PCM II Midterm Flashcards
(126 cards)
1
Q
visceral pain
A
cause: stimulation of visceral pain fiber
- secondary to organ involvement
- felt at midline of structure involved
- NOT LOCALIZED
2
Q
parietal (somatic) pain
A
cause: stimulation of somatic pain fibers
- secondary to inflammation in parietal peritoneum
- constant and more severe that visceral pain
- LOCALIZED
- aggravted by movement or coughing
3
Q
referred pain
A
problem originates within the abdomen but the pain is felt at distant sites which are innervated at the same spinal level as the disordered structure
4
Q
general vs focused ROS
A
general: same every time; based on discriminators and life threats
focused: based on CC (with abdominal pain review GI, GU, GYN)
5
Q
what are some additional social questions pertinent to CC of abdominal pain (besides drugs, tobacco, alcohol)
A
stress
travel
well water
ingestion of undercooked meats
6
Q
Order of the PE for an abdominal exam
A
- drape the patient
1. inspect
2. auscultation
3. percussion
4. palpation
7
Q
what are the landmarks of the abdomen
A
- sternal xiphoid process
- costal margins
- umbilicus
- ASIS
8
Q
what abdominal organs are located in the epigastric area
A
pancreas
liver
gallbladder
stomach
9
Q
what is normal bowel sounds numerical classification
A
5-34 clicks, gurgles/minute
10
Q
numerical dx for absent bowel sounds and possible causes
A
no sounds for greater than 2 minutes
-chronic intestinal obstruction, intestinal perforation, mesenteric ischemia
11
Q
numerical classification for decreased bowel sounds and possible causes
A
none for 1 minute
-post-surgical ileus, peritonitis
(post surgical ileus is malfunction of intestinal motility following an abdominal surgery)
12
Q
numerical classification and possible causes of increased bowel sounds
A
greater than 34 per minute
-diarrhea, early bowel obstruction
(***remember late bowel obstruction caused absent sounds)
13
Q
Abdominal auscultation: tinkling sound like raindrops on metal
A
high pitched bowel sounds
-sign of early intestinal obstruction
14
Q
Abdominal auscultation: vascular sounds resembling a heart murmur over abdominal arteriole vasculature
A
bruits
-sign of vascular obstruction
15
Q
Abdominal auscultation: grating sounds with respiratory variation
A
friction rub
- sign of visceral peritonitis
- *listen over liver and spleen
16
Q
Abdominal auscultation: soft humming noise
A
venous hum
- sign of increased collateral circulation between portal and systemic venous systems (portal HTN)
- *listen over epigastric and umbilical regions
17
Q
abdominal percussion: describe tympany vs dullness vs resonance vs hyper-resonance
which sound is the major sound of the abdominal viscera and GI tract
A
tympany: high pitched; air filled
dullness: non-resonating; solid organ/mass
resonance: hollow organs (lungs)
hyper-resonance: air filled hollow organ (pneumothorax of lungs)
- tympany predominates - bc of gas in GI tract
- *BUT scattered areas of dullness is normal from fluid and feces
18
Q
abnormal abdominal percussion findings
A
Normal: tympany with scattered small areas of dullness
- large dull areas from a mass or enlarged organ
- protuberant (budging) abdomen with tympanitic sounds throughout may indicate an intestinal obstruction
19
Q
how to palpate the abdomen
A
with the palmer aspect of the hand and fingers together, gently palpate all 4 quadrants, then deeply palpate all 4 quadrants
*always start farthest from the tender area
20
Q
how to assess spleen with percussion? how would splenomegaly present?
A
- start from cardiac border at left anterior axillary line and percuss laterally
- tympany found here = unlikely splenomegaly
- dullness found here = splenomegaly
21
Q
how to asses the liver with percussion? what are abnormal findings?
A
- start in RLQ, percuss midclavicular line and up until sound changes from tympany to dull (lower border)
- in RUQ, percuss midclavicular line and down until sound changes from lung resonance to dull (upper border)
- normal vertical span: 6-12cm
- increased: hepatomegaly from cirrhosis, lymphoma, hepatitis, right-sided heart failure, amyloidosis, hemochromatosis
- decreased: shrunken liver from cirrhosis
22
Q
how to asses the liver via palpation? abnormal findings?
A
-left hand behind pt supporting 11th and 12th ribs pressing anteriorly, right hand on pt right abdomen pushing posterioly, ask pt to take deep breath and feel the liver edges as it comes down to meet your right hand
normal liver: slight tender, soft, smooth surface
abnormal: irregular edge/nodules (from hepatoceullar carcinoma) or firmness/hardness (from cirrhosis, hematochromatosis, amyloidosis, lymphoma
23
Q
how to assess spleen with palpation? abnormal findings?
A
- noramlly not palpable unless enlarged
- when enlarged it protrudes anterior, inferior, and medially
-reach over pt and posteriorly grasp pt LUQ with left hand, place right hand below left costal margin and press posteriorly. ask pt to breath and feel for spleen as it comes down to meet your LEFT hand.
- in 5% of normal adults, tip will be palpated
- tip is palpated in those with low/flat diaphragm like COPD
24
Q
causes of splenomegaly
A
portal HTN , blood malignancies, HIV, splenic infarct, hematoma, mononucleosis
25
what are the special test for ascites? abnormal findings that indicate a positive test for ascites?
1. shifting dullness test
- percuss tympanic and dullness border with pt supine, then again with pt lateral recumbent
- normal (-) = borders are same
- abnormal (+) = dullness shifts to dependent side and tympany shifts to top
2. test for a fluid wave
- have pt place hands over chest, ask assistant to place ulnar aspect of hand midline, you tap on one flank sharply with finger tips
- normal (-) = no impulse transmission
- abnormal (+)- transmission of impulse to contralateral flank
26
special tests for appendicitis
1. mcburneys point (2/3 way between umbilicus to ASIS; + = tenderness)
2. rovings sign (palpate LLQ deeply; + = RLQ pain)
3. psoas sign (have pt lift right thigh against resistance while supine then extend right hip while lateral recumbent; + = abdominal pain during either)
4. obturator sign (flex pt right hip with knee bent then internally rotate the hip; + = right hypogastric pain
27
special test for biliary colic (pain in gall bladder)
murphys sign - palpate deeply under pt right costal margin and ask pt to breath deeply; + = sharp increases tenderness with sudden stop in inspiration
28
what are sign of peritoneal inflammation (acute abdomen)
1. gaurding (voluntary contraction during palpation)
2. rigidity (involuntary contraction of abdominal wall, can see it, can palpate it, and won't see ab move while breathing)
3. rebound tenderness (push down deep and then let go quickly, if more tender when letting go than pushing it is a positive sign)
29
retrosternal sensation of burning or discomfort usually occurring after eating when lying supine or bending over
heartburn symtpms typical of GERD
30
what are the typical symptoms of GERD
heartburn
regurgitation
dysphagia (sensation that food is stuck in retrosternal area occurs in 30% of GERD pts)
31
are coughing, wheezing, hoarseness, sore throat, otitis media, non cardiac chest pain, and enamel erosion typical or atypical signs of GERD
atypical
32
most common digestive complaint in US
constipation
33
what are the tools that can be used to categorize constipation
1. Rome III criteria (for constipation)
* experienced 2 of the following in past 3 months: < 3 poops/week ; straining ; lumpy/hard stool ; sensation of incomplete defecation ; manual maneuvering required to defecate
2. Bristol Stool scale
- way for pt and dr. to agree on feces. 3-4 are normal (formed and easy to pass) 1-2 are likely in constipation (separate hard lumps like nuts, sausage shaped but lumpy, hard to pass)
34
what is rome criteria
-it is a questionnaire to help dx and tx of functional GI problems
made by the Rome foundation to help classify and categorize the GI symptoms associated with illness that are GI in nature with no evidence of organic disease to explain symptom
35
PE exams for constipation? findings?
1. abdomen exam
- constipation: distention, masses, large abdominal hernias may interfere with generation of internal pressure needed to start defecation
2. pelvic exam for females
- palpate posterior vaginal wall at rest and while straining to check for internal rectal prolapse or rectocele
3. anorectal exam
- blood? hemorrhoids? pain? mass? sphincter tone? fecal impaction?
36
a nonspecific term, first seen with diarrhea but also nausea vomiting and abdominal pain , "stomach flu". usually caused by infectious agent such as virus, bacteria, parasite, food toxin, or drug linked
gastroenteritis
**associated with diarrhea
37
two viral causes of gastroenteritis
norovirus
-sudden onset of uncontrolled vommiting 12-48 hrs after exposure, vommitting > diarrhea, resolves 36 hrs after start, usually the causes of outbreaks
rotavirus
- will have by age 5 if not vaccinated, can lead to severe dehydration
38
3 causes of bacterial gastroenteritis
salmonella
-eating something contaminated, onset 12-36 hr after
difficile
-from antibiotic exposure; most common hospital acquired GI illness
coli
- food, water, or person -person transmission. onset within 5 days and lasts 2 weeks,
* most common cause of travelers diarrhea
39
common cause of parasitic gastroenteritis
giardiasis
- causes diarrhea, FATTY STOOL THAT FLOATS, bloating, ab cramping, N/V
- trasmits by person-person, animals-humans through fecal oral route, most commonly from infected water
40
drugs associated with diarrhea
- quinidine
- colchicin
- PPI
- antibiotics
- laxatives
- sorbitol
41
postprandial urgency, alteration between diarrhea and constipation , stubbornness to laxatives, defaction improves ab pressure but does not relieve it are all common signs of
IBS (irritable bowel syndrome )
*abdominal pain/bloating and altered bowel habits
42
___ volume of stool associated with enteric infection and ____ volume of stool associated with colonic infection
large - enteric (SI)
| small-colonic (LI)
43
copious rice water diarrhea is a hallmark of
cholera
44
would you do a murphys sign test if you have LLQ?
no
45
what must happen for vitamin D to increase absorption of calcium from diet
-1 alpha hydroxylase in the kidneys converts calcium into active 1,25 hydroxy state via the stimulation by PTH from the parathyroid gland
46
what is the most common cause of hypocalcemia
hypoparathyroidism
47
what is Chvostek sign? and what is it used for?
- for hypoparathyroidism, hypocalcemia
| - tap facial nerve and look for a spasm of facial muscles
48
what is trousseaus sign? and what is it used for ?
- for hypoparathyroidism, hypocalcemia
| - characteristic flick of wrist when used a blood pressure cuff on that arm
49
when doing a workup for hypo/hypercalcemia, you check for calcium, albumin, magnesium, and PTH levels [CAMP levels]. if albumin comes back low you must?
calcium will need to be adjusted bc albumin binds to both H+ and Ca2+
50
primary vs secondary hyperparathyroidism
**BOTH ARE INCREASED PTH LEVELS
primary: adenoma or hyperplasia of parathyroid gland causes increased PTH secretion and high calcium levels
secondary : low calcium levels cause increased PTH ; possible causes are V-D def, calcium def, malabsorption, renal failure
51
most common cause of hypothyroidism ? hyperthyroidism ?
hoshimotos (hypo)
(high TSH, low T3 T4)
graves (hyper)
(low TSH, high T3 T4)
52
will thyroiditis cause hyper or hypo thyroidism
hyper
53
tx/managment for hypo and hyper thyroidism
hypo
-supplement synthetic thyroid hormone, monitor TSH levels periodically (bc of goiter)
hyper
-methimazole, radioiodine ablation (removal), thyroidectomy
54
what is addison's disease ? symptoms ? tx?
primary adrenal insufficiency (low cortisol)
- primary (most common): high ACTH and low cortisol due to autoimmune disease or TB, surgery, cancer cells affecting adrenals.
- symptoms: hyperpigmentation, salty food cravings, hypotension, fatigue, LOA, wt loss, low BG
tx: steroids
* *secondary: low ACTH and cortisol due to no ACTH release from:
1. suddenly stopping exogenous glucocorticoids (prednisone)
2. removal of ACTH-releasing tumors
3. pituitary problem causing low ACTH
55
what is an Addisonian crisis
- acute primary adrenal insufficiency appearing at time of stress (illness or surgery) causing sudden pain of the back and extremities, N/V
* *if lead untreated can be fatal
56
what is Cushings syndrome? symptoms ? tx?
- adrenal cortisol overproduction
- affects females > males
- signs: buffalo hump, moon face, purple striae, easy bruising, hirsutism in women
- symptoms: fatigue, back aches, swelling, irritability, repeated infections, poor wound healing, acne, hair loss, wt gain around abdomen
dx: overnight 1 mg dexamethasone suppression test (low dose) to confirm cushing SYNDROME, then do high dose test to confirm cushings disease. (exogenous cortisol in high doses should decrease ACTH production by negative feedback and therefore cortisol production if pituitary tumor is present; other tumor sources will not decrease cortisol production)
57
Cushings disease vs Cushings syndrome
Cushings syndrome = increased cortisol production that can be caused by endogenous or exogenous causes (big picture)
*low does dexamethasone test
Cushings disease is the most common cause of endogenous cortisol overproduction as a result of pituitary tumor (secondary adrenal hypercortisol production)
*high dose dexamathose test
58
adenomas are associated with
MEN 1
59
ACTH release triggers
adrenal glands to make cortisol and sex hormones
(adrenal gland makes glucocorticoids (cortisol) androgens (sex hormones) and mineralcorticoids (aldosterone ** not regulated by ACTH)
60
mass effect of pituitary tumors describes what
the side effects caused by tumor compression of cranial structures (i.e. optic chiasm compression causing double vision, loss of balance, seizures, and headaches)
61
most common cause of hyperprolactinemia? symptoms? tx? dx tool?
- pituatary adenoma (prolactinoma)
- symptoms : galactorrhea (breast milk discharge); menstrual irregularities; hypogonadism (low LH and FSH) ; erectile dysfunction ; infertility ; if large tumor it can cause vision problems and headaches from optic chiasm compression
dx: MRI
tx: dopamine agonist, surgery
62
definition of scoliosis ? what are the 3 classification ? most common?
lateral curve of spine greater than 10 degrees Cobbs angle with vertebral rotation greater then 7 degrees ( angle of trunk rotation: ATR > 7, cobb angle > 10)
dx: radiography allows cobb angle measurement
classifications:
1. idiopathic (infantile 0-2, juvenile 3-9, adolescent >10)
2. congenital
3, neuromuscular
most common : adolescent idiopathic scoliosis (AIS)
63
is scolisosis more common in men or women? how does family history affect dx?
- minor scoliosis (10 degrees) is equal in males and females
- women are 5-10 times more likely to progress to severe scoliosis that requires treatment
- if both parents have AIS then the child is 50X more likely to require treatment as compared to general population
64
what is the most common scoliosis screening test? describe the complications of screening for scoliosis (specifically AIS)
- Adam's forward bending test (w/ or w/o scoliometer) which is variably accurate
- the screening itself carries low risk to pt, however due to decreased use of radiographs and referrals bc of potential harm, risk, and expense, treatment of AIS based on screening can lead to moderate harm via unnecessary bracing.
- most cases detected through screening do not progress to clinically significant scoliosis
- scoliosis needing surgery is likely to be detected without screening
* *insufficient evidence to support balance of benefit and harm in screening for AIS in kids 10-18
*used to screen in schools
65
T/F
| fair evidence supports treating AIS offers only a small portion of patients a decrease in pain and disability
TRUE
66
```
these are examples of clinical presentations of what?
diastematomyelia (congential splitting of spinal cord)
syringomyelia (cavity in spinal cord)
tethered spinal cord
spinal tumor
neurologic symptoms
neurofibromatosis
unilateral cavus foot
```
scoliosis (AIS)
*unilateral cavus foot can be causes by intraspinal pathology
67
are leg lengths equal in scoliosis ?
yes, usually
68
what might you find in PE of scoliosis dx
adams forward bending test- scoliosis causes side bending of spine but the curve will cause spinal rotation and a rib hump which can be seen on PE
```
Others:
body tries to keep eyes level
shoulder height difference
posterior scapula
waist creasing
***legs usually same length
```
69
what is Risser sign? how is it graded? and describe Riser sign-progression prediction ?
Risser sign- measure of skeletal maturity by amount of calcification present in iliac apophysis; measures the progressive ossification from anterolaterally to posteromedially (ASIS to posterior iliac crest)
Grading:
Grade 1-25% ossification
Grade 4 - 100% ossification
Grade 5 - complete fusion of iliac apophysis to iliac crest after 100% ossification
prediction:
- (immature) grades 0-1 with CA 20-29 degrees have 70% probability of 6+ degree progression
- (mature) grades 2-4 with CA 20-29 degrees have 20% probability of degree progression
70
red flags of scoliosis that indicate use of MRI
1. onset before 8 y.o
2. severe pain
3. rapid curve progression (>1 degree/month)
4. unusual left thoracic curve (convex to the left)
5. neuro deficits (midline hairy patch, cafe au last spots)
*right thoracic curve is most common
71
treatment of scoliosis (as divided by Cobb angle severity)
mild: < 10-15 degrees = no tx (unless indicated progression); monitor
moderate: 25-45 degrees immature: {used to tx with brace, but no proof it helps progression}
USE:
1. milwaukee brace 23hr/day and exercise muscles
2. boston brace (for lordosis and scoliosis if apex of curve is below T10
3. charleston nighttime brace at night, as effective as #1
severe: > 45 in kids >50 in adults: tx requires surgery: Harrington rod placement and bone grafting for partial or complete correction; Posterior spinal fusion to prevent progression
72
> 50 cobb angle puts __ at risk; > 75 degree Cobb angle puts __ at risk
pulmonary compromise
cardiac compromise
73
6-12 weeks of pain b/t costal angles and gluteal folds that may radiate down one or both legs (sciatica)
non-specific low back pain
tx: bed rest not helpful if dx is nonspecific acute LBP; NSAIDS and non-BZD muscle relaxants are effective
74
what are the red flag symptoms associated in low back pain ? what does it represent
i hurt my back when i went: TUNA FISH -ing
- trauma
- unexplained wt loss
- neuro symptpms
- age >50
- fever
- IV drug use
- steroid use
- history of cancer (prostate, renal, breast, lung)
*indicates a benign episode from more significant problem needing urgent work up and tx. but still use whole person approach
75
herniated nucleus pulposus in the lumbar region will exert pressure on nerve root of which vertebrae and effect what structures based on spinal level? side effect? how to dx?
the vertebrae below; radiation of sharp burning pain down leg (sciatica) , and weakness in affected myotome (decreased reflexes) and dermatome (decreased sensation)
Dx: MRI
-compression of lumbar root = more leg pain vs back
L1-L3 = radiate to hip or thigh (spine structures)
L4-S1 = radiate below knee (SI Joint )
+ SLR ??!?!
76
where does spine structures (muscles , ligaments, facets, disks) refer pain? SI joint?
1. refers to thigh, not below knee
| 2. refers to thigh, and can go below knee
77
syndrome in which large central disc herniation compressing the tail of the lumbar spine, causes compression of sacral nerve roots is called what ? what are the side effects? tx?
cauda equina syndrome
- S2-S4 impingment = bowel/bladder dysfunction, decreased rectal tone, saddle anesthesia
- tx: emergent surgery (delay = irreversible paralysis)
78
defect in par interarticularis w/o anterior displacement
spondylolysis
*spondylolisthesis can be dx with lumbar SP "step off"
79
motor , sensory, reflex associated with L3
hip flex
anterior/medial thigh
patella
80
motor , sensory, reflex associated with L4
knee extension
anterior thigh, leg, and medial foot
patella
81
motor , sensory, reflex associated with L5
dorsiflex/ great toe
lateral leg/dorsal foot
medial hamstring
82
motor , sensory, reflex associated with S1
plantar flex
poster leg/ lateral foot
achilles
83
motor function of L3/L4 ; L4/L5 ; L5/S1
3/4- Squat and rise
4/5- heel walk
5/1 toe walk
84
no imaging recommended for LBP in first 6 weeks except
red flags present
85
dx of DM
fasting BG > 126
A1C > 6.5
random BG >200
86
conseqeunces of DM
nephropathy
neuropathy (symmetric stocking and glove pattern)
retinopathy
frequent infections (UTI, year, cellulitis)
vascular changes ( increased MI, stroke events)
poor wound healing
acanthosis nigracans (black neck)
87
A1C target for T1DM and T2DM
T1DM : <7.5
T2DM: <7
88
what is metabolic syndrome
(aka Syndrome X / insulin resistance syndrome)
- signs: insulin resistance, abdominal obesity, HTN, hyperlipidemia, low HDL
- risks increased age, increased body weight
- cause: (exact cause unknown) visceral fat causing oxidative stress and vascular damage leading to plaque formation (atherosclerosis), increased cortisol production from hormonal changes
- tx: exercise, diet, HTN control , cholesterol control
* related to increased cortisol production (Cushings syndrome )
* related to PCOS
* increased risk from some medications
89
what is the Beers criteria
for geriatric patients in assessing medications:
1. what meds to never use for this population
2. what meds are inappropriate for this population with certain medical conditions
3. what meds should be used with caution
90
what is the STOPP criteria
for geriatric patent medication assessment:
- similar to Beers criteria but includes:
1. drug - drug interaction
2. duplication of drugs in classes
*Screening tool of older persons prescriptions
91
what is the START criteria
- 22 evidence-based prescribing indicators in older persons
| * Screening tool to Alert the Right Treatment
92
how to do a medical assessment of geriatric patients
1. bring in all meds/ supplements (brown bag check)
2. ask what prescription, OTC, supplement meds do you use
3. review meds every visit
4. Use beers or STOPP criteria to prevent adverse events
5. "start low, go slow"
6. close follow up after starting new meds
93
what tools are useful to asses geriatric functional ability
* to test ability to perform ADL
1. Katz Index of Independence in ADL
2. Lawton instrumental ADL scale
94
how to perform a vision assessment for geriatric population
* no specific recommendation
- periodic Snellen Eye chart assessment
- opthalmologist referral for DM pt (retinopathy)
- opthalmaogost referral for pt with high risk of glaucoma (Family history)
- asses vision for driving safety
95
how to do a fall risk assessment for geriatric pt
* risk factors and intervention to prevent falls are multifactorial
- TUG test (timed get up and go test)
- Tinetti Balance and Gait evaluation
96
how to test mental cognition in geriatric pt
1. Neurologic PE including:
- mental status screening tool
- CN for vision screen
- cerebellar status/motor system
- strength
- sensation
- reflexes
2. Depression assessment
97
what is presbycusis
age related sensorineural hearing loss causing progressive symmetric loss of high frequency hearing from destruction of cochlear hair cells and ganglion cells in the vestibulocochlear N.
signs: progressive hearing loss, tinnitus, vertigo
dx: otoscope exam, audioscope exam, whispered voice test
tx: hearing aid, auditory rehab, cochlear implant
*review meds list for ototoxicity
98
compares types of urinary incontinence: stress, urge, overflow. and list other causes
stress-increase intra-abdominal pressure (sneezing) causing involuntary leakage
urge- detrusor muscle overactivity causing uninhibited involuntary detrusor M. contractions during bladder filling
overflow- continuous urine leakage from incomplete bladder emptying bc detrusor M. under activity or bladder outlet obstruction
Other: UTI, DM, constipation
99
osteoporosis assessment and tx
- women > 65 DEXA Scan
- women < 65 with high 10-yr fracture risk use FRAX fracture risk assessment tool
tx: lifestyle changes (fall prevention, alcohol moderation), bisphosphonate therapy, hormone therapy
100
what vaccines are important to check in vaccination assessment for geriatric population
1. tetanus (with pertussis)
2. flu
3. pneumonia
4. Herpes Zoster (shingles)
101
how to perform a social support assessment for geriatric pt
- obtain good social history
- obtain pts advance care directive/ health care power of attorney
- asses for caregiver abuse
- asses caregiver burnout/ depression
102
when does menarche occur in females
2-3 years after initiation of puberty usually around breast stage 3 or 4
103
how to document 23 y.o with 3 pregnancies and 3 live births
```
G3P3
(gravida= number of pregnancies)
(para = number of viable births)
**TPAL for expansion of "para"
-term deliveries (>37 weeks gestation )
-preterm deliveries
-abortions (< 20 wks)
-live delivery regardless of age
```
104
when are pap smears and mammograms given
pap smear- 21-65 y.o (cervical cancer screen)
- yearly if abnormal
- every 3 years if normal
- every 5 years if normal and negative HPV
* none if noncancerous hysterectomy; continued if cancerous hysterectomy
mammogram- 50 y.o. (earlier if high risk)
105
what sample is collected in a pap smear
1. ectocervix
2. endocervix
3. transitional zone
4. squamocolumnar junction
**TZ is most common area for precancerous lesions and cancer
106
how do ectopic pregnancies present ? what is workup?
- pelvic pain with vaginal bleeding
- may have other pregnancy related symptoms (N/V , breast tenderness)
workup: pregnancy test, speculum pelvic exam, if confirmed pregnant then do transvaginal ultrasound
107
what is included in a routine well male exam
- not a prostate or testicular exam
- not a prostate specific antigen exam (unless FH of prostate cancer)
* *these are done on if pt has signs and symptoms
NO ROUTINE MALE GENITAL EXAM
108
how does an male inguinal hernia present ? what is the workup? tx?
- pain with increasing intra-abdominal pressure
- may have palpable bulge on affected side
- invaginate scrotum and cough to feel indirect hernia
- work up: ultra sound imaging
- tx: mild-watch ; moderate to severe- surgical repair
109
what are the 5 P's of sexual history
1. Partners (gender, new, number in last year)
2. Protection (STI and HIV protection with condom)
3. Practices (how often use condoms, anatomic site of exposure)
4. pregnancy prevention
5. Past history of STI (pt and partners)
110
how does presentation trichomonasis (protozoa, with flagella) STD present? workup? tx?
- male: most asymptomatic; rare: discharge
- female: foul smelling thin pus discharge, vaginal itching (pruritus), dysuria
workup: wet mount (see flagella); or NAAT with vaginal /penile fluid
tx: antiprotozoal meds (metronidazole)
111
how does gonorrhea (gram neg-diplococci) present ? complications?
workup? tx?
male-penile discharge, pain with urination
female- pelvic pain, mucous vaginal discharge
complications: PID ; uterine tube scarring / infertility
workup: NAATs (nucleic acid amplification test)
tx: antibiotics, and counseling pt and partner
112
how does chlamydia present? complications? workup? tx?
* usually asymptomatic
- female: vaginal discharge, vaginal bleeding, dyspareunia, dysuria
- male: penile discharge, pruritus (itching), dysuria
complications: PID, uterine tube scarring/infertility
workup: NAAT
tx: antibiotic, counseling
113
how does symphilis (treponema pallidum, spirochete) present? complications? workup? tx?
- primary: chancre
- secondary: joint pain, lymphadenopathy, rash
- latent: asymptomatic
- tertiary: nuerosymphilis (confusion, vision loss, stiff neck)
complication: progression to neurosyphilis
- workup: serologic testing, antibody testing, microscopy (non/trepomenal test)
- tx: antibiotic (penicillin)
114
how does genital herpes present (HSV2)? complications? workup? tx?
* *viral DNA travels by axons to spinal cords sensory ganglion and remains for life
- single/cluster of vesicles on genitalia, burning/tingling/pain prior to vesicle appearance
complications: meningitis, PID, hepatitis, risk of HIV
workup: serologic test, PCR of lesion
tx: antiviral (acyclovir)
115
how does HPV present? complications? workup? tx?
- genital warts
complications: most strains don't, high risk strains = cancer of mouth or genitals
workup: pap smear, HPV testing
tx: gardasil vaccine, wart removal
116
nexus criteria
-determine those with neck pain who need imaging
(meets all = no imaging/cleared , doesn't meet all = collar pt and get imaging)
1. absence of posterior midline cervical tenderness
2. normal level of alertness
3. not intoxicated
4. no abnormal neuro findings
5. no painful distracting injuries
117
how to clear c-spine radiographically if NEXUS indicates radiograph
**(practically) CT of cervical spine needed to clear
radiograph (+) for injury = CT
films (-) but suspicious = CT
all studies negative but still suspicious = MRI
118
any neuro deficit related to spinal cord with signs of bilateral/distal weakness numbness, clumsy hands, gait problems, bowel/bladder dysfunction, sexual dysfunction
cervical myelopathy
| -emergent MRI
119
any neuro deficit occurring at or nerve nerve root with signs of sharp/burning pain at trapezius/scapular area/down arm, weakness or paresthesias can develop weeks after pain onset
cervical radiculopathy
- urgent workup
- nonemergent MRI
- tx: NSAIDs, OMM, PT
120
fever, malaise, headaches, photophobia, neck pain, petechiae purpura. + nuchal rigidity, kernigs sign, and brudzinki sign. caused by bacterial hemophilus, or strep pneumonia. dx by lumbar puncture
meningitis
| DX BY LUMBAR PUNCTURE
121
reflex testing: biceps
C5
122
strength testing: bicep /wrist extension
C6
123
strength testing: tricep/wrist flexion
C7
124
strength testing: deltoid, shoulder abduction
C5
125
strength testing: scapular elevation
C2-4
126
strength testing-finger flexion ? abduction?
C8
| T1
