroke slowed and peak prolonged, tachycardia pulse, thready; due to stroke volume (heart failure, hypovolemia, aortic stenosis); TPR (exposure to cold and congestive heart failure) o Large bounding pulse: due to stroke volume anemia, hyperthyroid, aortic regurgitation, marked vasodilation; patent ductus arteriosus, bradycardia or complete heart block; compliance ( stiffness aging or artherosclerosis) Palpate tone o Normal: not palpable o Palpable: (chord-like) due to atherosclerosis Peripheral pulses: increased, normal, diminished, or absent Absent or diminished pulse: partial or complete arterial occlusion (arteriosclerosis) distal to occlusion; arteriosclerosis most commonly obstructs in the thigh femoral pulse absent & popliteal pulse decreased or absent Takayasus arteritis: weak pulses in the upper extremities Widened femoral pulse and popliteal pulse: femoral and popliteal aneurysm Dorsalis pedis absent may be congenital or branch may be higher in the ankle Absent dorsalis pedis with a femoral pulse diabetes mellitus Radial femoral delay: + if femoral pulse is smaller or later than radial pulse due to aortic coartation after left common carotid branch Water hammer pulse: + feel knocking/ bounding pulse then falls (collapsing pulse); due to fever, thyrotoxicosis, aortic regurgitation, anemia, Pagets disease, AV shunt Allens test: Normal: ulnar artery patent color returns to palm in 3-5 seconds Abnormal: > 3-5 seconds d/t occlusion of ulnar artery Blood Pressure Sphygomomanometers: Mercury: more accurate Aneroid (spring): less accurate, needs periodic calibration Electronic: very unreliable Reasons not to check BP: dialysis, shunt, brachial cut down (IVDA) Abnormally high reading: Short or high cuff Caffeine (<1 hour before) Exercise (<30 minutes before) Brachial Artery well below heart level when measure BP Patient arm is not relaxed Abnormally low reading Long or loose cuff Bladder balloons outside of cuff Hypotension: systolic blood pressure < 100 mmHg due to hemorrhage, cardiogenic shock, hypovolemic shock Orthostatic hypotension: check blood pressure standing and sitting (+ if systolic BP falls >20mmHg while standing); due to ANS diseases, hemorrhage, drugs, prolonged bed rest Systemic hypertension 9

Category HTN Stage 3 (severe) Stage 2 (moderate) Stage 1 (mild) High normal Normal Optimal

Systolic (mmHg) 180 160-179 140-159 130-139 <130 <120

Diastolic (mmHg) 110 100-109 90-99 85-89 <85 <85

Essential hypertension (MCC): defect in sodium excretion, transport; variation in genes encoding for renin-angiotensin system proteins; neurogenic vasoconstriction Secondary hypertension: renal disease (increased renin secretion, sodium retention, decreased vasopressin secretion, nephritic syndrome); endocrine causes (aldosteronism, contraceptives, pheochromocytoma, hyperthyroidism, Cushings syndrome); vascular (coarctation of the aorta, vasculitis, renal artery stricture or coarctation); neurogenic (psychogenic, increased intracranial pressure) Pulmonary hypertension: dependent edema, wide S2; hepatomegaly, ascites, Graham Steele murmer Kortokoff sounds: 1st systolic sound heard at least 2 consecutive beats; 2nd 3rd startend of auscultory gap (no sound heard); 4th muffling of sound; 5th diastolic when sounds disappear Auscultory gap: absences of sound within the range of the Korotkoff sounds; may overestimated diastolic or underestimated systolic meaurement Venous System a. Jugular Venous Pressure i. Used to check volume overload (right atrial filling pressure), venous return, and cardiac output CHARACTERISTIC JVP CAROTID Low in neck and lateral Deep in neck and medial Location Biphasic and diffuse Single-peaked and sharp Contour Undulant , NOT palpable Forceful, brisk, easily felt Character Varies w/ position No variation Response to position w/ inspiration No variation Response to respiration Displace pulse upward and Pulse unchanged Response to induces transient in pressure abdominal pressure Wave visible but nonpalpable Pulse unchanged, vessel Effect of palpation difficult to compress ii. Normal JVP: <4cm from sternal angle (<9cm above the RA) iii. JVP: >4cm above the sternal angle (>9cm above the RA); atrial pressure is (Hypervolemia); due to right heart failure, TV stenosis, constrictive pericarditis, pericardial tamponade, SVC obstruction, Pancoast tumor = blood flow to RA iv. JVP: at or below the sternal angle; atrial pressure (Hypovolemia) d/t severe burns, severe emesis, fistula, blood volume , dehydration v. A change in JVP is concern, not the instantaneous measurement 10 II.

b. Right atrial pressure wave (reflected in the biphasic jugular venous pulse) c. Hepato-jugular reflux: i. Tests hearts capacity to compensate for venous return (Starlings Law); ii. Normal: JVP with the increase abdominal pressure, then iii. Abnormal: JVP doesnt due to right-sided heart failure (RV filling problem), cardiac tamponade d. Kussmaul sign: i. Normal: JVP with inspiration ii. + JVP with inspiration: due to cardiac tamponade, right sided heart failure, RV stiffness

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Precordium Exam
Hi my name is ______, Im a second year medical student. What is your name? Its very nice to meet you. Mr./Mrs. ______ Ive been asked to come in and examine your heart. Is that ok with you? OK, if there is any discomfort at any time please let me know and Ill try my best to alleviate the discomfort. Ok, at this time Im going to have you uncover yourself from the waist up.

I. Inspection
Inspect with the patient in supine position with the arms at their sides Inspect from the foot of the bed, then on the right side of the patient o Check for signs of distress o Masses, scars, lesions o Apex beat o Symmetry o Upon inspection, the patient is not in any distress. The

patients chest is symmetrical. There are no masses, scars, or lesions. The apical beat is not visible.

Inspection from side of bed o Apical beat (use tangential lighting) o Upon closer inspection using tangential, the apical beat is not

visible.

II. Palpation
o Check for parasternal heave Place ulnar surface of hand perpendicular to sternum along parasternal edge

Can you please breathe out for me and hold?

Ask the patient to breath out and hold and observe any movement of hand o Check for thrills by placing palm of right hand over all 4 valve areas

13

Upon palpation no thrills were felt. There was no parasternal heave. The apical beat was located 7 cm from the midsternal line, just medial to the midclavicular line. Amplitude was normal. The diameter was 2.5 cm and focal. Apical beat duration was less than 2/3 systole. There was no dextrocardia (report only if the apical beat was nonpalpable)

o Localize apex beat Place palm of right hand underneath the patients left breast Pinpoint where it is felt with finger If you are unable to feel it, ask patient to turn to the left side, exhale, and stop breathing for a few seconds; try to locate again Note: Location: use left hand to count intercostal spaces and measure from midsternal line (cms) Diameter: measure using finger width (~1.5 cm) Duration: palpate the carotid pulse or radial pulse with your left hand and compare to apical beat (normal, sustained). Another way to check duration is to auscultate for S1 and S2 and palpate the apex beat. Amplitude: (normal, hypokinetic/hyperkinetic) Focal or diffuse o If you cant find the apical beat then check for dextrocardia (heart displaced to the right): place the palms of both hands on either side of sternum and locate patients heartbeat

III. Auscultation

o Mr./Mrs._____ Im just going to be listening to your heart

now. o Can you turn your head to the left please and breath normally
o Ask patient to turn their head to the left o While auscultating palpate the carotid pulse with your left hand to find S1 heart sound (upstroke of carotid is timed with S1 and auscultate) Start with bell from base apex (aortic pulmonary mitral tricuspid). Auscultate the tricuspid on two spots. (Warm the stethoscope with your shirt) Aortic valve is 2nd IS midclavicular line Pulmonary valve is 2nd IS midclavicular line Tricuspid valve is 3rd and 5th IS left of the sternum Mitral valve is 5th IS midclavicular line Check for mitral stenosis (pitch is low and quality is rumbling) Can you please roll to your left please and exhale

completely and hold for three seconds?

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Ask patient to roll onto left side (left decubitus position) while keeping stethoscope bell on chest Ask patient to completely exhale and hold breath for 3 seconds (brings the heart closer to chest wall)

Ask patient to return to supine position Flip to diaphragm and work back to base (tricuspid mitral pulmonary aortic) Check for aortic regurgitation (pitch is high and quality is blowing) Can you please sit up for me and lean forward -

Ok, go ahead and lie back down on your back please.

please?

Ask patient to sit up and hunch over

Can you exhale completely and hold for three seconds again?
Ask patient to completely exhale and hold breath for 3 seconds (brings the heart closer to the chest wall) Auscultate with the diaphragm along the sternal border in 2nd, 3rd, and 4th intercostal spaces.

Upon auscultation S1 and S2 were heard S3 and S4 were not heard. There were no murmurs, rubs, clicks, ejection sounds, or opening snaps. Mitral stenosis and aortic regurgitation were not heard.
MR. CEO - (Murmurs, Rubs, Clicks, Ejection sounds, Opening snaps)

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Precordium Exam Secondaries

I. Precordium a. Palpation i. Dextrocardia: heart, liver, stomach on right (situs inversus) 1. If heart on right and other 2 on left = congenital heart disease ii. Parasternal heave: if + hand will rise and tilt with each beat; due to right ventricular hypertrophy iii. Thrills (palpable murmurs) 1. Aortic: upper right sternal border 2. Pulmonary: upper left sternal border 3. Tricuspid: lower left sternal border 4. Mitral: horizontal across 5th IS iv. Apex beat 1. May not be found in: a. Obese b. Dextrocardia c. Emphysema d. Pericardial effusion (fluid in the pericardial sac) Signs and symptom is Becks Triad (hypotension, elevated JVP, and muffled heart sounds). All the chambers of the heart will have restrictive filling throughout diastole. e. Death 2. Apical beat: furthest down and out point. This is where the farthest point you can feel the beat, doesnt have to be the strongest. 3. Point of Maximal Intensity (PMI): area of maximal impulse; normally they are the same point 4. Location: normal = 5 IS MCL a. Displaced because of pregnancy, high left diaphragm, enlarged heart, thorax deformities; right ventricular hypertrophy lateral; left ventricular hypertrophy inferior and lateral, myocardial infarction, aneurysm superior and medial, and pulmonary pathology affecting the mediastinum 5. Amplitude: normal (small and gentle) a. Hypokinetic: dilated cardiomyopathy b. Hyperkinetic: anemia, hyperthyroidism, aortic stenosis, mitral regurgitation, hypertension (also increased duration), mitral regurgitation (also lateral apical beat), anxiety, atrial septal defect (no change in duration)

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6. Diameter: supine usually less than 2.5 cm; left lateral decubitus(the position of the patient in bed lying to the side) position - >3cm indicates left ventricular hypertrophy a. with left ventricular hypertrophy due to volume overload (aortic regurgitation) or pressure overload (aortic stenosis, hypertension) 7. Duration: a. Most useful to identify left ventricular hypertrophy; carotid pulse b. Normal: 2/3 systole duration (sustained if greater) c. Normal: <2 radial beats (sustained if greater) b. Auscultation: i. Aortic: 2nd IS right sternal border ii. Pulmonary: 2nd IS left sternal border iii. Tricuspid: 5th IS left sternal border iv. Mitral: 5th IS midaxillary line II. Heart Sounds a. S1: Mitral and tricuspid closure at beginning of systole, heard best at the apex i. Corresponds with carotid artery upstroke ii. in heart rate, cardiac output, mitral stenosis iii. in 1st degree heart block, calcified mitral valve (mitral regurgitation) left ventricle contractility (CHF, CAD) iv. Varying: complete heart block, irregular rhythm (atrial fibrillation) v. A normal split is detectable along the lower left sternal border; an abnormal split is due to right bundle branch block, premature venticular contraction b. S2: A2 = Aortic closure at the end of systole; P2 = Pulmonic closure at end of systole, heard best at the base i. Corresponds to radial pulse ii. P2 due to severe pulmonary hypertension iii. A2 due to systemic hypertension iv. Physiologic splitting (A2-P2) auscultate 2nd, 3rd left IS, accentuated by inspiration, disappears on expiration, especially when patient sitting up. Inspiration prolongs ejection of blood from the right ventricle but shortens ejection from the left ventricle. v. Pathologic splitting 1. Wide splitting: A2-P2 delay due to delay pulmonic valve closure (pulmonary stenosis, right bundle block), early closure of aortic valve (mitral regurgitation) 2. Fixed splitting: wide splitting that doesnt vary with respiration due to atrial septal defect, right ventricular failure

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3. Paradoxical/reverse splitting (P2-A2): accentuated on expiration and disappears on inspiration due to delay aortic valve closure (most common cause is left bundle branch block) c. S3: rapid filling of left ventricle in early diastole (later than an opening snap) i. A left sided S3 is heard best at the apex with patient on lying on the left side, left decubitus position, with the bell (dull and low pitched). A right sided S3 is heard best along the lower left sternal border with the patient supine ii. Normal in children, common in athletes, third trimester of pregnancy, pathologic in adults due to myocardium contractility, congestive heart failure, left ventricular or right ventricular failure, volume overload, or mitral/tricuspid regurgitation iii. Gallop (Ventricular Gallop) Kentucky (1-2-3)

d. S4: Atrial contraction ventricle filling occurs late in diastole i. A left sided S4 is heard best at the apex with patient on laying on the left side, left decubitus position, with the bell (dull and low pitched). A right sided S4, less common is heard best along the lower left sternal border with the patient supine. ii. Dull pitched and heard in trained athletes iii. Pathological due to ventricular compliance, - pressure overload states (aortic stenosis, chronic hypertension, myocardial infarct, CAD coronary artery disease); if accompanied by pain due to ischemia iv. Gallop (Atrial) Tennessee (4th 2nd 1st)

III.

Associated Sounds a. Clicks (high pitched) i. Ejection sounds: aortic and pulmonic valve stenosis ii. Mid or late systolic click is indicative of mitral valve prolapse; heard best with patient standing, eliminates all other clicks. 18

Standing (Valsalva or amyl nitrate) reduces left ventricular volume). Standing brings the click closer to S1

iii. Late systolic click: papillary muscle dysfunction (i.e. post-MI) b. Opening Snaps (high pitched): mitral valve stenosis (1 rheumatic heart disease) c. Rubs (high pitched) i. Inflammation of pericardium (pericarditis most common viral cause is secondary to coxsackievirus B and most common bacterial cause is Strep and Staph) ii. Best heard along left sternal border while leaning forward with held expiration iii. Scratchy, scraping quality d. Knocks, Crunches i. Pneumothorax: 1 in white, 20s, SOB, chest pain ii. Knock: early diastolic sound heard in patients with constrictive pericarditis iii. Crunch: beating heart hitting emphysematous lungs

IV.

Murmurs a. If a murmur is auscultated, report on: i. Location: murmurs originating in right side of heart tend to change more with respiration than left sided ones ii. Timing iii. Intensity 1. Very faint, may not be heard at all points 2. Quiet, immediately heard with stethoscope on chest 3. Moderately loud 4. Loud 5. Very loud, heard with stethoscope partly off chest 6. Heard without stethoscope Note: 4, 5, 6 are all thrills iv. Radiation v. Character 1. Rumbling: mitral stenosis 2. Blowing: aortic regurgitation 3. Musical: MV regular 4. Harsh: aortic stenosis vi. Pitch (low, high) b. Mechanism of murmur: i. flow/pressure across valve: anemia, thyrotoxicosis, exercise, fever, pregnancy

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ii. iii. iv. v. vi. c. Types

Irregular valve surface: aortic sclerosis, endocarditis Backward flow: aortic regurgitation, mitral regurgitation Stenosis: aortic stenosis, mitral stenosis Abnormal connection: ventral septal defect, atrial septal defect Flow into dilated chamber: aortitis, Marfans syndrome

i. Aortic regurgitation 1. Location: left sternal border 2, 3, 4 IS 2. Timing: diastolic, decrescendo 3. Radiation: left sternum down to apex 4. Intensity: strong 5. Pitch: high 6. Quality: blowing

ii. Mitral Stenosis 1. Location: apex 2. Timing: late diastolic: crescendo 3. Radiation: none 4. Intensity: 3-4 5. Pitch: low 6. Quality: rumbling

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iii. Mitral regurgitation 1. Location: apex 2. Timing: pansystolic, plateau 3. Radiation: axilla and behind shoulder blade 4. Intensity: 2-4 5. Pitch: high 6. Quality: musical

iv. Aortic Stenosis 1. Location: right 2nd IS 2. Timing: midsystolic, crescendo-decrescendo 3. Radiation: neck, left sternal border 4. Intensity: 3-4 5. Pitch: medium 6. Quality: harsh v. Early Systolic murmurs 1. Acute severe mitral regurgitation a. Timing: decrescendo b. Location: heard at the apex or medial to it c. Causes: i. Papillary muscle rupture complicating acute myocardial infarct (lateral, inferior, posterior) ii. Infective endocarditis: associated with fever, peripheral embolic lesions, + blood cultures iii. Rupture of chordae tendineae 21

vi.

vii.

viii.

ix.

x. xi.

iv. Blunt chest wall trauma 2. Small muscular ventricular septal defect with no pulmonary hypertension or left ventricular volume overload a. Location: left sternal edge b. Intensity: 4-5 3. Large, uncorrected ventricular septal defect with pulmonary hypertension 4. Tricuspid regurgitation a. Causes: infective endocarditis in (injection drug users) b. Soft c. Location: heard at the lower left sternal edge d. Carvallos sign: inspiration may accentuate Midsystolic murmurs 1. Aortic stenosis 2. Sclerosis of aortic valve (left sternal edge) 3. Pulmonic valve stenosis (pulmonic area) 4. Hyperdynamic states (fever, thyrotoxicosis, pregnancy, anemia) left sternal edge 5. Hypertrophic cardiomyopathy (left sternal edge, 2-3 intensity; loudest when decrease in left ventricular volume (Valsalva, standing, amyl nitrate) Late Systolic Murmurs 1. Mitral valve prolapse: a nonejection click followed by murmur, best heard at the apex to the left sternal edge, click and murmur moves toward S1 when there is a decrease in left ventricular volume (Valsalva, standing, amyl nitrate) Holosystolic (Pansystolic) Murmurs 1. Mitral regurgitation 2. Tricuspid regurgitation: intensity of 1 to 3 and at the left lower sternal edge, and increases upon inspiration 3. Ventricular Septal Defect: louder than tricuspid regurgitation and no change with inspiration Early Diastolic murmurs 1. Aortic regurgitation peripheral signs of wide systemic pulse pressure and water hammer carotid upstroke 2. Graham-Steele murmur (pulmonic valve regurgitation): early diastolic murmur, heard over right sternal border due to pulmonary hypertension; incompetent pulmonary valve; increase in intensity upon inspiration Middiastolic murmurs 1. Mitral stenosis 2. Tricuspid stenosis Austin Flint murmur: mild diastolic murmur at apex due to a chronic aortic regurgitation (hear over apex) left ventricle

22

xii. xiii. xiv.

xv. xvi. xvii.

volume overload originates at the mitral valve when blood enters simultaneously from both the left atrium and the aorta. Carey Coombs murmur: blubbering apical mid-diastolic murmur occurring in acute stage of rheumatic mitral valvulitis and disappearing as valvulitis subsides Patent Ductus Arteriosus PDA (normal is R L, abnormal is L R): machinery murmur at 2nd left IS bilaterally, loudest around S1 Venous hum: small murmur, origin in veins of children (disappears when child sits up), severe anemia, pregnancy, hyperthyroidism; continuous murmur; louder in diastole; hear above clavicles, around root of neck; obliterate with pressure on jugular veins; low pitch Benign pulmonary flow murmur: CV exam otherwise normal; hear over pulmonary artery, systolic murmur Mammary souffl: pregnancy and lactation blood to breasts, systolic and diastolic Cervical systolic murmur/bruit: carotid aorta due to atherosclerosis ventral septal defect early life; atrial septal defect late 20s

V.

Endocarditis a. Subacute bacterial endocarditis: i. Caused by strep. viridians, strep. fecalis, strep. bovis, hemophilus, parainfluenza ii. Occurs in previously diseased valves; bulky, friable vegetations (made of fibrin, inflammatory cells, and bacteria) on valves iii. Embolization of vegetations causes petechiae, infarcts, mycotic aneurysms b. Acute bacterial endocarditis: i. Caused by staph. Aureus; seeding previously normal valves ii. Complications include systemic pyemia; can cause death Left heart failure a. Causes: i. Essential hypertension hypertension without known cause ii. Mitral regurgitation iii. Aortic stenosis iv. Myocardial infarct v. Thyrotoxicosis vi. CAD vii. Constrictive pericarditis most common cause world wide is tuberculosis; most common cause in the US is idiopathic; open heart surgery; radiation of the mediastinum; neoplastic disease; previous pericarditis

VI.

23

viii. Hypertrophic cardiomyopathy ix. Pericardial tamponade x. Ischemic heart disease xi. Ventral septal defect xii. Patent ductus arteriosus (normal R L; abnormal L R) xiii. Bicuspid aortic valve b. Signs and symptoms: i. Exertional dyspnea ii. Cough iii. Fatigue iv. Orthopnea is discomfort in breathing that is brought on or aggravated by lying flat. v. Paroxysmal nocturnal dyspnea acute dyspnea appearing at night, usually awakening the patient after an hour or two of sleep caused by pulmonary congestion that results from left sided heart failure. vi. Cardiac enlargement vii. Pulmonary rales viii. Crepitations ix. Late inspiratory crackles x. Gallop rhythm hearing a third heart or fourth heart sound the 3rd or 4th heart sound, referred to as the Kentucky and Tennessee Gallop respectively. They occur in diastole and S4 is due to atrial contraction and S3 to rapid filling of a ventricle. There is also a summation gallop, which is both S3 and S4 and when the rhythm is fast they may sound as one. xi. Nocturia excessive urination at night xii. Pulmonary edema xiii. Pulmonary hypertension xiv. Respiratory alkalosis xv. Hypotension xvi. Fatigue xvii. Weakness VII. Right heart failure a. Causes: i. Left heart failure ii. Mitral stenosis iii. Pulmonic regurgitation iv. Pulmonary hypertension v. Pulmonary emboli vi. Myocarditis viral infection (coxsackievirus B) is the most common cause vii. Right ventricle infarction b. Signs and symptoms: i. Elevated JVP

24

ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. VIII.

Dependent edema Cyanosis Anorexia Ascites Exertional right upper quadrant pain Hepatomegaly ( unconjugated and conjugated bilirubin, ALP, AST, ALT) Oligouria (scanty urine) in day Oligouria (scanty urine) at night Polyuria (excessive urine) at night Weakness or mental aberration Early satiety

Symptoms a. Chest pain (C4-C5 dermatome) Levines sign; diagnosis myocardial infarct, pericarditis, aortic dissection b. SOB ( consciousness to respiratory effort) upon exertion; often 1st symptom of left-sided heart failure i. Relieved by rest diagnosis asthma, anemia ii. Aggravated by exercise, anxiety, after a meal c. Palpations patient aware of heart beat irregular or strong d. Edema feet, sacrum (diagnosis renal failure, liver failure, nutrition, obstruction) e. Fatigue (congestive heart failure, paroxysmal tachycardia) f. Cough dry, repetitive due to aortic pulmonary edema; hemoptysis (coughing up blood) with MS, pulmonary infarct g. Syncope h. Abdominal pain i. Medication j. Nocturia congestive heart failure k. Paroxysmal nocturnal dyspnea (PND) repetitive dry cough in PM, subsides in 30 minutes (complication pulmonary edema) l. Right upper quadrant pain (due to hepatomegaly with congestive heart failure) Anatomy a. Ventricles i. Chronic pressure overload ( after load) = hypertrophy ii. Chronic volume overload ( preload) = dilation and hypertrophy iii. SV = 70 ml/beat iv. AR = 70 beats/minute v. CO = 5L/minute b. Pressure: (systolic/diastolic) i. RA = 5/0 ii. LA = 5/0 iii. RV = 25/0

IX.

25

iv. LV = 120/0 v. Aorta = 120/80 mmHg vi. Arterioles = 35 mmHg (due to peripheral vascular resistance) 1. Kidney: up to 60 mmHg due to filtration process 2. Lung: as low as 20 mmHg because no fluid wanted in pulmonary system; therefore low pressure system favorable vii. Capillaries = approximately 3-5 mmHg viii. Plasma oncotic pressure: 1 due to albumin; prevent interstitial edema

26

Respiratory Exam

Hi my name is ______, Im a second year medical student. What is your name? Its very nice to meet you. Mr./Mrs. ______ Ive been asked to come in and listen to your lungs. Is that ok with you? Ok if there is any discomfort at any time please let me know and Ill try my best to alleviate the discomfort.

I.
-

Inspection
Look for (with the patient sitting): Symmetry, masses, scars, lesions Signs of distress or use of accessory muscles Breathing quality

Upon inspection the patient is not in any evident respiratory distress. There are no masses, scars, or lesion noted. The chest wall rises and falls symmetrically during breathing, and the breathing is abdominothoracal. No accessory muscles are being used during breathing
Palpate for pitting edema o Mr./Mrs. _____ Im just going to be pressing into your legs

and feet, just let me know if there is any pain at all

o Note: when palpating for pitting edema, the doctor should be looking at the patients face for any signs of tenderness o Press firmly but gently with thumb for > 5 seconds bilaterally over: The dorsum of foot Posterior to medial malleolus Over the shins Inspect the patients eye o Can you please look up for me? o Pull down underneath the patients eye to be able to inspect the conjunctival sac for signs of anemia o Can you please look down for me? o Pull up on the eyelids to be able to inspect the sclera for jaundice Inspect the patients tongue o Can you please open your mouth for me? o Checking for glossitis o Can you please lift up your tongue for me? o Checking for central cyanosis Inspect the patients fingers

27

o Bring up the patients fingers to eye level to check for clubbing and splinter hemorrhages o Capillary refill: pinch the patients fingers/nails for a second and look to see the blood flow back into the nails o Upon initial inspection the patient is not in any distress, there

is no pitting edema, no signs of anemia and jaundice. There are no signs of glossitis and central cyanosis. There is no clubbing, splinter hemorrhages, and capillary refill is normal.

Check respiration rate: o Look at stomach and at your watch (hold arm so that pt. doesnt know and therefore change the respiratory rate) o Up and down of chest = 1 A/P diameter: use hands to measure (normal 2:1)

The A/P diameter is 2 to 1, and the respiratory rate is 16.

II. Palpation
-

Im just checking your neck, ok.

Tracheal deviation: right index and ring on right and left sternoclavicular joints respectively, with middle on midline over trachea TVF (tactile vocal fremitus): palpable vibration o Mr./Mrs._____ can you please say 99, 99, 99. o Have patient say 99 (at each area) while placing ulnar surface of hands over 3 places bilaterally anteriorly i. 2nd IS midclavicular line ii. 4th IS midclavicular line iii. 4th IS anterior axillary line iv. Check for symmetry and presence Chest Expansion o Place hands on chest bilaterally so that thumbs bunch up skin in midline i. 2nd IS ii. 4th IS iii. 10th IS o Can you take deep breaths for me please? o Have patient take deep breath at each area and confirm symmetrical chest expansion (when fold flattens and thumbs move laterally) o Upon palpation, no tenderness was present. The trachea is

midline. Chest expansion is symmetrical and of normal force and extent. Tactile vocal fremitus was present and symmetrical.

28

III. Percussion
-

Mr./Mrs._____ Im going to tap on your chest now. Can you please turn your head to the left for me please...and now the turn the other way please
Ask patient to turn head to the opposite side and percuss from the apex When percussing place only the distal portion of the middle finger on the chest and percuss with the index finger. Percuss bilaterally (from left to right) i. Apex dorsal to clavical (above the clavicle) ii. 2nd IS MCL iii. 3rd IS MCL iv. 4th IS MCL v. 4th IS midaxillary line vi. 6th IS midaxillary line

Upon percussion, normal resonance was heard in all lung fields, except the expected dullness of the heart and liver.

IV. Auscultation
-

Mr./Mrs._____ Im going to be listening to your lungs now please breath normally for me now. Can you please turn your head to the left for me please...and now the turn the other way please
Ask patient to turn head to the opposite side and when auscultating the lungs. Listen bilaterally from left to right i. Apex (only place to use bell) dorsal to clavicle (above the clavicle) ii. 2nd IS MCL iii. 3rd IS MCL iv. 4th IS MCL v. 4th IS midaxillary line vi. 6th IS midaxillary line

Upon auscultation, normal vesicular breath sounds were heard in all lung fields and no adventitious sounds were heard.

TVF, auscultate for these: o Bronchophoney: ask patient to say 99 spoke words are louder, clearer (normal muffled, indistinct); increased intensity and clarity of voice sounds heard over a bronchus surrounded by consolidated lung tissue. o Egophony: ask patient to say ee long e changes to a (nasal) (normal muffled e); a peculiar broken quality of the voice sounds, like the bleating of a goat, heard about the upper level of the fluid in cases of pleurisy with effusion.

29

o Whispered pectoriloquy: ask patient to whisper 99 words heard louder, clearer (normal muffled, if at all); increased transmission of the voice sound through the pulmonary structures, so that it is clearly audible on auscultation of the chest; usually indicates consolidation of the underlying lung parenchyma.

V.
-

Posterior exam
Same as anterior exam with the following additions: Tracheal deviation (if not done anteriorly) be sure to show patient your hands first to comfort them Have the patient cross arms over chest moves scapula laterally to expose thorax TVF 4 places bilaterally o 1st IS midclavicular line o 2nd IS midclavicular line o 6th IS midclavicular line o 6th IS midaxillary line Chest expansion - 2nd IS - 5th IS - 10th IS Percuss and auscultate - 1st IS midclavicular line - 2nd IS midclavicular line - 4th IS midclavicular line - 6th IS midclavicular line - 8th IS midclavicular line - 6th IS posterior axillary line - 8th IS posterior axillary line

30

Respiratory Exam Secondaries

I. Inpection a. Clubbing

Check in abdominal, cardiovascular, and respiratory exams (pulmonary disease is the most common cause of clubbing). ii. Angle between plate and proximal nail fold 180, spongy nail bed iii. Due to infective endocarditis, liver cirrhosis, Crohns disease, ulcerative colitis, tuberculosis, chronic bronchitis, anemia, empyema (pus in cavity), RL shunts iv. Pseudo clubbing from Graves disease v. Pancoasts tumor: invasion (near trachea) of brachial plexus (usually T1-T2) and the cervical sympathetic chain by a primary (apical) lung cancer. Destruction of the T1-T2 sensory and motor nerves (most commonly by a primary squamous cell carcinoma of the lung) produces unilateral arm pain (ulnar nerve distribution), medial paresthesias, and wasting of the small muscles of the hand. Destruction of the cervical sympathetic ganglion produces Horners syndrome on same side of the lesion triad of ipsilateral lid lag, miosis (pinpoint pupil), and anhidrosis (lack of sweating); hoarseness; increased JVP, and unilateral clubbing. b. Cyanosis - deoxyHb i. Central: due to heart or lung disease (most common respiratory cause is bronchogenic carcinoma, chronic hypoxia); with central, have to have peripheral ii. Peripheral: due to frost bite, coarctation of aorta, Raynauds, poor circulation; with peripheral, do not have to have central c. Respiration i. Normal: 14-20 breaths/minute, abdomino-thoracal ii. Infants normal: 44 breaths/minute iii. Tachypnea: >20 breaths/minute ventilation will CO2 respiratory alkalosis (corrects metabolic acidosis) 1. Rapid shallow due to restrictive lung disease, chest pain, elevated diaphragm 2. Rapid deep hyperventilation due to exercise, anxiety, metabolic acidosis (Kussmaul breathing), anemia, early congestive heart failure iv. Bradypnea: < 14 breaths/minute ventilation will CO2 respiratory acidosis corrects metabolic alkalosis due to diabetic coma, drug induced respiration, depression, increased brain pressure

i.

31

II.

III.

v. Cheyne-Stokes breathing: hyperpnea with apnea (deep breaths and more rapid than normal with short periods of apnea); normal in infants and elderly due to heart failure, uremia, brain damage (especially medullary level), drug induced respiratory depression vi. Abdominal breathing: (more in males than females) stopped in ascites or peritonitis vii. Ataxic breathing (Biots): unpredictable, shallow then stops; due to respiratory depression, brain damage at medulla viii. Frequent sighing (hyperventilation syndrome): dizzy, dyspnea ix. Obstructive: prolonged expiration due to narrowing COPD x. Restrictive: rapid shallow breathing d. A/P diameter i. AP diameter: is measuring the distance of the anteroposterior to the distance of the transverse ii. Barrel chest - AP diameter; normal in old man; emphysema iii. Funnel chest (pectus excavatum): depression of lower sternum; associated with possible murmurs iv. Pigeon chest (pectus carinatum): increased AP diameter; depressed costal cartilage, sternum sticks out; associated with asthma v. Thoracic kyphoscoliosis: abnormal spinal curvatures and vertebral rotation deform the chest vi. Cooles test: place 2 fingers between notch and cricoid (2 should fit, barrel chest if < 2) Palpation a. Tracheal deviation i. Midline: consolidation ii. Same side (pulls): atelectasis; foreign body, tumor, fibrosis, pressure iii. Opposite side (pushes): thoracentesis (pleural tap), stab, rib fracture, pleural effusion, pneumothorax/tension (Air enters the pleural cavity and gets trapped upon expiration. The intra-thoracic pressure increases and compress the mediastinum and causes torsion of the Great Vessels leading to sudden death) iv. Moving: aortic arch aneurysm v. Descent: chronic over inflated lungs b. TVF (tactile vocal fremitus) i. Vibration: solid (tumor, consolidation) ii. Vibration: air (emphysema, bronchitis, asthma, pleural effustion, pneumothorax) iii. No TVF: atelectasis c. Chest expansion i. Nonsymmetrical chest expansion: broken ribs, musculoskeletal problems, collapsed lung, pneumothorax, pleural fibrosis, tumor, atelectasis, effusion, consolidation Percussion

32

IV.

a. Dull: lobar pneumonia (staph and strep), empyema, hemothorax, hydrothorax, exudate i. Fluid ususally sinks to the lowest part of the pleural space (posteriorly in a supine patient) ii. Only a very large effusion can be detected anteriorly b. Resonance: normal, chronic bronchitis, asthma c. Hyperresonance: emphysema (may totally replace cardiac dullness), pneumothorax, asthma d. Tympanic: large pneumothorax (especially in dyspneic newborns) e. Stony dull or flat: (like thumping the floor) pleural effusion f. Abscess: see air fluid level on chest x-ray; most commonly due to staph, klebsiella, anaerobes i. Note: apex site of 2 tuberculosis due to V/Q Auscultation a. Lung sounds

i. Vesicular: inspiratory sounds last longer, and louder than expiratory (normal) ii. Bronchovesicular: inspiratory and expiratory sounds are equal (consolidation, normal along sternum large bronchi) iii. Bronchial: expiratory sounds last longer than inspiratory, gap exists between sounds (consolidation, normal over trachea) iv. Tracheal: inspiratory and expiratory sounds are equal gap exists between sounds b. Adventitious i. Crackles: discontinuous, intermittent, nonmusical, and brief sounds 1. Fine crackles: soft, high pitched and very brief (5-10msec) 2. Coarse crackles: louder, lower pitched and longer in duration (20-30msec) 3. Inspiratory a. Early: due to chronic bronchitis, LHF, COPD, asthma b. Late: due to pneumonia, fibrosis, early CHF, consolidation, interstitial lung disease c. Mid inspiration/expiration: due to bronchiectasis ii. Continuous sounds: > 250 msec but do not usually span entire length of respiratory cycle; musical

33

V.

1. Wheezes: high pitched with a hissing or shrill quality suggests narrowed airways, as in asthma (in expiration only or expiration & inspiration), COPD, or bronchitis 2. Rhonchi: low pitched with snoring quality; due to secretions or mass obstructing large airways 3. Stridor: a wheeze that is entirely inspiratory; heard loudest over the neck; due to partial obstruction of the larynx or trachea medical emergency; most common cause croup (laryngotracheobronchitis in infants & young children caused by parainfluenza viruses) in children or foreign body obstruction iii. Hammans sign: a mediastinal crunch/precordial crackles heard synchronous with the beat of the heart and not respiration; best heard in left lateral position; most common cause due to mediastinal emphysema (pneumomediastinum) and is a medical emergency iv. Pleural rub: inflamed and roughened pleural surfaces grate against each other; heard in both phases of respiration Anatomy a. Right lung (3 lobes) i. Right upper lobe ii. Right middle lobe (oblique fissure spinous process T3 midclavicular line 6th rib) iii. Right lower lobe horizontal fissure midaxillary line 5th rib midclavicular line 4th rib) b. Left lung (2 lobes) i. Left upper lobe ii. Left lower lobe (oblique fissure) c. Lobes surface anatomy i. 2-4 cm above the clavicle ii. 6th rib: midclavicular line iii. 8th rib: midaxillary line iv. Trachea bifurcates anterior T4, 5; posterior T4 spinous process d. Physiology i. Tidal volume: amount air inspired and expired with each normal breath ii. Vital capacity: Tidal Volume + Inspiratory Reserve Volume + Expiratory Reserve Volume 1. pO2: trachea 150, alveoli 100, systemic artery 100, mixed venous 40 2. pCO2: trachea 0, alveoli 40, systemic artery 40, mixed venous 46 iii. Oxygen Dissociation Curve: measures the % of Hb saturated with O2 at given pressure of O2

34

1. Left shift (latches), affinity of O2 to Hb due to pO2, pH, temperature, 2,3 DPG 2. Right shift (release), affinity due to pH, CO2, temperature, 2,3 DPG 3. V/Q: COPD; pulmonary embolis 4. Diffuse capacity: anemia, emphsema, fibrotic disease, polycythemia, early congestive heart failure e. Muscles of Respiratory i. Inspiration 1. Principal = external intercostals & diaphragm 2. Accessory = sternocleidomastoid (SCM) & scalenes ii. Expiration 1. Passive = recoil of lungs 2. Active = internal intercostals & abdomen muscles

35

Condition Normal Chronic Bronchitis (COPD) - Clinically defined as productive cough > 3 consecutive months >2 consecutive years - Cigarette smoking, air pollution, infection, & genetic factors - May lead to cor pulmonale - Small alveoli/big airways; hypersecretion of mucous & fibrosis of bronchioles (cant inflate the lungs) Emphysema (COPD) - Big alveoli/small airways; deficiency in alpha1-antitrypsin (protease inhibitor that neutralizes elastase) (cant deflate lungs) - Dilation of air spaces with destruction of alveolar walls - Cigarette smoking (inactivates alpha1 antitrypsin and attracts neutrophils, macrophages, and source of elastase) - Hereditary alpha1 antitrypsin deficiency (pi gene, chrom 14) 1. Centrilobular respiratory bronchioles, upper part of the pulmonary lobes 2. Pacinar entire acinus (alveoli, alveolar ducts, respiratory bronchioles, and terminal bronchioles), distributed uniformly throughout lung 3. Paraseptal distal part of acinus (alveoli, alveolar ducts), localizes subjacent to pleura and interlobar septa. Associated occasionally with large subpleural bullae, blebs, which may rupture pneumothorax 4. Irregular irregular involvement of acinus with scarring of the walls of enlarged air spaces Asthma (COPD) - Hyperresponsive airways to inflammatory mediators (LTs, histamine) - Extrinsic asthma type I hypersensitivity (IgE and mast cells), begins in childhood and family history of allergy - Intrinsic asthma begins in adult and no history Consolidation Bilateral CHF, hypoproteinemia Unilateral Xf, neoplasm (bronchogenic carcinoma), lymphatic drainage Collapse/ Atelectasis Bronchus obstruction (mucus, tumor, FB), pneumothorax, pleural effusion, surfactant loss/absence Pleural Effusion Xf (pyothorax), lymphatic drainage (chylothorax), stab (hemothorax) Pneumothorax Thoracentesis, stab, rib fracture

Trachea & TVF Midline & Normal Midline & Normal

Chest Expansion and Percussion Symmetrical and Resonant Symmetrical and Resonant

Breath Sounds & Adventitious Sounds Vesicular and none Vesicular and none/possible crackles, wheeze, ronchi

Notes

Accessory muscles used, smoking stains, decreased diaphragm movement Accessory muscles used, smoking stains, decreased diaphragm movement

Midline and normal

Symmetrical AP diameter and diffusely hyperresonant

/ absent and none/possible crackles, wheeze, ronchi

Midline and normal

symmetry and hyperresonant

Vesicular and wheezes

Accessory muscles used

Midline and bronchophony, egophony, whispered pectoriloquy Ipsilateral and absent Contralateral and /absent Contralateral (tension) and /absent

Normal > abnormal and dull

Bronchial and late inspiratory crackles

Decreased respiratory rate

Normal > abnormal and dull Normal > abnormal and stony dull Normal > abnormal and hyperresonant/ tympanic

Absent and none /absent and possible pleural rub /absent and possible pleural rub

36

Abdominal Exam
Hi my name is ______, Im a second year medical student. What is your name? Its very nice to meet you. Mr./Mrs. ______ Ive been asked to come in and check your stomach area. Is that ok with you? Ok if there is any discomfort at any time please let me know and Ill try my best to alleviate the discomfort. Ok Im going to need you to undress from the bottom of your chest to the knee and you can cover your groin area.

I. Inspection
Inspect from the foot of the bed Patient is supine arms are at side

Are you in any discomfort right now?

Contour Hernias Umbilicus Rashes Pulsations Peristaltic waves Symmetry Significant scars and stria Superficial veins Check the patient to see if they are in shock

Upon inspection of the patients abdomen, I see no masses, scars, or lesions. The contour is flat, there are no hernias, the umbilicus is inverted, and there are no rashes, pulsations, or peristaltic waves. There are no stria, superficial veins, and the abdomen is symmetrical.
Palpate for pitting edema o Mr./Mrs. _____ Im just going to be pressing into your legs

and feet, just let me know if there is any pain at all

o Note: when palpating for pitting edema, the doctor should be looking at the patients face for any signs of tenderness o Press firmly but gently with thumb for > 5 seconds bilaterally over: The dorsum of foot Posterior to medial malleolus Over the shins Inspect the patients eye o Can you please look up for me? o Pull down underneath the patients eye to be able to inspect the conjunctival sac for signs of anemia o Can you please look down for me? 37

o Pull up on the eyelids to be able to inspect the sclera for jaundice Inspect the patients tongue o Can you please open your mouth for me? o Checking for glossitis o Can you please lift up your tongue for me? o Checking for central cyanosis Inspect the patients fingers o Bring up the patients fingers to eye level to check for clubbing and splinter hemorrhages o Capillary refill: pinch the patients fingers/nails for a second and look to see the blood flow back into the nails

There is no pitting edema, no signs of anemia and jaundice. There are no signs of glossitis and central cyanosis. There is no clubbing, splinter hemorrhages, and capillary refill is normal.

II. Auscultation
-

Im just going to be listening to your stomach sounds.

Listen for bowel sounds o Use diaphragm (done before palpation/percussion because they may alter bowel sounds) o Listen in all four quadrants for at least 2 minutes Listen for arterial bruits (turbulent blood flow) o Use the bell o Abdominal aorta: above the umbilicus between the aorta and the xyphoid process o Renal arteries: to right and left of the abdominal aorta o Iliac arteries: above the inguinal ligament, straight down from the renal arteries o Femoral arteries: below the inguinal ligament way between the ASIS and the pubic symphysis Listen for friction rubs (due to inflamed capsule rubbing against the diaphragm; due to gonorrhea, liver tumor, and chlamydia) o Use the bell o Auscultate over liver and spleen; 11 intercostal space left and right patient must breathe Listen for venous hum (due to collateral circulation heard in both systolic and diastolic; liver cirrhosis is MCC, right heart failure) o Use bell o Auscultate over liver

Upon auscultation bowel sounds of normal pitch and frequency heard. There were no bruit heard, no friction rubs, no venous hum.

38

III. Percussion
-

Mr./Mrs._____ Im going to tap on your stomach right now.

Look at the patients face While standing percuss all four quadrants

Upon percussion, normal tympany was heard in all 4 quadrants.

Offer to check abdomen for ascites (normally do this with protuberant abdomen) **Shifting Dullness** Start percussion at midline close to umbilicas and percuss laterally away from you until dull sound is heard Keeping your finger at this dull point have the patient roll over to his/her side facing you so that if there is ascites it will flow down to the lowest point (on the patients side) Percuss again on the same point, if there is ascites the dullness will now be tympanic due to the shifting of the ascites, if there were no ascites that same point will remain dull Dullness tympanic, percuss down towards the umbilicus to measure where the ascites has collected to **Fluid wave transmission** Have the patient or assistant (professor) press with ulnar surface of both hands across the abdomen. This helps stop the transmission of a wave through fat. Tap on one side of the abdomen sharply with your fingertips, feel the opposite side for an impulse transmitted through the fluid +, If you feel fluid transmitting **Puddle sign**(do not do during the exam) Have patient put hands on knees and tap the belly Most sensitive

IV.
-

Palpation

Look at the patients face Use the right hand Dr should be sitting o Light palpation

Are you in any pain right now? Im going to press down on your stomach now.

Ask the patient if any pain present before palpation Palpate all 4 quadrants or 9 areas work counterclockwise; start in RLQ (or LLQ if pain is present in the RLQ) Use breathing: Expiration push hand in 1-2 inches palpate during inspiration o Deep palpation Dr should be standing Palpate all 4 quadrants or 9 areas (start in the RLQ) Push in 3-4 inches during expiration, palpate during inspiration o Upon palpation, no masses, guarding, or tenderness was noted 39

o Appendicitis Signs Search for areas of local tenderness (RLQ) Ask patient to cough Feel for muscular rigidity (voluntary guarding may be replaced by involuntary rigidity with time) Cutaneous hyperethesia gently pick up a fold of skin, without pinching, at a series of points down the abdomen Rebound tenderness press on McBurneys point, lift off quickly viscera rebound and hit appendix Rovsings sign press deeply and evenly in LLQ then quickly withdraw fingers Psoas test flex hip against resistance (put hand over patients right knee and ask to flex thigh against pressure) Obturator test rotate leg internally at hip with knee flexed Perform rectal exam and look for right-sided tenderness

V.
-

Organ Palpation
Liver o Inspection o Auscultation o Percussion

Im going to tap on your stomach and chest right now.

Percuss down the mid-clavicular line starting at the 2-3 intercostal space until dullness is heard, indicating the upper border of the liver (ask patient to mark point with fingers) Percuss up from the RLQ in the mid-clavicular line until dullness heard. Measure span of dullness (measure by finger/hand width)

o Palpate Starting at the ASIS, move the hand superiorly and deep on expiration

Mr/Mrs._____ Im going to press down on your stomach now.

Feel for the livers edge as it shifts caudally on inspiration Scooping method with the side of the hand and work up to the costal margin Hooking technique place hands side by side below area of liver dullness; pull in and up with fingers o Gallbladder **Murphys sign** Hook fingers or thumb on right hand under costal margin at border of lateral rectus and costal margin (9th IS) Have the patient take a deep breath in

40

Upon examination, the liver span is 8 cm, the liver edge was smooth and non-tender. There was a negative Murphys sign.

Spleen o Inspection o Auscultation o Percussion

Mr/Mrs. _____ Im going to tap on your stomach now.

Percuss along Traubs space from medial lateral (area of tympany between lung resonance above and costal margin below) Percuss 11th IS in left anterior axillary line (normal = tympanic) Ask patient to breath in and hold; percuss again (normal = tympanic)

Upon percussion a negative splenic sign was noted.

o Palpation

Im going to pressing into your stomach now.

Not palpable in normal patient Start at the right ASIS and progress to left costal margin because the spleen enlarges comma shaped Ask the patient to inspire deeply as you approach the left costal margin Feel for the spleens edge as it shifts position on inspiration Roll patient onto their right side facing you and repeat palpation (the patients left hand goes on your left shoulder, your left hand goes over the patients back, and you can use that hand to push behind the ribs to help push the spleen forward while you palpate with your right hand).

Upon examination the spleen was not palpable.

Kidney o Inspection o Auscultation o Palpation Sandwich technique: with the patient in supine position attempt to trap the kidney between your hands at the peak of the patients inspiration. Left hand push from back, right hand examines from abdomen. Check the other kidney o **Murphys Test ** Assessing kidney tenderness Patient should be sitting Ask the patient if he or she is having any lower back pain Place your palm over the patients kidney (costalvertebral margin between 11th & 12th intercostal space on posterior chest) Strike the back of your hand firmly with a closed fist Repeat with the other kidney

41

Upon examination the kidneys were non-palpable and non-tender.

42

Abdominal Exam Secondaries

I. Inspection

Inspection: CHURPPSS Contour: flat, round/protuberant, (fat, feces, flatus, full, fluid, fibroid, bladder, tumor), scaphoid (lean). Note: fat will hang over the belly, ascites will droop to the sides Hernias (Possible to hear bowel sounds; Will not be able to feel above a hernia; If possible, have the patient cough) o Femoral hernia: lateral to pubic tubercle, deep to inguinal ring; F>M o Direct inguinal hernia: acquired, does not descend, in older men usually. Goes only through the external inguinal ring. o Indirect inguinal hernia: congenital, most common, descends into the scrotum. Goes through both internal and external inguinal ring. o Ventral hernia: in the abdominal wall have patient raise head and shoulders off the table and look for an abdominal bulge. o Diastasis recti hernia: separation of two rectus abdominus muscles through which abdomen contents bulge to form midline ridge when patient raises head midline hernias; may be noticeable in latter trimester of pregnancy o Lipoma hernia: most common benign fatty tumors located in subcutaneous anywhere including abdominal wall; soft lobulated (press down bulge slips from beneath your finger) Umbilicus: inverted (obesity, normal), everted (ascites, hernia) Rashes Pulsations: abdominal aortic aneurysm, pulse pressure Peristalitic waves: o Hyperperistalsis: early sign of bowel obstruction (late-sign will be silent abdomen) o Five things that cause obstruction: feces, flatuss (gas), fetus (pregnancy), fluid (ascites), tumor Symmetry: abnormal large organ, mass Significant scars and stria: pregnancy (linea nigra brownish-black pigmented line following the midline of the abdomen), normal, Cushings disease purple stria Superficial veins: portosystemic circulation due to cirrhosis, IVC obstruction Caput Medusa (varicose veins radiating from the umbilicus) Shock: will be cyanotic, low pulse due to bleeding from peptic ulcer, ectopic pregnancy Jaundice: due to hepatitis; cirrhosis Clubbing: o Due to infective endocarditis, liver cirrhosis, Crohns disease, ulcerative colitis Abdominal Pain: Colic pain will build up (spasms) typical of biliary obstruction Acute salpingitis: bilateral, motion of uterus causes pain

43

 Tendor peritoneum: rigidity with tenderness throughout general peritonitis (involuntary rigidity guarding) due to: o Acute cholecystitis: RUQ, check Murphys sign o Acute pancreatitis: epigastric, rebound tenderness o Acute appendicitis: RLQ (umbilical) check flank (lumbar) o Acute diverticulosis: LLQ sigmoid colon (mimics appendicitis on left) Auscultation Bowel Sounds: Normal frequency: 5-34 bowel sounds/minute, pitch (high/low) bowel sounds: diarrhea, early intestinal obstruction bowel sounds: adynamic/paralytic ileus, peritonitis, late intestinal obstruction, recent abdominal surgery Borborygmi: loud, prolonged gurgle of hyperperistalsis (growling) Arterial bruits: turbulent blood flowing through a vessel, hepatic carcinoma, (partial occlusion) Friction rubs: inflammation of liver capsule peritoneal surface rubs with diaphragm due to gonorrhea, liver tumor, chlamydia, recent liver biopsy, splenic infarct Venous Hum: soft humming noise heard during both systolic and diastolic, indicating increased collateral circulation between portal system and systemic (liver cirrhosis, is most common cause, right heart failure) Percussion Dull sounds: ascites, mass, enlarged organ Tympanic: gas in GIT, normal 1) Ascites: accumulation of fluid in the peritoneal cavity (pus, exudate, blood, transudate) >500ml in pertoneal cavity = evident Alcoholic cirrhosis Congestive heart failure Hepatic vein obstruction (Budd-Chiari syndrome) Nephrotic syndrome Kwashiorkor 2) Portal hypertension Prehepatic: narrowing of portal vein thrombosis, massive splenomegaly with shunting of blood into splanchnic circulation Intrahepatic: cirrhosis, schistosomiasis, diffuse fibrosing granulomatous disease, nodular regenerative hyperplasia Posthepatic: severe right sided heart failure, constrictive pericarditis, hepatic vein outflow obstruction (Budd-Chiari syndrome) Palpation Light palpation

44

 If feel mass, have patient lift head off table (flex ab muscles) If you still feel it the mass is in the wall or is superficial If you dont feel it the mass is intrabdominal Rigid Abdomen = acute abdomen Guarding: chronic or old pathology Deep palpation Masses: pulsating (aneurysm), movement with breathing (organ), physiologic (pregnant uterus), inflammatory (diverticulus), vascular (abdominal aortic aneurysm), neoplastic (colon cancer), obstructive (dilated bowel loop) Appendicitis signs: McBurneyspoint way between ASIS and symphysis pubis and 1/3 of distance from this point to the ubilicus Classically pain begins near umbilicus then shifts to RLQ + Cough: pain + Cutaneous hyperesthesia: localized pain in RLQ + Rebound tenderness: peritoneal inflammation due to appendicitis Mimic on left: diverticulitis, salpingitis Mimic on same side: Yersinia, tumor of appendix + Rovsings sign: pain in RLQ when press on LLQ + Psoas test: abdominal pain due to psoas muscle irritating inflamed appendix + Oburator test: abdominal pain due to obturator muscle irritating inflamed appendix Surgery: ultimate way of knowing about appendicitis Lab: left shift, WBC, fever, becomes ischemic area so there is nothing there to fight it (cant get there) If there is a slight problem remove it Diagnosis RLQ pain: salpingitis, acute appendicits, ovaria cysts, mesenteric adenitis, Meckels Diverticulum, ectopic pregnancy Liver Percussion Normal: midclavicular line = 6-12 cm; midsternal line = 4-8 cm Dullness displaced inferiorly without enlargement due to COPD False increase in liver span dullness due to pleural effusion or consolidation False decrease in liver span due to gas in the abdomen (pneumoperitoneum), gas in bowels Palpate Normal liver: smooth, large, and non-tender Large, irregular liver: cirrhosis (late stage shrunken), malignancy Alcohol (most common cause) hepatocellular damage and liver failure Viral hepatitis Heart failure In CHF, long standing right sided heart failure or constrictive pericarditis or tricuspid insufficiency nutmeg liver (centrilobular is dark red, congested and the portal areas are poor) centrilobular fibrosis

45

 Biliary obstruction extrahepatic biliary obstruction, which leads to dilation and pressure within intrahepatic bile ducts and cholangioles ductal injury ductal and periductal inflammation fibrous tissue formation Hemochromatosis o Idiopathic familial defect of iron absorption. Neglect triad of cirrhosis, diabetes mellitus, and bronze diabetics ( skin pigmentation). o Secondary caused by iron overload, ineffective erythropoiesis and multiple transfusions. Wilsons disease (hepatolenticular degeneration) an autosomal recessive disorder of copper metabolism, serum ceruloplasmin, accumulation of copper in parenchymal cells Large, smooth and tender liver: Hepatitis Venous congestion CHF In CHF, long standing right sided heart failure or constrictive pericarditis or tricuspid insufficiency nutmeg liver (centrilobular is dark red, congested and the portal areas are poor) centrilobular fibrosis Budd-Chiari caused by thrombotic occlusion of the major hepatic veins Hepatosplenomegaly: CHF schistosomiasis Clinical signs of liver cirrhosis/failure: Portal hypertension: development of venous collaterals with the submucosal veins of the esophagus (seen in 65% of advanced cirrhosis), splenomegaly, caput medusa, hemorrhoids Hypoalbuminemia: anasarca (hydrothorax), edema, ascites Jaundice: Check eyes, palms, dark urine, pale stools Hyperestrogenism (cant break down): palmar erythema, spider telangiectasia, feminization of male sex organs gynecomastia, testicular atrophy Coagulopathies: synthesis of coagulation factors, bruises, bleeding (petechiae) Hepatic encephalopathy, asterixis, putrid breath: ammonia in blood CNS liver enzymes (AST, ALT) Hepatorenal failure: BUN, creatine, urine output, hyperosmolar urine Gall Bladder 1. Acute cholecystitis: (N/V/F) nausea, vomiting, & fever, RUQ pain, + Murphys sign 2. Sharp in tenderness with a sudden stop of inspiratory effort 3. + Courvoisiers sign: oval mass palpable below livers edge, no pain (cancer head of pancreas obstructs common bile duct) ii. Jaundice 1. Pre-hepatic (unconjugated)

46

a. Overproduction (intra or extravascular hemolysis, ineffective erythopoesis) 2. Hepatic (unconjugated) a. Decreased bilirubin conjugation (decreased glucouronyltransferase activity) i. Hereditary transferase deficiency 1. Gilberts syndrome modest elevation of unconjugated bilirubin, no clinical consequences 2. Crigler-Najjar I or II - levels of unconjugated bilirubin, one for leads to early death by kernicterus, damage to the basal ganglia and parts of the CNS ii. Neonatal jaundice iii. Acquired [hepatocellular diseases viral or drug induced hepatitis, cirrhosis, drug induced cholestasis (oral contraceptives, androgens, chlorpromazine), alcoholic liver disease, sepsis, postoperative state, parenteral nutrition, biliary cirrhosis (primary or secondary)] 3. Post-hepatic (conjugated) a. Impaired hepatic excretion (intrahepatic defects) i. Familial 1. Dubin-Johnson syndrome autosomal recessive defect in transport, brown to black discoloration of liver caused by deposition of granules of very dark pigment. 2. Rotor syndrome defect in transport 3. Recurrent intrahepatic cholestiasis 4. Cholestatic jaundice of pregnancy b. Extrahepatic biliary obstruction i. Intraductal: 1. Gallstones 2. Biliary malformation stricture 3. Atresia 4. Choledochol cyst 5. Infection 6. Malignancy 7. Inflammation-pancreatic c. Hepatitis, yellow fever, pancreatic neoplasm, transfusion, etc.

47

iii. Anatomy 1. Embryological origin: foregut 2. Blood coming to liver: a. Hepatic Artery 30-40% of volume of hepatic blood flow & 80% of oxygenated blood b. Portal Vein 60-70% of volume of hepatic blood flow b. Spleen i. Percussion 1. + Splenic percussion sign (dullness): splenomegaly ii. Causes of Splenomegaly 1. Congestive heart failure 2. Portal hypertension, cirrhosis, portal thrombosis, right sided heart failure 3. Early sickle cell anemia in young: (chronic autosplenectomy multiple small infarct fibrosis over time) 4. Leukemia (hairy cell leukemia, CML) 5. Shistosomiasis, malaria 6. Lymphomas, myelomas, leukemias, hemolytic anemias (extravascular) 7. Immunologic inflammatory conditions: SLE, rheymatoid arthritis, Feltys syndrome 8. Storage disease: Gauchers, Neiman Pick, mucopolysaccharidosis 9. Amyloidosis, neoplasm, cysts 10. Mono-EBV (heterophile +) > 50% lymphos 11. CMV (heterophile -) < 50% lymphos iii. Splenectomy - risk for S. pneumo, H influenza, Neisseria therefore vaccinate iv. Anatomy: 1. 1,3,5,7,9,11 (1 thick, 3 wide, 5 long, 7 oz, between ribs 9-11) 2. Anterior medial border notch 3. Extends beyond midline 4. Dullness upon percussion 5. Fingers cannot get between spleen and costal margin 6. Moves with respiration c. Kidney i. Enlarged Kidney 1. Masses or lumps (cancer, cysts) 2. Hydronephrosis, pyelonephrosis, renal cell cancer, polycystic kidney disease, Wilms 3. Kidney tumor sign & symptoms M>F, hematuria, flank mass, pain, paraneoplastic syndrome ii. Small Kidney

48

1. Congenital hypoplasia 2. Chronic pyelonephritis 3. Unilateral renal artery stenosis iii. Murphys punch 1. + Sign = musculoskeletal problem, pyelonephrosis, kidney infarcts iv. Calculus: block ureter sudden, severe paroxysomal renal colic pain, chills, F, hematuria, frequency of urination v. Anatomy 1. Tympanic upon percussion 2. Fingers can get between kidney and costal margin 3. Right kidney is usually lower than the left 4. Retroperitoneal

49

Breast Exam
Hi my name is ______, Im a second year medical student. What is your name? Its very nice to meet you. Mrs. ______ Ive been asked to come in and do a breast exam. Is that ok with you? 1. Have you ever had a breast exam done before? 2. Have you ever done a self-exam? 3. Do you notice any pain/tenderness or nodules? 4. What was the first day of your last menstrual period? (<7 days do not 5. Do you know of any breast cancer in your family? Im going to leave the room and Im going to need you to undress from your waist up. If you would like, you can have a family member or someone else in the room and there will also be a female assistant in the room during the exam. Ok if there is any discomfort at any time please let me know and Ill try my best to alleviate the discomfort.
do exam may get abnormal results; best time to do exam is between 7 and 14 days)

I.

Inspection
a. Patient sitting at the edge of the bed and arms at her side b. Breast i. Size ii. Symmetry iii. Contour iv. Shape v. Color vi. Masses/scars/lesions c. Nipples/ Areola

Upon initial inspection there are no visible masses, scars, or lesions. The contour is round, and the breasts are of equal size and symmetrical. The nipples are everted, and there are no signs of dimpling or nipple discharge.
d. Changes with movement i. Ask the patient to: 1. Raise hands above her head 2. Lean forward with hands above her head 3. Squeeze hands on her hips

Upon further inspection there are no signs of dimpling and there were no contour changes with movement

51

II.

Palpation
a. Always check the good side first

Go ahead and lay down on your back for me now with your head resting on your right/left hand. Im going to place this pillow underneath your shoulder. I am going to squeeze around the nipple area now, please let me know if you feel any pain. Ok, now Im going to place my hands on your breasts, let me know if there is any pain.
c. Check for nipple discharge by squeezing areola Do not touch nipple d. Palpate in light circles all around breast and axilla i. Best to use both hands, the non-palpating hand should be on the opposite side of the breast holding it in position while palpating in light circles with the palpating hand. ii. Repeat bilaterally and do not forget to palpate the axilla b. The patient should be supine with her hand (ipsilateral to breast being examined) behind head and pillow underneath shoulder blade.

Upon palpation there was no nipple discharge and there was no masses and tenderness noted.

Please sit up on the edge of the table for me. Upon inspection there are no rashes nor pigment changes. Im going to place my hands underneath your arms in the armpit area, let me know if there is any pain.
b. Examine the lymph nodes (bilaterally at the same time to compare) c. Place the hands in axilla make sure the arms are down over the patients hands d. Palpate and report at each lymph node (normally < 1cm, non-painful) a. Inspection

III. Axilla

i. Central (axillary): palpate along chest wall between axillary folds (drains into infraclavicular, receives from pectoral, lateral to subscapular) ii. Subscapular: ventral to post axillary fold (drains posterior chest wall, part of arm) iii. Lateral: along upper medial humerus (drains most of the upper arm)

52

Upon palpation of the lymph nodes no enlargement noted and no tenderness noted.

iv. Pectoral: lower border of pectoris major caudal to anterior axillary fold (drains anterior to chest) v. Infraclavicular: lateral to SCM inferior to clavicle (receives from central) vi. Supraclavicular: lateral to SCM superior to clavicle (receives from infraclavicular)

53

Breast Exam Secondaries

I. Inspection a. Tanners Stage of Development

Stage 1

Stage 2

Stage 3

Stage 4

Stage 5

b. c.

d. e.

f.

i. Preadolescent elevated nipples only ii. Breast bud elevation of breast, nipples as small mounds, enlarged areolar diameter iii. Further enlargement of elevation of breast and areola no separation of contours iv. Projection of areola and nipple Secondary mound on top of breast v. Mature projection of nipple only, areola has receded to general contour of breast Contour: i. Normal convex ii. Dimpling or flattening of the breast suggests CA Shape: i. Normal normal if one is bigger than other ii. Thick skin with enlarged pores (Peau d orange) due to lymphatic blockage Color: i. Same compared to rest of the body (redness with infection) Nipples: i. Inverted: if it has been inverted since birth or childhood then it is normal variant but if it is a recent occurrence then there may be underlying CA ii. Nipples pointing in alternate direction suggests CA iii. Rashes or ulcerations Pagets disease (underlying CA) iv. Ectopic breast (polymastia) v. Ectopic nipples (polethelia) Cracking of skin/discharge: i. Discharge 1. Milky (nonpuerperal galactorrhea) = hyperprolactinemia (prolactin producing tumors) 2. Bloody = intraductal papilloma 3. Can be caused by medications (methyldopa, birth control pills) ii. Pagets disease of breast: cracking, eczema, scaly, weeping, crusty. Paget's disease is a benign appearing eczematoid lesion of the 54

II.

III.

nipple caused by large malignant cells (Paget's cells) which arise from the ducts and which invade the surrounding nipple epithelium. In the absence of an underlying mass, this is usually due to an intraductal carcinoma. An underlying palpable mass usually indicates invasive ductal carcinoma in which case the prognosis is the same as that for any other invasive ductal carcinoma and is reflected by the status of the axillary lymph nodes. g. Changes with movement: i. Dimpling or retraction suggests CA pulling Ashley Cooper ligaments; DDx fatty necrosis Palpation a. Reporting a mass: i. Where: quadrant, or clock face ii. Size: diameter (cms) iii. Distance: cms from nipple iv. Shape: round, regular, irregular v. Consistency: firm, soft, hard vi. Mobility: freely mobile or fixed to chest wall vii. Delimitation: well circumscribed or not viii. Tenderness b. Enlarged axillary nodes due to (be sure to check other lymph nodes): i. Infection of hand/arm ii. Recurrent immunizations iii. Skin test in arm iv. Part of general lymphadenopathy v. Malignant: firm, adhesive to each other or underlying tissues Axilla a. Rash: due to deodorant

Hidradenitis suppurativa

Acanthosis Nigricans

IV.

b. Hidradenitis suppurativa: sweat gland infection with pus c. Acanthosis Nigricans: deeply pigmented axillary skin; associated with underlying malignancy Secondaries a. Lumps/Nodules: i. Fibroadenoma: 1. Firm like the tip of the nose 2. Mobile

55

ii.

iii.

iv. v.

vi. vii. viii. ix. x.

3. Non tender 4. Round benign 5. Well circumscribed 6. Single 7. No retraction 8. <35 Tumor 1. Hard like back of the mastoid 2. May be fixed 3. Non tender 4. Stellate 5. Non mobile 6. Retraction 7. 30 90 8. Breast tumors metastasize bone (osteoclastic) 9. Diagnose FNA (+) blood Cyst: 1. Soft (like air in cheeks) 2. Mobile 3. Tender 4. Round 5. Diagnose FNA serous fluid do cytology 6. Single/multiple 7. No retraction 8. Well outlined 9. 30 60 Fibrocystic change: do nothing for treatment feels like rice F/U: 1. Mammogram 2. FNA and cytology 3. Biopsy and histology 4. Lumpectomy, chemotherapy, radiation (not radical mastectomy because no difference in 10 years) Most common fibrocystic change (40% breast CA) Fibroadenoma Rx resection Most common breast cancer infiltrating ductal CA CA that metastasizes to bone (primary osteoclastic) 1. Thyroid, lung, breast, prostate, kidney Risk factors for breast CA 1. Familial 2. No children (nulliparity) 3. Age 40-50 4. Early menarche/late menopause (exposed to more hormone) 5. Combo BCPs 6. Obesity

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V.

7. Any other CA (especially in opposite breast) 8. Exposure to ionizing radiation xi. Breast Cancer (fibrotic shortening retraction) 1. Skin dimpling 2. Abnormal contours (compare two sides) 3. Nipple retraction xii. Males: 2/3 of adolescent males develops gynecomastia due to gland enlargement, imbalance of estrogen, drugs, liver failure bilateral enlargement (unilateral may be cancer) Anatomy a. Position: i. Between 2nd and 6th ribs between sternal edge and midaxillary line ii. 2/3 superior to pec major iii. 1/3 superior to serratus anterior iv. Nipples and areola lateral to midline of breast b. 3 components: i. Glandular tissue 1. 12-14 lobules of glandular tissue make up breast 2. Produce milk after delivery of infant 3. Organized in lobes that radiate around nipple 4. Fibrous tissue Ashley Cooper ligaments; suspensory ligaments that are connected to both skin and fascia underlying the breast 5. Fat surrounds the breast; both superficially and peripherally ii. Surface Areola: has elevations that mark locations of sebaceous glands (of Montogomery) 1. Axillary hair: ~ 2 years after pubic iii. Aging: 1. Breast size (glandular tissue atrophies, replaced with fat) 2. Total fat , proportionately of fat/glandular 3. Loss of axillary hair 4. Breast: flabby, hangover on chest

57

Cranial Nerves
I. Olfactory
A. Check if both nasal passages are open by closing one nostril and have patient breathe (in and out) B. Check one nostril at a time to see if patient to smell and ID familiar odors with their eyes closed (coffee packet)

Nasal passages conduct air and familiar odor is noted bilaterally

II.

Optic
A. Visual Acuity (report Yaeger score) i. Ask patient

1. Can you read? 2. Do you wear contacts? 3. Are you wearing them right now? 1. How many fingers am I holding up?

ii. If they cant read or cant see, use fingers and ask: iii. Use Snellen chart to measure distance (14 from chin) iv. Ask patient to cover one eye and read lowest line possible on Snellen chart v. Ask patient to cover other eye and read the same line backwards vi. If patient is unable to read line, read the next one up The visual acuity is +1 bilaterally (report Yaeger score so patient doesnt know results) B. Confrontation test i. Align yourself with patient so that you are at eye level ii. Place your hands 2 feet apart, lateral to patients ears in their visual field iii. Wiggle your fingers over visual field

Please point to the moving fingers as soon as you can see them and tell me if you stop seeing them at any time. Make sure you can see your own fingers because you are comparing your visual field (assumed to be normal) to your patients.

iv. Move hands toward midline v. Repeat exam and test lower visual field vi. If defect is found, test one eye at a time (i.e. you cover your right eye and patient covers left eye) 1. Move fingers from defect area toward normal vision 2. Cover other eye and do it again to define borders vii. Upon confrontation test, no visual defect was noted.

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C. Pupillary light reaction (turn off lights, crack door) i. Turn off lights, crack door ii. Shine light on wall and ask patient to fixate on this point iii. Direct: bring light from behind ear to eye and observe constriction iv. Consensual: bring light to same eye but observe opposite eye with oblique lighting (enough light to see pupil but not cause consensual miotic reactions in opposite eye) v. Repeat bilaterally vi. The pupils are equal and round, they are reactive to light

and accommodation is intact.

D. Opthalmoscopic exam (fundoscopy) (turn off lights, crack door) vii. Turn off lights, crack door viii. Use right hand and eye, look at patients right eye ix. Place left thumb on patients eyebrow (to open eye if necessary) x. Shine light on wall and ask patient to fixate on this point xi. Start 15 lateral to patients line of vision, shine light on pupil 1. Note orange glow in pupil (red reflex) xii. Move inwards keeping your index finger on focus dial at all times (start with 0 diopters) xiii. Observe optic disc (follow As centrally) and physiologic cup viii. Repeat in patients left eye using your left eye and left hand to hold the opthalmoscope

Red reflex is present, the retina is visible, the optic disc is clear and pinkish. The physiologic cup is clean and half the size of the disc. The A-V crossings are normal.

III. Oculomotor
A. H test (III, IV, VI): ask patient to follow pen while making a wide H a. Extreme right b. Right and up (pause to check nystagmus) c. Right and down d. Without pause extreme left e. Left and up f. Left and down B. Accommodation a. Hold pen 10cm from patients nose b. Ask patient to look at point on wall (dilate), then look at pen (constrict) C. Convergence and lid lag a. Convergence: ask patient to follow pen as move it toward bridge of nose b. Lid lag: ask patient to follow pen as you move it slowly from up to down in midline D. Strabismus (if DDx) check using the cover uncover test have the patient look at the pen, cover one eye and the other will realign (+)

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IV. Trochlear
A. H test (III, IV, VI): ask patient to follow pen while making a wide H a. Extreme right b. Right and up (pause to check nystagmus) c. Right and down d. Without pause extreme left e. Left and up f. Left and down

V. Trigeminal
A. Motor while palpating ask patient to: a. Clench teeth (masseter and temporalis) b. Move jaw to sides against resistance (pterygoid) c. Push down against resistance (temporalis) d. Normal strength of temporalis, masseter, and pterygoid

bilaterally

B. Sensory a. Test 6 sites: forehead, cheeks, and jaw bilaterally i. Light touch: (dont brush/drag) use a cotton swab ii. Pain: test sharp vs. dull iii. Temperature: test cold (tuning fork) vs. warm (hand) b. Corneal reflex i. Ask patient to look up and away from you, approach from other side, out of patients line of vision. Touch the cornea lightly with wisp of cotton (avoid eyelashes) not done in exam c. Jaw jerk reflex i. Place finger on tip of chin and hit with hammer; + jaw jerks posterior d. Sensory system is intact, corneal reflex is present, and jaw

drop reflex is present

VI. Abducens
A. H test (III, IV, VI): ask patient to follow pen while making a wide H a. Extreme right b. Right and up (pause to check nystagmus) c. Right and down d. Without pause extreme left e. Left and up f. Left and down

VII. Facial
A. Inspection a. Assess facial symmetry (especially nasal labial folds for CN lesion) B. Motor

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C. Upon inspection of the face, there are no masses, scars, lesions, or deformities and symmetry is noted. Full muscular force and strength is noted bilaterally. The corneal reflex is intact.

a. b. c. d. e. f. g.

Raise eyebrows Frown Close eyes tightly (pull up on eyelids to test strength) Show teeth Smile Blow out cheeks Corneal reflex

VIII. Acoustic
A. Inspection a. Upon inspection there are no masses, scars, or lesions and

symmetry is noted.

B. Test acuity a. Do you have any hearing problems/devices? b. Can you close your eyes? c. Rub your fingers together. d. Do you hear this? e. If hearing is diminished, try to distinguish between conductive and sensorineural hearing loss f. Sound was heard equally in both ears. C. Offer Weber-Rinne a. Weber (lateralization) i. Tap the tuning fork (512 Hz) against a knuckle so that it begins to vibrate ii. Place fork firmly on patients forehead iii. Which side do you hear better? b. Rinne i. Place the vibrating tuning fork on the mastoid bone behind the ear, level with the ear canal (bone conduction) ii. Ask the patient when sound can no longer be heard place the fork close to the ear canal and ask the patient if the sound is still audible (air conduction). iii. U of the fork should be facing forward to maximize vibration iv. Place fork next to your ear to confirm sound presence c. Auditory acuity is normal bilaterally. Sound was heard equally

in both ears. Air conduction was greater than bone conduction.

D. Check for nystagmus ask patient to follow pen without moving head; move pen side to side then to extreme side

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IX. Glossopharyngeal
A. Test CN IX and CN X since functions overlap

X. Vagus
A. Motor a. Ask the patient to say ah and note position of soft palate and uvula b. Ask patient to swallow c. Gag reflex: stimulate back of the throat lightly on each side in turn not asked to do in exam d. Check hoarseness ask patient to say their name e. Ask patient to blow out their cheeks B. Motor system is intact. The gag reflex is noted. The uvula is

midline.

XI. Accessory
A. Inspect (from behind) for symmetry, muscle bulk, fasiculation B. Motor ask patient to: a. Shrug against resistance (trapezius ipsilateral) b. Turn head to sides against resistance (SCM ipsilateral) C. Upon inspection, normal muscle bulk and symmetry noted. Full force

and strength bilaterally.

XII. Hypoglossal
A. Inspect tongue B. Motor ask patient to: a. Move tongue to sides b. Stick out tongue C. Put hands over cheek and ask patient to push tongue against cheek D. No atrophy or fasiculations of the tongue as it lies in the floor of the

mouth. With the patients tongue protruded, there is normal symmetry, on atrophy, and no deviation from the midline. Full force and strength bilaterally

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Cranial Nerve Secondaries

I. Olfactory a. Function: special sense = smell b. Olfactory pathway: i. Olfactory receptor cells (1st order neurons) ii. Mitral cells (+ glutaminergic) of olfactory bulb iii. Olfactory tract iv. Lateral olfactory stria v. Primary olfactory cortex (piriform cortex that lies over the parahippocampal uncus) and the amygdala; primary olfactory cortex is BA 34 c. Olfactory hallucinations [uncinate fits (seizures) with deja vu]: lesions involving the parahippocampal uncus d. Ipsilateral anosmia (loss of smell): lesion of the olfactory pathway; olfactory groove meningioma (compress the olfactory tract and bulb), esthesioneuroblastoma (olfactory neuroblastoma), head trauma (cribiform plate damage), anterior fossa meningioma, smoking, cocaine, congenital, deviated septum, frontal lobe lesion e. Foster Kennedy syndrome (FKS): ipsilateral anosmia, ipsilateral optic atrophy, and contralateral pailledema (cause: anterior fossa meningioma) II. Optic a. Function: special sense = vision and pupillary light reflex (afferent limb) b. Visual Pathway: i. Ganglion cells of the retina: forms the optic nerve ii. Optic chiasm: optic nerve projects to the lamina cribrosa of the scleral canal through the optic canal; nasal hemiretina fibers cross iii. Optic tract: contains ipsilateral temporal hemiretina and nasal hemiretina fibers and projects to iv. Lateral geniculate body: 6 layered nucleus (layer 1, 4, 6 contra fibers & layers 2, 3, 5 ipsi fibers) v. Geniculocalcarine tract

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vi. Primary visual cortex (BA 17): divided by calcarine sulcus; lesions macular sparing 1. Cuneus: the upper division, input from superior retinal quadrants inferior visual field quadrants 2. Lingual gyrus: the lower division, input from inferior retinal quadrants superior visual field quadrants (pie in the sky); loops through the Meyers loop c. Pupillary Light Reflex Pathway i. Ganglion cells of the retina: bilaterally to ii. Pretectal nucleus of the midbrain: Crossed (posterior commisure) and uncrossed fibers of CNII iii. Edinger-Westphal nuclus of CNIII: preganglionic parasympathetic fibers and CNII exit to iv. Ciliary ganglion: postganglionic parasympathetic fibers to v. Sphincter muscle of Iris d. Pupillary Dilation pathway: i. Hypothalamus ii. Ciliospinal center (T1-T2) of the intermediolateral cell column of the spinal cord: projects preganglionic sympathetic fibers to iii. Superior cervical ganglion: projects postganglionic sympathetic fibers through perivascular plexus of the carotid system to iv. Dilator muscle of Iris e. SEE HEAD AND NECK EXAM III. Oculomotor a. Function: i. Special sense = pupil control/lens focus ii. Motor = move eye up, down, and medially b. Near Reflex and Accommodation Pathway i. Cortical Visual Pathway: Primary visual cortex (BA 17) to ii. Visual association cortex (BA 19): projects through the corticotectal tract to iii. Superior colliculus and pretectal nucleus

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 iv. Oculomotor complex (midbrain) 1. Rostral Edinger-Westphal nucleus: pupillary constriction 2. Caudal Edinger-Westphal nuclues: contraction of the ciliary muscle increases refractive power 3. Medial rectus subnucleus of CNIII: convergence c. SEE HEAD AND NECK EXAM d. Levator palpebrae superioris innervates skeletal portion e. PNS component: i. Ciliary muscle ii. Sphincter pupillae f. SNS component: i. Dilator pupillae ii. Superior tarsal muscle g. CNIII palsy: transtentorial herniation (tumor, subdural and epidural hematomas) supratenotorial pressure forces the hippocampal uncus throught the tentorial notch and compresses CNIII; aneurysms of the carotid and posterior communicating arteries compress CNIII within the cavernous sinus or interpeduncular cistern; diabetic oculomotor palsy affects CNIII unlike others it spares the pupilloconstrictor fibers i. Pupilloconstrictor fibers: affected first dilated and fixed pupils ii. Somatic efferent fibers: affected last external strabismus iii. Ptosis: due to denervation of levator palpebrae muscle iv. Down and out: denervation of the extraocular muscles h. Light reflex: II afferent, III efferent IV. Trochlear, VI Abducens a. Funtion: motor to superior oblique depresses, intorts, and adducts the eye b. Pathway: i. Trochlear nucleus (caudal midbrain) ii. Crosses at superior medullary velum (midbrain) iii. Exits at the brain stem (dorsal surface, caudal to the inferior colliculus) iv. Encircles the midbrain v. Passes through cavernous sinus vi. Orbit (through superior orbital fissure) vii. Superior Oblique Muscle

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c. CNIV Palsy: Extorsion of the eye and weakness in looking down and in i. Vertical Diplopia: increases when looking down ii. Head tilting: to compensate for the extorsion iii. Head trauma: CNIV is vulnerable because it wraps around the midbrain iv. d. Strabismus (eye deviations) i. Nonparalytic strabismus imbalance in oculomotor tone 1. Esotropia convergent strabismus 2. Extropia divergent strabismus 3. Nystagmus: fine rhythmic oscillation of eyes (few beats with extreme lateral gaze is normal; defined by the fast phase (in left horizontal nystagmus, the eye drifts slowly to the right and jerks back to the left); can be vertical, horizontal, or rotary; due to disorders of labyrinth, cerebellum, drug toxicity V. Trigeminal a. V1 opthalmic nerve: innervates the forehead, dorsum of the nose, upper eyelid, orbit (cornea and conjunctiva), and cranial dura b. V2 maxillary nerve: innervates the upper lip and cheek, lower eyelid, anterior portion of the temple, oral mucosa of the upper mouth, nose, pharynx, gums, teeth and palate of the upper jaw, and cranial dura c. V3 mandibular nerve: GSA innervates the lower lip and chin, posterior portion of the temple, external auditory meatus, and tmpanic membrane, external ear, teeth of the lower jaw, oral mucosa of the cheeks and floor of the mouth, anterior 2/3 of the tongue, temporomandibular joint, and cranial dura. SVE innervates the muscles of mastication, mylohyoid, anterior belly of the digastric, and tensores tympani and veli palatini. It innervates the muscles that move the jaw, the lateral and medial pterygoids. d. Function: Motor = mastication, lateral jaw movement, initiate swallowing, auditory dampening i. Temporalis (elevate/retract), masseter (elevates), pterygoid (protrude, side to side) ii. Spasm of muscles of mastication = tetanus and adverse reaction to phenothiazines iii. Corneal reflex: a consensual disynaptic reflex (afferent V-1/ efferent VII); abnormal patient doesnt blink iv. Jaw Jerk reflex: a monosynaptic myotatic relex (afferent V-3/ efferent V-3) 1. Muscle spindle from masseter muscle 2. Mesencephalic nucleus (primary neuron)

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3. Motor nucleus of CNV (secondary neuron) 4. Masseter muscle v. Trigeminal neuralgia (tic douloureux): recurrent paroxysms of sharp, stabbing pain in one or more branches of the trigeminal nerve on one side of the face. e. Pathway of Ventral trigeminothalamic tract (pain and temperature) i. Trigeminal ganglion: are where the first-order neurons are and descend in the ii. Spinal trigeminal tract: to the iii. Spinal trigeminal nucleus: where the second-order neurons are and decussate and terminate at the iv. VPM: contralateral ventral posteromedial nucleus of the thalamus where the third-order neurons are and project to the v. Posterior limb of the internal capsule vi. To the somatosensory cortex (BA 3, 1, 2) face area f. Pathway of Dorsal trigeminothalamic tract (discrimination and pressure sensation) i. Meissners and Pacinis corpuscles ii. Trigeminal ganglion: are where the first-order neurons are and synapses at iii. Principle sensory nucleus of CNV: are where the second-order neurons to project to the iv. VPM nucleus of the thalamus (ipsilateral): are where the thirdorder neurons are located and projects to the v. Posterior limb of the internal capsule vi. To the somatosensory cortex (BA 3, 1, 2) face area

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VI.

Abducens a. Function: motor to lateral rectus muscle abducts the eye b. Pathway: i. Abducent nucleus: found in the dorsomedial tegmentum of the caudal pons ii. Corticospinal tract: goes through the iii. Pontine cinstern and cavernous sinus: to the iv. Orbit (through superior orbital fissure) c. CNVI palsy: most common isolated palsy; seen in patients with meningitis, subarachnoid hemorrhage, late-stage syphilis, and trauma i. Esotropia: convergent (medial) strabismus with inablitiy to abduct the eye [Extropia divergent strabismus] ii. Horizontal diplopia: double images are farther apart when looking towards the affected lateral rectus muscle

VII.

Facial a. Function: i. Special sense = taste anterior 2/3 ii. Motor = facial movements, close eye, corneal reflex, salivation, lacrimation, general sensation from the external ear b. Lower motor neuron lesion (Bells palsy) parotid tumor, middle ear infection, lyme disease i. Paralysis of ipsilateral entire face c. Upper motor neuron lesion stroke, multiple sclerosis, tumor i. Paralysis to contralateral lower face

VIII. Acoustic a. Function: special sense i. Vestibular nerve: maintains equilibrium and balance 1. Kinetic labyrinth: three semicircular ducts respond to angular acceleration and deceleration of the head. Hair cells respon to the flow of endolymph 2. Static labyrinth: utricle and saccule (contains hair cells whose cilia are embedded in the otolithic membrane) respond to the position of the head with respect to linear acceleration and the pull of gravity 3. Pathway: a. Hair cells of the semicircular ducts and utricle are innervated by bipolar cells

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b. Vestibular ganglion (located in the fundus of the internal auditory meatus) c. Vestibular nerve to vestibular nuclei and to d. The flocculondoular lobe (cerebellum) e. Nuclei also projects to: - CNIII, IV, VI through MLF - Spinal cord through lateral vestibulospinal tract - Ventral posteroinferior and posterolateral nuclei of the thalamus postcentral gyrus ii. Cochlear nerve: mediates hearing 1. Pathway: a. Vibration of the basilar membrane stimulates b. Hair cells of the organ of Corti (innervated by peripheral processes of bipolar cells of the spiral ganglion c. Bipolar cells of the spiral (cochlear) ganglion project centrally as the cochlear nerve to the d. Cochlear nuclei e. Projects contralaterally to the superior olivary nucleus (sound localization) and projects to f. Lateral lemniscus projects to g. Nucleus of inferior colliculus projects through the brachium of the inferior colliculus to h. Medial geniculate body projects to through the internal capsule as the auditory radiation to i. Primary auditory cortex (transverse temporal gyri of Heschl BA 41 & 42) 2. Sensorineural (perceptive or nerve) deafness: is caused by disease of the cochlea, cochlear nerve (acoustic neuroma), or central auditory connections.

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3. Conduction deafness: is caused by interruption (obstruction wax, otosclerosis, or otitis media) of the passage of sound waves through the external or middle ear. 4. Tinnitus: irritative lesions causing ear ringing 5. Aoustic neuroma: is a schwann cell tumor of the cochlear nerve that causes deafness b. Dolls eyes: if damage to CN8 when doctor moves patients head side to side the eyes move with head (normal = eyes move opposite of head rotation); due to lesion of midbrain or pons IX. Glossopharyngeal a. Function: special sense = taste posterior 1/3 b. Afferent i. Carotid sinus (baroreceptor) ii. Carotid body (chemoreceptor) Vagus a. Function: motor = pharynx, larynx, palate b. Lesion in vagus i. Dysphagia: pharyngeal or palatal weakness ii. Palate: 1. Fails to rise: bilateral 2. Abnormal side fails to rise, uvula deviates to normal side: unilateral 3. Nasal voice iii. Vocal cord paralysis: aortic aneurysm, bronchogenic CA = damage recurrent laryngeal nerve iv. Gag reflex (afferent IX/efferent X) abnormal patient doesnt gag Accessory a. Function: motor = SCM, upper trapezius b. Ipsilateral muscle control right SCM turns head to right c. Lesion XI i. Weakness, atrophy, fasiculations peripheral nerve disorder ii. Paralyzed trapezius: shoulder drop, scapula displaced down and laterally iii. Paralyzed SCM: difficulty raising head off pillow Hypoglossal a. Function: motor = tongue b. Lesion XII i. Atrophy, fasiculations ii. Tongue deviates to same side when protruded iii. Force is greater to unaffected cheek iv. Cerebellum dysfuntion: spasticity, paralysis

X.

XI.

XII.

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Bulbar Palsy: palsy affecting cranial nerves of medulla (V, VII, IX, X, XII); reflexes (jaw jerk, gag) Pseudo Bulbar Palsy: same cranial nerves but upper motor neurons; reflexes Jugular Foramen syndrome: IX, X, XI; ipsilateral weakness of pharyngeal, laryngeal, trapezius, SCM muscles; ipsilateral loss of sensation of pharynx Wallenberg Syndrome: (posterior inferior cerebellar artery occlusion) V, IX, X ipsilateral; spinothalamic (contralateral)

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Head & Neck Exam

I. Head
a. Patient sitting b. Inspection i. Symmetry ii. Masses, scars, lesions iii. Fasiculations, abnormal tics iv. Hair quantity, distribution, texture, lice/nits

The patients hair is of normal quantity, texture and distribution. There are no lice or nits. The skull and face are symmetrical with no masses, scars, or lesion. There is no movement or edema and the skin is normal in pallor and texture.

II.

Eyes
a. Inspection i. Eye symmetry ii. Eyebrows iii. Eyelashes iv. Eyelids: have patient close eyes v. Lacrimal glands and apparatus vi. Conjunctive and sclera vii. Cornea and lens: use oblique lighting from the top to inspect opacities

The patients eyes are symmetrical. Eyebrows are of normal thickness. No lesions or periorbital edema. Lacrimal apparatus is functional. No conjunctivits, anemia, or jaundice noted. No opacities noted.
b. Visual acuity i. Ask patient

1. Can you read? 2. Do you wear contacts? 3. Are you wearing them right now? 1. How many fingers am I holding up?

ii. If they cant read or cant see, use fingers and ask: iii. Use Snellen chart to measure distance (14 from chin) iv. Ask patient to cover one eye and read lowest line possible on Snellen chart v. Ask patient to cover other eye and read the same line backwards vi. If patient is unable to read line, read the next one up

76

The visual acuity is +1 bilaterally (report Yaeger score so patient doesnt know
results) c. Pupil size i. Compare to pupil size chart d. Confrontation i. Align yourself with patient so that you are at eye level ii. Place your hands 2 feet apart, lateral to patients ears in their visual field iii. Wiggle your fingers over visual field

Upon inspection, pupil size is 4 bilaterally.

Please point to the moving fingers as soon as you can see them and tell me if you stop seeing them at any time. Make sure you can see your own fingers because you are comparing your visual field (assumed to be normal) to your patients.
iv. Move hands toward midline v. Repeat exam and test lower visual field vi. If defect is found, test one eye at a time (i.e. you cover your right eye and patient covers left eye) 1. Move fingers from defect area toward normal vision 2. Cover other eye and do it again to define borders

Upon confrontation test, no visual defect was noted. No crescentric shadow noted.
e. Iris shine light from temporal side

The pupils are equal and round, they are reactive to light and accommodation is intact.
h. Extraocular muscles i. H test: ask patient to follow pen while making a wide H 1. Extreme right 2. Right and up (pause to check nystagmus) 3. Right and down 4. Without pause extreme left 5. Left and up

f. Accommodation i. Hold pen 10cm from patients nose ii. Ask patient to look at point on wall (dilate), then look at pen (constrict) g. Pupillary light reaction i. Turn off lights, crack door ii. Shine light on wall and ask patient to fixate on this point iii. Direct: bring light from behind ear to eye and observe constriction iv. Consensual: bring light to same eye but observe opposite eye with oblique lighting (enough light to see pupil but not cause consensual miotic reactions in opposite eye) v. Repeat bilaterally

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Eyes show good use of extraocular muscles. There is no lid lag and convergence is normal. Corneal reflection is symmetrical

6. Left and down ii. Lid lag: ask patient to follow pen as you move it slowly from up to down in midline iii. Convergence: ask patient to follow pen as move it toward bridge of nose iv. Corneal reflection: hold light 2 feet from patients eyes 1. Ask patient to look at light 2. Observe location of reflection

Red reflex is present, the retina is visible, the optic disc is clear and pinkish. The physiologic cup is clean and half the size of the disc. The A-V crossings are normal.

i. Ophalmoscope exam (fundoscopy) i. Turn off lights, crack door ii. Use right hand and eye, look at patients right eye iii. Place left thumb on patients eyebrow (to open eye if necessary) iv. Shine light on wall and ask patient to fixate on this point v. Start 15 lateral to patients line of vision, shine light on pupil 1. Note orange glow in pupil (red reflex) vi. Move inwards keeping your index finger on focus dial at all times (start with 0 diopters) vii. Observe optic disc (follow As centrally) and physiologic cup viii. Ask patient to look into the light last (to observe the macula) ix. Repeat in patients left eye using your left eye and left hand to hold the opthalmoscope

III. Ear
a. Inspection i. Patient sitting ii. Look for masses, scars, lesions, deformities, and symmetry b. Palpation i. Palpate preauricular and posterior auricular lymph nodes ii. Pull up, back, down on alae iii. Palpate tragus iv. Palpate mastoid process c. Hearing i. Test acuity

Upon inspection, no masses, scars, or lesions noted. Symmetry is noted

No tenderness, or masses noted on palpation

1. Do you have any hearing problems/devices? 2. Can you close your eyes?
3. Rub your fingers together. 78

4. Do you hear this? Sound was heard equally in both ears

5. If hearing is diminished, try to distinguish between conductive and sensorineural hearing loss

Which side do you hear better?

ii. Weber (lateralization) 1. Tap the tuning fork (512 Hz) against a knuckle so that it begins to vibrate 2. Place fork firmly on patients forehead

Auditory acuity is normal bilaterally. Sound was heard equally in both ears. Air conduction was greater than bone conduction.
d. Otoscope exam

iii. Rinne 1. Place the vibrating tuning fork on the mastoid bone behind the ear, level with the ear canal (bone conduction) 2. Ask the patient when sound can no longer be heard place the fork close to the ear canal and ask the patient if the sound is still audible (air conduction). a. U of the fork should be facing forward to maximize vibration 3. Place fork next to your ear to confirm sound presence

I am going to look into your ear, you may feel some discomfort, but tell me if you have any pain.
i. Pull patients alae up and back (to straighten ear canal), rest hand on zygomatic arch, insert ear speculum (left hand/left ear; right hand/right ear); use largest ear speculum that ear canal can accommodate ii. Inspect for discharge, foreign bodies, inflammation, cerumen iii. Inspect ear drum (color/contour) 1. Describe tympanic membrane 2. ID cone of light (anterior inferior to handle of malleus) 3. ID The handle of malleus, and incus if possible

Upon inspection, no inflammation or foreign bodies present, the ear drum is pink and smooth. The cone of light and the handle of malleus are visible.

IV.

Nose and Paranasal Sinuses

a. Inspect anterior and inferior surfaces of nose b. Test for nasal obstruction

Im going to look into your nose, if you feel any pain please tell me Please occlude one nostril and breathe in and out through your nose. And with the other.

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Upon inspection, there are no masses, scars or lesion on the nose. The nasal mucosa is red and there is no bleeding, ulcers, or polyps. The septum is intact. The inferior and middle conchae are visible. Upon palpation there was no tenderness in the paranasal sinuses
e. Palpate maxillary, frontal sinuses with thumbs noting any tenderness f. Offer to illuminate sinuses i. Turn off lights, crack door ii. Frontal: place light snugly deep under each brow, close to nose, and shine up; look for dim glow of forehead iii. Maxillary: ask patient to lie supine and open mouth; shine light downward from just below inner aspect of each eye; look through mouth for dim glow of hard palate

c. Gently press on nose with thumb (widens nostrils) inspect nasal orifices with pen light d. Ask patient to tilt head back, insert speculum (without touching nasal septum) and observe: i. Nasal mucosa: color, swelling, bleeding, exudate, polyps, ulcers ii. Nasal spetum: deviation, inflammation, perforation

V.

Mouth and Pharynx

a. Inspect i. Use pen light and tongue depressor ii. Lips iii. Oral mucosa iv. Gums v. Teeth vi. Tongue and floor of mouth vii. Soft palate viii. Anterior and posterior pillars ix. Uvula x. Tonsils xi. Pharynx xii. Not the color, symmetry, inflammation, ulcers, lesions, and any other abnormalities

Upon inspection the lips are not dry and there are no lesions, ulcers or cracking. There are no masses, scars, or lesions on the oral mucosa. The teeth are intact. The gums are pink. There are no lesion on the tongue and there is no glossitis. There are no lesions on the floor of the mouth. The pharynx is not inflamed, and there are no ulcers or visible lesions.

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VI.

Neck
a. Inspection: look for masses, scars, or lesions, symmetry b. Palpate parotid and submandibular glands

Upon inspection, the patients neck is symmetrical with no masses, scars, or lesions. The parotid and submandibular glands are not enlarged
c. Palpate lymph nodes using pads of index and middle fingers i. Ask patient to slightly flex head forward 1. Preauricular (front of ear) 2. Postauricular (front of mastoid) 3. Occipital (base of skull posteriorly) 4. Tonsillar (mandible angle) 5. Submandibular (1/2 way between angle and tip of mandible) 6. Superficial cervical (above SCM) 7. Post cervical (along anterior edge of trapezius muscle) 8. Deep cervical (deep to SCM) 9. Supraclavicular (dorsal to clavicle where it meets the SCM) 10. Infraclavicular (caudal to clavicle where it meets the SCM 11. Note: shape, size, delimitation, mobility, consistency, and any tenderness 12. If enlarged node, the reexamine the area it drains

Upon palpation, the patients lymph nodes are not hard or enlarged, and no tenderness is noted.

VII. Thyroid
a. Patient sits b. Inspection i. Ask patient to extend neck back slightly ii. Use pen light directed down from patients chin iii. Inspect the region below the cricoid cartilage for the gland iv. Ask patient to take a sip of water but not to swallow until you are ready to observe; when patient swallows, observe cricoid cartilage and thyroid gland movement (normal rise and fall symmetrically)

Upon inspection the thyroid gland is not enlarged and it is symmetrical. It elevates and then returns to normal position upon swallowing.
c. Palpate i. Stand behind patient ii. Place your fingers (use both hands) on the patients neck just below the cricoid cartilage iii. Show hands to patient before placing them on neck patient comfort iv. Palpate the thyroid, cricoid cartilage and thyroid gland v. Note the size, shape, and consistency of gland

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Upon palpation, the thyroid gland is normal size, shape, and consistency. There were no nodules, and no tenderness was noted.
d. Associated exam i. Palpate the hair ii. Inspect for thinning of the eyebrows iii. Convergence iv. Lid lag v. Exopthalmos vi. Check for sweaty palms vii. Tremors (place a piece of paper over patients hands) viii. Pulse ix. Myxedema periorbital edema

vi. If gland is enlarged, listen for a bruit with bell of stethoscope

Upon further examination the hair is of normal texture, there is normal convergence of the eye. No lid lag, no exopthalmos. No sweaty palms, no tremors. The eyebrows are of normal thickness. There is no periorbital edema. The pulse is 72 beats per minute, the rhythm is regular, the character is normal and the volume is normal.

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Head and Neck Exam Secondaries

I. Head a. Cushings syndrome: ACTH; patient resembles a lemon on a stick; moon (round) face, red cheeks; excess facial hair lips and chin; buffalo hump b. Parkinsons disease: decreased facial motility (mask-like face less blinking, seems to peering forward), oily skin, drooling may occur c. Facial fractures: nose (most common fractured bone in the body); jaw d. Enlarged skull: Pagets disease of bone; hydrocephalus e. Asymmetrical face: CN7 lesion f. Hair: fine due to hyperthyroidism g. Seborrheic dermatits: inflammatory skin disease; round, irregular lesions covered with yellow or brown-gray greasy scales (dry or weeping) h. Pilar cysts i. Psoriasis: erythematous papules, plaques with distinct borders j. Nits: eggs of lice ovoid, granular, white, adhere to hair k. Down syndrome: low set ears l. Fontanelles: i. Anterior: closes at 12 months, delayed in hydrocephalus, early in craniosynostosis; ii. Posterior closes at 2 months, check for dehydration Eyes a. Inspection i. Eye position: exopthalmos Graves disease (bilateral); ocular tumors ii. Eye brows: 1. Hypothyroidism thin laterally 2. Seborrheic dermatitis scaly iii. Eyelashes (direction they point)

II.

Ectropion

Entropion

Stye (hordeolum)

1. Ectropion: margin of lower lid is turned outward exposing palpebral conjunctiva; strabismus associated; most common in elderly 2. Entropion: inward turning of lid margin lashes irritate the cornea; ask patient to squeeze lids together, then open them may reveal it; most common in elderly

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3. Sty (acute hordeolum): painful, tender, red inflammation around the hair follicle of the eyelash a. External hordeolum caused by staph infection of superficial accessory glands of Zeis or Moll located in the eyelid margin b. Internal hordeolum occurs after suppurative infection of the oil secreting meibomian glands with in the tarsal plates of eyelid iv. Eyelids

Epicanthus

Blepharitis

Ptosis

Chalazion

Xanthelasma

Pinguecula

1. Epicanthus: vertical fold of skin over medial eye; Asians, Down syndrome, convergent strabismus (floating eye) assoc. 2. Blepharitis: inflammation of the eyelids along the margins, often with crusting or scales. Most common form occurs in association with acne rosacea or seborrheic dermatitis 3. Ptosis: down and out eye due to aneurysm, herniation, Myasthenia Gravis; Horners syndrome; CN3 damage; Lambert-Eaton syndrome (cant release Ach) 4. Chalazion: chronic inflammatory lesion involving a meibomian gland (upper lid). Produces pea-like nodule within the eyelid 5. Xanthelasma: slightly raised, yellowish, well circumscribed plaques in the skin along the nasal portion of the eyelid; sign of hypercholesterolemia 6. Pinguecula: yellowish nodule in the bulbar conjunctiva on either side of the iris; appear frequently in aging v. Lacrimal apparatus 1. Epiphora: tearing 2. Dry (keratoconjunctivitis sicca): Sjorgrens, MiKulicz disease, sarcoidosis; test by Schirmer strip (measures tear production)

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3. Dacryocystitis: inflammation of the lacrimal sac (swelling between the lower lid and nose) a. Acute: painful and red b. Chronic: obstruction of a nasolacrimal duct 4. Excessive tears: a. Conjunctival inflammation b. Nasal lacrimal duct obstruction c. Ectropion: impaired drainage of tears vi. Conjunctiva and sclera

Corneal Scar

Bitots spots 1. Jaundice 2. Episcleritis: local noninfectious inflammation of the superficial tissues of the sclera; the thin layer of connective tissue between the conjunctiva and the sclera 3. Conjunctivitis: diffuse redness, watery eyes due to bacterial, viral (most common is adenovirus), allergy 4. Allergic conjunctivits: a. Hay fever conjunctivitis seasonal, IgE mediated activation of mast cells cause itching, redness, & edema b. Vernal conjunctivitis seasonal, unknown cause itching, photophobia, epiphora, and mucous discharge c. Atopic conjunctivitis occurs with atopic dermatitis or asthma 5. Corneal injury or infection: red just around iris; watery, abrasions, infections 6. Acute iritis: red just around iris; non-watery, decreased vision; with ocular and systemic disorders 7. Acute glaucoma: red just around iris; intense itching, cloudy cornea; an emergency: acute increase in intraocular pressure; pain is due to the stretch of the cornea (chronic glaucoma no pain, tunnel vision is 1st sign) 8. Subconjunctival hemorrhage: pure red, less vessel demarkation just blood (rupture of blood vessels bridging the potential space between the episclera and the conjunctiva; from eye rubbing, vigorous cough, trauma or bleeding disorders; resolves without treatment 9. Bitots spots: foamy soap suds appearance early sign of keratomalacia vitamin A deficiency

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vii. Cornea and lens: 1. Cornea:

Herpes virus a. b. c. d. e. f. g. h. i.

Corneal arcus

Pterygium

j.

Dryness: cobblestone appearance on red reflex Glaucoma: cloudy corneal edema Trauma: permanent scar Vitamin A deficiency: opacification Sjogrens Keratitis: impairs vision by corneal clouding, scarring, and perforation blindness (trachoma and vitamin A deficiency world leading cause) Herpes virus: major cause of blindness from keratitis; unilateral follicular blepharoconjunctivitis; dentritic tree pattern of corneal epithelial ulceration Corneal arcus: thin gray arc at edge of cornea; suggests hyperlipoproteinemia; associated with elderly, African Americans Corneal scar: superficial opacity of cornea from old injury (DDx-cataract is deeper = opacity of the lens); best seen with fluorescein strips and slip lamp using cobalt blue light Pterygium: bulbar thickening of conjunctiva that slowly grows across the edge of the surface of cornea, fleshy material; removed if signs and symptoms of irritation or blurring recurrence is common problem

2. Lens: a. Cataract (most common): milky whiteness in pupil, dark spot on red reflex background; most develop slowly as a result of aging visual impairment; occurs more rapidly in patients with history of ocular trauma, uveitis, or diabetes mellitus; acquired in myotonic dystrophy, neurofibromatosis type 2, galactosemia. b. Nuclear cataract: gray with flashlight looks back against the red reflex c. Peripheral cataract: spot-like shadows that grow inward b. Visual acuity (Snellen chart) refractive error

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Myopia

Hyperopia

Presbyopia

Astigmatism

i. Cant tell if patient is near-sighted with pocket Snellen (Rosenbaum card); testing vision through a pinhole aperture is a useful way to screen quickly for refractive error, if visual acuity is better through pinhole than unaided eye refraction needed to correct visual acuity ii. Emmetropia (20/20): parallel rays from infinitely are focused perfectly up on the retina; distance from chart/distance normal eye can be read line from iii. Hyperopia: impaired near vision; globe is too short; Rx converging (convex) lens iv. Myopia: impaired far vision; globe is too long; Rx diverging (concave) lens v. Presbyopia: impaired near vision due to loss of refractive power to accommodate near objects; in middle and old age Rx convex lens; if previously hyperopia bifocals to see near objects; if previously myopia take off glasses to see near objects vi. Astigmatism corneal surface is not perfectly spherical, need cylindrical corrective lens or LASIK (laser in situ keratomileusis) or PRK (photoreactive keratectomy) c. Pupil size: i. Anisicoria: pupillary inequality <0.5 mm (benign; normal in 20% of pupil); ok as long as the asymmetry of pupil is constant with light changes 1. Inequality >0.5 mm in Horners syndrome caused by; oculomotor paralysis; tonic pupil; open angle glaucoma 2. If anisicoria increases in dim light: indicates a sympathetic paresis of the iris dilator muscle 1 of the pupils is not dilating because of the paresis. Brainstem stroke, carotid dissection, or neoplasm impinging on sympathetic chain Horners syndrome (miosis, ptosis, & anisicoria) 3. If anisicoria increases in bright light: indicates a parasympathetic paresis ii. Miosis: constriction of the pupils iii. Mydriasis: dilation of the pupils 1. Contraindications for mydriatic drops head injury, coma, narrow angle glaucoma 2. Acute mydriasis occurs with damage to the ciliary ganglion; infections (herpes zoster & influenza), trauma

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(blunt, penetrating, surgical), or ischemia (diabetes & temporal arteritis) iv. Tonic pupil (Adies Pupil): large pupil unilateral; reaction to light /slowed; near reaction is slowed; deep tendon reflexes due to PNS lesion (nerve or ciliary ganglion) v. Argyll Robertson: small pupil unilalteral, accomomodation normal, but doesnt react to light; due to neurosyphilis, diabetes, lesions of the dorsal midbrain (obstructive hydrocephalus, pineal region tumors), aberrant regeneration (oculomotor nerve palsy, Adies tonic pupil) vi. Horners syndrome: small pupil, ptosis, anhidrosis; normal pupillary light reaction and accommodation due to SNS lesion vii. Uveitis: pain with constriction; inflammation of the uveal tract (iris is part of uveal tract), always unilateral viii. Marcus Gunn: (swinging flashlight test) direct and consensual in normal eye, then see dilation of both when shine light in abnormal eye (due to relaxation from light in normal), light shined in the abnormal eye causes no reaction in either eye, no pupillary reflex due to afferent optic nerve lesion ix. Webers syndrome: CN3 paresis with contralateral hemiplegia due to midbrain stroke x. Parinauds syndrome: midbrain lesion no upward gaze, no pupillary light reflex, but normal accommodation xi. Oculomotor nerve paralysis ptosis; pupil is dilated and not reactive to light (often with lateral deviation) xii. Unilateral blindness does not cause anisicoria as long as the sympathetic and parasympathetic innervation is intact; light in the good eye causes constriction in both eyes, light shined in the blind eye causes no reaction in either eye d. Confrontation i. Normal: fingers seen in visual fields ii. Visual defects: 1. Legal blindness constricted visual field of 20 or less in good eyes; 20/200 or less in the good eye with glasses on 2. Horizontal defect (central retinal artery) 3. Blind eye (optic nerve lesion) 4. Bitemporal hemianopsia (nasal of retina, lesion of optic chiasm) 5. Homonymous hemianopsia (contralateral optic tract, also seen with occipital radiation lesion) 6. Homonymous quadratic lesion (partial lesion of contralateral optic radiation) 7. Tunnel vision: 1st sign of chronic glaucoma, retinitis pigmentosa, papilledema, migraine (transient) 8. Scotoma: 1 retinal diseases affecting macula due to diabetes mellitus, hypertension, vitamin B12 deficiency,

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retrobulbar neuritis (most common), vascular lesion of ocular pole., methanol 9. Strabismus: signs and symptoms diplopia (brain cuts off image from bad eye normal vision, eventually leads to blindness of bad eye); Diagnose cover test (tests alignment) patient fixes on point, cover fixed eye, gloating eye realigns 10. Note: Names are from the patients visual field e. Iris i. + crescentric shadow due to narrow angle glaucoma the iris bulges too far forward creating a narrow angle between the iris and the cornea in intraocular pressure due to aqueous humor drainage is blocked ii. Hypopyon: pus in anterior chamber in front of iris (with corneal ulcers) iii. Hypehema: blood in anterior chamber in front of the iris due to blunt trauma Accomodation i. Pupillary constriction with near effort, eyes move medially, ciliary muscle contracts tension on suspensory ligament of the lens convex lens (near vision) Pupillary light reaction i. Afferent CN2; efferent CN3; mediated by input to pretectal olivary nuclei in the midbrain projects output to ipsilateral and contralateral Edinger-Westphal nuclei of the oculomotor nuclear complex (cells here provide parasympathetic innervation to the iris sphinctor via interneuron in the ciliary ganglion). ii. Direct reaction: pupillary constriction of the same eye as stimulated by light iii. Consensual reaction: pupillary constriction in the opposite eye Extraocular muscles i. Convergence: poor due to hyperthyroidism ii. Lid lag: rim of sclera seen between upper lid and iris due to hyperthyroidism (normal: upper lid slightly overlaps the iris) iii. Corneal reflection: (tests ocular alignment) normal reflection is slightly nasal to center of pupils; cover test is more precise have patient look at distant object, cover eye while observing other eye; any shift means misaligned; repeat with other eye iv. Corneal reflex: afferent CN5; efferent CN7 Opthalmoscope exam i. Red reflex not seen if: detached rim, absent eye, retinoblastoma, cataracts (black spots on red background); = DARC; red reflex test looking at the retina ii. Optic disc 1. Clarity of disc outline 2. Color: normal yellowish orange to creamy pink

f.

g.

h.

i.

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3. Central physiologic cup: Normal white and < diameter of disc 4. Character and size of arteries and veins (see retina below); pulsatory veins suggest CSF press is normal 5. Normal optic disc variations a. Rings and crescents seen around discs temporal border (pigment) b. Medulated nerve fibers white patches where the vessels are occluded; obscures the edge of the disc 6. Abnormalilities of the optic disc a. Optic atrophy: less of disc vessels, whitish in color b. Papilledma: vessel stasis leads to engorgement, disc swollen, margins blurred, due to intracranial pressure (meningitis) c. Acute glaucoma: pressure in the eye leads to backwards depression of the disc; the base of the cup is enlarged; pink hyperemic, disc vessels more numerous and swollen at borders, stony hard eye; size of optic cup > size diameter of disc 7. Optic nerve disorder: glaucoma, acuity, optic neuritis (in MS), methanol, thrombosis of retinal vein sudden loss of vision, emboli in central retinal artery sudden loss of vision iii. Retina 1. Arteries: light red, smaller, and brighter light reflex 2. Veins: dark red, larger, and absent light reflex 3. Hypertension: a. Copper wiring: artery becomes tortuous and light reflex giving a copper appearance b. Silver wiring: narrowed artery becomes completely opaque c. Superficial hemorrhages: small, linear, flameshaped red streaks in the fundus due to severe hypertension, papilledema, and occlusion of the retinal vein d. Cotton wool patches: white or grayish, ovoid lesion with irregular borders; most commonly due to infarcted nerve fibers e. Hard exudates: small, round yellowish, with well defined borders, often in clusters or circular, linear patterns (also in diabetic retinopathy) f. A-V crossings i. Tapering: vein appears to taper down on either side of the artery ii. Nicking: vein appears to stop abruptly on either side of the artery

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4.

5. 6. 7.

iii. Banking: vein twists on the distal side of the artery and forms a dark, wide end Diabetic Retinopathy: a. Non-proliferative: i. Deep retinal hemorrhages: small rounded irregular red spots that occur deep in the retina ii. Microaneurysms: tiny, round, red spots seen most commonly around macular region; consist of minute dilations of tiny retinal blood vessels iii. Hard exudates b. Proliferative: i. Neovascularization: formation of new blood vessels that are more numerous, tortuous, narrower than the other vessels; most commonly seen in late stage diabetes ii. Bands of white fibrous tissue that develop iii. Vitreous hemorrhages: newer blood vessel grow into vitreous because of CHO, more friable than other blood vessel Drusen: small yellowish round spots, haphazardly distributed, concentrated at the posterior pole; seen with aging and macular degeneration Healed chorioretinitis: a well defined irregular patch of white sclera marked with dark pigment, due to toxoplasmosis, laser surgery Coloboma of the choroid and retina: developmental abnormality, large to moderate size white oval of sclera, well demarcated, pigmented borders

j. Blindness i. Most common cause in US diabetes ii. Most common cause in World chlamydia; others = cataract, glaucoma (chronic open angle intracellular pressure bilaterally), Chlamydia trachomatis (old most common cause), onchocerciasis Rx ivermectin iii. Childhood most common cause of blindness measles (keratoconjunctivitis), xerophthalmia (due to deficiency in vitamin A cornea drying and rupture), ophthalmia neonatum (affected in birth canal), retinopathy of prematurity (retrolental fibroplasia), congenital cataract k. Color Vision i. Red, green, & blue cones 1. Red & green X chromosome 2. Blue chromosome 7; mutations are rare ii. Can be 20/20 with hue discrimination impaired

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iii. Ishihara plates detects red-green color blindness iv. Color blindness disease of macula and optic nerve, bilateral strokes involving the ventral portion of the occipital lobe (cerebral achromatopsia) v. Color anomia can discriminate colors, cant name colors; infarcts of the dominant occipital lobe l. Anatomy i. Aqueous humor is made by ciliary body (posterior chamber pupil anterior chamber canal schlemm) ii. Posterior chamber: cornea iris iii. Anterior chamber: iris lens III. Ear a. If they ask to do ear exam inspect the face first b. Inspection i. Position of ears (Downs syndrome low set) ii. Scars (mastoidectomy) iii. Lesions 1. Chondrodermatitis helices: painful inflammatory purple papule on helix or antihelix ulceration and crusting; biopsy needed to distinguish from a carcinoma; most common in older men 2. Cauliflower ear: inflammation of auricle cartilage (perichodritis) due to pseudomonas aeruginosa Xf 3. Squamous cell carcinoma: most common on helix, but check behind the ear as well; confirm with biopsy; occasional metastasis to regional lymph nodes 4. Basal cell carcinoma: raised nodule with lustrous center and telangiectatic vessels, slow growing, rare mets; most common in light skinned people with frequent exposure to the sun 5. Cutaneous cyst: benign, closed sac on dermis blackhead maybe visible on surface 6. Epidermoid cyst: common on the face and neck, may become inflamed 7. Pilar (trichilemmal) cyst: common on the scalp 8. Tophi deposit of uric acid crystals: hard nodules on the helix or antihelix; may discharge white, chalky crystals (also seen near joints, hands) due to chronic tophaceous gout 9. Rheumatoid nodules: small lumps on the helix or antihelix; may come before the arthritis; check for other nodules on the body (ulnar surface of arm, heels, knees); ulcerations may result from repeated small injuries; DDx tophi

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10. Keloid: firm, nodular, hypertrophic mass of scar tissue extending beyond the area of injury; most common on shoulder or upper chest (appears in pierced skin); darker skinned people are predisposed; recurrence likely 11. Lepromatous leprosy: multiple papules and nodules on the auricle 12. Referred pain to the ear (five Ts) a. Throat, TMJ, Tonsil, Teeth (cutting in babies), Tongue c. Palpation i. Tragus and auricle movement tenderness due to otitis externa inflammation of ear canal ii. Mastoid process: tenderness 1. Upper: due to mastoiditis swollen, red, swollen pre- and post- auricular lymph nodes death if untreated 2. Lower: furuncular otitis externa (boil communicates with abscess in middle ear); otitis media/interna d. Weber-Rinne i. Weber 1. Unilateral sensorineural hearing loss: sound is heard in good ear 2. Conductive hearing loss: sound is heard in impaired ear ii. Rinne 1. Normal: air conduction is better than bone conduction 2. Conductive hearing loss: sound is heard through bone as long as or longer than it is through air 3. Senorineural hearing loss: sounds is heard longer through air iii. Hearing disorders 1. Conduction loss: no air conduction; due to obstruction of ear canal (foreign body, cerumen), otitis media, perforation, otosclerosis 2. Sensorineural loss: no air/bone conduction; due to sustained exposure to loud noise, drugs (neomycin quinine), inner ear infections (syphilis, mumps, rubella), trauma, tumors, congenital disorders, aging (presbycusis) 3. Hyperacusis (excessive acuteness of hearing): paralysis of stapedius or tensor tympani 4. Otosclerosis: abnormal bone deposition around the stapes conductive loss 5. Presbycusis: damage to organ of Corti with old age iv. Acoustic dampening 1. Nerve to stapedius (CN VII) 2. Tensor tympani (CN V) e. Otoscope exam i. Ear Canal

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1. Acute otitis externa: canal is swollen, narrowed, moist, tender, red 2. Chronic otitis externa: skin of canal is thickened, red, itchy 3. Exostoses: nontender nodular swellings in ear canal 4. Excess cerumen: Rx a. Put metal syringe up against roof of ear canal at border of tympanic membrane; gently let stream of water flow through, which will bounce off tympanic membrane and push cerumen out; keep small dish under ear to collect water and cerumen b. H2O2 (2-3 days later) c. Baby oil ii. Tympanic membrane 1. Normal: pinkish/gray, translucent, no opacities 2. Otitis media: red, bulging, purulent (may rupture drum relief of pain) a. Due to Hemophilus influenza, S. Pneumonia b. Rx: analgesics to temperature, decongestant to open tube, if not healing within 2 weeks, antibiotics 3. Perforated Eardrum: holes in the eardrum resulting from infections: a. Central perforations not extended to margins of the drum; more common b. Marginal perforations involve the eardrum margins c. Rx: ear toilet swab for pus until no more, then gentamicin drops will heal but membrane may be extremely thin and transparent; at 12 years old, tympanoplasty 4. Tympanosclerosis: chalky white patch with irregular margins due to deposition of hyaline materials within the layers of the eardrum; may follow otitis media 5. Amber drum: serous effusion caused usually by viral upper respiratory tract infection or sudden change in ATM pressure air completely absorbed into the bloodstream from the middle ear and serous (containing serum) accumulates there instead 6. Prominent handle, short process of malleus and incus: retracted drum due to otitis media with effusion (OME); movement of drum with pneumatic otoscope 7. Bullous myringitis: bullae on ear drum, painful/hemorrhagic; due to viral infection 8. Translucent: healed perforation f. Auditory procedure

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i. Audiometry: device procedures auditory stimuli of different frequencies ii. Tympanometry: positive, normal, negative air pressure in external auditory meatus; monitor resulting energy flow; energy flow will be increased if fluid in middle ear or is ear drum is retracted by negative pressure in the middle ear cavity iii. Myringotomy: insert needle into middle ear to drain fluid IV. Nose and paranasal sinuses a. Viral rhinitis: mucosa reddened and swollen b. Allergic rhinitis: mucosa pale and bluish or red c. Polyps: pale, semi-translucent mass, most commonly on middle meatus d. Ulcers: due to cocaine use e. Septal perforation: due to trauma, surgery, intranasal use of cocaine and amphetamines f. Nose fracture: can get septal hematoma septal perforation g. Acute sinusitis, fever, pain, nasal discharge; Dx transilluminate Mouth and Pharynx a. Lips i. Cyanosis: purple color ii. Ulcers (herpes) iii. Cracking: angular cheilitis nutritional deficiency or over closure of mouth iv. Scaliness: actinic cheilitis lips are thickened, everted, loss of redness v. Lip carcinoma: (most common bottom lip) ulcer with/without crust or nodular lesion; sun risk vi. Angioedema: non-pitting swelling, no itch, usually allergic, associated with hives vii. 1 syphilitic chancre: ulcerating button like lesion viii. Hereditary hemorrhagic telangiectasia: dilated red capillaries; associated nosebleeds and GI bleeding ix. Peutz-Jeghers syndrome: intense freckling directly on the lips; associated with intestinal polyps b. Oral mucosa i. Ulcers ii. White patches (leukoplakia) iii. Chancres iv. Karposis sarcoma: purple color mucosal lesion; associated with AIDS c. Gums i. Pregnancy tumors (epulis, pyogenic granuloma) originates 1 in interdental papilla ii. Lead line: bluish, back line on the gums due to chronic lead poisoning; absent where no teeth

V.

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iii. Swollen interdental papilla gingivitis 1. Marginal gingivitis: reddened and swollen bleeding gums, plaque covers teeth, most common teens 2. Acute necrotizing ulcerative gingivitis: fever, malaise, enlarged lymph nodes, ulcers develop in the interdental papilla and spreads along the gums, bleeding; most common young adults, teens 3. Chronic gingivitis may progress to periodontitis (deep tissues that holds teeth in place) 4. Gingival hyperplasia: heaped up masses that even cover the teeth due to Dilantin therapy, puberty, pregnancy, and leukemia iv. Teeth 1. Dental Caries: x-ray needed for early detection starts as white chalky plaque 2. Attrition of teeth (and recession of gums): elderly, chewing surface worn down; dentin exposed 3. Erosion of teeth: chemical erosion from regurgitation (i.e. bulimia, etc.) 4. Hutchinsons teeth: small, wide spacing; sides tapered to biting edge; sign of congenital syphilis 5. Abrasion of teeth: notching of biting surfaces due to holding nails or bobby pins in teeth v. Tongue and floor of mouth 1. Fissured tongue: (scrotal tongue) little significance; seen with age 2. Hairy tongue: elongated papilla on back of tongue yellowish to brown black (harmless) 3. Geographic tongue: dorsum of the tongue has smooth red areas (no papilla), map-like pattern; benign with unknown cause 4. Smooth tongue (atrophic glossitis) due to deficiency in B12, folic acid, pyridoxine, niacin, iron 5. Hairy Leukoplackia: most often affects side of tongue, cannot be scraped off (unlike candida); associated with HIV 6. Candidiasis: may cause redness with/ without coating; AIDs associated 7. Mucous patch of syphilis: slightly raised and oval with grayish membrane due to secondary syphilis 8. Aphthous ulcer: small whitish ulcer surrounded by reddish halo; heals in 7-10 days; recur 9. Varicose veins: (caviar lesions) purplish/blue black swellings under tongue; not significant 10. Carcinoma: most common side of tongue, floor of the mouth; surrounded by reddened area

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11. Tori mandibulares: bony protuberances from inner surface of teeth of the mandible 12. Nerve damage: CN12 tongue deviates to side of lesion 13. Carcinoma most common side of tongue, floor; 2nd most common cancer of mouth 14. Lou Gehrigs Disease: tongue is atrophied vi. Pharynx 1. CN10 paralysis: ipsilateral soft palate does not rise, uvula deviates to the contralateral side 2. Pharyngitis: reddened pharynx with exudate; sore, scratchy throat; fever; cervical lymphadenopathy due to group A strep, EBV 3. Exudative tonsillitis: due to Strep A enlarged anterior cervical nodes, mono enlarged posterior cervical nodes 4. Diptheria: gray, exudative pseudomembrane; uvula, pharynx, tongue 5. Thrush: candida thick white plaques; due to antibiotic treatment, AIDs 6. Torus palatinus: bony growth of the hard palate (common in adults) 7. Kaposis sarcoma: deep purple lesions, palate is common site; associated with AIDs 8. Kopliks spots: small white specks on red background due to rubeola measles 9. Fordyce spots: normal sebaceous glands that appear as small yellowish spots on buccal mucosa or lips; normal 10. Petechiae: on buccal from biting cheek, infection, decreased platlets, or trauma 11. Leukoplakia: thickened white and dull (not candida); due to tobacco VI. Neck a. Enlarged parotid gland i. Chronic bilateral (obesity, diabetes, cirrhosis) ii. Unilateral enlargement suggests neoplasm iii. Acute enlargement suggests mumps b. Virchows node: enlarged supraclavicular node (left) thoracic/abdominal metastasis c. Lymph nodes i. Infection/fever: easy to press; feel pain in swollen node ii. Cancer: no pain; node is hard

suggests

VII.

Thyroid a. Goiter (hyper/hypothyroid): the general name for an enlarged thyroid gland; compensatory hyperplasia of follicular epithelium 2 to impaired production of thyroid leads to elevated TSH levels;

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i. Diffuse enlargement of thyroid: includes isthmus and lateral lobes; Graves, Hashimotos, I2 deficiency, pregnancy ii. Multinodular goiter: 1. 2 or more nodules suggests metabolic problem (not neoplastic); 2. Radiation/family history suggests malignancy 3. Single nodule: cyst, benign tumor, possible malignancy 4. Dx of nodule: a. FNA cytology b. Isotype I131 c. Cold: due to thyroid adenoma, Dequervains thyroiditis d. Hot: due to thyrotoxic adenoma, Graves, follicular CA 5. Hashimotos Thyroiditis: goitrous hypothyroidism due to defective function of thyroid specific CD-8 T cells, resulting in the emergence of CD-4 T cells directed at the thyroid and auto-Abs to various components of thyroid such as thyroid peroxidase, TSH receptors, and thyroiglobulin 6. Graves disease: goitrous hypothyroidism due to a defect in thyroid specific CD-8 T cells the production of: a. TSH Ab b. Thyrotropin binding inhibitor Ab activity of thyroid epithelial cells TSH c. Long acting TSH fat deposition behind eye exopthalamos b. Hyperthryoridism i. Signs: tachycardia/a fib; hyperkinetic pulse (may be collapsing Water hammer); systolic/ diastolic; warm, moist skin; tremor/weak proximal muscles; stare, lid lag; diplopia, exopthalamos (bilateral = Graves Disease); fine hair, poor convergence; localized/carotid bruit; pretibila edema; general myxedema, brisk reflexes bilateral, heat intolerance, hyperglycemia ii. Symptoms: nervousness, weight loss, sweating, palpitations, diarrhea, muscles/tremors, menstrual irregularities, appetite c. Hypothyroidism i. Signs: bradycardia; systolic/ diastolic; dry, coarse, cool skin; nonpitting myxedema (dull puffy face pronounced around eyes); coarse thin hair; thinning of eyebrows lateally; amenorrhea; hoarseness, slow relaxation of reflexes (seen in ankle reflex), ascites ii. Symptoms: fatigue, lethargy, weight gain, cold intolerance, constipation, weak, cramps, parasthesias, amnesia, appetite, libido

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d. Treatments: i. Surgery: pre-treat with iodine to decrease chances of bleeding and thyroid storm during surger 1. Complication: recurrent laryngeal nerve (left loops down; right goes straigher); lesion hoarseness ii. Iodine: inhibits release of T3/T4 iii. Propylthiouracil: inhibit iodination of MIT-DIT and inhibit coupling to form T4/T3 iv. Pechlorate/thiocyanate: inhibits iodine transport v. Radioactive I2: uptake = hyperthyroid; uptake = hypothyroid e. DDx: i. Acromegaly: excess growth hormone; prominent forehead, nose and lower jaw; generally coarsened facial features; soft tissue of nose, lips, and ears enlarged ii. Nephrotic syndrome: pale edematous face, usually around the eyes in the morning (eyes become slit like as the edema gets worse) f. Pembertons sign if thyroid is retrosternal, have patient raise arms thyroid moves upwards hits carotid artery faint g. Good prognosis papillary thyroid CA, medullary CA h. Anatomy i. Thyroid hormones synthesis 1. Eat iodine, becomes iodide in stomach; iodide trapped in thyroid, oxidized to iodine by thyroid peroxidase; complexed with tyrosine molecules in thyroglobulin (MIT or DIT); DIT + MIT tri-iodothyronine 2. DIT + DIT thyroxine; thyroid hormones transported in vascular system bound to albumin, trans-thyrectin, etc.; T3 is more potent, T4 is present in higher quantities ii. TSH: stimulates: I-uptake, oxidase, iodinase, coupling enzyme, protease VIII. Tracheal deviation: pneumothorax due to telectasis, mediastinal mass, tenison

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Male Genitalia Exam

I. Inspection
a. Exposed patient from waist down b. Penis i. Skin ii. Prepuce (foreskin) iii. Glans iv. Location of urethral meatus v. Inspection for discharge c. Scrotum i. Inspect skin, contours (lumps/swelling) ii. Lift scrotum to examine posterior surface

II.

Palpation
a. Between thumb and first two fingers b. Shaft of penis (not done on asymptomatic young patients) c. Testis, epididymis, spermatic chord i. Palpate between thumb and first two fingers ii. Note size, shape, tenderness d. Hernias i. Tell patient to strain down and look for bulges (inguinal/femoral areas) ii. Push finger up into scrotum into external inguinal ring and have patient cough see if masses touch fingers (inguinal) iii. Put finger on thigh have patient cough (femoral)

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Male Genitalia Secondaries

I. Tanner Stages a. Hair i. None (preadolescent) ii. Sparse, curly, base of penis iii. Darker, coarser, over pubic symphysis iv. Coarse, curly, covers more area v. Hair spread to thighs b. Penis i. Same as in childhood ii. Slight increase iii. Increase length iv. Increase length, width, glans developed v. Adult in shape and size c. Scrotum i. Same as in childhood ii. Testes/scrotum increase iii. Increase size iv. Increase size, skin dark v. Adult in size and shape Penis a. Skin i. Induration along ventral surface: cancer, urethral stricture ii. Peyronies disease: hardening of corpora cavernosa nontender hard plaques beneath skin on dorsum of penis; crooked, painful erection iii. Lice (crabs): excoriation, itchy, small, red maculopapules b. Prepuce (foreskin) i. Phimosis: cant be retracted ii. Paraphimosis: retract but wont go back edema c. Glans i. Balanitis: inflammation of glans ii. Balanoposthitis: inflammation of glands and prepuce d. Location of urethral meatus: i. Hypospadius: urethral meatus on inferior surface of penis ii. Epispadius: urethral meatus on superior surface of penis e. Discharge i. Gonorrhea: profuse and yellow ii. Non-gonococcal (1 chlamydia): scanty, clean iii. Dx: gram stain, culture f. Lesions of penis: i. Genital herpes (most common cause HSV2): shallow painful, small ulcers

II.

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ii. Syphilitic chancre (1 syphilis): round, dark, red, painless ulcer; non-tender inguinal lymphadenopathy iii. Condyloma Accuminatum (most common cause HPV Types 6 and 11): rapidly growing; moist, malodorous III. Scrotum a. Testis and epididymis i. Painless nodule: testicle cancer 20 to 30 years; curable ii. Cryptochism: undescended testicle; cancer risk of testicles b. Spermatic cord (cystic means hydrocele of cord) c. Examine swellings using light shine light behind scrotum i. Transmits light 1. Chylocele 2. Hydrocele: serous fluid in tunica vaginalis; can get fingers above mass 3. Cyst of epididymis (no sperm) 4. Spermatocele (contains sperm) ii. Doesnt transmit light 1. Tumor of testicle: painless; suspect malignancy 2. Varicocele: varicose veins of spermatic cord (feels like bag of worms separate from testis); collapse when patient is supine; infertility may be associated 3. Scrotal edema: congestive heart failure or nephrotic syndrome 4. Scrotal hernia (1 indirect) cant get finger above mass iii. Pain with swelling: 1. Acute epididymitis 2. Acute orchitis (with mumps) 3. Torsion of spermatic cord (emergency because blood in but not out) 4. Strangulated inguinal hernia Hernias a. Indirect: internal inguinal canal out external inguinal ring; all ages, both sexes; into scrotum; cough hernia comes down and touches fingertip b. Direct: less common; only through external inguinal ring; > 40 years; rarely into scrotum; cough hernia bulges forward and pushes hand c. Femoral: least common; F>M; below inguinal ligament more lateral than inguinal; never into scrotum; coughs nothing touches (canal is empty) d. Complications i. Incarcerated cant be returned to abdomen ii. Strangulated blood supply to contents comprised; suspect especially if tender surgery iii. Scrotal hernia fingers cant get above mass (indirect) e. Femoral canal contents: NAVEL (lateral to medial nerve, artery, vein, empty space, lymphatics)

IV.

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Musculoskeletal Exam
Hi my name is ______, Im a second year medical student. What is your name? Its very nice to meet you. Mr./Mrs. ______ Ive been asked to come in and check your muscles and joints. Is that ok with you? Ok if there is any discomfort at any time please let me know and Ill try my best to alleviate the discomfort.

I.

Head and Neck (patient sitting)

a. Temporomandibular joint (TMJ) i. Look 1. Inspect for masses, lesions, scars, swelling 2. Upon inspection, there are no masses, scars or

lesions visible. There is no visible swelling present. There are no visible deformities or nodules, and the muscles show no signs of atrophy.

ii. Feel 1. Palpate with the tips of 2nd and 3rd fingers over temporomandibular joint 2. Upon palpation, there was no tenderness, nodules,

or masses felt. There was no palpable bogginess or swelling in the joints. mouth for me?

iii. Move 1. Can you please open your mouth and close your 2. Ask the patient to open and close his mouth while palpate TMJ for: a. Tenderness b. Swelling c. Range of motion d. Some crepitations is normal 3. Upon movement, there was no pain or crepitations.

The range of motion was normal.

b. Neck i. Look 1. Inspect for masses, scars, lesions, deformities, abnormal posture 2. Upon inspection, there are no masses, scars, or

lesions visible. There is no visible swelling present. There are no visible deformities or nodules, and the muscles show no signs of atrophy.

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ii. Feel 1. Palpate the cervical processes and surrounding musculature for tenderness a. Spinous process b. Levator scapula c. Upper trapezius d. Sternocleidomastoid 2. Upon palpation, there was no tenderness, nodules,

or masses felt. There was no palpable bogginess or swelling in the joints.

iii. Move (cup your hand over the back of the patients neck) - AROM 1. Can you bring your chin to your chest Flexion (between skull and C1) 2. Can you look over your left shoulder... your right shoulder - Rotation (C1, C2) 3. Can you bring your ear to your shoulder... and the other - Lateral bending (C2-C7) 4. Can you look up to the ceiling - Extension (between skull and C1) 5. Upon movement, there was no pain or crepitations.

II. Spine patient standing

The range of motion was normal.

a. Look i. Inspect the cervical, thoracic, and lumbar curvatures ii. Look for differences in height of the shoulders, iliac crests, and skin creases below the buttocks iii. Upon inspection, there are no masses, scars, or lesions

visible. There is no visible swelling present. There are no visible deformities or nodules, and the muscles show no sign of atrophy.

b. Feel i. Palpate the spinous process with your thumb and the paravertebral muscles for tenderness or spasm ii. Palpate the rhomboids and quadratus lumborum iii. Upon palpation, there was no tenderness, nodules, or

masses felt. There was no palpable bogginess or swelling in the joints.

c. Move (cup hand over the lumbar spine) - AROM i. Stand on side of patient to be able to catch ii. Try touching your feet with both hands flexion (lumbar curvature should flatten out)

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iii. Slide your right hand down the side of your leg... and your left lateral bending (support by holding patients waist) iv. Lean backwards extension (stand behind the patient to support) v. Twist to your right... your left rotation (hold the patient at the hips) vi. Upon movement, there was no pain or crepitations. The

III. Shoulders (patient sitting)

a. Look i. Inspect for any swelling, deformities, or muscular atrophy of the shoulder and shoulder girdle both anteriorly and posteriorly ii. Upon inspection, there are no masses, scars, or lesions

range of motion was normal.

visible. There is no visible swelling present. There are no visible deformities or nodules, and the muscles show no sign of atrophy.

b. Feel i. Palpate: 1. Sternoclavicular joint 2. Acromioclavicular joint 3. Subacromial joint 4. Bicipital groove 5. Pec major and minor 6. Biceps and triceps 7. Upper trapezium 8. Levator scapula 9. Supra and infraspinatous 10. Rhomboids 11. Teres groups ii. Upon palpation, there was no tenderness, nodules, or

masses felt. There was no palpable bogginess or swelling in the joints.

c. Move (cup hands over the patients shoulder) PROM and AROM

i. Raise your hands over your head in front of you flexion ii. Raise your hands over you head out to the side... bring your hands back down abduction and adduction iii. Bring your hands behind your neck with your elbows out
iv. Place both your hands behind your back internal rotation external rotation

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v. Upon movement, there was no pain or crepitations. The

IV. Elbow (patient sitting)

range of motion was normal.

a. Look i. Inspect the elbow, olecranon proces and ulnar extensor for: 1. Swelling 2. Nodules ii. Upon inspection, there are no masses, scars, or lesions

visible. There is no visible swelling present. There are no visible deformities or nodules, and the muscles show no sign of atrophy.

b. Feel i. Palpate the olecranon process and the grooves between the medial & lateral epicondyles of the humerus for: 1. Tenderness 2. Thickening 3. Swelling ii. Palpate: 1. Biceps 2. Triceps 3. Wrist extensors 4. Wrist flexors iii. Upon palpation, no tenderness, nodules, or masses were

felt. There was no palpable bogginess or swelling in the joints.

c. Move (cup the elbow with your hands)- PROM and AROM i. Can you flex your arm... and back flexion and extension ii. Can you show your palms... now show me the top of your hands supination and pronation iii. Upon movement, there was no pain or crepitations. The

V.

Hands and Wrists (patient sitting with hands on thigh)

a. Look i. Inspect for any swelling, inflammation, nodules, deformities, or muscular atrophy ii. Upon inspection, there are no masses, scars or lesions

range of motion was normal.

visible. There is no visible swelling present. There are no visible deformities or nodules, and the muscles show no sign of atrophy.

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b. Feel i. Palpate: 1. Wrist joint with your thumbs on the dorsum of the wrist and fingers beneath it 2. Distal interphalangeal (DIPS), proximal interphalangeal (PIPS), & metacarpophalangeal (MCPS) joints between your thumb and index finger 3. Radial styloid, Ulnar styloid, wrist extensors & flexors, thenar and hypothenar eminence 4. Squeeze the patients hand (not too firmly) to check for a tenosynovitis ii. Upon palpation, there was no tenderness, nodules, or

masses felt. There was no palpable bogginess or swelling in the joints.

c. Move - AROM i. Ask patient to (doctor can hold patients hand to feel for crepitation during movement): 1. Make a fist... flex your wrist... extend your wrist back wrist flexion and extension 2. Open your fingers...close your fingers abduction and adduction 3. Bend your wrist towards your midline... bend your wrist away from your midline ulnar and radial deviation of wrist 4. Upon movement, there was no pain or crepitations. 5. **De quervains tenosynovitis** a. Ask the patient to flex the fingers over the flexed thumb and ulnar deviate will elicit pain 6. **Phalens test** a. Ask the patient to press the back of both hands together to form right angles b. This maneuver compresses the median nerve 7. **Tinels sign** a. Percuss lightly over the course of the median nerve in the carpal tunnel

The range of motion was normal.

VI. Hips (supine position)

a. Look i. Inspect for any deformities, muscle atrophy or scars, shortening of limbs, position, fasiculations ii. Upon inspection, there are no masses, scars, or lesions

visible. There is no visible swelling present. There are no

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visible deformities or nodules, and the muscles show no signs of atrophy.

b. Feel i. Palpate: 1. Iliac tubercle, iliac crest, ASIS, PSIS, greater trochanter, ischial tuberosity, ischial tuberosity, pubic symphysis 2. Quadriceps femoris muscle (rectus femoris, vastus lateralis, vastus intermedius, vastus medialis), Hamstrings (semimembranosus, semitendinosus, biceps femoris) 3. 3 bursas: a. Iliopectineal anterior to joint, lateral to femoral artery b. Trochanteric posterior on femur; patient lying on side (decubitus position) c. Ischial bursa patient lying on side with hip and knee flexed ii. Upon palpation, there was no tenderness, nodules, or

masses felt. There was no palpable bogginess or swelling in the joints.

c. Move i. Put hand on opposite side to stabilize PROM and AROM 1. Lift heal off table and leave the other leg extended (flexor and psoas) 2. Lie patient on side and extend hip (gluteus maximus) 3. Adduct leg (until opposite buttocks comes off table) 4. Abduct leg 5. Rotation flex leg to 90, stabilize thigh; left hand over rectus femoris; grab ankle with right hand and external and internal rotate leg 6. Never touch calf muscle due to DVT ii. Upon movement, there was no pain or crepitations. The

VII.Knee (supine position)

range of motion was normal.

a. Look i. Inspect for swelling, scars, inflammation, deformities ii. Upon inspection, there are no masses, scars, or lesions

visible. There is no visible swelling present. There are no visible deformities or nodules present and the muscles show no signs of atrophy.

b. Feel i. Palpate

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ii. Upon palpation, there was no tenderness, nodules, or

1. Patients knees flexed at 90 with feet flat on the table 2. Tibial tuberosity, medial and lateral tibial plateau, condyles (tibial and femoral) 3. Medial/lateral collateral ligaments 4. Patellar tendon, patella, quad tendon 5. Feel for heat

masses felt. There was no palpable bogginess or swelling in the joints.

c. Move (cup hand over the knee to feel for crepitations) PROM and AROM i. Slide your foot towards your butt - Slide leg up table, while keeping foot on the table go as far as possible ii. Upon movement, there was no pain or crepitations. The

range of motion was normal.

d. Ligaments i. Lateral collateral 1. Have leg slightly bent, apply pressure to medial aspect of joint (the thigh) with left hand while adducting lower leg with right hand ii. Medial collateral 1. Have leg slightly bent, apply pressure to lateral aspect of joint (the thigh) with left hand while abducting lower leg with right hand iii. Cruciate ligaments 1. **Drawer test** a. Patients knee flexed to 90, and the foot flat on the table, sit on foot. Grab hold of the leg just below the knee joint (thumbs on tibial tuberosity and fingers behind joint line no on calf due to DVTs) b. To test of a competent ACL, pull the leg towards you c. PCL push the leg away from you d. If the leg moves more than what is considered normal, than respective cruciate ligament is torn and gives a + drawers sign for that ligament 2. **Lachmans** a. Patients leg slightly bent, left hand just proximal to joint and right hand just distal to joint, push on thigh and pull up on calf (ACL) b. Pull on thigh and push on calf (PCL) [+ if movement] e. Meniscus i. **McMurrays Test** 1. Medial meniscus 106

a. Right Leg - Grasp the heel and flex the knee with the right hand. b. Cup the left hand over the knee joint with the fingers over the anterior-medial and the thumb over the posterior aspect. c. From the heel slowly rotate the leg externally while slowly extending the leg. Simultaneously, push with the left hand medially, applying a valgus stress on the medial side of the joint. 2. Lateral meniscus same but, rotate internally and push laterally

f. **Bulge sign ** (for minor effusions) i. With the knee extended, milk the medial aspect of the knee (suprapatellar pouch) firmly downward 2-3 times to displace any fluid in the medial aspect of the knee to the lateral side. ii. + Bulge sign will show a bulge on the lateral side of the patella (normally indented in) g. **Balloon sign** (for major effusions) i. Right leg - place the thumb and index finger of your right hand on each side and caudal to patients patella ii. With the left hand, milk the suprapatellar pouch down towards the patella 2-3 times with the last stroke holding the knee firmly just above the patella compressing the suprapatellar pouch against the femur iii. + Ballooning, feel for fluid underneath the your thumb and fingers in the right hand next to the patella iv. Fluid returning to the suprapatellar pouch confirms an effusion or v. Ballotte (push) the patella - if the fluid is seen filling the joint space and/or feel the fluid underneath your thumb and fingers than with the index finger of your right hand, press the patella backwards against the femur to confirm

VIII. Ankles and Feet (patient sitting)

a. Look

107

i. Inspect for signs of swelling, inflammation, scars, lesions, warts, calluses, corns, or deformities ii. Upon inspection, there are no masses, scars, or lesions

visible. There is no visible swelling present. There are no visible deformities or nodules, and the muscles show no signs of atrophy.

b. Feel i. Palpate: 1. Achilles tendon 2. Anterior and posterior aspects of the ankle joint 3. Each metatarsophalangeal joint of foot 4. Plantar surface of foot, plantar fascia 5. Calcaneus, Navicular ii. Upon palpation, there was no tenderness, nodules, or

masses felt. There was no palpable bogginess or swelling in the joints.

c. Move PROM and AROM i. Dorsal and plantar flex ankle (talocrural joint) ii. Invert and evert ankle (subtalar joint) iii. With the heel stabilized, invert and evert ankle joint (transverse tarsal joint) iv. Ask the patient to wiggle toes (metatarsophalangeal joints) v. Upon movement, there was no pain or crepitations. The

range of movement was normal.

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Musculoskeletal Exam Secondaries

I. Head and Neck a. Temporomandibular Joint i. Decreased range of motion arthritis, inflammation, fibrosis, ankylosis, arthrodesis ii. Increased range of motion instability of the joint iii. Arthritis swelling, tenderness, bogginess b. Neck i. Kyphosis head back, neck forward ii. Stiff neck lots of causes lasts 1-4 days; local muscle tenderness and pain iii. Aching neck may be related to sustained muscle contraction, local muscle tenderness, also elsewhere in body iv. Cervical sprain more severe and longer lasting than stiff neck; often precipitated by whiplash injury, heavy lifting, sudden movements; no dermatomal distribution v. Neck pain with dermatomal radiation compression of nerve roots via herniated disc or degenerative disease; limited range of motion, tenderness, pain vi. Neck pain with symptoms of compressed cervical cord due to herniation, spurring or trauma muscle weakness vii. Ankylosing spondylitis chronic inflammatory joint disease of the vertebra and the sacroiliac joint; usually in men; immunogenetic origin with antibody directed towards joint elements; head and neck thrust forward Spine a. Flexures: 1 - thoracic and sacral (in fetus); 2 - cervical and lumbar; cervical and lumbar concave, thorax convex b. Lumbar curve: due to herniated lumbar disc or ankylosing spondylitis; concavity persists with flexion; look also for muscle spasms in the lumbar area and for decreased spinal mobility c. Lumbar lordosis: accentuation of the normal lumbar curve (develops to compensate for protuberant abdomen of pregnancy, obesity, kyphosis, or flexion deformities of the hips); deep midline furrow may be seen between the lumbar paravertebral muscles d. Kyphosis: rounded thoracic convexity seen in aging, especially in women (osteoporosis) e. Scheuermanns disease: kyphosis; 1 male adolescents f. Scoliosis: lateral curvature of the spine (plumb line drops through gluteal cleft) i. Structural scoliosis associated with rotation of the vertebra upon each other rib cage is accordingly deformed seen best when patient flexes forward

II.

109

g. h. i. j. k.

l. m. n. o. p. q. III.

ii. Functional scoliosis compensates for other abnormalities (unequal leg length, no vertebral rotation); disappears with forward flexion Gibbus: angular deformity due to collapsed vertebra [due to metastatic cancer (osteoclastic cancer) of from tuberculosis of the spine (Potts disease)] List: lateral tilt of the spine; most common cause herniated disc or paravertebral muscle spasm Torticollis: lateral deviation of the head; due to contraction of SCM Spondylolisthesis: forward slippage of vertebra on one below may compress spinal cord Sciatica: sharp pain shooting down posterior thigh; movement pain; due to herniated disc, osteoarthritis, inflammation (metabolic, toxic or infectious); sciatic nerve lies midway between trochanter and ischial tuberosity and exits through sciatic notch Valgus: distal part away from midline; i.e. knock knees Varus: distal part toward midline; i.e. bowlegs Unequal iliac crests: due to uneven lengths of legs, scoliosis, hip deformities (adduction/abduction of lower limb) Herniated discs: most common cause between L4/L5 or L5/S1; tenderness of the spinous process, intervertebral joints, or paravertebral joints Spina bifida: associated with birthmarks, port-wine stains, hairy patches or lipoma overlying defect Neurofibromatosis: cafe-au-lait spots, skin tags, fibrous tumors

Shoulders a. Axioscapular muscles: traps, rhomboids, serratous rotate and fix scapula; pull shoulder back b. Axiohumeral muscles: pecs and lats internal rotation shoulder c. Rotator cuff muscles: S-I-T-S supraspinatus, infraspinatus, teres minor, and subscapularis; all insert onto the greater tubercle of the humerus except subscapularis which inserts onto the lesser tubercle d. Rotator cuff tears: i. Repeated impingement may weaken the rotator cuff and cause tears and deposition of calcium salts ii. Usually > 40 year old male (pitcher, gymnast, swimmer) iii. Manifestations: weakness, atrophy, supra- and infraspinatus muscle pain, tenderness iv. Incomplete tear (suprispinatus tendon) there is limited abduction compensates by shrugging shoulder to raise arm e. Calcific tendonitis: i. Degenerative process of the tendon associated with deposition of calcium salts ii. Most commonly involves supraspinatus tendon (acute, disabling attacks of shoulder pain)

110

f.

g.

h.

i.

iii. Arm is held close to side, tenderness is maximal below the tip of the acromion (subacromial bursa inflammation) iv. Usually in women ~30 years old Bicipital tendonitis: i. Inflammation of the long head of the biceps tendon causing anterior shoulder pain resembling rotator cuff tendonitis (may coexist) ii. Tenderness is maximal in the bicipital groove iii. By externally rotating and abducting you can easily palpate and separate this area from the subacromial tenderness of supraspinatus tendonitis iv. Confirmed by supinating (elbow at 90) against resistance causing pain in bicipital groove Acromioclavicular arthritis: (uncommon) direct injury to the shoulder girdle with resulting degenerative change (localized over the acromioclavicular joint); movement of the scapula (shoulder shrug) is painful Adhesive capsulitis: (frozen shoulder) fibrosis of the glenohumeral joint capsule; diffuse, dull, aching pain in the shoulder and progressive restriction of motion (not localized); unilateral; MC 50-70 years of age; chronic course lasting months to years, but may resolve spontaneously Dislocation of the shoulder: i. Anterior most common (route inferior anterior superior) ii. Posterior anterior aspect of shoulder flattened

IV.

Elbow a. Rheumatoid nodules: subcutaneous nodules that are firm, non-tender, and not attached to the overlying skin. Most common along the extensor surfaces of the ulna b. Epicondylitis: i. Lateral epicondylitis (tennis elbow) occurs after repetitive extension of the wrist or pronation supination of the forearm and results in pain when the patient extends the wrist; swelling; tenderness ii. Medial epicondylitis (golfers elbow) occurs after repetitive flexion of the wrist and results in wrist pain upon flexion; swelling; tenderness c. Olecranon bursitis: swelling/inflammation of the olecranon bursa from trauma, rheumatoid or gouty arthritis; swelling is superficial to the olecranon process d. Arthritis of the elbow: synovial inflammation or fluid felt best in the grooves between the olecranon process and the epicondyles on either side; palpate for a boggy, soft, or fluctuant swelling and tenderness e. Ulnar nerve: between olecranon and medial epicondyle f. Median nerve: through cubital fossa

111

g. Radial nerve: anterior to lateral epicondyle then wraps to posterior forearm V. Hands and Wrist a. Gonococcal arthritis: Neisseria gonorrhea commonly infects the wrist joint or tendon sheath and present with pain, tenderness, and decreased range of motion (Rx = ceftrizxone, doxacycline) b. Osteoarthritis: progressive, deterioration of the articular cartilage, mainly in weight bearing joints, leading to subchondral bony thickening and bony overgrowths (osteophytes) about the joint margins; Heberden nodes:(DIP) and Bouchards nodes (PIP) hard, painless; Rx NSAIDS (Indomethacin) c. Rheumatoid Arthritis: (PIP, MCP) a chronic, severe synovitis that leads to destruction and ankylosis of affected joints while also affecting blood vessels, heart, eyes, nerves, skin, and lungs; bilateral with swelling, tenderness, or bogginess; Pannus formation of the joint is characteristic in RA and leads to the bony ankylosis. Boutonneire and Swan Neck deformities with chronic RA due to inflammation fluid lifts and shifts tendons d. Caplins nodes: intrapulmonary nodules (histologically similar to subcutaneous rheumatoid nodules): associated with RA, pneumoconiosis in coal workers e. Rheumatoid nodules are seen in both acute and chronic RA; feel warm and tender f. Bacterial arthritis: affects only one joint g. Dupuytrens Contracture: flexion contracture of the fingers due to thickening of the flexor tendon of the ring finger or 5th digit at the level of the distal palmar crease (fibrosis of Palmar Fascia) h. Acute tenosynovitis: extreme pain upon compression due to inflammation of the flexor tendon sheath may follow injury (even minor); swelling along course of tendon may spread to involve thenar space and adjacent facial spaces in palm not in joint i. Dequervains tenosynovitis: inflammation of extensor and abductor tendons of thumbs as they cross the radial styloid pain j. Tophaceous (gouty) nodules: mimic osteoarthritis and rheumatoid, no symmetric sometimes ulcerate and discharge white chalky urate crystals k. Ganglion cysts: round nontender swellings on tendon sheaths or joint capsules: frequent on dorsum of wrist; best seen on wrist flexion l. Felon: infection in the closed facial spaces of finger pad from a pucture wound m. Trigger finger: caused by painless nodule in flexor tendon in the palm nodule is too big to enter tendon sheath for extension (extends with a snap) n. Hypothenar Atrophy: ulnar nerve disorder o. Thenar atrophy: median nerve disorder p. Carpal Tunnel Syndrome

112

i. Causes: acromegaly, obesity, pregnancy, trauma, idiopathic ii. Carpal Tunnel occurs most commonly in secretaries iii. Carpal Tunnel contents: median nerve, flexor digitorum superficialis (4 tendons), flexor digitorum profundus (4 tendons) iv. Signs and symptoms: numbness and tingling in 1st, 2nd, 3rd, of 4th fingers (median nerve) v. Dx: 1. Tinels sign press/tap on median nerve; + if tingling is felt 2. Phallens sign flex both wrists and hold dorsum of hands together for 30 seconds; + if get tingling vi. Rx: incision in flexor retinaculum to relieve pressure on median nerve and tendons q. Colles fracture: tenderness over ulnar styloid r. Scaphoid fracture: tenderness in snuff box VI. Hips a. Bursitis: tenderness over bursa b. Joint pain: i. Congenital: dislocation 1. Ortolanis maneuver in newborn ii. Inflammation: septic arthritis, RA, osteoarthritis ( most commonly restricted rotation, abduction) iii. Trauma: fracture due to fall iv. Neoplastic v. Metabolic: SSA, gout c. Sciatica: pain in the lower back and hip radiating down the back of the thigh into the leg, initially attributed to sciatic nerve dysfunction, but now known to usually be due to herniated lumbar disk compromising the L5 or S1 root. Knee a. Normal flexion = 135-140 b. Signs of inflammation are: i. Tenderness (arthritis, tendonitis, bursitis) ii. Heat (tender and heat RA) iii. Red (septic/gouty arthritis) iv. Synovial membrane (synovitis, effusion, thickening of membrane) v. + Bulge, balloon test c. Synovial fluid i. Normal amount is 1mL ii. Hemophiliac blood in knee iii. Bulge sign (2-40 mL in knee) iv. Balloon sign (>40 mL) d. Bakers cyst: herniation of knee joint capsule and synovium into the popliteal space due to increased intra-articular fluid exudate as seen in RA

VII.

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e. Bursa i. Suprapatellar: proximal patella ii. Infrapatellar: deep to patella iii. Prepatellar: superficial to patella f. Clergymans knee: infrapatellar bursitis g. Housemaids knee: prepatellar bursitits h. Patellofemoral disorders present with pain and crepitaitons along with a history of knee pain i. Cruciate ligaments i. ACL 1. Origin: anterior tibia 2. Insertion: posteriolateral surface of lateral femoral condyle ii. PCL 1. Origin: posterior tibia 2. Insertion: anterolateral surface of medial femoral condyle j. Most common tear: anterior collateral ligament, medial meniscus and medial collateral (these are joined commonly injured together) k. +McMurrays: pain in joint line; due to torn meniscus l. Osteoarthritis: Rx NSAIDs indomethacin, gold salts, penicillamine i. Aging degeneration ii. Bony ridges felt along joint margins m. Rheumatoid arthritis i. Systemic disease, autoimmune ii. Most common in females n. Osgood-Schlatter disease: aseptic necrosis of tibial tuberosity osteochodrosis; leg pain; most common in adolescents VIII. Ankles and Feet a. Rheumatoid nodules on tendon b. Tendor tendon: tendonitis or bursitis c. Gout i. Wine, meat eater ii. Most commonly in big toe (50%), ankle, knee iii. Occurs when blood concentration of uric acid is >7 mg/dL iv. Drugs: allopurinol inhibitis xanthine oxidase; probenecid - excretion d. Acute gouty arthritis: metatarsophalangeal joint = (big toe) is usually the first painful, tender, hot, dusky, red swelling, also dorsum of foot affected e. Pseudogout: i. Similar to gout but any joint can be affected (most commonly the knee and intervertebral discs) ii. Due to the deposition of calicum pyrophosphate crystals and no Rx exists to date f. Hallux valgus: big toe is abnormally abducted and metatarsal itself is deviated medially and bursa may become inflamed

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g. Flat foot: only seen when standing, sole touches floor; due to loss of longitudinal arch h. Ingrown toenail: sharp edge of toenail may dig into and injure the lateral nail fold inflammation and infection (most commonly the big toe) i. Hammer toe: most commonly involves the second toe; hyperextension at the metatarsophalangeal joint and flexion at the proximal interphalangeal joint (frequently with a corn) j. Corns: painful conical thickening of skin that results from recurrent pressure on normally thin skin (apex of the corn points inward) i. Pain characteristically occurs over bony prominences (most commonly 5th toe) ii. Soft corn located in moist area (most commonly between 4th and 5th toe) k. Calluses: thick skin developing in entire region of recurrent pressure; involves skin that is normally thick (sole) and is painless i. If it is painful, suspect underlying plantar wart l. Plantar wart: (verruca vulgaris) located in the thickened skin of the sole; characteristically small dark spots stippled appearance m. Neuropathic ulcer: (via diabetic neuropathy) formed when pain sensation is diminished or absent develop at pressure points on the feet often deep, infected, and indolent, but they are painless i. Callus formation around ulcer is diagnostically helpful since it also results from chronic pressure

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Pelvic Exam
Hi my name is ______, Im a second year medical student. What is your name? Its very nice to meet you. Mrs. ______ Ive been asked to come in and do a pelvic exam. Is that ok with you? 1. Have you ever had a pelvic exam before? It entails placing 2 gloved, lubricated fingers into your vagina. You may feel slight discomfort but let me know if you feel any pain. 2. When was the first day of your last menstrual period? (>2 weeks, pap is
3. Are you in any pain or discomfort? 4. Are you sexually active? 5. Have you ever been pregnant before? (To know strength of walls and how easy it is to insert finger) 6. Could you be pregnant right now? 7. Have you had any vaginal discharge? 8. Can I supply you with a mirror and flashlight to watch the exam? not accurate; Do even on period not Cx. Note ovulation is fixed at 14 days before end of cycle, not beginning)

Im going to leave the room and Im going to need you empty your bladder if you havent already done so and to undress from your waist down. If you would like, you can have a family member or someone else in the room and there will also be a female assistant in the room during the exam. Ok if there is any discomfort at any time please let me know and Ill try my best to alleviate the discomfort.

I.

Position Patient
A. B. C. D. Pull out the stirrups Pull up the bed to 60 Slide the patient all the way to the edge of with their butt a little off the table, guide heels to stirrups. Drape the patient so that you can still see patients face and she can see yours from the pubis to knees

The stirrups are cold so you can leave your socks on.

II.

Prepare
A. B. C. Offer to perform abdominal exam Put on glove Ask for some water as lubrication (use water so you dont contaminate cytology)

63

III. Inspect
Im going to put my hands on your inner thighs now...
C. Ask patient feels any pain/discomfort, put fingers on inner thigh; inspect (LUMP): a. Labia majora b. Urethral meatus c. Mons pubis d. Perineum A. B. Dr. Sits Assess stage of maturity: Tanner stages

Upon inspection of the labia major, urethral meatus, mons pubis, and perineum, there were no visible masses, scars, or lesions. There were no excoriations or inflammation.
D. Separate the labia majora and inspect (LUCI): a. Labia minor b. Urethral meatus c. Clitoris d. Interoitus

I am going to touch you now. Upon inspection of the labia minora, urethral meatus, clitoris, and interoitus, no masses, scars, or lesions were visible.
E. Inspect and milk Bartholins glands (insert index finger into vagina on the posterior end of the introitus and place thumb on outside of labium majorus) and Skenes Glands (same as before but at anterior end of interoitus)

Upon inspection of Bartholins and Skenes glands, no tenderness, inflammation, or discharge noted. Upon milking the urethra, no tenderness, inflammation, or discharge noted.
G. F. Milk urethra gently from inside outward

The cervix is midline and 4cm deep.

H.

Insert index finger into vagina and locate cervix (do this to know what size speculum to use) Assess support of vaginal walls: as you withdraw your finger open the labia folds with middle finger and index finger and tell patient to bear down, note any bulging of walls Tell patient to cough and check for urinary incontinence.

No cystocele, rectocele, cystourethrocele noted. No incontinence noted.

I.

IV.

Do speculum Exam
A. Not asked to do in oral, but do understand how to operate speculum.

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V.

Bimanual Exam
A. B. C. D. Dr. Stands Look at the patients face Put lubrication (not water because done with Pap) on your index finger and middle fingers without letting bottle touch your fingers (this will contaminate the gloves and bottle) Insert fingers downward at a 45 angle into vagina (keep thumb abducted and 4th and 5th fingers flexed into palm) Palpate cervix: note size, shape, position, tenderness, mobility Do cervical excitation (Chandelier test): tap cervix on each side Palpate the fornices: a. Left lateral b. Anterior c. Right lateral d. Posterior

The vaginal walls are non-tender and no masses or lesions noted.

E. F. G.

The cervix is midline, round, firm, and mobile. All four fornices are palpable and no masses or lesions were noted. Chandelier test is negative.
H. Palpate the uterus: push up on cervix so the uterus moves anteriorly feel with left hand on abdomen about midway between the umbilicus and the symphysis pubis as you push down and in. a. Note shape, consistency, mobility, masses, and tenderness.

The uterus is firm, smooth and mobile. There are no masses or tenderness present. It was felt through the anterior fornix indicating normal positioning.
I.

There were no masses or lesion palpable in the right and left adenexa.
J.

Palpate the adenexae: press the abdominal hand (left hand on RLQ and LLQ) in and down, trying to push the adenexal structures toward the pelvic hand (2 fingers in respective fornix) Take fingers out part ways and ask patient if she can feel your fingers a. If she can, ask patient to squeeze your fingers together

Can you feel my fingers? Can you try to squeeze my fingers? Pelvic muscle strength is normal. The fit was snug, and lasted for more than three seconds.

65

Pelvis Exam Secondaries

I.

II.

III.

Indications a. Delayed puberty: (>15 years) due to chronic disease, abnormal hypo-ant pituitary ovary axis b. Precocious puberty: <10 years c. Amenorrhea: absence of menses d. Dysmenorrhea: painful menses (common in young girls who are starting menstruation) e. Menorrhagia: syn hypermenorrhea f. Hypermenorrhea: excessively prolonged or profuse menses g. Polymenorrhea: occurrence of menstrual cycle greater than normal frequency h. Intermenstral bleeding i. Unexplained abdominal pain j. Vaginal discharge: i. Yellowish-green (trichomonas), painful urination, malodorous: do a wet mount ii. White and curdy (candida), vaginal soreness, painful urine, pruritus (itching): KOH prep for hyphae iii. Grey or white (gardnerella), fishy/musty odor with KOH: saline wet mount for clue cells k. Vulval area discomfort l. Assessment of infertility m. Assess pelvic capacity for delivery: if you can feel the sacral promontory she cannot give birth vaginally n. Contraceptives: not necessary anymore for initial contraceptive prescription o. Injury and Rape: only for female practitioners; special training required Contraindications (consider a rectal exam which may be just as informative) a. Incompetent os during pregnancy fetal loss >20 weeks b. Bleeding in the last trimester; placenta covers internal os c. Painful situations (PID) d. Severe limitation of movement in the hip joints e. Intact hymen f. Menstruation is not a contraindication (pap smears are more accurate in the absence of menstruation; IUD insertion is preferred during menstruation) Common stresses of exam a. Genital exposure b. Pain with exam c. Loss of control 66

IV.

d. Possible malignancy finding Inspection a. Materials needed (on tray): i. Gloves, speculum in warm water, swabs, warm water, mirror, flashlights, jelly, Ayres spatula, culture plates, Papanicolaou slides and fixative, endocervical swab, cervical brush (for pregnant woman), b. Tanner Stages: i. No pubic hair ii. Sparse long hair along labia iii. Darker, coarser spreading over pubis iv. Coarse and curly covering more surface area v. Hair on medial thighs not on abdomen c. Lice (crabs) excoriations, itchy, small, red maculopapules d. Clitoris is enlarged in masculinizing conditions e. Lesion of the vulva: i. Genital herpes (MCC by HSV2): shallow, painful, small red ulcers ii. Syphilitic Chancre (primary syphilis): round, dark red painless ulcers (most chancres go unnoticed because they are internal); nontender inguinal lymph nodes, most common postmenopausal iii. Condyloma Latum (secondary syphilis): raised, flat papules covered with gray exudate, contagious iv. Condyloma Accuminatum (venereal wart) (most common cause HPV types 6 and 11): cauliflower-shaped in vestibule, malodorous v. Extrammary Pagets Disease: red, crusty, sharply demarked on labia majora vi. Vulvar Dystrophy (Lichen Schlerosis and Squamous Hyperplasia, epidermoid cysts) vii. CA of vulva: in elderly, ulcerated or raised vulvar lesion f. Urethra: i. Caruncle: benign lesion just inside urethra non-tender, nonnodular (vs. CA), check inguinal lymph node ii. Most sensitive part of vagina urethra (not clitoris) iii. Urethral prolapse (procidentia of urethra) iv. Most common cause of urethritis: Neisseria gonorrhea and Chlamydia trachomatis g. Bartholins gland: infection/cyst = most common chlamydia or gonorrhea h. Discharge: urethritis, vaginitis, cervicitis, PID, CA i. Bulging of vagina walls (due to weak vaginal musculature): i. Cystocele: bladder bulges into vaginal canal ii. Rectocele: rectum bulges into vaginal canal iii. Cystourethrocele: both bladder and urethra bulge into vaginal wall

67

V.

VI.

j. Incontinence: i. Stress: void with cough (weak bladder sphincter, multiparous female) ii. Overflow: could lead to urethrocele, cystocele; painless, small frequency voidings (overfill or pathologically volume due to obstruction, usually CA) iii. Urge: involuntary contraction, completely empty of bladder [Parkinsons, after stroke, infection (UTI)] iv. Drugs make it worse i.e. caffeine, antidepressants Do Speculum Exam a. Normal uterus: posterior fornix depth b. Retroverted uterus: anterior fornix depth c. Pap smear i. Endocervical Swab: moisten applicator stick with saline; insert into cervical os; roll it back and forth between finger and thumb; remove and smear glass slide with swab ii. Cervical scrape: place scraper into cervical os; scrape in full circle... be sure to include squamocolumnar junction iii. Cervical brush: used primarily for pregnant woman Bimanual Exam a. Cervix: i. Shape: round 1. Nodules myoma 2. Enlargement: a. Pregnancy elongates b. Carcinoma of the cervix (most common Squamous Cell CA) i. Begins with metaplasia, CIN I mild dysplasia, CIN II moderate dysplasia, CIN III (CIS); cauliflower like growth ii. risk with: multiple partners, HIV virus, sexually active at early age, smoking (i.e. prostitute) c. Cervical Polyp (benign but may bleed) usually arises from the endocervical canal; bright, red, soft, fragile ii. Size: 2-3 cm in diameter iii. Position: anterior, midline, 3-5 cm deep iv. Tenderness: PID, mucopurulent Cervicitis (most common cause by Neisseria gonorrhea, Chlamydia trachomatis) v. Mobility: with PID b. Cervical Excitation + with: i. PID: most common cause by Neisseria gonorrhea and Chlamydia trachomatis; salpingitis or salpingooophoritis that causes extreme tenderness and pain of pelvic region; resolves leaving tubal adhesion that may cause infertility or an ectopic pregnancy

68

VII.

ii. Ectopic pregnancy: fertilized egg implants in the fallopian tube rather than the uterine wall (most common in the ampulla). If the tube ruptures, patient will present with: 1. Faintness 2. Syncope 3. Nausea and vomiting 4. Tachycardia 5. Shock due to severe hemorrhage 6. Abdominal pain c. Uterus i. Normal uterus: midline, 3-4 cm below umbilicus ii. Mass: most common tumor fibroid (fibroma), myoma iii. Check for pregnant uterus (gravid) 1. 12-14 weeks: above the pubic symphysis 2. 20 weeks: to umbilicus 3. 36 weeks: to sternum (xiphoid process) iv. If uterus is non-palpable, it may retrodisplaced (retroverted and retroflexed) if this is the case, then place pelvic hand into the posterior fornix and feel for the uterus pushing against your fingertips. d. Adenexa (ovary, broad ligament, fallopian tubes) i. No ovaries are normally felt (exception on thin female) ii. Mass: swollen fallopian tubes of PID, nodule, ovarian cyst, tubal pregnancy iii. Extreme tenderness in uterosacral ligaments DDx endometriosis e. Pelvic muscle strength: full strength hold for >3 seconds, and compresses fingers snugly; weak DDx endometriosis, past vaginal delivery, neurological deficits, old age; associated with urinary incontinence Anatomy a. Blood supply of uterus: uterine artery main branch of internal iliac b. Vaginal blood supply: i. Upper third: cervico-vaginal branches of uterine arteries ii. Middle third: inferior vesical arteries iii. Lower third: middle rectal, internal pudendal arteries c. Extensive venous plexus: drain into internal iliac veins i. Lymphatics: 1. Lower third of vagina and vulva inguinal lymph nodes 2. Middle third internal iliac nodes 3. Upper third iliac nodes d. Perineum i. Pelvic diaphragm 1. levator ani muscles 2. Cocccygeus muscles and fascial coverings ii. Urogenital diaphragm 1. Deep transverse perineal muscles 2. Constrictor of urethra

69

VIII. Secondaries a. Gynecology i. Terminology 1. Amenorrhea: absence of flow for >90 days 2. Menorrhagia: excessive amount and duration, regular intervals 3. Metrorrhagia: normal amount, irregular intervals 4. Menometrorrhagia: excessive in amount and duration 5. Oligomenorrhea: >35 days between menses, usually irregular 6. Polymenorrhea: <21 days between menses, regular or irregular 7. Hypermenorrhea: >7 days, or excessive amount 8. Hypomenorrhea: low in amount 9. Dysmenorrhea: painful menses b. Menopause: i. Period of permanent cessation of menses (normal = 35-58 years old) ii. HRT (hormone replacement therapy) tender breasts, nausea, cramps, weight gain, biliary tract disease, bleeding, depression, hot flashes, sleep disturbances, osteoporosis iii. Cx: estrogen dependent breast tumor c. Problem of penetration: i. Hymen ii. Mutilation iii. Vaginismus: reflex contraction of muscles around lower vaginal sphicter/introitus; usually psychological problem iv. Atrophic vaginitis d. Dyspareunia: i. Bleeding after sex (polyps, STD, PID, forced sex, fibroids, CA) e. Family planning: i. Oral contraceptives (estrogens with progesterone, progesterone only) ii. Injectable contraceptives (progesterone only no period) iii. IUD iv. Natural (thermal sustained basal temperature for 3 days = ovulation); fertile period shortest = 2 days, longest = 10 days v. Breast feeding: on demand; < likely to get pregnant vi. Emergency: morning after pill f. Pregnancy: i. Signs and Symptoms: 1. Amenorrhea 2. Morning sickness 3. Breast: venous patterns, areola darker with first pregnancy

70

4. Chadwicks sign: soft, cyanosed cervix; early in pregnancy and continuous throughout pregnancy 5. Hegars sign: sign of early pregnancy; fundus moves independently (softening of lower part of uterus - isthmus) 6. Goodall sign: cervix feels like lips due to edema at 8 weeks 7. Naegeles rule: to find EDC (expected date of confinement): 1st day of LMP (Last menstrual period) +7 days 3 months + 1 year; i.e. Sept. 8th, 1999 = LMP, June 15th, 2000 = EDC. ii. Terminology 1. Still birth (birth of dead fetus) 2. Neonatal death (death of child less than 28 days old) 3. Term (gestation age 38-42 weeks) 4. Pre-term (less than 38 weeks) 5. Post-term (greater than 42 weeks) 6. Primipara: delivered once and fetus who reached viability 7. Multipara: completed 2/more pregnancies to viability 8. Nulligravida: woman who is not now and has never been pregnant 9. Gravida: woman who is or has been pregnant irrespective of the pregnancy outcome: primigravida; multigravida 10. Nullipara: woman who has never completed a pregnancy beyond abortion 11. Parturient: woman in labor 12. Puerpera: woman who has just delivered g. Problems in pregnancy: i. Pelvic capacity ii. Abortion iii. Sheehans syndrome: most commonly due to postpartum, hemorrhage, shock; test visual field for bitemporal hemianopsia iv. Ectopic Pregnancy v. Molar Pregnancy 1. False pregnancy due to hydatidiform carcinoma of uterus s/s of pregnancy ( HCG, size of belly, amenorrhea) 2. Dx US h. Infertility: i. Ignorance of physiology of reproduction ii. Chemicals and substances: medications, douching iii. High temperature (hot baths) iv. Health problems (STDs) v. Anatomic problems vi. Hormonal problems vii. Genetic problems i. Pelvic Pain/Backache:

71

i. Chronic: common with dysmenorrhea, PID, chlamydia, gonorrhea; often exacerbated with period microbe medium F/discharge (can lead to peritonitis) ii. Acute: ruptured ectopic pregnancy or threatened abortion (blood loss in early pregnancy); check external os (if no dilation no abortion, or threatened; if dilated inevitable) j. Exposure to diethylstilbestrol (DES) as fetus i. Most of cervix is covered by columnar epithelium ii. Vaginal adenosis iii. Circular collar between cervix and vagina k. Abnormal bleeding: i. Early menarche - <9 years old, delayed - >15 years old (may be due to imperforate hymen complete closure of vaginal orifice) ii. Disturbance in pituitary ovarian axis (most common cause) iii. Fibroids, polyps iv. Dysfunctional menstrual bleeding: (Anovulatory cycle) young females shortly after menarche; painless v. 2 Amenorrhea: anorexia, hypothyroidism, DM, CA, chronic disease; DDx = Amenorrhea of pregnancy vi. Dysmenorrhea: females in late 20s and 30s, cause is obscure in older females, possible endometriosis (endometrium pieces get outside birth canal, deposit on ovaries, in peritoneal cavity and during period, enlarge in response to hormones; can get into pleural cavity pneumothorax) vii. Postmenopausal bleeding: indicates CA or use of estrogen viii. Retained production: i.e. incomplete abortion (not all production of conception are out and os has closed up) or i.e. not everything is out after pregnancy ix. Early pregnancy: threatened abortion or pregnancy

72

Peripheral Nervous System

Upper Limb Compare bilaterally I. Motor
a. Inspection i. Look for masses, scars, lesions, symmetry, fasiculations ii. The patients body position is normal, there are no

involuntary movements, there is no atrophy, hypertrophy, or fasiculations.

b. Muscle tone i. PROM assess resistance while flex/extend/adduct/abduct wrist, elbow, shoulder ii. Note spasticity or floppiness iii. Muscle tone is normal. c. Muscle strength ask patient to: i. Shoulder 1. Shrug up/down 2. Abduct/adduct 3. Internal and external rotation with arms at side ii. Elbow 1. Flex (biceps musculocutaneous nerve C5, C6) 2. Extend (triceps radial nerve C6 C8) iii. Wrist 1. Flex (medial nerve C5 T1) 2. Extend (radial nerve C6, C7, C8) 3. Abduct (radial nerve C5 T1) 4. Adduct (ulnar nerve C8 T1) iv. Fingers 1. Abduct (ulnar nerve C8 T1) Dont let me close your 2. Adduct (ulnar nerve C8 T1) Dont let me open

fingers

your fingers

3. Opposition flexion thumb and pinky together (median nerve C8 T1) Dont let me break this apart 4. Grasp fingers (median nerve C8 T1) Dont let me pull my fingers out 5. Muscle strength is grade 5 bilaterally

II.

Reflexes
a. Look at muscle for reflex b. Biceps: place thumb or finger over tendon and hit with point of hammer (C5, C6) 130

c. Triceps: hit with base of hammer (C6, C7) d. Brachioradialis: proximal to radial styloid hit with base of hammer (C5, C6) e. No response (3x), reinforce by clenching teeth for upper limb; only last for approx. one second, therefore do during test f. Hoffman sign: flex middle finger, flick it g. Clonus: keep arms straight out, flex wrist then rapidly extend wrist and hold h. Reflexes are present and normal

III. Sensory
a. Patients eyes are closed and start the exam from the periphery and continue proximally b. Light touch: (brush from neurological hammer dont brush/drag) c. Pain: sharp vs. dull (broken wood ear swab) d. Temperature: test cold (tuning fork) vs. warm (hand) e. Vibration i. Vibrate (128 Hz) tuning fork and place on patients sternum, then stop and put on sternum again exemplifies the difference to patient ii. Place vibrating fork on distal phalange of large toe iii. Ask patient what they feel (vibration or touch) iv. If impairment noted, move proximal f. Position sense: i. Hold edges of interphalangeal joint of big toe, and show patient what is up and down ii. Test patient with eyes closed iii. Move up and down, then hold and ask patient for position iv. If impairment noted, move to proximal joints g. Offer these tests i. Graphesthesia 1. Ask patient if he/she can read/write 2. Demonstrate by tracing a # on palm (handle of reflex hammer) 3. Test with eyes closed 4. Ask patient to identify # traced ii. 2 point discrimination (use paper clip) 1. Find minimal distance that two points can be distinguished from one on pads of patients finger (open paper clip) 2. Normal < 5mm iii. Stereognosis: put a object in hand (coin) and ask patient to identify iv. Extinction: simultaneously touch opposite, corresponding areas of patients body and ask patient where touch is felt h. Sensory system is intact

131

Lower Limb Compare bilaterally IV. Motor

a. Inspection i. Look for masses, scars, lesion, symmetry, muscle bulk, fasiculation ii. The patients body position is normal, there are no

involuntary movements, there is no atrophy, hypertrophy, or fasiculations.

b. Muscle tone i. PROM asses resistance while: 1. Rotate leg internally then externally 2. Relax leg and pull leg up quickly (normal heel stay son the table; upper motor neuron lesion leg lifts off table) 3. Flex/extend/abduct/adduct hip, knee, and ankle ii. Muscle tone is normal iii. Muscle Strength 1. AROM ask patient to: 2. Hip a. Flexion (psoas nerve L2, L3) b. Extension (inferior gluteal nerve L5 S2) c. Abduction (superior gluteal nerve L4 S1) d. Adduction (obturator nerve L2 L4) 3. Knee a. Flex (sciatic nerve L4 S2) b. Extend (femoral nerve L2 L4) 4. Ankle a. Dorsi flexion (deep peroneal nerve L4 S1) b. Plantar flexion (tibial nerve L5 S2) 5. Muscle strength is grade 5 bilaterally.

V.

Reflexes
a. Look at muscles for reflex b. Patella: flex knees bilaterally- base of hammer (L2 L4) c. Achilles: bend one leg, suspend it over the other, dorsi flex ankle hit with base of hammer (S1) d. Clonus: hold and flex knee so foot is off table, plantar flex anke then rapidly dorsi flex and hold e. Babinskis sign: use handle of reflex hammer; run along plantar surface of foot from heel along lateral edge of foot across to big toe f. No response (3x) reinforce by tightly pulling hands apart (Jendrassik maneuver); only lasts for approximately one second, therefore do during test g. Reflexes are present and normal

132

VI.

Sensory
a. Patients eyes are close and start the exam from the periphery and continue proximally b. Light touch: (brush from neurological hammer dont brush/drag) c. Pain: sharp vs. dull (broken wood ear swab) d. Temperature: test cold (tuning fork) vs. warm (hand) e. Vibration i. Vibrate (128 Hz) tuning fork and place on patients sternum, then stop and put on sternum again exemplifies the difference to patient ii. Place vibrating fork on distal phalange of large toe iii. Ask patient what they feel (vibration or touch) iv. If impairment noted, move proximal f. Position sense: i. Hold edges of interphalangeal joint of big toe, and show patient what is up and down ii. Test patient with eyes closed iii. Move up and down, then hold and ask patient for position iv. If impairment noted, move to proximal joints

VII. Cerebellum
a. Test patients coordination, each side separately b. Observe for speed, rhythm, smoothness c. Rapidly Alternating movements i. Disdiadokokinesia 1. Ask patient to strike palm then dorsum of hand repeatedly in palm of opposite hand d. Point to point i. Heel to shin 1. Have patient rub heel up and down opposite shin 2. Go over movement with patient 2-3 times then have patient close eyes and do it alone ii. Finger to nose 1. Have patient touch finger to your finger, then touch their nose repeatedly 2. Do it with eyes open a few times, then have patient close eyes and repeat e. Gait i. Heel to toe 1. Walk heel to toe on straight line (follow the patient) f. Stance i. Romberg 1. Patient stands up with feet together, arms out in front (pretend catching a ball) 2. Eyes open the closed (20-30 seconds) ii. Pronator Drift 133

iii. Cerebellar function intact

1. Ask patient to close eyes, put arms out, palms up 2. Slap hands down 3. Observe movements of arms

134

Peripheral Nervous System Exam Secondaries

I. Motor a. Inspect i. Pseudohypertrophy: Duchenne muscular dystrophy increase in size by not strength ii. Weakness: paresis iii. No strength: paralysis iv. Symmetrical weakness of proximal muscles: myopathy b. Muscle tone i. Dystonia: limb moves as one with passive range of movement ii. Hypertonia 1. Clasp knife: initial resistance with movement, then 2. Lead pipe: resistance remains constant with movement 3. Cogwheel: Parkinsons due to underlying tremor iii. Spasticity: upper motor neuron lesion (corticospinal tract); increased tone that is rate-dependant (tone is greater with fast moves) iv. Rigidity: lesion of extrapyramidal system (basal ganglia) increased resistance throughout the movement lead pipe rigidity; Cogwheel rigidity v. Flaccidity: lower motor neuron or anterior root; hypotonia causes limb to be loose and floppy and hyperextensible; cause: GuillainBarre syndrome, spinal cord injury, stroke; DDX cerebellar disorder vi. Paratonia (lesion in both hemispheres usually in frontal lobes): sudden loss of tone, increases the ease of motion common cause is dementia c. Muscle strength i. 0 no muscular contractions detected ii. 1 barely detectable flicker or trace of contraction iii. 2 active movement with gravity eliminated iv. 3 active movement vs. gravity v. 4 active movement vs. gravity and some resistance vi. 5 active movement vs. full resistance (normal) Reflexes a. Reflex Grades i. 0 no response ii. 1 diminished, low normal iii. 2 average, normal iv. 3 brisker than average, not necessarily abnormal v. 4 hyperactive (with clonus) b. + Hoffmans sign: if pointer finger moves toward thumb due to upper motor neuron lesion c. + Clonus: hand spasmodically flexes/extends; must have hyperreflexia

II.

135

III.

d. + Babinski sign: toes fan out and towards patient due to upper motor neuron lesion; 1-2 years old, unconscious, (drug, alcohol, intoxication) e. Babinski sign: toe curls down Sensory a. Do pain/temp/touch on: i. C4 shoulders ii. C6 lateral forearm iii. T1 medial forearm iv. C6 thumb (web) v. C8 little finger vi. L2 anterior thigh (quad area) vii. L4 medial leg viii. L5 lateral leg ix. S1 little toes or heal x. S2 post thigh xi. S3 medial buttocks b. Sensory loss i. Anesthesia: absence of touch ii. Hypersthesia: increased sensitivity to sensory stimuli iii. Analgesia: absence of pain iv. Hyperalgesia: excessive sensitivity to pain v. Hypalgesia: lessened sensitivity to pain vi. Lesion of DC/ML: agraphesthesia, loss of 2 point, astereognosis vii. Peripheral neuropathy: 3 syphilis (Tabes Dorsalis), diabetes, trauma viii. Glove and stocking sensory loss: symmetrical distal sensory loss of a polyneuropathy seen in alcoholism and diabetes ix. Loss of vibration sense: most commonly the 1st sensation lost in the polyneuropathies of alcoholism and diabetes; DC/ML disease in 3 syphilis and vitamin B12 deficiency x. Syringomyelia: chronic, progressive disease of spinal cord cavities lesion spinothalamic tracts xi. Cortical and subcortical: 1. Loss of discriminative sensation and specific cortical function (i.e. agraphesthesia, astereognosis, sensory extinction, no 2 point, R/L disorientation, agnosia) due to CVA, MS, space occupying lesions, degenerative disease (Alzheimer, Picks), subcortical dementia (i.e. Parkinsons) affecting posterior right parietal lobe xii. Suprathalamic: deficit in sensation requiring cortex (2 point, proprioception, stereognosis); 1 parietal affected due to CVA; little defect in pain, temperature, vibration, touch xiii. Thalamic contralateral loss of all modalities; PCA occlusion; partial recovery Thalamic syndrome (burning sensation on contralateral) xiv. Mononeuropathies

136

1. Median nerve: carpal tunnel syndrome pain, paresthesia in thumb and 1st 2 fingers, weakness, wasting of arms due to idiopathic, pregnancy, myxedema, RA, old scaphoid Fx, amyloidosis 2. Radial nerve: paresthesia dorsum of hand and forearm; wrist drop (Klumpkes paralysis), weakness of finger and thumb extensors, supinator; most common cause humerus Fx 3. Ulnar nerve: paresthesia medial hand and fingers; no flexion of distal phalanges of 4th and 5th, no abduction/adduction of fingers; claw hand (flexed MP joint of 4th and 5th fingers due to paralysis of 3rd and 4th lubicles, flexion of IP joint); most common cause medial epicondylar Fx of humerus 4. Peroneal nerve: foot drop, paresthesia over anterolateral lower leg and dorsum of foot and webspace between 1st and 2nd metatarsals 5. Multiple mononeuropathies: Fx of fibula, Charcot Marie Tooth syndrome; collagen vascular disease (PAN, SLE) sarcoidosis, metabolic (DM, amyloidosis), infectious disease (Lyme, HIV, leprosy), drugs, metals 6. Peripheral polyneuropathies: (multiple modalities affected motor, sensory, ANS) peripheral tingling, numbness, burning pain worsens at p.m., reflexes, atrophy; MI (DM, chronic uremia), toxic (Pb, Isoniazid), inflammation (Guillan Barrre syndrome), Xf (leprosy), met (B12, Thiamine deficiency), neoplasm IV. Cerebellum a. Cerebellar disease: incoordination that gets worse with eyes closed; clumsy movements; vary in speed/force b. Disdiadochokinesia: i. Dominant hand usually better ii. Abnormal: slow, clumsy movement c. Heel to shin i. Cerebellar disease: clumsy unsteady movements with possible overshoot (dysmetria); with eyes closed ii. Proprioceptive abnormal: only abnormal with eyes closed d. Finger to nose i. Cerebellar disease overshoot (dysmetria) e. Heel to toe i. Instability: UMN lesion, ataxia DDx cerebellar, intoxication, proprioception abnormal ii. If +, have patient hop in place/ do a shallow knee bend; DDx muscle weakness, cerebellar, DC/ML f. Romberg (Dorsal column test) i. Fall to one side (vestibular ipsilateral to lesion)

137

V.

ii. Eyes closed and fall: DC/ML, vestibular, proprioceptive loss iii. Eyes open and fall: Cerebellum problem/ ataxia g. Pronatory Drift i. Contralateral corticospinal problem one side drifts down and pronates ii. Slap hands: normal come back to the same level; overhoot cerebellar disease; dont come back or poorly position sense abnormal (DC/ML) Secondaries a. Spinal cord tracts: i. Posterior column: (DC/ML) carries fibers for tactile discrimination, vibration sensation, form recognition, and joint and muscle sensation (proprioception) 1. Fasciculus cuneatus (lateral): C2-T6 upper extremities 2. Fasciculus gracilis (medial): T6-S5 lower extremities 3. Both give rise to internal arcuate fibers decussate in lower medulla ii. Spinothalamic: carries fibers for pain and temperature sensation decussate at level of spinal cord entry iii. Corticospinal: carries fibers for voluntary skilled motor activity decussate in pyramids of medulla (90%); decussate at level of SC exit (10%) b. Cerebellum: i. Structure 1. Flocculonodulus: vestibulocerebellar 2. Vernis, parvernal: spinocerebellar 3. Lateral hemisphere: cerebrocerebellar ii. Functions: 1. Vestibular nuclei flocculonodular fastigial (and back to vestibluar nuclei) a. Balance, posture, and vestibular reflexes 2. Spinocerebellar tracts vermis fastigial reticular system a. Execution and coordination of movement in axial and proximal muscles 3. Spinocerebellar paravermal interposed nuclei lateraal descending tracts a. Execution and coordination of movements in distal muscles 4. Cortical tracts lateral hemispheres dentate cortex a. Planning, timing, initiation, terminate motor action

138

Rectal Exam
Hi my name is ______, Im a second year medical student. What is your name? Its very nice to meet you. Mr./Mrs. ______ Ive been asked to come in and do a rectal exam. Is that ok with you? 1. Have you ever had a rectal exam? 2. Do you know what it entails? It entails inserting a gloved, lubricated finger up your back end. You will feel slight discomfort but let me know if you feel any pain. 3. Do you have any pain right now? 4. Did you empty your bladder before you came in here/ Would you like to empty your bladder right now. Im going to leave the room. Im going to need you to undress from the waist down. Mr./Mrs.______ lie on the table for me on your left side for me please. I need you to flex your hips and knees. Also bring the top leg slightly over to the front of the bottom leg. Make sure the butt is hanging over the table.
Female patients: - Examine in lithotomay position (after examine genitals) - Feel cervix through anterior rectal wall - Palpate retroverted uterus or retroflexed I. Inspect a. Put gloves on and spread buttocks apart b. Look for lumps, ulcers, inflammation, rashes, hemorrhoids, dilated veins, cracking (STDs), scars, bleeding, eczema, sentinel tags, carcinoma, nodules (HSV2) or warts

Upon inspection of the peri-anal area and anus, there are no masses, lesions, or ulcerations. No swelling or discharge noted.
II. Exam a. Look at the patients face

You may feel as if you are going to move your bowels, but you wont. Bare down for me please. There are no signs of rectal prolapse or hemorrhoids.
b. Have the patient bare down and note any lesions hemorrhoids, rectal prolapse c. Rest the pad of your lubricated gloved index finger over the index

Bare down again and there may be discomfort but if you feel pain please let me know.
d. Have the patient bare down

58

Bare down again Bare down again

e. Gently insert the fingertip into the anal canal in the direction of the umbilicus (Pad of finger in the anus should be facing you 1st). i. Posterior wall ii. Right Wall with finger inserted as far as possible, rotate hand clockwise to get right side

Im going to palpate the prostate, you may feel as if youre going to urinate but you wont. Bare down
iv. Anterior wall and prostate gland twist body around so that back is to patient and arm is pronated f. Everytime you check a wall, have the patient bare down g. If excruciating pain, pull out h. Palpate prostate lateral lobes and median suclus between them, noting size, shape, and consistency of prostate

iii. Left Wall turn finger counterclockwise

Upon palpation of the rectal walls, no masses, or lesions were noted. The patient demonstrated no signs of tenderness. Upon palpation of the prostate, no tenderness or masses were noted. The median sulcus is palpable.
i. Check rectal shelf if possible higher than prostate j. Gently withdraw finger and check for blood or fecal matter; wipe finger over slide to do Guiac test and send for cytology (not required in test) k. Offer patient a tissue to clean himself

59

Rectal Exam Secondaries

I. Indications for exam a. Frequent urination, dribbling, hesitancy, poor stream, retention with overflow incontinence, hematuria, hemospemia, sexual problems, enlarged prostate b. Pay close attention to GIT (constipation, diarrhea, abdominal pain, bleeding-melena, and hematechesia) Inspection a. Pilonidal cyst: congenital abnormality in midline superficial to coccyx or lower sacrum; ID by open sinus tract; may have small tuft of hair and halo of erythema; generally asymptomatic; slight drainage; abscess sinus tracts b. Anorectal fistula: inflammatory tract/tube one end opens into anus/rectum, other end onto skin surface; abscess before fistula c. Polyps: vary in size and number; can develop stalk (pedunculated) or on mucosal surface (sessile); soft, difficult to feel; proctoscopy to diagnose; biopsy for malignancy d. External Hemorrhoids: dilated veins originating below pectinate line and covered with skin due to venous obstruction; asymptomatic without thrombosis; acute local pain - with defecation, sitting; tender, blue, swollen, ovoid mass visible at the anal margin; Rx nick veins e. Internal Hemorrhoids: enlarged vascular cushions above pectinate not usually palpable; may be bright red; bleeding on defecation; may prolapse = red, moist, protruding mucosa f. Cracking: STDs g. Anal fissure: a painful longitudinal/oval ulceration of the anal canal; found MC in the midline posteriorly; inspection may show a sentinel skin tag just below the anal opening; sphinctor is spastic and the exam is painful h. Nodules: HSV2 Exam a. Sphincter: i. Tight due to anxiety, inflammation, scarring ii. Loose due to neurological disease b. Induration: due to inflammation, scarring or malignancy c. Rectal Prolapse: prolapse of rectal mucosa on straining for bowel movement i. Prolapse of only mucosa = small, radiating folds ii. Whole bowel prolapse = large, concentrically circular folds d. Prostate: i. Normal: rubbery, non-tender ii. Abnormal: 1. Cancer of the prostate: 60

II.

III.

e. f. g. h. i. IV.

a. Hardened, non-tender, irregular shaped enlarged gland; starts peripherally; median sulcus may be obscured b. Metastic to spine via posterior intervertebral plexus (osteoblastic) c. Lithotomy position: may help you reach a CA thats higher up d. Dx: i. PSA: prostate specific antigen ii. PAP: prostate acid phophatase iii. FNA cytology e. Rx: i. Most common resect prostate (worry about impotence if you cut nerves) ii. Flutamide (estrogen), leuprolide (antitestosterone) 2. Prostatitis: a. Acute, febrile condition due to bacterial infection; gland is very tender, swollen, firm, and warm b. Chronic prostatitis does not produce consistent physical findings and may not be tender or warm to the touch 3. Benign Prostatic Hypertrophy: Most common >50 years; gland symmetrically enlarged, smooth, firm, slightly elastic; median sulcus may be absent to palpation; enlarged gland may obstruct urinary outflow; Rx prazosin 4. Hard areas: DDx CA, prostatic stones, chronic inflammation 5. Prostatic Urethral Obstruction: signs and symptoms = nocturia, poor stream force, start/stop/start pee, polyuria, pain because bladder expands Rectal Shelf: metastases from peritoneal reflection anterior to the rectum (in females recto-uterine pouch (of Douglas) behind cervix and uterus) Perianal abscess: painful, tender, indurated, red mass Puritis ani: swollen, thick, fissured skin with excoriate Pale stool (clay colored): conjugated bile (no stecobilin) due to CA head pandreas, CA ampulla of Vater, gallstones obstruct common bile duct Bleeding per rectum: diverticulitis, IBD, CA

Anatomy a. Prostate (normal 2-5 cm); heart shaped (only palpate posterior wall) b. Anorectal junction (pectinate, dontate line): Anal canal demarcated from rectum superiorly by serrated line marking change from skin to mucous membrane, denotes boundary between somatic and visceral nerve supplies not palpable c. Anterior to rectum: males = prostate; females uterus

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d. Valves of Houston = 3 inward foldings of rectal wall; can feel lowest on left; can feel peritoneal inflammation or nodularity of peritoneal metastases above the rectal shelf e. Prostate gland; small in boyhood; 5x size in puberty and adulthood; size due to hyperplasia in 50s

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