Fall 11 Abdominal, Neuro, Musculoskeletal and GastroUrin
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| venous drainage of the abdominal portion of th GI tract (except the inf portion of rectum, panc and gb), is through what? | hepatic portal system - generally drains the areas supplied by the celiac trunk, SMA and IMA
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| what are the two veins that make up the hepatic portal vein or system? | splenic vein and superior mesenteric vein
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| the hepatic portal system begins and ends where? | begins in the capillaries of the digestive organs; ends in the portal vein (the portal vein conveys venous blood FROM the GI tract TO the liver for metabolism and detox before blood is returned to systemic circulation via hepatic veins w/c drain to IVC)
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| what should you check during the inspection portion of an abdominal exam? | flat/distended (organomegaly or ascites), scars, stretch marks, hernias, vascular changes, lesions, rashes, patient's movement (lack - peritonitis, writhe - kidney stones)
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| what should you check during the auscultation portion of an abdominal exam? | bowel sounds (peristaltic nouse every 2-5s), hyperactive - diarrhea
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| what should you check during the percussion portion of an abdominal exam? | percuss all 4 quadrants (typanic - normal, dull - underlying abdominal mass)
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| what should you check during the palpation portion of an abdominal exam? | palpate all 4 quadrants, superficially then deeply
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| what is rebound tenderness and what is it usually a sign of? | pain upon removal of pressure rather than application of pressure, sign of peritonitis
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| what possible pathologies would you find if there is an abdominal mass on the right upper quadrant? | liver, gallbladder, kidney
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| what possible pathologies would you find if there is an abdominal mass on the right lower quadrant? | ascending colon, appendix, ovary, fallopian tube
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| what possible pathologies would you find if there is an abdominal mass on the left upper quadrant? | pancreas, splee, kidney
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| what possible pathologies would you find if there is an abdominal mass on the right left lower quadrant? | sigmoid and descending colon, ovary, fallopian tube
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| non pathologic findings on the abdomen | stool filled cecum or sigmoid colon, full bladder, pregnant uterus
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| describe how to properly conduct an aortic palpation | press down deeply in the midline above the umbilicus. the aortic pulsation is easily felt on most individuals. well-defined, pulsatile mass >3cm across suggests aortic aneurysm
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| describe how to properly conduct kidney palpation (if suggestive of kidney infection - fever, back pain, UTI) | pound gently with bottom of fist on costo-vertebral angle (cvat)
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| dscribe how to properly conduct gallbladder palpation (murphy's sign for cholecystitis) | ask pt to breathe out, place hand below costal margin on r side at mid-clavicular line, pt breathe in, if pt winces = positive sign; also no pain with maneuver on left side
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| describe the rosving's sign for appendicitis | RLQ pain w/ palpation of LLQ (d/t pain nerves deep in intestines do not localize well to an exact spot on ab wall but follow a referral pattern, pushing RLQ stretches entire peritoneal lining but only pain where irritating muscle; if LLQ pain/both = other
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| what are possible causes of pain if on right upper quadrant | acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower lobe pneumonia
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| what are possible causes of pain if on right lower quadrant | appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion
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| what are possible causes of pain if on left upper quadrant | gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia
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| what are possible causes of pain if on left lower quadrant | diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion
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| what are possible causes of pain if on midline or periumbilical | early appendicitis, gastroenteritis, myocardial ischemia or infarction, pancreatitis
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| a consequence of chronic liver disease characterized by replacement of liver tissure by fibrotic scar tissue and regenerative nodules which leads to loss of liver function | cirrhosis
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| past medical history for liver disease | previous jaundice (acute hep, hepatobiliary d/o, drug-ind liver disease), recurrent jaundice (reactivated, viral infecion, onset hep decompensation), blood transfusion, schistosomiasis, IV drug abuse, wilson's disease, diabetes mellitus, hyperlipidema
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| symptoms of liver disease | spontaneous bleeding, easy bruising, encephalopathic symptoms (disturbed sleep-wake cycles, deterioration of cognition, memory loss), jaundice, dark uine, edema, abdominal swelling, pruritus, pale stools, steatorrhea
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| liver disease physical examination | encephalopathy, peripheral edema & ascites, caput medusa, small or enlarged liver, splenomegaly (portal htn), black tarry stool on rectal exam (upper GI bleeding)
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| diseased liver unable to conjugate or secrete bilirubin appropriately and can lead to icterus, jaundice, and bilirubinuria | hyperbilirubinemia
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| accumulation of transudate fluid in peritoneal cavity from increased resistance to blood flow though an inflamed and fibrotic liver (portal vein hypertension) | ascites
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| impaired synthesis of protein albumin leading to lower intravascular oncotic pressure and leakage of fluid into soft tissues, especially in lower extremities | edema
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| liver unable to process particular hormones leading to peripheral conversion into estrogen | increased systemic estrogen levels (gynecomastia, spider angiomata, testicular atrophy)
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| associated with portal htn in w/c blood finds alternative pathways back to heart that do not pass through liver | varices (most common is splenic and short gastric veins w/c pass though esophageal venous plexus enroute to superior vena cava)
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| love involved in auditory perception but also contains the area involved in the understanding of written and spoken language, as well as the hippocampus (long term memories) | temporal lobe
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| two parts of the cerebral cortex links to speech | Wernicke's and Broca's area (connected by a large bundle of nerve fibers called the arcuate fasciculus)
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| where is the wernicke's area located? | posterior section of the superior temporal gyrus in the dominant cerebral hemisphere (w/c is left hemisphere in 90% of people)
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| impairment of language ability - can speak w/ normal grammar, syntax, rate, intonation & stress but content is incorrect (inserting wrong or nonexistent words into speech) | Wernicke's Aphasia (also called fluent or receptive aphasia)
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| where is the primary motor cortex located | frontal lobe
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| an area within the posterior inferior frontal lobe linked to speech production | Broca's Area
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| region of the brain that plays an important role in motor control as well as cognitive functions such as attention and language (does not initiate movement but coordinates, provides precision and timing) | cerebellum (fine tune motor activity - damage does not cause paralysis but produces d/o in fine movement, equilibrium, motor learning)
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| difference between UMN and LMN | damage to UMN is a CNS problem and causes hyperrefelxia; damage to LMS is a PNS problem and causes hyporeflexia
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| what is CN I? | olfactory nerve (sense of smell)
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| what is CN II? | optic nerve (sense of vision)
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| what is the snellen visual acuity? | if a person sees 20/40, at 20 ft from chart a person with 20/20 vision can read at 40 ft away
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| what is CN III? | oculumotor nerve (4 motor extrinsic eye muscles) - can have drooping of eyelid if damaged
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| isolated weakness in one muscle of the eye muscles results in what? | deviation of the eye toward the unaffecte side
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| when there is an extraocular muscle defect, what is the patient's complaint? | double vision (diplopia)
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| what is CN IV? | trochlear nerve (superior oblique eye muscles)
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| what is CN V? | trigeminal nerve (sensory information from the face and mastication)
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| what is CN VI? | abducens nerve (lateral rectus muscle of the eyes)
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| what is CN VII? | facial nerve (motor innervation to the muscles for facial expression) - Bell's palsy
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| what is CN VIII? | vestibulocochlear nerve (hearing and balance)
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| what is CN IX? | glossopharyngeal nerve (throat muscles for swallowing)
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| what is CN X? | vagus nerve (throat, vocal chords, thorax, abdominal cavity)
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| how to check CN IX and CN X dysfunction | say ahhh (dysfunction will cause uvula to deviate away from affected side)
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| what is CN XI? | accessory nerve (shrugging of shoulders and turning head laterally)
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| what is CN XII? | hypoglossal nerve (tongue) - dysfunction will deviate to affected side
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| tests for cerebellar functioning | finger nose finger, heel to shin, rhomberg exam
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| performed when the sole of the foot is stimulated with a blunt instrument | Babinski's exam (downward response - normal; upward response - UMN lesion, damage to corticospinal tract)
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| pain, weakness, numbness or tingling in leg caused by injury to or pressure on the sciatic nerve | sciatica
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| common causes of sciatica | spinal disc herniation, degenerative disc disease, lumbar spinal stenosis, spondylolisthesis (ant/post displacement of vert or vert column in relation to vert below)
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| where is the sciatic nerve? | large nerve fiber derived from spinal nerves L4 through S3 which supplies sensory innervation to the skin of the low back and leg and motor innervation to the muscles of back and thigh, lower leg and foot
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| fibrous tissue that connects bones to other bones | ligaments
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| tough bands of fibrous connective tissue which connect muscle to bone | tendons
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| small fluid-filled sacs found in synovial joints which provide a cushion between bones and tendons and/or muscles | bursae
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| covers the ends of the tibia and femur as well as the underside of the patella | articular cartilage
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| cartilaginous tissues that provide structural integrity to the knee when it undergoes tension and torsion | lateral and medial knee menisci
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| connects the posterior femur to the center of the tibia anteriorly (back of femur to front of tibia) | anterior cruciate ligament (ACL)
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| function of ACL | limit forward motiona of tibia and knee joint rotation
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| connects medial condyle of the anterior femur posteriorly to the intercondylar area of the tbia (front of femur to back of tibia) | posterior cruciate ligament (PCL)
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| function of PCL | limits backward motion of the tibia
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| fibrous band on the medial side of the knee joints attached to the medial condyles fo femur and the tibia | medial collateral ligament
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| function of MCL | resists forces that would push knee medially (valgus deformity)
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| connects the lateral epicondyle of the femu to the head of the fibula | lateral collateral ligament
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| function of LCL | resists forces that would push the knee laterally (varus deformity)
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| inflammation of the bursae caused by repetitive use of a joints and/or minor trauma | bursitis
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| swelling over patella | prepatellar bursitis
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| swelling over tibial tuberosity | infrapatellar bursitis
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| localized tenderness over the AC joint | subacromial bursitis
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| physical examination for bursitis | point tenderness to palpation
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| treatment for bursitis | rest, ice, OTC inflammatory medications, steroid injection
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| describe the sub-acromial palpation for bursitis | identify acromion by walking fingers along spine of scapula until lateral endpoint, palpate region of subacromial space, positive sign for bursitis if painful
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| group of 4 muscles which connect the humerus to the shoulder blade and stabilize the shoulder joint (teres minor, infraspinatus, supraspinatus, subscapularis) | rotator cuff (inserts at the scapula and has a tendon that attaches to the humerus - together form a cuff around the humerus)
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| repetitive extension or pronation-supination of the forearm, pain develops 1cm distal to lateral epicondyle of humerus and extensor muscles, worse with extension of wrist | lateral epicondylitis (tennis elbow)
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| repetitive wrist flexion, tenderness medial and distal to medial epicondyle of humerus, worse with wrist flexion | medial epicondylitis (pitcher's elbow)
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| narrow passageway in which the 9 flexor tendons and median nerve pass through in order to supply function, feeling and movement to the thumb, index, middle, and 1/2 of ring finger | carpal tunnel
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| describe carpal tunnel syndrome | increased flexor tendons d/t increased/repetitive activity like typing causing the tendons to become shorter/thicker and decreased space within the CT and compression of median nerve and blood vessels
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| Carpal Tunnel Syndrome testing | weakness on thumb abduction
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| describe the phalen's sign | press the backs of the hands together at riht angles for 60s, compressing the median nerves, positive sign is numbness and tingling over median nerve
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| ottawa rules for ankle sprain | ankle pain in malleolar zone and (1) bone tenderness along distal 6cm of post edge of tibia or tip of med malleolus, (2) bone tenderness along post edge of fibula or tip of lat malleolus, or (3) inability to bear weight both immediately
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| originated on the medial tubercle of the calcaneous and fans out over the bottom of the foot to insert onto the proximal phalanges and the flexor tendon sheaths, it forms the longitudinal arch of the foot and function as a shock absorber and arch support | plantar fascia
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| degenerative disease caused by repetitive microtrauma to the fascia | plantar fasciitis
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| hs of plantar fasciitis | inferior heel pain with first few steps in the am, limp, prefer to walk on toes, pain decreases with ambulation but increases throughout the day
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| PE of plantar fasciitis | tenderness upon palpation of the anteromedial aspect of the heel, exacerbated by passive/active dorsiflexion of toes
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| tx of plantar fasciitis | arch taping, cushioned inserts, night splints, NSAIDs
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| muscle strength testing | 0/5 no muscle mov't, 1/5 visible muscle mov't no mov't at joint, 2/5 mov't at joint not against gravity, 3/5 mov't against gravity not against resistance, 4/5 mov't against resistant less than normal, 5/5 normal strength
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| describe proper joint examination | examine unaffected side to assess ROM for active/passive activity, check signs for inflammation, single or multiple joints, acute/gradual onset
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| describe knee inspection | check how pt walks, evidence of bowing (varus) or knock kneed (valgus), note scars or asymmetry, swelling
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| knee djd evaluation | grasp ankle/calf with hand, place other hand on patella, flex knee, feel for crepitus (crackling/griding sensation reflecting loss of normal smooth movement b/w articulating structures) or pain
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| accumulation of fluid within the joint space | knee effusion (if from inflammatory arthritis, will have warmth, redness, and pain)
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| a sizable effusion wherein the patells feels as if floating and bounce back up when pushed down | ballotment
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| distinguish DJD and IA | DJD slowly progressive, few signs of inflammation & a degree of preserved ROM, fewer WBC; IA has a more acute presentation, warm, red, painful, recurrent, inflammatory fluid has high WBC (gout-uric acid)
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| systemicc symptoms of IA | fever, rash, anorexia, weight loss, great toe MTP in gout, MCP of hands in RA
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| progressive loss of cartilage within joints which leads to damage of the underlying bone, usually in sites of previous joint injury | osteoarthritis
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| common locations of osteoarthritis | cervical/lumbar spine, hip, knee, wrists, distal interphalangeal joints, monoarticular joint involvement, absent generalized symptoms
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| chronic inflammation of joint synovial membranes leading to secondary erosion of adjacent bone and cartilage | rheumatoid arthritis
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| common locations of rheumatoid arthritis | knees, ankles, feet, hands, symmetrical joints, systemic symptoms present like weakness, fatigue, low grade fever, weight loss
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| occur when a torn piece interrupts normal smooth movement of the joint causing a sensation of pain, instability, or locking position in which can lead to degenerative arthritis | meniscal injury
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| injury when foot is planted while extreme rotational force is applied | ACL tear
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| injury when a posterior force on the tibia leads to disruption | PCL tear
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| injury of a direct force on the medial aspect of knee while the foot is planted | LCL tear
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| injury of a direct force on the lateral aspect of the knee while the foot is planted | MCL tear
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| risk factors for breast cancer | family history in 1st degree, increasing pt age, prolonged/uninterrupted exposure to estrogen (early menarche, never having been pregnant, older age pregnancy, older menopause), BRCA1/BRCA2 (DNA mutations)
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| breast related symptoms | discrete masses, pain (hormonal changes), nipple discharge (blood, milk, pus), skin discoloration (redness - mastitis, peau d' orange - aggressive inflammatory malignancy)
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| how to properly conduct a clinical breast exam | pt lying flat, one hand behind head for easier access, uncover only the one being examined, observe for nipple dimpling/retraction, discoloration, masses, asymmetry, palpate w/ 3 middle finges circularly w/ steady pressure & 3 depth levels
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| how to properly conduct axillary exam | abduct arm 20-30cm away, direct fingertips twd top of axilla, push palm twds chest wall, check abnormalities/nodules - note firmness, quantity, mobility
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| characteristics of malignant nodules | firm, increased quantity, adherence to each other and/or chest wall, irregular/hard to define borders
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| situations where axillary adenopathy may not be due to breast disease | hand infections can cause acute, painful adenopathy, systemic disease (lymphoma, sarcoidosis) can also caused lymph node enlargement
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| what causes puckering/dimpling of the breast tissue | underlying mass distorting skin above it
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| what causes nipple retraction of breast tissue | mass growing underneath nipple
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| what causes redness/pain of breasts | inflammation or infection, note temp differences and extent of redness, focal swelling or fluctuance suggest underlying abscess
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| an aseptic inflammation of breast in connection with pregnancy and breastfeeding, typically after 2nd postpartum week, precipitated by milk stasis | mastitis (tension and engorgement of breasts due to blocked milk duct)
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| unilateral plugging of lactiferous ducts creating bacterial growth (staphylococcus aureus) | breast abscess
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| affect 30-60% women, bilateral noncancerous breast lumps, lumpy texture of breasts with lumps smooth edges, free-moving, found in upper/outer sections of breast near axilla | fibrocystic breast changes (breast cancer risk elavated for only a small fraction of proliferative lesions)
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| painless, firm, solitary, mobile, slowly growing lump common in women under 40, composed of stromal/epithelial hyperplasia from increased estrogens (hypovascular and regress after menopause) | fibroadenomas
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| benign tumors that grow in a milk duct of breasts often in women in late reproductive/postmenopausal years, | intraductal papilloma (w/ bloody or clear unilateral nipple discharge in <6 months, no palpable mass, not seen via mammography, can be extracted but can an increased risk for cancer)
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| chronic eczematous disease on the skin of nipple and areola associated with intraductal carcinoma of underlying breast, malignant epithelial cells from underlying ductal adenocarcinoma invasion | paget's disease
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| a painful sensation elicited on pelvic examination with movement of cervix, usually indicative of inflammatory processes in pelvic organs (chronic pelvic pain, infertility, ectopic pregnancy) | cervical motion tenderness for pelvic inflammatory disease (uterus, fallopian tubes, or uterus from scarring inside fallopian tubes)
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| causes of pelvic inflammatory disease | STD, postpartum, post-AB, IUD
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| an infection spreading to the peritoneum causing inflammation and formation of scar tissue on the external surface of the liver | Fitzhugh-Curtis syndrome
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| a screening test to detect pre-/cancerous in endocervical canal (cervical intraepithelial neoplasia/cervical dysplasia - premalignant transformation and abnormal growth of cervical squamous cells) | pap smear (speculum used to open vaginal canal and allow collection of cells from outer cervix and endocervix)
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| benign tumors that originate w/in uterine myometrium and accompanying CT, most commonly founf during middle/later reproductive years, usually asymptomatic but can cause heavy/painful menses, painful intercourse, urinary frequency/urgency | uterine fibroids (symptoms indication for hysterectomy)
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| physiologic function of PSA (prostate specific antigen) | dissolution of the coagulum (sperm entrapping gel) so that the sperm can be liberated
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| highest amounts are found in and what are normal levels | seminal fluid; some PSA escapes the prostate and found in serum (indicative of prostate cancer, benign prostatic hyperplasia, acute bacterial prostatitis), normal levels are <4.0
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| age-related, progressive neoplastic condition of prostate gland with increased risk of presence of circulating androgens | benign prostatic hyperplasia (BPH)
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| characteristics of BPH | lower urinary tract symptoms such as urinary hesitancy, weak stream, straining to pass urine and terminal dribbling (no causal relationship with benign/malignant)
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| 47% asymptomatic, diagnosis based on abnormalities in screening PSA level or findings on digital rectal examination | prostate cancer
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| hx of prostate cancer | urinary frequencey, decreased urine stream, urinary urgeny, hematuria, in advanced stages may include weight loss/loss of appetite, anemia d/t bone marrow suppression, bone pain, spinal cord compression, lower extremity pain and edema
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| PE prostate cancer | cancer cachexia, bony tenderness, lower extremitt lymphedema or deep venous thrombosis, adenopathy, overdisteded bladder due to outlet obstruction
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| firm, painless unilateral mass, dull ache or sense of scrotal heaviness, most commonly occurring cancer in young men | testicular mass
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| most common cause of painful swelling of the testis in postpubertal males | epididymitis (often an ascending infection N gonorrhea and C trachomatis)
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| characteristics of epididymitis | gradual development of scrotal pain, fever, urethral discharge, urinary symptoms, epididymis enlarged or sensitive
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| abnormal tortuosity and dilation of the pampiniform venous plexus, often asymptomatic, most common surgically correctable cause of male infertility, mostly on left side, dilation decreased when supine and increased when upright | varicocele (left testicular vein drains into renal vein and right testicular vein drains into vena cava)
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| painless cyst, separate from testis, formed from a tubule of the rete testis or epididymal head, contains sperm, located superior and posterior to testis, freely movable and transilluminates, | spermatocele
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| protrusion of abdominal cavity contents through the inguinal canal (passage in the anterior abdominal wall which in men conveys spermatic cord and in women the round ligament | inguinal hernia
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