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Articular structures

synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule and juxtaarticular bone

Deep or diffuse pain
Pain on active and passive movement
Limited range of motion on active and passive movement
Swelling
Crepitation
Instability
Locking
Deformity

1

Nonarticular structures

include supportive extraarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, overlying skin

Painful on ACTIVE range of motion
Focal tenderness in regions adjacent to articular structures
Have physical exam findings remote from joint capsule
Rare to have swelling, crepitus, instability, deformity

2

Osteoarthritis

*Most common MSK condition*

Crepitus with active motion: crunchy

Risk factors:
-age
-obesity
-female gender
-joint injury
-genetics

*Knee, hip, wrist (carpometacarpal squaring), hand carpometacarpal, DIP, PIP *(no synovitis, erythema, warmth), *only RA involves the MCP*), spine, shoulder (NFL touchdown sign is positive

Chronic pain, loss of function
*-Morning stiffness < 30 min*

Diagnose with history and physical

Xray: insensitive test, absence of findings does not rule out disease
*-asymmetric joint space narrowing*
-spur formation
-cortical bone thickening
-subchondral cysts

ACR criteria:
-cold effusion

3

Pes Anserine Bursitis

Pain just below knee at ateromedial aspect of tibia that occurs when exercising or climbing

4

Meniscal injury

Pain usually occurs acutely and is associated with trauma

Buckling and locking of knee

Tenderness over joint line

McMurray: clicking felt when knee compressed and rotated during varus and valgus; point knee towards shoulders while flexing

5

Trochanteric bursitis

Pain and tenderness over greater trochanter

Pain can radiate down thigh in some cases

Should do Xray to insure no other contributions

6

Biceps tendonitis

results from impingement or instability

Pain aggravated by lifting, pulling or repetitive overhead movements

Tenderness on palpation of biceps tendon with arm slightly externally rotated

7

Adhesive capsulitis

ROM limited on active and passive motion

Usually painless

Present with patient with chronic shoulder problems, seen in Parkinson's patients

Physically cannot raise arm
-should be able to get arm to T7-T8

8

Rotator Cuff Tendonitis

Pain is worsened activity and night

*Most common shoulder pain: 29%*

Usually no history of trauma

Should not have weakness (if weakness = tear)

9

Carpal Tunnel Syndrome

Nocturnal aching wrist
-pain with squaring of the palm
-bilateral hand numbness and tingling: *helps with shaking it out
-worse at night
-numbness along middle finger*

Risk:
-female
-obesity
-pregnancy

Tinel's = taping test
Phalen's = funny; 1 min; fingers pointed down, wrists facing each other

10

DeQuervain's Tenosynovitis

Exercise related involving extensive wrist and thumb action
-gripping/grasping like carry small children

Tenderness at anatomic snuff box

Finkelsteins maneuver to aid diagnosis

Women 30-50 yo

11

Rheumatoid arthritis

Need to check RF, anti-ccp, Xrays (periarticular osteopenia, erosion, *symmetric joint space narrowing*)

*Involves the MCP and PIP joints bilaterally*

*Symmetric polyarthritis with prolonged morning stiffness*

30% have normal labs

12

Psoriatic arthritis

*Dactylitis: finger like a sausage

Pencil in cup deformity on Xray*

Nail pitting is specific

Can precede skin findings by up to 10 years

13

Spondyloarthropathies

refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra itself

14

Acral lentiginous melanoma

with nail bed involvement the nail plate may have dark brown discoloration (due to melanin).

15

Beau's lines

transverse grooved (e.g. depressed) lines parallel to lunula occurring after serious *medical illness, post-surgical and/or severe infections*.

16

Clubbing

produced by soft tissue growth at the nail bed and identified by noting a greater anterior-posterior distance at the nail bed as compared to the same distance at the distal interphalangeal joint (also creates a nail-finger angle >180 degrees).

typically occurs in response to *thoracic disease, including cyanotic congenital heart disease, cystic fibrosis, pulmonary fibrosis, lung cancer, and severe hepatic cirrhosis* (with hepato-pulmonary syndrome). Although reported in severe *COPD, other pathology (e.g. lung cancer)* must be excluded before accepting COPD as the sole cause.

17

Koilonychia

(aka spooning of nail) - the nail curves upward away from nail bed (concave instead of the normal convex appearance). This is a classic finding in *iron deficiency anemia/malnutrition.*

18

Lindsay's nails

also termed half-and-half nails, the proximal portion of the nail is pale/whitish while the distal 20-60% of the nail is brown, pink or reddish.

*Associated with renal failure and hyperkalemia (abnormal heart rhythms, peaked T waves with QRS widening*
-administer calcium

19

Mees' lines

transverse white band parallel to the lunula.

Originally described with arsenic intoxication, may also be seen with thallium as well as after acute medical conditions such as lymphoma and malaria.

Most common etiology is following *cancer chemotherapy (a poison of sorts) and arsenic poisoning*

20

Muehrcke's lines

two or more paired transverse white bands associated with severe *hypoalbuminemia* (usually < 2.2 g/dL).

21

Nail pitting

small depressions in nail that are present in up to 50% of patients with *psoriasis* (usually more severe cases).

22

Onycholysis

irregular separation of the nail plate from the hyponychium. Can be traumatic in origin, but also seen in *psoriasis and hyperthyroidism/Graves's*

23

Periungual fibroma

(aka Koenen tumor) - flesh-colored papule of nail folds (toes > hands) seen in ~50% of patients with tuberous sclerosis (see below under skin).

24

Quitter's nail

heavy cigarette smoking leads to orange-brown discoloring of the nails and fingers holding the cigarette. A normal proximal nail with distal discoloration indicates smoking cessation - chronicity of abstinence can be estimated by understanding that nail growth is 0.8 - 1.0 mm per week.

25

Splinter hemorrhages

small brown or red streaks perpendicular to the lunula, and often involving the distal nail. These are most commonly traumatic in origin, but classically a consequence of *microembolism from infectious endocarditis*. They are also reported in scleroderma and trichinosis.

26

Terry's nails

proximal paleness of nail with only 1-2 mm of preserved pink distal border (appears dark).

-originally described with *liver cirrhosis, TB, heart failure,* but can also be seen in other severe medical conditions (e.g. heart failure, poorly controlled diabetes, hepatitis).

27

Arachnodactyly (aka spider fingers)

long fingers that are associated with Marfan syndrome. The wrist circumference is less than the distance encompassed by the subject's 5th finger and thumb.

28

Bouchard's node

bony protuberance of proximal IP joint without findings of inflammation - this is a finding in osteoarthritis.

29

Boutonniere deformity

produced by extension at the distal IP joint and flexion at the proximal IP joint - *a finding in severe, chronic rheumatoid arthritis*.

30

Dupuytren's contractures

shortening of the finger flexors in the palm, may be idiopathic in origin but also associated with alcohol abuse and alcoholic cirrhosis

31

Heberden's node

bony protuberance of distal IP joint without findings of inflammation - this is a finding in *osteoarthritis*.

32

Janeway lesion

painless red macular lesion of palms/soles produced by embolism, usually due to *infectious endocarditis*

33

Joint hypermobility

ability to dorsiflex 5th finger > 90 degrees with forearm flat and/or passive apposition of the thumb to the flexor aspect of forearm; these findings suggest classic *Ehlers-Danlos syndrome*

34

Large, fleshy hands

consider acromegaly if rings no longer fit

35

Mechanic's hands

thickened, cracked and dirty-appearing palmar skin mimicking those of a manual laborer suggests the *anti-synthetase syndrome variant of dermatomyositis*.

*consider lung disease, internal cancer, or autoimmune*

Subtype of dermatomyositis

36

Osler node

originally described in *subacute bacterial endocarditis*, these are painful red raised lesions of the ventral surface of fingers/toes caused by *immune complex deposition*

37

Pallor

Nail beds and palms is associated with *severe anemia* (hemoglobin < 7.0 g/dL)

however, the conjunctivas are a better site for assessment

38

Swan neck deformity

produced by extension at the proximal IP joint and flexion at the distal IP joint - a finding in *severe, chronic rheumatoid arthritis*

39

Actinic keratosis

pre-malignant lesion typically seen over sun-exposed areas.

Tips of ears, face, back of hands, pre-cancerous

40

Basal cell carcinoma

*low grade cancer* with typical appearance: papule with translucent and "umbilicated" border, central ulceration and telangiectasia

*Pearl colored papula*

41

Dermatomyositis

♣ Gottron's papules/sign - red, often scaly papules over the *MCPs and PIPs* - the term Gottron's sign is applied to similar finding of the fingers, elbows and knees.
♣ Heliotrope rash - violet discoloration of upper eyelids
♣ Shawl sign - widespread, flat, reddened area over upper back, shoulders and posterior neck
♣ V sign - similar to shawl sign, except that reddened skin conforms to a V-neck sweater pattern of the anterior chest

Internal malignancies

42

Gottron's papules

red, often scaly papules over the MCPs and PIPs - the term ________ sign is applied to similar finding of the fingers, elbows and knees.

43

Heliotrope rash

violet discoloration of upper eyelids

44

Shawl sign

widespread, flat, reddened area over upper back, shoulders and posterior neck

**Dermatomyositis**

45

V sign

similar to shawl sign, except that reddened skin conforms to a V-neck sweater pattern of the anterior chest

**Dermatomyositis**

46

Hyperextensibility

defined as ability to stretch the skin >4 cm at forearm or neck before feeling resistance; this is a finding in *Ehlers-Danlos syndrome*

47

Hyperpigmentation

must consider the patient's background race/ethnicity and sun exposure.

diffuse ____________ may be seen with primary adrenal failure (aka Addison's disease), hemochromatosis and hyperthyroidism

48

Livedo reticularis

mottled/reticulated, red-blue *lacy skin discoloration* with central pallor *associated with small vessel vascular processes including vasculitis*

**-anti-phospholipid syndrome
-cholesterol embolism syndrome**

49

Malar rash

one of the diagnostic criteria for *systemic lupus erythematosus* (and the genesis of the term lupus: Latin for wolf)

50

Melanoma

malignant tumor of melanocytes with multiple manifestations (e.g. lentiginous, nodular).

occur on skin without striking sun exposure (e.g. vulva) and remember ocular site.

Depth determines prognosis
-most malignant skin cancer

51

Neurofibromas

non-tender, soft, fleshy, sessile or pedunculated skin tumors - if present in great number should consider *Von Recklinghausen's disease and seek café-au-lait macules and axillary freckles (aka Crowe sign)*

Axillary freckling with Lisch nodules = 100% specific

52

Psoriasis

common disease (1-2% of population) most commonly manifested as red plaques with silvery scales of the extensor surfaces of arms and legs, as well as trunk and scalp. Other types include guttate, pustular, inverse and erythrodermic

53

Squamous cell carcinoma

often occur on sun-exposed skin (70%) and also associated with chronic scarring and inflammation, these usually begin as a nodule that often grows into a fungating lesion.

Develops from actinic keratosis

54

Thin skin with visible small vessels

a finding in Ehlers-Danlos syndrome type 4, a condition associated with arterial rupture (e.g. aortic dissection)

55

Tuberous sclerosis

characteristic skin findings include hypopigmented, often elliptical macules (aka ash-leaf spots), flesh-colored or red papules of central face that may mimic acne vulgaris (angiofibromas - previously adenoma sebaceum), periungual fibromas and Shagreen patch (flesh-colored, orange-peel-like connective tissue plaque, usually located on the lower back)

*patients usually have epilepsy, cognitive and neuropsychiatric disorders, an increased risk of cancer, a distinctive renal lesion (angiomyolipoma) and a risk of developing cystic lung disease* (confirm with TSC gene test).

56

Vitiligo

focal loss of melanin usually due to autoimmune condition; consider other autoimmune conditions

Consider hashimotos thyroiditis

57

Xanthomas

(tuberous, eruptive and tendon) - nodular, papular and tumorous lesions
-*collection of cholesterol and found in hyperlipidemia (familial variants)*

*Early atherosclerosis*

58

Blastomycosis

skin is the 2nd most common organ involved; the lesions may appear verrucous, ulcerate and closely mimic squamous cell cancer

Only present for weeks to months

59

Ecthyma gangrenosum

hemorrhagic vesicles or pustules that evolve into necrotic ulcers, these are a manifestation of infectious vasculitis due to *Pseudomonas aeruginosa bacteremia*.

60

Erythema chronicum migrans

painless, rounded, slowly expanding red lesions with central clearing (may be target-like) at site of tick bite in early Lyme disease.

Treat with antibiotics

61

Herpes zoster

manifestation of recurrent VZV (herpes) infection, begins with burning dysesthesias of involved dermatome followed in a few days by *vesicular dermatomal rash that does not cross the midline*. Over time the rash will crust and fade, but the neuropathic pain may persist for many weeks.

62

Lupus vulgaris

(aka tuberculous chancre) - due to *primary bacillus inoculation (TB)* in non-sensitized host, it usually involves the face and hands, often in the setting of previous local minor trauma. *Begins as a nodule that ulcerates with induration*.

63

Secondary syphilis

multiple presentations, rash often involves the palms and soles.

64

Bell's palsy

an idiopathic disorder of the Facial nerve (CN 7) producing unilateral facial weakness including an inability to close the eye.

65

Bilateral ptosis

unusual finding that signals neuromuscular weakness - disorders to consider include myasthenia gravis, Miller-Fisher variant of Guillain-Barre syndrome and botulism.

66

Corneal reflex

using a cotton wisp the examiner's hand approaches from lateral aspect (avoiding being seen) and lightly strokes the cornea over the sclera; this is predominantly a test of sensation via ophthalmic division of Trigeminal nerve (CN 5), but Facial nerve (CN 7) fibers involved in efferent limb of reflex.

67

Deep tendon reflexes

• test the peripheral nerve (e.g. lower motor neuron), motor unit and upper motor neuron input with 2+/4 being normal. Hyper-reflexive responses (≥3+/4) can be seen diffusely with hyperadrenergic states (e.g. hyperthyroidism, amphetamine use) and focally with upper motor neuron disease, as the latter exert an inhibitory effect on lower motor neurons. Hyporeflexia occurs with neuropathy, acute spinal disease, lower motor neuron damage/disease and neuromuscular junction disease such as myasthenia gravis (and poor technique).

o Clonus is the term given to repeated contraction after elicitation of the deep tendon reflex, indicating extreme hyper-reflexia (aka 4+/4)
o Hypothyroidism (picture) is associated with a slow relaxation phase of the deep tendon reflex.

68

Clonus

term given to repeated contraction after elicitation of the deep tendon reflex, indicating extreme hyper-reflexia (aka 4+/4)

69

Hypothyroidism

associated with a slow relaxation phase of the deep tendon reflex.

o Coarse, dry hair and skin with loss of lateral eyebrows
o Moderate weight gain and myalgia
o Bradycardia
o Cold intolerance
o Constipation
o Deep tendon reflexes with slow relaxation phase (aka Woltman sign)

70

Cortical stroke

hemiplegia/paresis usually indicates a vascular etiology for the weakness.

80% caused by ischemia (most in the carotid artery distribution), produce weakness in a predictable pattern based on the arrangement of the cortical motor strip (see slideshow). Hand and face have large representation due to their multiple complicated actions; as such, there tends to be involvement of both with often relative sparing of the lower extremity.

usually involve sensory cortex, and often areas serving speech (deficit = aphasia).

71

Lacunar stroke

typically produce pure motor (or pure sensory) deficits.

*Upper face involvement differentiates cortical stroke*

Pathologically are infarcts of small penetrating arterioles that effect the radiation (or white matter projections) of the cortical neurons, and as such, a relatively small lesion can effect a larger distribution (e.g. upper and lower extremity) without sensory deficit or other indication of a cortical event.

72

Transient ischemic attack (TIA)

may involve different mechanisms: 1) Low flow states due to large artery occlusion; 2) Small emboli, which can be from large artery or heart (two most common sources); or 3) Lacunar from stenosis of a small penetrating vessel.

may involve the anterior circulation (carotid arteries) or the posterior circulation (vertebral and basilar arteries), and the symptoms will reflect such. By definition resolves within 24 hours and identifies a patient at high risk of stroke. It is essential that these patients be evaluated promptly.

73

Doll's eyes

(aka oculocephalic reflex) - this is a test of brainstem, Vestibulocochlear nerve (CN 8) and semicircular canal function that should be performed in comatose patients only. Manually raise both eyelids and move the head side-to-side - the eyes should move in tandem; failure to do so implies damage to one or more of structures above.

74

Frontal release signs

Reflect primitive reflexes in patients with diffuse frontal lobe pathology (e.g. Alzheimer's dementia)

-palmomental reflex: stroking the thenar area of the hand causes a reflex contraction ipsilaterally of the orbicularis oris and mentalis muscles
-suck reflex: sucking movements by the lips when they are stroked or touched
-snout: puckering or protrusion of the lips with percussion
-grasp reflex: the examiners hand is placed softly into patient's palm during distraction - stroking of the patient's palm produces a grasp by the patient that persists with movement

75

Cerebellar ataxia

*wide-based, unsteady, *lateral veering (e.g. multiple sclerosis, tumor of cerebellum)

76

Sensory ataxia

Loss of proprioception*, such that the patient substitutes visual and nociceptive clues in an attempt to maintain stability. This produces the *"stamp and stick" gait (cannot orient body in space, stomp feet on the ground)*

*Causes include B12 deficiency, tabes dorsalis and other causes of posterior column disease.*

77

Festinating gait

*shuffling steps with rigidity*; lower body appears to be chasing upper body - this is the classic gait of *Parkinson's disease.*

78

Equine gait (or steppage gait)

*inability to dorsiflex foot *(e.g. trauma to peroneal nerve, *Charcot-Marie-Tooth disease*)

79

Plantar reflex

nociceptive (aka painful) reflex commonly elicited by firmly stroking the plantar surface of the foot from posterior to anterior. The normal response is flexion of the toes. Extension (aka Babinski reflex) is normal in the newborn, but is otherwise pathologic, indicating a problem with upper motor neurons. Common etiologies include cortical stroke, spinal cord disease from B12 deficiency, and occasionally from drug-induced encephalopathy.
o Triple flexion is the ultimate Babinski reflex with extension and fanning of the toes, dorsiflexion at the ankle, and flexion at the knee and hip

80

Triple flexion

ultimate Babinski reflex with extension and fanning of the toes, dorsiflexion at the ankle, and flexion at the knee and hip.

81

Pronator drift

*Test of subtle upper motor neuron disease (e.g. suspect cortical stroke with borderline weakness). *

The patient is instructed to hold arms out, palms upward and then close eyes. Patients with unilateral weakness have the effected limb drop with simultaneous pronation. Other diagnoses that may be suggested including, 1) malingering - the involved limb drops without pronation and 2) posterior column disease - the involved limb may "search" for the other limb, such as by moving superiorly.

82

Romberg test

tests posterior column function (e.g. position sense), initially used as a test of tabes dorsalis (tertiary syphilis). The patient is instructed to stand with feet together, and after stable to close eyes. Healthy persons can usually stand this way with eyes closed for 60 seconds

83

Action (or postural) tremor

becomes evident with action and includes hyperadrenergic (e.g. cocaine use, hyperthyroidism), physiologic, alcohol withdrawal and essential tremor.

84

Resting tremor

occurs in posture of repose and suppressed with activity; *classic "pill-rolling" tremor of Parkinson's disease* *(usually disappears with activity and complete relaxation).*

85

Intention tremor

appears with action and worsens as goal is reached; cause relates to *cerebellar disease*.

86

Abducens palsy

presents as an inability to abduct the involved eye. This nerve has a relatively long course in the subarachnoid space and cavernous sinus, and as such, may be involved by meningeal processes (e.g. infectious meningitis), diseases associated with neuropathy (e.g. diabetes mellitus), cavernous sinus diseases (e.g. carotid artery aneurysm, rhinocerebral mucormycosis) and diseases that cause increased intracranial pressure (e.g. brain tumor).

87

Arcus senilis

white corneal ring associated with hyperlipidemia in patients < 40 years of age (normal finding in older patients).

88

Argyll Robertson pupil

caused by damage to the Edinger-Westphal nucleus, this was originally described in neurosyphilis. The pupils are small and do not react to light but do constrict (if closely examined) to the accommodation maneuver.

89

Blue sclera

although rarely reported in other entities, this finding strongly suggests osteogenesis imperfecta, a disease associated with recurrent bone fracture, short stature, scoliosis, hearing loss and skin laxity.

90

Cotton wool spot

white retinal lesion reflecting a micro-infarct, this can be seen in many diseases including *diabetes and hypertension*.

91

Diabetic retinopathy

Microaneurysms and intraretinal microhemorrhages (aka dot and blot changes - see slideshow), cotton wool spots, flame hemorrhages, and vessel proliferation

Only secondary papilledema.

92

Hollenhorst crystal

a small bright lesion in a small retinal artery indicating cholesterol embolization and atherosclerosis.

93

Holmes-Adie syndrome

part of a systemic neurologic syndrome manifested as an *irregular dilated pupil that has a delayed constriction to light*.

Initially unilateral, this *frequently progresses to involve both eyes and can be associated with a lack of deep tendon reflexes (areflexia)*.

*involves denervation*

94

Hypertensive retinopathy

Microvascular effects.

Papilledema in conjunction with the other findings denotes grade IV.

95

Internuclear ophthalmoplegia (INO)

this disorder is produced by damage to the medial longitudinal fasciculus running in the brainstem - this is not a cranial nerve palsy!

*The exam finding is the inability to adduct the involved side* - it may be unilateral or bilateral - there may be nystagmus of abducting eye.

Multiple sclerosis is the most common cause, but brainstem stroke and rarer pathology can potentially produce this finding.

*Unilateral: stroke
Bilateral: MS or other demyelinating diseases*

96

Marcus Gunn pupil

(afferent pupillary abnormality) - the involved eye does not react to light directly but does constrict to light directed to the opposite eye (consensual response) - see slideshow.

97

Oculomotor palsy

1) a downward and laterally deviated eye, 2) unilateral ptosis and 3) dilated pupil (mydriasis).

The parasympathic fibers mediating pupillary constriction tend to run on the outside of the nerve, and the fibers innervating extraocular muscles in the nerve core.

can occur with nerve core infarction (spares pupillary function) or early in the course of external compression (only a "blown" pupil)

*Down and out palsy*

eye deviated laterally and inferiorly (down and out) - may also have dilated pupil and ptosis. *Causes include uncal herniation (greatest fear), diabetes, infarct*

98

Papilledema

blurring of the optic disc margins produced by increased pressure transmitted through the optic nerve. As such, any disorder leading to increased intracranial pressure (ICP) may produce this: hypertensive crisis (aka malignant hypertension), brain tumor or abscess, meningitis

Retinal vein occlusion can produce findings without increased ICP.

99

Roth spot

representing hemorrhage within a cotton wool spot, this finding was initially described in **infective endocarditis, but also can be seen in systemic lupus, diabetes and leukemia** (and others).

100

Xanthelasma

yellowish subcutaneous lipid collection adjacent to medial canthus of eye that is indicative of hyperlipidemia/collection of cholesterol.

Consider athlerosclerosis with high risk of progression if Hollenhorst crstal is found

101

Aphthous ulceration

painful lesion of unknown etiology, often triggered by minor trauma. They are shallow and white-centered with erythematous border.

Behcet's disease is a multisystem disorder with diffuse mucosal _________________, systemic vasculitis and CNS involvement.

102

Coating

caused by accumulation of dead cells and microbial colonization (often correlated with illness, poor oral intake and lack of oral hygiene). Other diagnoses to consider include *candidiasis (aka thrush) - often with burning pain*, leukoplakia (see below) and secondary syphilis (aka condyloma lata).

103

Epiglottitis

*classically caused by H. influenza infection in childhood, this is a medical emergency*.

*Look for thumb sign on Xray*

The patient will have a *sore throat, difficult phonation, dysphagia, odynophagia, dyspnea and drooling*. Exam reveals a red, enlarged epiglottis. Get immediate surgical consultation and do not swab the area - you may precipitate acute airway occlusion!

104

Epistaxis

(nosebleed) - the nasal mucosa is very vascular and subject to frequent local trauma and inflammation, explaining the frequency of its occurrence.

divided into anterior and posterior sites: anterior bleeding presents at the nares in the upright person, while posterior bleeding drains through the pharynx where it may be "coughed" up.

Most cases will be benign in origin, but as with any clinical bleeding, the patient should be queried about possible bleeding diathesis (e.g. cirrhosis, anticoagulant medication, blood dyscrasia). Recurrent bleeding may also be a clue to more serious local pathology (e.g. tumor, vasculitis).

105

Frank's sign

(aka diagonal earlobe crease) - has been *associated with coronary artery disease (CAD)* and peripheral vascular disease, the associated relative risk for this sign is debated, although bilateral, deep creases may convey a higher risk.

106

Gingival hyperplasia

*the most common cause is chronic use of phenytoin (Dilantin®, seizure medication)*. Other drugs to be considered include calcium channel blockers and cyclosporine. Leukemic infiltration (due to acute myelogenous leukemia) may mimic this condition.

107

Atrophic Glossitis

an abnormality of the tongue resulting in inflammation (often painful), there are multiple causes (often benign disorders). Chronic glossitis with atrophy may be a clue to a more *widespread nutritional disorder* (e.g. vitamin and mineral deficiency). Look for other signs of *nutritional deficiency (e.g. angular cheilitis, anemia, peripheral neuropathy, dermatitis)*.

Smooth tongue due to loss of papillae

Tongue may be painful or painless

108

Gorlin sign

the ability to touch the nose with tongue occurs in ~50% of subjects with Ehlers-Danlos syndrome, but < 10% of normal subjects can perform this feat

109

Hoarseness

encompassed change in voice character or strength and implies pathology of the vocal cords. This may be due to focal damage/neoplasm or nerve damage.

Persisting beyond (3) weeks demands evaluation, including in most cases direct laryngoscopic examination.

110

Kaposi sarcoma

immunocompromised patients (esp. AIDS) may develop this neoplasm related to Human Herpes Virus 8 infection. It appears as raised or flat purple-red lesions anywhere on the oral mucosa (e.g. gingiva, tongue, palate).

111

Koplik's spot

white lesion on a red base found on the buccal mucosa and lips in measles.

112

Lead lines

actually a series of grey-black dots observed 1 mm from the free margin of the gum.
-heavy metal toxicity, including lead, bismuth, mercury, gold, silver, thallium and copper
-not seen where teeth are absent.

113

Leukoplakia

these are pre-malignant lesions associated with tobacco use. Hairy __________ is a lesion generally found on the lateral aspect of the tongue in immunocompromised patients, esp. HIV/AIDS. This lesion reflects Epstein-Barr Virus induced epithelial hyperplasia. Unlike oral ____________ this is not pre-malignant. *Discovering hairy ____________ in a patient should suggest HIV testing if status unknown*.

Oral:
White plaques anywhere on the oral mucosa
A response to chronic irritation, a pre-malignant lesion
Should be biopsied

Hairy:
Corrugated white lesion seen on the lateral aspect of the tongue
Reflects EBV-induced epithelial hyperplasia
*Suspect HIV/AIDS*

114

Lemierre's syndrome

(aka septic jugular vein thrombophlebitis) - usually begins as pharyngitis due to *Fusobacterium necrophorum infection that invades tissue and spreads to the carotid sheath, producing the septic thrombosis of the jugular vein (resides in sheath).

Patients present with fever, neck stiffness and dysphagia*. Important exam findings are tenderness over jaw angle and sternocleidomastoid muscle. The infected thrombus may embolize to lung producing mass lesions that may cavitate (aka septic pulmonary embolism).

115

Ludwig's angina

(aka submandibular space infection) - begins as an infection of mandibular teeth with extension into submandibular space. Expanding infection of this space elevates the floor of the mouth and tongue leading to airway compromise.

116

Macroglossia

(aka large tongue) - most commonly due to trauma or inflammation from caustic ingestions or allergic reactions (e.g. angioedema); however, can also be a finding in hypothyroidism, acromegaly and amyloidosis.

117

Nasal pruritis

(aka Wartenburg symptom) - intense and unrelieved __________ has been associated with brain tumor, esp. with involvement of the floor of the 4th ventricle.

118

Nasal septal perforation and saddle nose deformity

processes that destroy the nasal cartilages produce these findings, including intranasal cocaine abuse, Granulomatosis with polyangiitis (formerly Wegener's granulomatosis), congenital syphilis, sarcoidosis and relapsing polychondritis (red ear). The saddle nose deformity is a depression over the nasal bridge caused by collapse of the underlying cartilage.

119

Parotitis

these glands may be inflamed and tender in multiple conditions including viral infections (e.g. mumps), inflammatory conditions (e.g. sarcoidosis, systemic lupus erythematosus), and many others.

Unilateral swelling, tenderness, and fever
-a condition caused by an impacted calculus usually seen in chronically ill patients (*Staph. aureus is the usual causative organism*). Painless parotid and lacrimal gland enlargement is a finding in alcoholism.

120

Pharyngeal exudate

Although *Streptococcus pyogenes (group A, β-hemolytic) is the best known pathogen*, fusobacterium, EBV, gonorrhea, and other pathogens are considerations. Most cases occur in children, where the child presents with abrupt fever, sore throat, headache, and difficulty swallowing.

Exam findings include the classic triad of objective fever, _______________, and tender anterior cervical adenopathy.

*Untreated there is a risk of rheumatic fever*.

121

Pharyngeal pseudomembrane

typically caused by **Corynebacterium diphtheria infection**, this disease can be confused with more common causes of pharyngitis.

*This complication can be life threatening as it may obstruct the airway*.

CM:
Fever, sore throat, weakness and odynophagia
Grayish membrane formation is very specific (but less sensitive)
**Complications include myocarditis, neuritis and death due to airway obstruction**

Other findings include *cervical adenopathy (bull's neck), fever, weakness, heart failure, neuropathy and malodorous breath. Throat culture should identify the pathogen*.

122

Rhinorrhea

(aka "runny nose") - may be part of acute rhinitis occurring in the context of viral infection, or be non-infectious in origin (i.e. allergic rhinitis).

CSF _______ is a rare and serious condition to consider in the setting of prior facial/skull injury or surgery - this reflects a fistula between the nose and subarachnoid space, and as such places the patient at risk for bacterial meningitis.

123

Tooth tenderness

use a tongue blade to assess
-dental caries could be present

also a useful finding if tooth abscess is suspected, such as in a diabetic with unexplained ketoacidosis. *Maxillary teeth may also be tender when maxillary sinusitis* is present.

Acute sinusitis:
A complication of sinus ostia obstruction (e.g. nasal polyp)
Symptoms: facial and maxillary tooth pain; sinus congestion
Exam: facial and maxillary tooth tenderness; abnormal transillumination
Complications: periorbital cellulitis, meningitis, subdural empyema, cranial sinus thrombosis

124

Tragus sign

tenderness with depression of _________ *suggests otitis externa *(as will pulling on the involved pinna), usually a bacterial infection of the epidermis of the ear canal. These signs are not present with otitis media (differential feature).

Pulling on ear elicits pain = otits externa

125

Vertigo

the feeling of unsteadiness with motion, most often rotary in nature. The patient may fall down or have great difficulty remaining upright during the symptom. Associated symptoms may include nausea, pallor, and sweating.

dysfunction of the vestibular system is present. This includes the inner ear structures, CN VIII, and the brainstem.

drug and alcohol use should be assessed.

126

Gout

caused by uric acid crystal deposition in joint, this disease usually begins acutely with intense pain and inflammatory joint finding. 90% of patients have great toe involvement. Rarely occurs in premenopausal women.

127

Pes anserine bursitis

produces pain with exercise and/or stair climbing inferior to knee at antero-medial aspect of tibia; tenderness to percussion over bursa is clinically confirmatory

128

McMurray test

palpable clicking with knee compression and rotation during varus and valgus stress; positive test indicates meniscal injury (acute onset of pain, often with trauma, buckling or locking sensation)

129

Drawer sign

knee flexed to 90 degrees and examiner pulls lower leg anteriorly; ability to move leg > 1 cm is consistent with anterior cruciate ligament tear

130

Drop arm test

the patient raises arm to 90 degrees of abduction and lower it slowly. A suddenly dropped arm is considered positive and suggestive of a rotator cuff tear.

131

Adhesive capsulitis

Reduced passive and active range of motion (ROM), usually painless

Positive Touchdown Sign is expected: inability to fully raise effected arm

132

Bicipital tendonitis

pain aggravated by lifting, pulling or overhead movements; confirmatory test is palpation tenderness over bicipital tendon

133

Phalen's test

Carpal Tunnel Syndrome test

compression of wrists together (flexed) for 60 seconds produces pain/paresthesia in median nerve distribution (positive test)

134

Tinel's sign

Carpal Tunnel Syndrome test

percussion over the median nerve produces pain/paresthesia in median nerve distribution (positive test)

135

Finkelstein maneuver

pain elicited by flexing thumb into palm, closing fingers over thumb, then bending wrist in ulnar direction; a confirmatory test in DeQuervain's tenosynovitis (also look for tenderness at anatomic snuffbox)

136

Acanthosis nigricans

**Diabetes findings**

finding of hyperpigmented, velvety plaques most often seen in intertriginous areas (e.g. axilla). Although more commonly seen in insulin-resistant states, it can be a paraneoplastic finding of internal malignancy.

commonly associated with insulin resistance.

137

Chloroma

soft tissue mass, typically greenish in color (due to myeloperoxidase), reflecting extramedullary myeloblastoma (collection of primitive granulocytic precursors)

**manifestation of acute myelogenous leukemia**

138

Hyperviscosity syndrome

may occur with high level paraproteinemia (e.g. multiple myeloma, Waldenstrom's macroglobulinemia), hyperleukocytosis from acute myelogenous leukemia or severe polycythemia;

patients present with *mucosal bleeding, visual disturbance, neurologic findings* (e.g. altered sensorium) and often cardiorespiratory findings. The *main physical findings relate to etiology, evidence of bleeding diathesis (e.g. ecchymoses) and retinal vein engorgement and segmentation.*

139

Sign of Lesar-Trelat

paraneoplastic process of abrupt appearance of multiple seborrheic keratosis *reflecting internal malignancy*

140

Sister Mary Joseph's node

(aka periumbilical adenopathy) - described in patients with abdominal or pelvic neoplasm (e.g. ovarian cancer).

141

Superior vena cava syndrome

although originally described with syphilitic aortic aneurysm, currently most likely due to malignant mediastinal adenopathy (e.g. lung cancer, lymphoma).

facial plethora (red-blue discoloration and swelling), chest wall neovascularity (in chronic cases), jugular vein distention and papilledema (due to retinal vein hypertension) - findings may be precipitated/accentuated by raising both arms (Pemberton's sign - large thyroid goiters inlet may also have this sign

142

Tripe hand

paraneoplastic finding of thickened and velvety-white palmar skin that indicates cancer in approx. 90% of cases.

143

Trousseau's sign

*migratory superficial thrombophlebitis in the setting of malignancy*, esp. pancreatic carcinoma.

*medical sign observed in patients with low calcium*.[1] This sign may be positive before other manifestations of hypocalcemia such as hyperreflexia and tetany,

144

Unilateral scleral icterus

metastatic melanoma (ocular melanoma results in eye enucleation and subsequent glass prosthesis - melanoma has propensity for liver metastasis).

145

Virchow's node

(aka *left supraclavicular adenopathy*) - is malignant in 90% of patients > 40 years of age, and usually indicates *cancer below the diaphragm, including common sites such as gastric, pancreatic, prostate and testicular*.

146

Stocking-glove sensory neuropathy

Diabetes findings

typically symmetric and correlated with poor glucose control. Patients may develop foot ulcers over metatarsal heads (pressure points) and Charcot joints (repeated damage due to joint anesthesia).

147

Necrobiosis lipoidica diabeticorum

Diabetes findings

pretibial lesion occurring in < 1% of diabetics, it begins as a well-circumscribed plaque with waxy-appearing center with telangiectasia

148

Addison's disease

o Diffuse hyperpigmentation (ACTH involvement), including scars and oral mucosa
o General asthenia (aka weakness)
o Psychiatric symptoms, including depression, schizophrenia and bipolar illness
o Enhanced olfaction, taste and hearing
o Low blood pressure
o Weight loss
o Hirsutism

149

Cushing's disease

o Buffalo hump, truncal obesity, peripheral edema and thin extremities
o Skin - abdominal striae , thin skin with easy bruising
o Rounded "moon" facies
o Gynecomastia
o Amenorrhea and hirsutism in women
o Hypertension may be present

150

Acromegaly findings

o Large and thick hands - should ask regarding rings that no longer fit
o Characteristic facies, including enlarged mandible and frontal bone prominence
o Visual field abnormalities may be present due to large pituitary adenoma - classically bitemporal anopsia
o May have heart failure findings (most common cause of death)

151

Hyperthyroidism

o Lid lag - examiner asks patient to look up and then rapidly downgaze; lid lag present if sclera can be seen between iris and lid (due to high sympathetic tone of levator palpebrae muscle) - this is not the same as proptosis!
o Tremor - fine tremor ("action" tremor) due to hyperadrenergic state
o Smooth, velvety skin
o Heat intolerance
o Diarrhea and weight loss
o Onycolysis (see above under nails)
o Tachycardia, may have findings of high-output heart failure (e.g. leg edema, increased JVD, S3)
o Deep tendon reflexes are very rapid

152

Pemberton's sign

facial plethora produced by raising both arms can be seen in large thyroid goiters that extent into thoracic inlet (also seen with SVC syndrome)

153

Graves' disease

autoantibody that stimulates thyroid hormone production.

*Lid lag*

These patients have findings of hyperthyroidism, but additionally may have *proptosis (due to soft tissue accumulation behind globe), thyroid gland enlargement and pretibial myxedema *(localized, non-pitting, infiltrative dermopathy occurring in ≤ 5% of patients with autoimmune thyroid disease).

154

Paget's disease

eczematoid change of the nipple associated with underlying invasive carcinoma.

155

Peau d'orange

(French for orange peel) - dimpled, firm breast due to lymphatic invasion by breast carcinoma (aka **inflammatory breast carcinoma**).

156

Scrotal transillumination

scrotal lesions that include hydrocele: increased fluid around the testis, spermatocele and varicocele.

157

Testicular torsion

acute, unilateral scrotal pain usually occurring in adolescent due to sudden twisting of spermatic cord producing testicular ischemia. The involved testicle is tender, edematous and indurated; elevation of testicle does not relieve pain.

Order a scrotal ultrasound

158

Testicular cancer

non-tender, solid ________ mass is assumed to be cancer until proven otherwise.

most common solid cancer in men 15-35 years of age.

Enlarged Virchow's node: left supraclavicular node, location of mets from cancers below the diaphragm

159

Varicocele

common condition due to *dilatation of pampiniform plexus of spermatic veins, recognized as scrotal enlargement that feels like "bag of worms"*.

Usually asymptomatic and more often left-sided, *it can be a cause of infertility. Rarely may signal left renal cell carcinoma* if cancer invades left renal vein and impedes left testicular venous drainage.

Testicular atrophy and infertility

*Much more common on the left side: drains directly into renal vein, reveals renal cancer* or nephrotic syndrome with renal vein thrombosis
-could be due to aortic dilation

160

Genital warts

reflecting papilloma virus (HPV) infection, this is a sexually transmitted disease and a risk factor for penile carcinoma (and for cervical cancer in sex partners).

161

Herpes simplex lesion

usually occurs in the form of *multiple painful vesicles* due to HSV-2 infection; primary infection occurs about 6 days after exposure and is very painful with associated dysuria, fever, inguinal adenopathy and headache (occasionally with frank viral meningitis). Recurrent disease has milder symptoms. Asymptomatic patients may shed virus and transmit disease with sexual contact. The attack rate is 70% in sero-negative exposed subjects.

Can spread the lesion even if it asymptomatic

162

Paraphimosis

inability to replace a retracted foreskin; typically a very painful condition, this can be a *medical emergency as increasing penile edema will result in penile ischemia and necrosis if not reduced*

163

Penile cancer

*squamous cell carcinoma in most*, begins as a painless papule that progresses. HPV DNA is found in 30-50% of lesions.

164

Phimosis

inability to retract foreskin, this is a strong risk factor squamous cell carcinoma of the penis

risk factor for penile cancer

165

Syphilitic chancre

*painless lesion occurring* ~21 days after exposure reflecting site of spirochete entry. Begins as a solitary papule that ulcerates, it is indurated and without exudate. It will heal in 4-8 weeks without treatment.

166

Direct inguinal

usually due to congenital weakness in abdominal wall musculature, the hernia proceeds directly through abdominal wall. The hernia sac will touch the side of the examining finger in the inguinal canal.

Does not enter the inguinal canal
-goes directly through the abdominal wall

167

Indirect inguinal

usually acquired and more common in elderly and obese man, the hernia proceeds indirectly into scrotal sac via the inguinal canal. The hernia sac will touch the tip of the examining finger in the inguinal canal.

Transabdominally through the inguinal canal

168

Femoral hernia

*more common in women*, this hernia occurs through the femoral canal and is *inferior to the inguinal ligament* (latter feature differentiates this from above inguinal hernias).

169

Palpable kidneys

normal kidneys are not palpable (except in extremely thin individuals)

found in adult polycystic kidney disease, renal cell carcinoma, angiomyolipoma (tuberous sclerosis) and xanthogranulomatous pyelonephritis.

170

Costo-vertebral angle tenderness

due to swelling of renal capsule and elicited by percussion with medial aspect of fist, this is *most commonly due to pyelonephritis*, but can also be caused by hydronephrosis.

171

Uremic frost

white powdery dusting of the skin most common in patients with severe renal failure with* BUN > 200 mg/dL* (reflects crystallized urea from sweat).

172

Large V waves

Jugular vein findings

suggest tricuspid regurgitation, as the incompetent valve allows a pressure deflection occurring during systole (where the X descent should occur).

173

Large (aka "cannon") A waves

Jugular vein findings

produced by atrial contraction on a closed tricuspid valve, these waves signify atrial-ventricular dissociation.

174

Kussmaul's sign

**Rise in JVD during inspiration**, this has been associated with constrictive pericarditis, right ventricular infarction, massive pulmonary embolism (likely related to RV infarction) and restrictive cardiomyopathy

175

Bounding pulse

Carotid pulse findings

classic for aortic regurgitation, but can also be present in pregnancy, hyperthyroidism, exercise, hyperadrenergic states, anemia, Paget's disease of bone and "wet" beriberi.

176

Pulsus parvus et tardus

Carotid pulse findings

slow rising carotid pulse of low amplitude associated with severe aortic valve stenosis.

177

Double-peaked pulse

Carotid pulse findings

may be due to severe heart failure, pericardial tamponade and constriction (aka dicrotic pulse - the 2nd peak occurs after S2), and bisferious pulse in hypertrophic obstructive cardiomyopathy (the 2nd peak occurs before S2).

178

Point of maximal impulse (PMI)

Precordial palpation

normally dime-sized and on the mid-clavicular line (MCL) in the 5th intercostal space. Cardiac dilation (e.g. systolic heart failure) causes lateral deviation and enlargement with a prolonged impulse. Hypertrophic heart disease (e.g. hypertensive, aortic stenosis, cardiomyopathy) may cause a prolonged PMI with an occasional palpable atrial contraction (equivalent to an S4 - see below). Emphysema and aging often make the PMI unappreciable.

179

Thrill

Precordial palpation

palpable finding suggesting blood movement in significant systolic cardiac murmurs and vascular bruits. Murmurs associated with thrills are graded as ≥ 4/6 intensity.

180

Left lower sternal pulsation

Precordial palpation

(aka heave) - suggests right ventricular hypertrophy; may be better appreciated in chest hyperexpansion (e.g. COPD) with subxiphoid palpation.

181

Pulmonary impulse

Precordial palpation

appreciated by palpation in the left 2nd ICS, associated with pulmonary artery dilation (usually due to pulmonary hypertension).

182

Aortic insufficiency murmur

a diastolic murmur heard best along the left lower sternal border. To maximize detection, the patient should be sitting up and leaning slightly forward, use diaphragm of stethoscope and have the patient exhale and transiently stop breathing.

183

Carvallo's sign

increased intensity of heart sounds of right-sided origin during inspiration (due to increased RV preload).

184

Fourth heart sound (S4)

also a low frequency sound best appreciated with the bell of the stethoscope, the S4 is produced by atrial contraction into a stiff, non-compliant ventricle (a late diastolic sound) - an S4 indicates cardiac hypertrophy (4-H). As for the S3, the S4 can be left- or right-sided. The rhythm of the S4 gallop has been described as TEN-NES-SEE (S4-S1-S2).

185

Murmurs

due to increased flow, the valvular structure may be pathologic or normal, the latter occurring with exercise, anemia, hyperthyroidism and late pregnancy. Murmurs should be characterized as systolic or diastolic and right- or left-sided (see Carvallo's sign). Murmurs whose mechanism involves left ventricular systolic pressure (e.g. aortic stenosis and regurgitation, mitral regurgitation) will be higher frequency sounds and will be heard best with the diaphragm of the stethoscope By contrast, murmurs generated by lower pressure (e.g. mitral stenosis and most right-sided valve lesions) will be best heard best with the bell of the stethoscope.

186

Pericardial friction rub

classic finding in pericarditis of any cause (specific, but < 100% sensitive). Auscultation reveals rough, sandpaper-like sound that typically has 3 components corresponding to atrial contraction, ventricular systole and early diastolic filling - can sound like an old-fashioned washing machine.

187

Rheumatic mitral stenosis

the classic early diastolic rumble heard best at the cardiac apex, in the left lateral decubitus position, and with the bell of the stethoscope. Mitral stenosis may have a preceding sharp-sounding opening snap early in diastole (due to the opening of a stiff mitral valve under pressure) and a presystolic (late diastolic) murmur due to atrial contraction producing flow across the stenotic valve.

188

Second heart sound (S2)

a high frequency sound reflecting the closures of the aortic and pulmonic valves. Because the left ventricle depolarizes 1st, the aortic component of the second heart sound (A2) comes before the pulmonic (P2) - this is the origin of the physiologic splitting of S2. Situations leading to delayed ejection of right ventricular blood (e.g. during inspiration, right bundle branch block, pulmonic stenosis) will increase the splitting of S2, but there should be variation in the width of the split with the respiratory cycle (even with the pathologies noted above). However, there is one notable entity with a widely split S2 that does not vary with the respiratory cycle (aka fixed): atrial septal defect. Disorders that delay left ventricular ejection (e.g. left bundle branch block, severe aortic stenosis) will decrease the splitting of S2, and in severe cases may actually produce a paradoxical split of S2 (e.g. increased split during expiration). Pulmonary hypertension may produce an accentuated S2 (due to a louder P2), and a mechanical aortic valve will produce a loud, unmistakable S2.

189

Third heart sound (S3)

a low frequency sound best appreciated with the bell of the stethoscope produced by rapid, early ventricular filling of a dilated ventricle (an early diastolic sound) - an S3 indicates cardiac dilation (3-D). Third heart sounds may be left- or right-sided, which can be differentiated by location and Carvallo's sign. The rhythm of the S3 gallop has been described as KEN-TUCK-Y (S1-S2-S3).

190

Amaurosis fugax

this refers to transient monocular vision loss due to a small retinal artery embolism, often described as a "shade being lowered" in the involved eye. This symptom is by definition transient because infarction of the retina doesn't occur. However, this is a very worrisome symptom often due to carotid artery stenosis and demands prompt evaluation.

191

Aortic coarctation

congenital stenosis of thoracic aorta that produces hypertension proximal to stenosis.

***Blood pressure may be different in the upper extremities (if stenosis proximal to left subclavian artery) but will always be lower if taken in the leg***

Chest radiography should reveal **rib notching over the inferior aspects** (due to intercostal artery hypertrophy).

Risk for heart failure and stroke

192

Aortic regurgitation

Quincke's pulse - intermittent capillary bed flush with pressure to the nail bed

Corrigan's pulse (or water-hammer pulse) - bounding radial pulse that is accentuated by raising the wrist

Müller's sign - pulsatile uvula

193

Quincke's pulse

Aortic regurgitation

Capillary pulsation, as shown by alternate reddening and blanching of the nailbed with each heartbeat; it is a sign of arteriolar dilation and aortic insufficiency

intermittent capillary bed flush with pressure to the nail bed

194

Corrigan's pulse

Aortic regurgitation

(or water-hammer pulse) - bounding radial pulse that is accentuated by raising the wrist

195

Müller's sign

Aortic regurgitation

pulsatile uvula

196

Chronic limb ischemia or chronic arterial insufficiency

**Due to atherosclerosis**

constellation of findings include:
-skin atrophy and reduced hair
*-reduced pulses*
-*lower leg dependent rubor (redness when lowering leg)
-pallor with elevation*
**-claudication: pain of working musculature**
-bruits: femoral, popliteal
-**painful foot and toe ulcers/gangrene**

Risk factors:
-smoking
-male sex
-diabetes
-hypertension
-lipid disorders

197

Claudication

**Pain of active musculature due to ischemia (leg)**

**Associated with cholesterol embolism/atherosclerotic plaque and vision loss**

hallmark symptom of large vessel peripheral vascular disease

peripheral vascular correlate of angina, reflecting vascular narrowing

Progressively less exertion needed for symptoms

***1) relief with rest (usually requires a few minutes), and 2) reproducibility with similar exertion.***

198

Cullen's sign

periumbilical ecchymoses seen in conditions with retroperitoneal hemorrhage, including:
-***ruptured abdominal aorta aneurysm***
-hemorrhagic pancreatitis
-ruptured ectopic pregnancy
-primary retroperitoneal bleeding

199

Grey-Turner's sign

flank ecchymoses seen in conditions with retroperitoneal hemorrhage, including:
-***ruptured abdominal aorta aneurysm***
-hemorrhagic pancreatitis
-ruptured ectopic pregnancy
-primary retroperitoneal bleeding

200

Homan's sign

calf pain induced by passive dorsiflexion of the ankle; this is an insensitive sign of deep vein thrombosis

201

Jaw claudication

ischemia-related pain of the muscles of mastication that occurs with chewing and relieved with rest

**Specific finding for temporal arteritis**

202

Raynaud's phenomenon

Vascular spasm of the small arteries, the hands are painful and undergo color change

Changes include white (spasm), followed by blue (cyanosis due to prolonged ischemia), and finally red (reperfusion after relaxation of spasm).

Provocative factors include cold temperature and emotional upset. On exam the ulnar and radial artery pulses should be normal.

-may occur as a part of a systemic collagen vascular disease (e.g. scleroderma) or as a primary disease

**May develop digital gangrene

Radial and ulnar pulses should be normal**

203

Unequal arm pulses

**Acute: dissection + embolization
Chronic: atherosclerosis**

-atherosclerosis
-aortic coarctation proximal to subclavian artery takeoff
-aortic dissection
-Takayasu's arteritis
-**subclavian steal syndrome**: subclavian stenosis producing *ipsilateral* retrograde vertebral artery flow, *syncope, dizziness*, visual, and cerebellar changes

symptoms (when they occur) tend to involve ischemia of the ipsilateral arm during work, esp. overhead work, and posterior circulation cerebral ischemia (e.g. dizziness, vertigo, syncope, dysarthria, visual loss and diplopia).

204

Venous insufficiency

edema, hyperpigmentation and ulceration of the ankle area

Chronic = pulses are normal

**Not associated with gangrene/ulcers**

205

Chest auscultation

o Coarse or wet crackles - inspiratory sounds that are produced by fluid oscillating in small airways, these sounds can be heard in pneumonia, florid heart failure and other entities.
o Fine crackles - inspiratory sounds suggesting opening of small airways, can be seen with interstitial lung disease, bronchiolitis and heart failure. Sometimes described as "Velcro-like" when occurring late in inspiration, this would be more suggestive of lung fibrosis.
o Pleural rub - finding in pleuritis and caused by inflamed visceral and parietal pleura rubbing together during inspiration. It is a rough/coarse sound that should be sought at point of maximal pain (ask the patient where it hurts most and listen there).
o Rhonchi - lower-pitched sounds suggesting secretions in larger airways, also may be inspiratory or expiratory. Rhonchi are typical of bronchitis and bronchopneumonia.
o Wheezes - high-pitched musical sounds suggesting narrowed small airways, may be inspiratory or expiratory (latter more common). Although typical of asthma, many other diseases manifest wheezing (e.g. bronchiectasis, heart failure) and not all asthmatics wheeze.

206

Coarse or wet crackles

Chest auscultation findings

inspiratory sounds that are produced by fluid oscillating in small airways, these sounds can be heard in pneumonia, florid heart failure and other entities.

207

Fine crackles

Chest auscultation findings

inspiratory sounds suggesting opening of small airways, can be seen with interstitial lung disease, bronchiolitis and heart failure. Sometimes described as "Velcro-like" when occurring late in inspiration, this would be more suggestive of lung fibrosis.

208

Pleural rub

Chest auscultation findings

finding in pleuritis and caused by inflamed visceral and parietal pleura rubbing together during inspiration. It is a rough/coarse sound that should be sought at point of maximal pain (ask the patient where it hurts most and listen there).

209

Rhonchi

Chest auscultation findings

lower-pitched sounds suggesting secretions in larger airways, also may be inspiratory or expiratory. _______ are typical of bronchitis and bronchopneumonia

210

Wheezes

Chest auscultation findings

high-pitched musical sounds suggesting narrowed small airways, may be inspiratory or expiratory (latter more common). Although typical of asthma, many other diseases manifest wheezing (e.g. bronchiectasis, heart failure)

211

Dahl's sign

above the knee, patches of hyperpigmentation or bruising caused by constantly resting hands or elbows to improve inspiratory mechanical advantage in patients with severe COPD/emphysema.

212

Dextrocardia

if the patient has chronic respiratory symptoms should consider Kartagener's syndrome: bronchiectasis, sinusitis, infertility and situs inversus (due to microtubule defect).

213

Hoover's sign

recognized as inspiratory inward motion of inferior rib cage, this indicates severe lung hyperexpansion (e.g. severe emphysema).

214

Lupus pernio

(sarcoidosis finding) - usually multiple papular and nodular red-violet lesions involving the central face, these lesions tend to recur after treatment, and are usually associated with respiratory tract involvement.

215

Pectus excavatum

depressed sternum that can produce restrictive thoracic impairment, dyspnea and apparent cardiomegaly on chest x-ray (artifact due to cardiac compression between spine and sternum).

216

Respiratory failure

o Paradoxical breathing - with the patient supine the chest and abdomen normally rise together; however, with respiratory failure they become dyssynchronous and ultimately paradoxical due to fatigue of the diaphragm. Paradox may also be seen with bilateral diaphragmatic paralysis. Should not confuse with reverse paradox seen with low cervical spinal cord injury (e.g. diaphragm contracts but chest wall moves inward due to denervation).
o Accessory muscle use - with diaphragm fatigue the scalene, sternocleidomastoid and trapezius muscles are recruited to assist inspiration (in roughly that order).
o Diaphoresis - produced by high sympathetic tone (e.g. sympathetic cholinergic nerves).

217

Paradoxical breathing

Respiratory failure findings

with the patient supine the chest and abdomen normally rise together; however, with respiratory failure they become dyssynchronous and ultimately paradoxical due to fatigue of the diaphragm. Paradox may also be seen with bilateral diaphragmatic paralysis. Should not confuse with reverse paradox seen with low cervical spinal cord injury (e.g. diaphragm contracts but chest wall moves inward due to denervation).

218

Accessory muscle use

Respiratory failure findings

with diaphragm fatigue the scalene, sternocleidomastoid and trapezius muscles are recruited to assist inspiration (in roughly that order).

219

Diaphoresis

Respiratory failure findings

Unusual sweating due to a drug or disease state
-produced by high sympathetic tone (e.g. sympathetic cholinergic nerves).

220

Stridor

auscultatory inspiratory squeaks and/or rhonchi heard over the trachea, this sound correlates with narrowing of airway above thoracic outlet (e.g. laryngeal edema).

221

Tracheal shift

should be assessed above suprasternal notch (e.g. not laryngeal position); shift implies either volume loss on the side toward the shift (e.g. atelectasis, lung resection, obstructing tumor) or increased intrapleural pressure on the side away from the shift (e.g. tension pneumothorax, massive pleural effusion or hemothorax)

222

Cutaneous hyperesthesia

pain upon gently picking up abdominal wall skin; associated with acute appendicitis.

223

Murphy's sign

splinting and increased tenderness on inspiration upon palpation of the right upper quadrant (RUQ) in acute cholecystitis.

224

Obturator sign

internal rotation of the flexed hip causes hypogastric pain when inflammation overlies the fascia of the obturator internus muscle (described in acute appendicitis).

225

Psoas sign

the patient lies on the side opposite the suspect pathology while the examiner extends the thigh to full extent; alternatively the patient can be asked to actively flex the thigh against pressure. A positive __________ (pain on extension) denotes inflammation overlying the psoas muscle (described in acute appendicitis)

226

Rebound tenderness

quickly releasing pressure during deep abdominal palpation yields diffuse abdominal pain, associated with diffuse peritoneal inflammation (e.g. peritonitis from ruptured viscus).

227

Referred pain from biliary colic

the pain of biliary colic is typically epigastric or RUQ in location and is referred to an area just inferior to the right lower scapular border.

228

Rovsing's sign

pain in the RLQ upon pressure to LLQ suggests acute appendicitis

229

RUQ tympani

usually dull to percussion, tympanic percussion over the liver (in setting of acute abdominal pain) should suggest a significant amount of intraperitoneal air due to ruptures viscus.

230

Desmoid tumor

Gastrointestinal bleeding findings

a tumor of fibroblasts that can be superficial or intra-abdominal; if present with multiple colonic polyps suggests Gardner's syndrome (variant of Familial Adenomatous Polyposis syndrome).

231

Large midline abdominal surgical scar

Gastrointestinal bleeding findings

may indicate prior open abdominal aortic aneurysm repair, which if present suggests the possibility of aorto-enteric fistula - the leak typically occurs at the suture line (less likely with endovascular repair) and involves the distal duodenum in ~75%.

232

Mucosal hyperpigmentation

Gastrointestinal bleeding findings

dark spots on lips and buccal mucosa (due to melanin accumulation) indicates Peutz-Jeghers syndrome, which produces hamartomatous and adenomatous GI polyps, the latter are a risk for colon cancer and GI bleeding.

233

Telangiectasia of mucosa

Gastrointestinal bleeding findings

may indicate hereditary hemorrhagic telangiectasia syndrome (aka Osler-Weber-Rendu), an autosomal dominant syndrome of diffuse mucosal and visceral telangiectasia - abnormal vessels in GI tract produce blood loss and iron deficiency anemia.

234

Gastrointestinal bleeding

o Desmoid tumor - a tumor of fibroblasts that can be superficial or intra-abdominal; if present with multiple colonic polyps suggests Gardner's syndrome (variant of Familial Adenomatous Polyposis syndrome).
o Large midline abdominal surgical scar - may indicate prior open abdominal aortic aneurysm repair, which if present suggests the possibility of aorto-enteric fistula - the leak typically occurs at the suture line (less likely with endovascular repair) and involves the distal duodenum in ~75%.
o Mucosal hyperpigmentation - dark spots on lips and buccal mucosa (due to melanin accumulation) indicates Peutz-Jeghers syndrome, which produces hamartomatous and adenomatous GI polyps, the latter are a risk for colon cancer and GI bleeding.
o Telangiectasia of mucosa - may indicate hereditary hemorrhagic telangiectasia syndrome (aka Osler-Weber-Rendu), an autosomal dominant syndrome of diffuse mucosal and visceral telangiectasia - abnormal vessels in GI tract produce blood loss and iron deficiency anemia.

235

Liver disease and cirrhosis

o Abdominal wall vein distention - commonly found in portal hypertension due to cirrhosis, this can also be seen in SVC syndrome and IVC occlusion, but the direction of flow is different for all these conditions.
o Alcoholism - findings may include Dupuytren's contractures, lacrimal and parotid gland enlargement (see above).
o Asterixis - non-specific finding in metabolic encephalopathy (also seen in uremia, hypercarbic respiratory failure and drug overdose), the patient is asked to extend hands at the wrist (e.g. the policeman's stop!) and hold in this position. The patient intermittently loses extensor muscular tone producing a flapping motion (aka liver flap) - this is not a tremor.
o Caput medusa - due to portal hypertension and porto-systemic venous collateralization in cirrhosis, these large periumbilical veins suggest the head of the doomed goddess.
o Cutaneous vasculitic rash - in the setting of hepatitis C must consider mixed cryoglobulinemia, a vasculitis causing glomerulonephritis and immune complex-related small vessel vasculitis.
o Diffuse hyperpigmentation - a finding in hemochromatosis, a multisystem disease due to iron overload; other findings include cardiomyopathy, diabetes mellitus, poly-endocrine hypofunction (e.g. hypogonadism) and osteoarthritis of hands.
o Feminization: gynecomastia and testicular atrophy - also due to high estrogen level in cirrhosis
o Kayser-Fleischer ring - brown corneal ring due to copper deposition that is specific for Wilson's disease, usually requires slit lamp exam to appreciate.
o Palmar erythema - due to increased serum estrogen in cirrhosis (liver metabolizes poorly) and most prominent over thenar and hypothenar eminences (also seen in late pregnancy).
o Scleral icterus - usually not visible until total bilirubin is 2-2.5 mg/dL
o Shifting dullness - a finding indicating ascites (due to portal hypertension)
o Spider angiomas - also due to high estrogen in cirrhosis, red lesions caused by neovascularity - lesions blanch with central pressure; not found below the chest.
o Splenomegaly - due to portal hypertension (see Castell's sign below)

236

Abdominal wall vein distention

Liver disease and cirrhosis findings

commonly found in portal hypertension due to cirrhosis, this can also be seen in SVC syndrome and IVC occlusion, but the direction of flow is different for all these conditions.

237

Alcoholism

Liver disease and cirrhosis findings

findings may include Dupuytren's contractures, lacrimal and parotid gland enlargement

238

Asterixis

Liver disease and cirrhosis findings

non-specific finding in metabolic encephalopathy (also seen in uremia, hypercarbic respiratory failure and drug overdose), the patient is asked to extend hands at the wrist (e.g. the policeman's stop!) and hold in this position. The patient intermittently loses extensor muscular tone producing a flapping motion (aka liver flap) - this is not a tremor.

239

Caput medusa

Liver disease and cirrhosis findings

due to portal hypertension and porto-systemic venous collateralization in cirrhosis, these large periumbilical veins suggest the head of the doomed goddess

240

Cutaneous vasculitic rash

Liver disease and cirrhosis findings

in the setting of hepatitis C must consider mixed cryoglobulinemia, a vasculitis causing glomerulonephritis and immune complex-related small vessel vasculitis.

241

Diffuse hyperpigmentation

Liver disease and cirrhosis findings

a finding in hemochromatosis, a multisystem disease due to iron overload; other findings include cardiomyopathy, diabetes mellitus, poly-endocrine hypofunction (e.g. hypogonadism) and osteoarthritis of hands.

242

Gynecomastia and testicular atrophy

Liver disease and cirrhosis findings

due to high estrogen level in cirrhosis

243

Kayser-Fleischer ring

Liver disease and cirrhosis findings

brown corneal ring due to copper deposition that is specific for Wilson's disease, usually requires slit lamp exam to appreciate.

244

Palmar erythema

Liver disease and cirrhosis findings

due to increased serum estrogen in cirrhosis (liver metabolizes poorly) and most prominent over thenar and hypothenar eminences (also seen in late pregnancy).

245

Scleral icterus

Liver disease and cirrhosis findings

Eye involvement usually not visible until total bilirubin is 2-2.5 mg/dL

hepatobiliary disease, brisk hemolysis

246

Shifting dullness

Liver disease and cirrhosis findings

a finding indicating ascites (due to portal hypertension)

247

Spider angiomas

Liver disease and cirrhosis findings

due to high estrogen in cirrhosis, red lesions caused by neovascularity - lesions blanch with central pressure; not found below the chest.

248

Splenomegaly

Liver disease and cirrhosis findings

Spleen enlargement due to portal hypertension

*Spleen should move with the diaphragm because it is in peritoneal cavity*
-renal masses do not change position with respiration

249

Castell's sign

the examiner percusses the most inferior interspace on the left anterior axillary line (Castell's point, which is usually tympanic) while the patient deeply breathes: the sign is negative if the percussion remains tympanic throughout the respiratory cycle. Castell's sign is positive when percussion changes from tympanic to dull during the respiratory cycle, indicating splenomegaly.

250

Courvoisier's sign

an enlarged, non-tender gallbladder indicating extra-hepatic biliary obstruction, most commonly due to carcinoma of the pancreatic head.

251

Steatorrhea

quintessential finding in malabsorption; malodorous stool that is difficult to flush - other reported findings are less reliable: floating stool, greasy appearance.

252

Miosis

usually narcotic-related, but consider pontine stroke, neurosyphilis and Wernicke's encephalopathy

253

Mydriasis

sympathomimetic drugs (e.g. cocaine), medullary stroke, anticholinergic drugs (e.g. atropine, belladonna)

254

Anisocoria

normal (< 0.5 mm difference), anticholinergic drops, CN 3 palsy, Holmes-Adie syndrome, Horner's syndrome, glaucoma crisis

255

Nephrotic syndrome

Periorbital edema in diffuse edematous state

256

Bilateral lacrimal gland enlargement

alcoholism (usually with parotid enlargement), Sjogren's syndrome, sarcoidosis, others

257

CN 6 Palsy

failure to abduct - increased intracranial pressure (e.g. meningitis, tumor), meningeal process, cavernous sinus process, diabetes

258

Internuclear ophthalmoparesis (INO)

problem with medial longitudinal fasciculis, MS (demyelinating disease, electric shock symptoms Lhermitte's sign), diabetes, sarcoidosis, plaques in the brain

failure to adduct - brainstem stroke, multiple sclerosis, diabetes, others

259

Horner's syndrome

Ipsilateral involvement of sympathetic chain

anhydrosis (only sweat on one side of face), miotic, ptosis

260

Unilateral proptosis

retro-ocular tumor, periorbital and/or cavernous sinus infection

261

Scleritis

Rheumatoid arthritis, vasculitis, deep vessel inflammation, others

262

Glaucoma crisis with corneal edema

Cloudy/steamy cornea

263

Dysarthria

Disorder of coordination of muscles of speech

Causes:
-cortical stroke
-cerebellar disease
-peripheral neuropathy

264

Expressive aphasia

Difficulty forming words with preserved understanding

Lesion in inferior frontal cortex (Broca's)

265

Receptive aphasia

Fluent speech devoid of meaning due to lack of comprehension of language

Caused by lesion in superior temporal lobe (Wernicke's area)
-interpretation area

266

Anomic aphasia

Primary problem naming objects: present in most aphasias

267

Stroke

Generally presents with unilateral weakness

268

Pancreatic disease

.

269

Anterior Pituitary tumor

.

270

Esophageal web

Presents with dysphagia and anemia

Due to iron deficiency

271

Pica

Eating rocks, dirt, soap to account for iron deficiency anemia

272

Ehlers-Danlos Syndrome

Hypermobility of joints and hyperflexible skin

273

Articular damage

Deep or diffuse pain
Pain on active and passive movement
Limited range of motion on active and passive movement
Swelling
Crepitation
Instability
Locking
Deformity

274

Non articular damage

Painful on ACTIVE range of motion
Focal tenderness in regions adjacent to articular structures
Have physical exam findings remote from joint capsule
Rare to have swelling, crepitus, instability, deformity

275

Monoarticular arthritis

Joint degradation due to:
-crystalline (gout/pseudogout)
-infectious (septic, Lyme disease)
-traumatic hemarthrosis

276

Oligoarticular arthritis

2-4 joints involved

Joint degradation due to:
-gonorrhea
-spondyloarthropathy/connective tissue disease (RA, lupus)
-osteoarthritis

277

Diffuse Polyarthritis

Joint degradation due to:
-acute viral infections
-RA, lupus
-spondyloarthropathy

278

Weber test

Tests for conductive hearing loss: normally heard at midline
-sound can localize at certain ear for abnormal test

279

Rinne Test

Compares sound conduction of air to bone

Normally air > bone conduction
-function of tympanic membrane apparatus

280

Sinus transillumination

Fluid in sinus does not transilluminate well

Specificity is poor

281

Keloid

Exuberant scar formation following skin trauma

282

Polychondritis

Inflamed external ear

severe, episodic, and progressive inflammatory condition involving cartilaginous structures, predominantly those of the ears, nose, and laryngotracheobronchial tree. Other affected structures may include the eyes, cardiovascular system, peripheral joints, skin, middle and inner ear, and central nervous system.

pathogenesis is autoimmune. The evidence for an autoimmune etiology includes pathological findings of infiltrating T cells, the presence of antigen-antibody complexes in affected cartilage

283

Ramsay hunt syndrome

Zoster of the geniculate ganglion with facial nerve palsy

284

Mastoiditis

.

285

Purulent otitis media

usually caused by bacterial infection:
S. pneumonia, S. pyogenes, S. aureus, H. influenza

Symptoms are earache and fever - a possible long-term sequelum is conductive hearing loss
Mastoiditis occurs with extension of infection

286

Serous Otitis Media

.

287

Nasal cavity polyps

Soft, jelly-like overgrowths produced in patients with sinus inflammation (e.g. allergic rhinitis)
Produce symptoms through obstruction (e.g. sinusitis, anosmia)
Asthma is a frequent concomitant condition

288

Oral cancer

Mostly squamous cell carcinoma

Strong relationship with tobacco use, alcohol, and HPV

289

Candidiasis (thrush)

A painless white plaque usually involving the tongue and/or palate
Difficult to scrape off
Predisposing conditions: *steroid use, diabetes, immunocompromised states (HIV/AIDS)*
Process may spread to pharynx and esophagus, where pain may occur

Risk factors for secondary syphilis

290

Extraocular eye movements

.

291

Myxedema

Hypometabolic state due to thyroid hormone deficiency

Insidious onset; often not noticed by the patient

Symptoms:
Cold intolerance
Modest weight gain
Loss of libido; easy fatigability

Exam findings:
Apathetic facies
Coarse hair and skin
Lateral loss of eyebrows
Large tongue
Bradycardia
Delayed relaxation phase of DTR

292

Seminoma

germ cell tumor of the testicle or, more rarely, the mediastinum or other extra-gonadal locations. It is a malignant neoplasm and is one of the most treatable and curable cancers, with a survival rate above 95% if discovered in early stages.

Will not transilluminate

293

Spermatocele

abnormal sac (cyst) that develops in the epididymis — the small, coiled tube located on the upper testicle that collects and transports sperm. Noncancerous and generally painless,

294

Hydrocele

fluid-filled sac surrounding a testicle that causes swelling in the scrotum.

Common in newborns and usually disappears without treatment during the first year of life.

Older boys and adult men can develop symptoms due to inflammation or injury within the scrotum.

Usually isn't painful or harmful and might not need any treatment.

295

Renal cell carcinoma

kidney cancer that originates in the lining of the proximal convoluted tubule

Palpable kidneys

296

Adult Polycystic Kidneys

Palpable kidneys

*Cysts vary in size and, as they accumulate more fluid, they can grow very large*.

Although kidneys usually are the most severely affected organs, *can cause cysts to develop in your liver and elsewhere in your body*. The disease causes a variety of serious complications.

*AD inheritance

Associated with:
-recurrent abdominal pain
-hematuria
-hypertension
-renal stones
-50% of patients develop renal failure by age 60
-5-10% have cerebral anaerysms which may present as subarachnoid hemorrhage.*

297

Angiomyolipomas in tubular sclerosis

most common benign tumor of the kidney and are composed of blood vessels, smooth muscle cells and fat cells.

Strongly associated with the genetic disease tuberous sclerosis

Caused by mutations in either the TSC1 or TSC2 genes, which govern cell growth and proliferation

298

Xanthogranulomatous pyelonephritis

Palpable kidneys

chronic inflammatory disorder of the kidney characterized by a destructive mass that invades the renal parenchyma.

most commonly associated with Proteus or Escherichia coli infection

299

Impetigo

Due to *staph or group A strep (could cause post strep glomerulonephritis)*

300

Henoch-Schonlein purpura

Vasculitis of small vessels

Look for RBC casts: acute glomerulonephritis

301

Oxalate crystals

Increased AGAP: ethylene glycol ingestion

302

Struvite crystals (triple phosphate)

*Alkaline urine

UTI infection with proteus: urea-splitting bacteria
-staghorn calculi* within the kidneys

303

Uric acid crystals

Acidic urine

Uric acid stones or gout

304

White cell cast (coarse granular cast)

Inflammatory states of tubules

Acute pyelonephritis

305

Red cell cast

Acute glomerulonephritis
-very specific (not sensitive)

306

Pylonephritis

Cost-vertebral tenderness

Kidney infection

307

Anticholinergics

*Causes acute urinary retention in the setting of prior BPH and abdominal distention*

308

Endocarditis

Indicated by vasculitis with **fever, nigh sweats, diastolic murmur and Roth spots**

Get blood culture

309

Benign prostatic hypertrophy

Non-tender prostate

Difficulty urinating, common in older men
Presents with frequent urination, incomplete emptying

310

Sacroiliitis

an inflammation of one or both of your sacroiliac joints — the places where your lower spine and pelvis connect.

can cause pain in your buttocks or lower back, and may even extend down one or both legs.

often aggravated by prolonged standing or by stair climbing.

311

Scleroderma

hardening and tightening of the skin and connective tissues — the fibers that provide the framework and support for your body.

-skin
-blood vessels
-internal organs
-digestive tract

312

Anacrotic pulse

Due to *aortic stenosis: delayed pulse with decreased amplitude*

313

Alternans pulse

Due to poor functioning left ventricle

314

Paradoxical pulse

Due to tamponade: compression of the heart by an accumulation of fluid in the pericardial sac

Elevated JVP without vein engorgement

315

Bruits

Rushing sound due to atherosclerotic stenosis of an artery

316

Livedo reticularis

mottled/reticulated, red-blue lacy skin discoloration with central pallor associated with vascular processes of small vessels, including vasculitis of various causes, anti-phospholipid syndrome and cholesterol embolism syndrome, as well as numerous other etiologies.

317

Superior vena cava syndrome

**-facial plethora (red-blue discoloration and swelling)
-chest wall dilated veins (in chronic cases)
-jugular vein distention**
-papilledema (due to retinal vein hypertension)
**-dyspnea
-head fullness/headache**

Findings may be precipitated/accentuated by raising both arms (Pemberton's sign)

**Lung cancer is most common cause**

318

Acute limb ischemia or acute arterial insufficiency

Acute onset **due to thrombus/embolism (medical emergency)**

Findings: 5 P's
-pulseless extemity
-pallor of the skin
-pain
-paresthesia: tingling
-paralysis

Source: heart
-**left atrial thrombus in the setting of atrial fibrillation/irregularly irregular heart rhythm**

319

Ankle/brachial index

Judges degree of stenosis

***Highest pedal pressure/highest brachial pressure***

**Normal = 1.0
Intermittent claudication = 0.6
Rest pain = 0.3
Impending gangrene < 0.2**

320

Aortic aneurysm

Enlargement of the aorta

**Most often due to atherosclerosis**

Risk of rupture increases markedly above 5 cm diameter
-important to perform surgery before rupture

*Not associated with unilateral ischemic leg*

Can be associated with tertiary syphillis

321

Cholesterol embolization

Rupture of atherosclerotic plaque after cardiac catheterization

322

Aortic dissection

**A tear in the inner layer of the aorta with mediastinal widening**
-normal cardiac border

Hypertension is major risk factor

**>90% have chest pain and unequal pulses is diagnostic in context**

Associated with Marfan's

The distal anterior spinal cord vascular territory is at risk of ischaemia or infarction if there is damage to the artery of Adamkiewicz

323

Takayasu's arteritis

Decreased pulses in the upper extremity and normal pulses in the lower extremity

Inflammation of the aorta and its major branches

324

Deep vein thrombosis

Causes venous valve insufficiency leading to post-phlebitic leg with ankle area ulcers and **"brawny/woody" edema of leg with hyperpigmentation**

Thrombus can create pulmonary embolus or move to systemic system and cause a stroke (patent foramen ovale)

Prone to phlegmasia: ischemia due to high pressure

325

Vasculitis

Inflammation of vessels

326

Giant cell (temporal) arteritis

Most common form of vasculitis

**Causes jaw claudication**

Enlarged temporal artery

-low grade fever
-headache
-visual changes

327

Allen test

**Assesses collateral circulation to hand through ulnar artery**

Compressing both radial and ulnar arteries with clenched fists
-ulnar artery released
-normal = reprofussion

Capillary refill is assessed by compressing nail bed (>2 profusion is prolonged)

328

Congestive heart failure

**Presents with dyspnea, orthopnea, leg edema, and S3**

Inability to pump blood effectively

329

Periarteritis nodosa

Multisystem disorder:
-**renal failure
-joint pain
-hematuria
-neuropathy
-livedo reticularis**

330

Hyperdynamic pulse

Rapidly rising pulse with increased amplitude

Due to:
-**aortic regurgitation**
-hyperthyroidism, fever, anemia
-*patent ductus arteriosis*
-AV fistula
-hematic cirrhosis
-stiff aortic wall

331

Buerger's disease (thromboangiitis obliterans)

*Inflammatory vascular disorder involving the limbs*
-Occlusive disorder of small and medium sized vessels (arteries usually, but also veins)
-Begins with inflammation of the vessel intima leading to a local prothrombotic state
-Thrombosis produces severe ischemia leading to gangrene and limb loss

Most patients are men aged 25-40 years

*More commonly seen in men of Indian, Korean, Japanese and Ashkenazi Jewish background*

***Definite relationship to tobacco use (usually smoking), and abstinence is the only effective treatment***

332

Retinal artery occulsion

Ophthalmologic emergency that causes blindness due to retinal infarction

**Etiologies include: embolic phenomenon, thrombosis due to atherosclerosis, vasculitis**

Fundoscopy reveals segmentation of venous vessels and macular **"cherry-red" spot**

333

Retinal vein occulsion (thrombosis)

Produces papilledema and retinal hemorrhage

334

Diabetic retinopathy

Too many vessels