Exam 4 Flashcards
(114 cards)
1
Q
Causes of gynecomastia
A
increased estrogen, decreased testosterone and medication side effects.
2
Q
Medications associated with breast pain
A
psychotropic drugs, e.g. SSRIs, haloperidol, spironolactone and digoxin.
3
Q
*Pathologic galactorrhea
A
Not affiliated with pregnancy or lactation and if bloody or serous, unilateral, spontaneous, associated with a mass and occurring women aged 40+ years.
4
Q
*Breast CA masses
A
Irregular, firm, may be mobile, or fixed to surrounding tissue.
5
Q
Risk factors for breast CA
A
- Most important RF: age.
- Other non-modifiable RFs: family history of breast and ovarian cancers, inherited genetic mutations, personal history of breast CA or lobular carcinoma in situ, high levels of endogenous hormones, breast tissue density, proliferative lesions with atypia on breast bx, and duration of unopposed estrogen exposure related to early menarche, age of first full-term pregnancy, and late menopause.
- Modifiable RFs: breastfeeding for less than 1 yr, postmenopausal obesity, use of HRT, cigarette smoking, alcohol ingestion, physical inactivity, and type of contraception.
6
Q
BRCA1 and BRCA2 gene
A
occur in <1% of the population but account for roughly 5-10% of female breast cancers. They also confer increased risk for ovarian CA.
7
Q
Radiologic breast tissue density
A
Studies show that when percentage of breast area reaches 60 to 75%, the RR of breast CA increases 4-6x in part related to the masking effect of breast density on smaller cancers, which have the same x-ray attenuation as fibroglandular breast tissue.
8
Q
*Screening for breast CA recommendations
A
Evaluate risk as early as age 20s, ask about family history especially regarding breast and ovarian CA in maternal or paternal family members (autosomal dominant genetic mutations).
Mammography combined with CBE are most common screening modalities, however, recommendations vary by professional groups on when to start, how often, how to screen.
USPSTF -
- <= 50 years, individual screening based on specific factors
- ages 50-74, biennial mammography
- >= 75 years, insufficient evidence for testing
- Recommends against BSE
ACS
- Ages 40-45, optional annual screening
- 45-54 years, annual screening
- >=55 years, biennial screening with option to continue annual screens
ACOG
- >= 40 years, annual screening
- CBE: 20-39 years, every 3 years
- CBE: >=40 years, annually
- Recommends breast self-awareness
9
Q
Digital mammography
A
Performs better in younger women and women with higher breast density.
10
Q
*Changes seen in breast CA
A
I: Thickening of skin with unusually prominent pores (peau d’orange), asymmetry due to change in nipple direction, nipple retraction, breast dimpling or retraction seen with arms overhead, asymmetry or retraction may be seen better with leaning forward position. Abnormal contouring.
P: hard, irregular poorly circumscribed nodules, fixed to the skin or underlying tissues. Thickening of the nipple and loss of elasticity. Nodes that are large (>=1 to 2 cm) and firm or hard, matted together, or fixed to the skin or underlying tissues suggest malignancy.
11
Q
Breast palpation
A
is best performed when the breast tissue is flattened and patient is supine.
12
Q
*Intraductal papilloma s/s
A
*Spontaneous unilateral bloody discharge from one or two ducts warrants further evaluation for intraductal papilloma, ductal carcinoma in situ or Paget disease of the breast.
13
Q
BSE
A
best timed 5-7 days after menses, when hormonal stimulation of breast tissue is low.
14
Q
Direct vs. indirect inguinal hernias
A
- Direct - arise more medially due to weakness in the floor of the inguinal canal and are associated with straining and heavy lifting. A bulge near the external inguinal ring. Less common, usually in men 40+, rare in women.
- Indirect - develop at the internal inguinal ring, where the spermatic cord exits the abdomen. May form a scrotal hernia. A bulge near the internal inguinal ring. Chance of incarceration is 10 x more common in this type. More common, in all ages, often in children.
15
Q
Femoral hernias
A
more likely to present as emergencies with bowel incarceration or strangulation. More common in women than in men.
16
Q
Penile discharge
A
- Gonorrhea - yellow
- non-gonococcal urethritis - white
17
Q
Disseminated gonorrhea
A
rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms.
18
Q
Penile/scrotal sores
A
- Syphilitic chancre and herpes - ulcer
- HPV - warts
- mumps orchitis, scrotal edema, and testicular CA - swelling
- testicular torsion, epididymitis and orchitis - pain
19
Q
Phimosis and paraphimosis
A
- Phimosis - tight prepuce that cannot be retracted over the glans.
- Paraphimosis - tight prepuce, that once retracted, cannot be returned. Edema ensues.
20
Q
Tender painful scrotal swelling
A
present in acute epididymitis, acute orchitis, torsion of the spermatic cord, or a strangulated inguinal hernia.
21
Q
Testicular cancer
A
Painless nodule on the testis a potentially curable cancer
Peak incidence between ages 15-34 years
Cryptorchidism, present in 7-10% of men with testicular cancer, confers a 3-17 fold increased risk for testicular CA.
Other risk factors: history of carcinoma in the contralateral testicle, mumps orchitis, and inguinal hernia, a hydrocele in childhood and a postive family history.
22
Q
Varicocele
A
With patient standing, palpate the spermatic cord about 2 cm above the testis. Have patient hold his breath and beard down against a closed glottis for about 4 seconds (Valsalva maneuver)
A temporary increase in diameter of the cord indicates filling of abnormally dilated spermatic veins draining the testis.
23
Q
Hydroceles
A
Swellings containing serous fluid that light up with a red glow, or transilluminate. Those containing blood or tissue, such as normal testis, a tumor, or most hernias, do not.
24
Q
Palpating the epididymis
A
Feels nodular and cord-like and should not be confused with an abnormal lump and should not be tender.
25
Suspect intestinal strangulation
in the presence of tenderness, nausea, and vomiting, and consider surgical intervention.
26
\*TSE
* **USPSTF**- concluded inadequate evidence for the benefit of screening, either by clinical examination or self-examination, and advised against screening for testicular cancer in asymptomatic adolescent or adult males.
* **American Cancer Society-** recommends a testicular exam should be part of a general physical exam, they do not have a recommendation for regular testicular self-examinations (TSE’s) but advise men to seek clinical attention for: painless lump, swelling, enlargement of either testicle, pain or discomfort in testicle or scrotum, feeling of heaviness or a sudden fluid collection in the scrotum, or a dull ache in the lower abdomen or groin.
* Testicular Self-Exam best performed after a warm bath or shower.
* Testicular cancer strikes men ages 15 to 34, especially those with a positive family history of cryptorchidism
27
Causes of secondary dysmenorrhea
endometriosis, adenomyosis, PID, and endometrial polyps.
28
Causes of secondary amenorrhea
low body weight from malnutrition and anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction.
29
Causes of abnormal vaginal bleeding
Vary by age group and include pregnancy, cervical or vaginal infection or CA, cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, and hormonal contraception or replacement therapy.
30
\*Menopause symptoms
Diagnosed between ages 48-55 years. Cessation of menses x 12 months, progressing through several stages of erratic cyclical bleeding. Stages of variable cycle length, often with vasomotor symptoms: hot flashes, flushing and sweating, represent perimenopause.
* Estrogen and progesterone drop
* Testosterone production persists
* LH and FSH are markedly elevated
Studies suggest that only vasomotor symptoms, vaginal symptoms, and trouble sleeping are consistently linked to menopause. Vaginal symptoms are due to vulvovaginal atrophy with vaginal drying, dysuria, or dyspareunia.
31
\*Post-menopausal bleeding
Always ask about any bleeding or spotting after menopause as this may be an early sign of CA. Causes may include endometrial CA, HRT and uterine/cervical polyps.
32
Amenorrhea followed by heaving bleeding...
suggests a threatened abortion or dysfunctional uterine bleeding related to lack of ovulation.
33
\*PID
STIs and recent IUD insertion are red flags for PID. Always rule out ectopic pregnancy first with serum or urine testing and possible ultrasound.
Cervical motion tenderness and/or adnexal tenderness are hallmark signs.
34
\*Acute pelvic pain
in menstruating girls and women warrants immediate attention. The DDx is broad but includes life-threatening conditions such as **ectopic pregnancy, ovarian torsion, and appendicitis.**
Also consider mittelschmerz, ruptured ovarian cyst and tubo-ovarian abscess.
Endometriosis affects 50-60% of women and girls with pelvic pain. Other causes include PID and adenosis, and fibroids, which are tumors in the uterine wall or submucosal or subserosal surfaces arising from the smooth muscle cells of the myometrium.
_However, the m*ost common cause is PID*, followed by ruptured ovarian cyst, and appendicitis. STIs and recent IUD insertion are red flags for PID._
_Cervical motion tenderness and/or adnexal tenderness are hallmarks of PID, ectopic pregnancy, and appendicitis._
35
\*Chronic pelvic pain
Red flag for history of sexual abuse. Also consider pelvic floor spasm from myofascial pain with trigger points on examination.
36
Cervical cancer
Most important risk factor for cervical CA is persistent infection with high-risk HPV subtypes, especially HPV-16 or HPV-18. Other two notable risk factors including failure to undergo screening, which accounts for roughly half of women diagnosed with cervical CA, and multiple sexual partners.
37
\*Cervical cancer screening for average-risk women
(USPSTF, ACS/ASCCP/ASCP, and ACOG)
* Initiate: at age 21 years
* Interval
* Ages 21-65 cytology q 3 years
* OR
* Ages 21-29: cytology every 3 years
* Ages 30-65 yrs, cytology plus HPV testing every 5 years
* Age at which to end screening: age \> 65 yrs after 3 consecutive negative results on cytology or two on cytology plus HPV testing within 10 years
* Screening after hysterectomy with removal of cervix (TAH): not recommended.
38
HPV vaccine
the CDC and AAP recommend a 3-dose series over 6 months with either the quadrivalent (HPV 16,18,6,11) or bivalent (HPV 16,18) vaccine for girls and boys at age 11 or 12, before their first sexual encounter; the series can begin as early as age 9 years.
Catch-up: recommended for females ages 13-26 years who have not had prior vaccination or completed the 3-dose series. Through age 21 in males not vaccinated previously (age 26 years if immunocompromised or having sex with other men).
39
Ovarian CA s/s, risk factors, screening
abdominal distention, abdominal bloating, and urinary frequency; however, these are usually reported within 3 months of diagnosis and frequently occur in other conditions.
Risk factors: family history and presence of the BRCA1 or BRCA2 gene mutation. Risk is tripled if there is a first-degree relative with breast or ovarian CA.
Other risk factors: obesity, nulliparity, growing evidence of increased risk from postmenopausal HRT.
Risk decreased by: use of oral contraceptives, multiple pregnancies, breastfeeding, and tubal ligation.
Currently, there are no effective screening tests. CA-125 is neither sensitive nor specific and may be elevated in many other conditions and cancers including pregnancy.
40
\*Most common STI
Chlamydia trachomatis infection which is a cause of urethritis, cervicitis, PID, ectopic pregnancy, infertility, and chronic pelvic pain.
Chlamydia infection rates are highest in women ages 20 -24 years, closely followed by women ages 15 to 19 years. AA women and American Indian/Alaskan natives are at highest risk for infection.
As with other STIs, risk factors are:
* Younger than 24 years and sexually active
* Prior infection with chlamydia or other STIs
* New or multiple partners
* Inconsistent condom use, and
* Occupational sex work
41
\*STI and HIV screening per CDC 2014
* Chlamydia and gonorrhea screening annually for all sexually active women ages \< 25 years and older with risk factors of new or multiple sex partners, or a sex partner infected with an STI.
* Chlamydia, syphilis, hep B and HIV screening for all pregnant women and gonorrhea screening for at-risk pregnant women starting early in pregnancy.
* Chlamydia, gonorrhea, and syphilis screening at least annually for all sexually-active gay, bisexual, and other MSM. MSM who have multiple or anonymous partners should be screened more frequently for STIs (3-6 month intervals).
* HIV testing at least once for all adults and adolescents from ages 13-64 years.
* HIV testing at least annually for anyone having unsafe sex or using injection drug equipment. Sexually active gay and bisexual men may benefit from testing q3-6 months.
42
Inserting speculum
Some clinicians carefully enlarge the vaginal introitus by lubricating one finger with water and applying downward pressure at its lower margin, then palpate the location of the cervix in order to angle the speculum more accurately.
43
CBE
The vertical strip pattern shown is currently the best validated technique for detecting breast masses. Using the pads of the 2nd, 3rd and 4th fingers, keeping the fingers light flexed, spend about 3 minutes for each breast. Palpate in small, concentric circles applying light, medium and deep pressure at each examining point.
44
\*Descriptors of breast nodule
1. Location - by quadrant or clock, with cm from nipple
2. Size in cm
3. Shape - round or cystic, disclike, or irregular in contour
4. Consistency - soft, firm, or hard
5. Delimitation - well circumscribed or not
6. Tenderness
7. Mobility - in relation to the skin, pectoral fascia and chest wall.
45
\*Nonpuerperal galactorrhea
Milky discharge unrelated to a prior pregnancy and lactation. Causes include hyperthyroidism, pituitary prolactinoma, and dopamine antagonists, including psychotropics and phenothiazines.
46
Causes of primary dysmenorrhea
increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline.
47
PMS (pre-menstrual syndrome)
Criteria for diagnosis are symptoms and signs in the 5 days prior to menses for at least 3 consecutive cycles; cessation of symptoms and signs within 4 days after onset of menses; and interference with daily activities.
48
\*Primary amenorrhea
Absence of ever initating periods by age 16.
Causes:
Issues with pituitary gland or hypothalamus from gonadal dysgenesis including Turner syndrome (43%), Mullerian agenesis (lack of vagina – 15%), constitutional delay (less common in females, 14%), PCOS (7%), isolated GnRH deficiency (5%), anorexia nervosa (2%), hypopituitarism (2%), and others.
49
Postcoital bleeding
suggests cervical polyps or cancer, or in an older woman, atrophic vaginitis
50
Suspect HIV infection in women with...
recurrent vulvocandidasis, concurrent STIs, abnormal Pap smears (occurring in 40% of HIV-positive women), and HPV infection: HIV testing is indicated
51
Failure rates of family planning methods
* Lowest - subdermal implant, IUD, female sterilization, vasectomy
* Intermediate - injectables, oral contraceptives, the patch, vaginal ring, and diaphragm
* Highest - male and female condoms, withdrawal, sponge in parous women, fertility awareness methods and spermicides
52
Bimanual examination of the vagina
Palpate the cervix - cervical motion tenderness and/or adnexal tenderness are hallmarks of PID, ectopic pregnancy, and appendicitis.
Palpate the uterus - with your other hand on the abdomen about midway between the umbilicus and the symphysis pubis. Uterine enlargement suggests pregnancy, uterine myomas (fibroids), or malignancy.
Palpate each ovary - Normal ovaries are somewhat tender. Within 3-5 years after menopause, the ovaries become atrophic and usually nonpalpable. If palpable, may investigate further for ovarian cyst or ovarian CA.
53
Rectovaginal Examination, if indicated
Three primary purposes
1) to palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac and adnexa;
2) to screen fro colorectal cancer in women ages 50 and older; and
3) to assess pelvic pathology.
Index finger in vagina and middle finger into rectum. Ask woman to strain. Apply pressure agains anterior and lateral walls, and downward pressure with hand on abdomen.
54
\*Trichomonal vaginitis
* Often but always sexually acquired
* Discharge is yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorous
* Pruritis, pain on urination, dyspareunia
* Vestibule and labia minora may be erythematous, vaginal mucosa diffusely reddened, small red granular spots or petechiae in the posterior fornix, in mild cases, the mucosa looks normal
* Scan saline wet mount for trichomonads
55
\*Candidal vaginitis
* Many factors predispose esp. antibiotics
* Discharge is white and curdy; may be thin but typically thick; not as profuse as in trichomonal infection; not malodorous
* Pruritis; vaginal sorenes; pain on urination (from skin inflammation); dyspareunia
* Vulva and surrounding skin are often inflamed and sometimes swollen, vaginal mucosa is often reddened, with white tenacious patches of discharge
* Scan KOH prep for the branching hyphae of Candida
56
\*Bacterial vaginosis
* Often transmitted sexually
* Gray or white, thin, homogeneous, malodorous; coats the vaginal walls, usually not profuse, may be minimal
* Unpleaseant fishy or musty genital odor, reported to occur after intercourse
* The vulva and vaginal mucosa usually appear normal
* Scan saline wet mount for clue cells (epithelial cells with stippled borders), sniff for fishy odor after applying KOH ("whiff test"); **test vaginal secretions for pH \>4.5**
57
Risk factors for Prostate Cancer
1. Age - rates increase rapidly after age 50
2. Ethnicity - AA have highest incidence and mortality rates
3. Family hx - Risk increases 2x for one affected first-degree relative, increase 5-11x with 2-3 first-degree relatives
4. Other rf: exposure to Agent Orange by Vietnam vets, diets high in animal fat, obesity, and cigarette smoking. **BPH is not a risk factor for prostate CA!**
58
\*Prostate cancer screening
Providers are encouraged to support shared decision making because cancer-screening decisions are complex and very sensitive to patient preferences regarding the potential benefit and harms of screening.
*_May begin offering screening beginning at age 40-45 years to men at high risk for CA, African Americans and those with a family hx of prostate CA. Otherwise, may begin at age 50._*
1) If agreeable, PSA testing recommended q1-2 years
2) DRE is considered optional
3) Stop offering screening at age 70 or whenever life expectancy is less than 10 years
59
Male genitalia in newborns
Two common scrotal masses: hydroceles and inguinal hernias.
Both may coexist on the right side.
Hydroceles are not reducible, and can be transilluminated and most resolve by age 18 months.
Hernias are usually reducible, often do not transilluminate and do not resolve.
60
\*Cremasteric reflex
Scratch the medial aspect of the thigh.
The testis on the side being scratched will move upward
61
\*Female puberty
\*Physical changes in girl's breast are of the first signs of puberty. Menarche usually occurs when a girl is in breast stage 3 or 4.
## Footnote
General order of pubertal changes: height spurt, breast changes, pubic hair, menarche.
Normal range of onset of breast development is 7 years for white girls and 6 for AA and Hispanic girls.
Delayed puberty (no breasts or pubic hair development by age 12 years) is usually caused by inadequate gonadotropin secretion from the anterior pituitary due to defective hypothalamic GnRH production. A common cause is anorexia nervosa.
62
\*Male puberty
First reliable sign between ages 9 and 13.5 years is increase in testes size, then appearance of pubic hair, with progressive enlargement of the penis, and finally a growth spurt.
## Footnote
Delayed puberty is suspected in boys who have no signs of pubertal development by 14 years of age.
63
Chronic pain (spectrum)...
may be a spectrum disorder in patients with anxiety, depression, or somatic symptoms.
64
Borderline personality disorder
* show "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity."
* they make "frantic efforts to avoid real or imagined abandonment and show recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior."
* more than 90% of patients with this disorder meet criteria for other personality disorders
* RECOGNITION OF BORDERLINE FEATURES IS ESSENTIAL FOR PATIENT UNDERSTANDING, REDUCTION OF PATIENT SELF-HARM, AND REFERRAL FOR EXPERT EVALUATION.
65
High-yield screening questions for DEPRESSION
1. Over the past 2 weeks, have you felt down, depressed, or hopeless?
2. Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)?
[(sensitivity: 83%, specificity 92%) for detecting major depression]
All positive screening tests warrant full diagnostic interviews.
66
High-yield screening questions for ANXIETY
1. Over the past 2 weeks, have you been feeling nervous, anxious, or on edge?
2. Over the past 2 weeks, have you been unable to stop or control worrying?
3. Over the past 4 weeks, have you had an anxiety attack--suddenly feeling fear or panic?
67
Screening for SUICIDE
The USPSTF has insufficient evidence as to the efficacy of suicide screening in a primary care setting (grade I), but statistics underscore the importance of investigating patient clues and risk factors.
68
Substance abuse
Every patient should be asked about alcohol use, substance abuse, and misuse of prescription drugs. The USPSTF gives a grade B for screening adults 18 and over for alcohol misuse. However, it has issued a grade I recommendation for screening for illicit drug use.
69
\*Components of Mental Status Examination
1. Appearance and behavior
2. Speech and language
3. Mood
4. Thoughts and perceptions
5. Cognitive function
70
Small- and large-fiber neuropathy
Diabetic patients with small-fiber neuropathy report sharp, burning, or shooting foot pain.
Diabetics with large-fiber neuropathy experience numbness and tingling or even no sensation at all.
71
muscle stretch reflexes - parts
same as deep tendon reflexes
For the reflex to occur, all components of the reflex arc must be intact: sensory nerve fibers, spinal cord synapse, motor nerve fibers, neuromuscular junction, and muscle fibers.
72
muscle stretch reflexes
Ankle reflex - S1
Knee relfex - L2,L3,L4
Brachioradialis reflex - C5,C6
Biceps reflex - C5,C6
Triceps reflex - C6,C7
73
Myasthenia gravis
proximal typically asymmetric weakness that gets worse with effort (fatigability), often with associated bulbar symptoms such as diplopia, ptosis, dysarthria, and dysphagia.
74
Polymyositis and dermatomyositis
Proximal limb weakness, when symmetric with intact sensation, occurs in myopathies from alcohol, drugs like glucocorticoids, and inflammatory muscle disorders such as polymyositis and dermatomyositis.
75
Polyneuropathy
bilateral predominantly distal weakness, often with sensory loss, suggests a polyneuropathy, as in diabetes.
76
\*Causes of near-syncope and syncope
seizures, neurocardiogenic conditions such as vasovagal syncope, postural tachycardia syndrome, carotid sinus syncope, and orthostatic hypotension, and cardiac disease causing arrhythmias, especially V. tach and bradyarrhythmias.
77
Focal seizures
originating within networks limited to ONE HEMISPHERE
* discretely localized or more widely distributed
* originate in subcortical structures
* do not fall into any recognized set of natural causes
78
Generalized seizures
originating at some point within, and rapidly engaging, bilaterally distributed networks that include cortical and subcortical structures, but do not necessarily include the entire cortex.
## Footnote
location and lateralization are not consistent from one seizure to another
can be asymmetric
may begin with body movements, impaired consciousness, or both
Causes may include alcohol withdrawal, uremia, hypoglycemia, hyperglycemia, hyponatremia, drug toxicity, and bacterial meningitis
79
Pseudoseizures
may mimic seizures but are due to a conversion disorder (termed functional neurologic symptom disorder in DSM-5)
Movements may have personally symbolic significance and often do not follow a neuroanatomic pattern. Injury is uncommon.
80
Epilepsy
two or more seizures that are not provoked by other illnesses or circumstances
Generalized epilepsy syndromes usually begin in childhood or adolescence.
Adult-onset seizures are usually partial.
81
Ischemic stroke symptoms
* occlusion of MCA - visual field cuts and contralateral hemiparesis, and sensory deficits
* occlusion of left MCA - aphasia
* occlusion of right MCA - neglect or inattention to the opposite side of the body
82
Documented and modifiable risk factors for stroke
* Hypertension
* Smoking
* Dyslipidemia
* Diabetes
* Weight
* Diet and nutrition
* Physical inactivity
* Alcohol use
83
Stroke: Disease-specific risk factors
* Atrial fibrillation
* CAD
* OSA
84
\*Neurologic exam
Whether comprehensive or screening, organize your thinking in 5 categories
1. Mental status, speech and language
2. Cranial nerves
3. The motor system
4. the sensory system
5. Muscle stretch reflexes
85
\*Nystagmus
* named for the direction of the quick component
* plane of nystagmus: horizontal, vertical, rotary, or mixed
* With gait ataxia and dysarthria (increases with retinal fixation) is seen in cerebellar disease
* Vestibular disease (decreases with retinal fixation)
* internuclear ophthalmoplegia
86
Sensory system
* pain and temperature (spinothalamic tracts)
* position and vibration (posterior columns)
* light touch (both of these pathways)
* Discriminative sensations, which depend on some of the above sensations but also involve the cortex
87
Patterns of neurological testing
Focus on areas that have numbness or pain, motor or reflex abnormalities suggesting a lesion of the spinal cord or PNS, and trophic changes such as absent or excessive sweating, atrophic skin, or cutaneous ulceration.
88
Vibration...
sense is often the first sensation lost in a peripheral neuropathy and increases the likelihood of peripheral neuropathy 16-fold.
Causes include DM, alcoholism, and posterior column disease, seen in tertiary syphilis or vitamin B12 deficiency.
89
Hypothyroidism
Slowed relaxation phase of reflexes in hypothyroidism is often best detected during the ankle reflex
90
Abdominal reflexes
may be absent in both central and peripheral nerve disorders.
91
Brudzinski Sign
Flex neck, watch hips and knees.
If they flex, it is positive and you may consider meningitis or subarachnoid hemorrhage.
92
Kernig Sign
Flex the patient's leg at both the hip and knee, then slowly extend the leg and straighten the knee.
Pain and increased resistance to knee extension are a positive Kernig sign and concern for meningitis or subarachnoid hemorrhage should be raised.
93
Straight-leg Raise
In supine position, raise the patient's relaxed and straightened leg, flexing the thigh at the hip.
Pain radiating into the ipisilateral leg is a positive straight leg test for lumbosacral radiculopathy.
Foot dorsiflexion can further increase leg pain in lumbosacral radiculopathy, sciatic neuropathy, or both.
Increased pain when the contralateral healthy leg is raised is a positive crossed straight-leg raise sign.
94
Structural lesions
from stroke, abscess, or tumor mass may lead to asymmetrical pupils and loss of the light reaction
The eyes "look at the lesion" in the affected hemisphere
95
Signs of severe neurological disease in infants
* extreme irritability
* persistent asymmetry of posture
* persistent extension of extremities
* constant turning of the head to one side
* marked extension of the head, neck and extremities (opisthotonus)
* severe flaccidity
* limited response to pain
* sometimes seizures
96
Neonatal behaviors related to nicotine withdrawal
* fine tremors
* irritability
* poor self-regulation
97
\*Ankle reflex in infant
Grasp infant's malleolus with one hand and abruptly dorsiflex the ankle. You may note rapid, rhythmic plantar flexion of the newborn's foot (ankle clonus) in response to this maneuver. Up to 10 beats are normal in newborns and young infants (unsustained ankle clonus).
## Footnote
*With sustained ankle clonus, CNS disease should be suspected.*
98
List of primitive reflexes (present in newborns)
* palmar grasp reflex - birth to 3-4 months - pyramidal tract dysfunction
* plantar grasp reflex - birth to 6-8 months - pryamidal tract dysfunction
* rooting reflex - birth to 3-4 months - severe generalized or CNS disease
* moro reflex (startle) - birth to 4 months - CP
* Asymmetric tonic neck reflex - birth to 2 months - asymmetric CNS development, CP
* trunk incurvation (Galant) reflex - birth to 2 months - transverse spinal cord lesion or injury
* Landau reflex - birth to 6 months - delayed development
* Parachute reflex - 8 months and does not disappear - delay in appearance my predict future delays in voluntary motor development
* Positive support reflex - birth to 2-6 months - hypotonia or flaccidity, CP
* Placing and stepping reflexes - birth; best after 4 days - Paralysis or newborn born by breech delivery may not have such reflexes
99
\*Signs of drug withdrawal in newborns
irritable, jittery and has tremors, hypertonicity, and hyperactive reflexes, also poor feeding and seizures.
100
Signs of autism
problems with social interaction, verbal and nonverbal communication, restricted interests, and repetitive behaviors
101
Vibratory sense in elderly
May frequently lose some or all vibration sense in the feet and ankles but not in the fingers or over the shins.
102
Diminished reflexes in elderly
gag reflex, abdominal reflexes, ankle reflexes.
Less commonly, knee reflexes may diminish.
103
Dementia, definition
an acquired condition that is characterized by a decline in at least two cognitive domains--loss of memory, attention, language, or visuospatial or executive functioning--that is severe enough to affect social or occupational functioning.
The DSM-5 classifies it as a "major neurocognitive disorder"
Delirium and depression must be excluded
104
Dementia screening tests
Mini Mental State Examination (copyrighted)
Mini-Cog
MoCA
105
Examples of age-related abnormalities
* Unequal pupil size
* Decreased arm swing and spontaneous movements
* Increased leg rigidity and abnormal gait
* Presence of the snout and grasp reflexes
* Decreased toe vibratory sense
106
\*Parkinson disease s/s
* T = Tremor
* R = Rigidity
* A = Akinesia
* P = Postural instability
* **Bradykinesia (most characteristic clinical sign)**
* Micrographia
* Shuffling "freezing" gait
* Difficulty rising from chair
107
Increased risk for falls
Abnormalities of gait and balance, especially widening of base, slowing and lengthening of stride and difficulty turning
108
Delirium features
* Acute onset
* Fluctuating course with lucid intervals, worse at night
* Lasts hours to weeks
* Sleep/wake cycle is always disrupted
* General illness or drug toxicity are either or both present
* Example causes: DT, uremia, acute hepatic failure, acute cerebral vasculitis, atropine poisoning
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Dementia features
* Insidious onset
* Course is slowly progressive
* Lasts months to years
* Sleep/wake cycle in which sleep is fragmented
* general illness or toxicity often absent
* Example causes: Vitamin B12 deficiency, thyroid disorders, AD, vascular dementia, dementia due to head trauma
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\*Fibroadenoma
- noncancerous breast tumor common in young women (and up to age 55).
- smooth, round, well defined, usually solitary, 1-2 cm
- "slippery tumor"
- very mobile
- painless, non-tender
- does not change with cycles
-no retraction signs
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\*Breast Cysts
* Usually found in age 30-50, regress after menopause unless on estrogen therapy
* Single or multiple
* Round
* Soft to firm, usually elastic
* Mobile
* Often tender
* Absent retraction signs
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\*Breast Cancer
* Usual in age 30-90 years, most common over age 50
* Usually single, although may coexist with other nodules
* Firm or hard
* Irregular or stellate
* Firm or hard
* Not clearly delineated from surrounding tissues
* May be fixed to skin or underlying tissues
* Usually nontender
* Retraction signs may be present
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\*Hematochezia (stool with red blood)
* Colon CA - often with change in bowel habits, weight loss
* Hyperplasia or adenomatous polyps - often no other symptoms
* Diverticula of the colon - often no symptoms unless inflammation causes diverticulitis
* Inflammatory conditions of colon/rectum
* U.C./Crohn's
* Infectious diarrhea
* Proctitis (various causes including anal intercourse) - rectal urgency, tenesmus
* Ischemic colitis - lower abdominal pain, sometimes fever or shock in older adults; abdomen typically soft to palpation
* Hemorrhoids - blood on the toilet paper, on the surface of the stool, or dripping into the toilet
* Anal fissure - blood on the toilet paper or on the surface of the stool; anal pain
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\*Neonatal behaviors r/t nicotine withdrawal
fine tremors, irritability and poor self-regulation
