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Question 1

What are the normal variants of the epidydimis?

Answer 1

Usually a vertical ridge of soft nodule at upper testicular pole, usually lying behind the testis (~7% are anterior, a normal variant).

Question 2

What’s the technique for palpating the inguinal ring for hernias?

Answer 2

Place the tip of your index finger at the most dependent part of the scrotum and slowly direct it up into the external inguinal ring.
Have patient strain (valsalva) and cough (away from you). Note any palpable herniating mass against your fingertip.

Question 3

What’s the difference between direct and indirect inguinal and femoral hernias?

Answer 3

Indirect hernia
o Most common, all ages, both sexes.
o Tissue herniates through internal ring.
Direct hernia
o Less common, usually in men over 40 years of age.
o Tissue herniates behind external ring.

Question 4

Are the testicles usually equal in position, or is one lower than the other?

Answer 4

left is lower

Question 5

What is the normal size and shape of the testicle?

Answer 5

Solid ovoid in shape, suspended in the scrotum with the long axis aligned vertically.
5-7 cm x 2.5

Question 6

Differentiate spermatocele, testicular cancer, hematocele, and hydrocele.

Answer 6

Hematocele
o Nontender accumulation of blood.
o Swelling resembles a hydrocele, but opaque on transillumination
Hydrocele
o Nontender accumulation of serous fluid from infection or trauma.
o Testis and epididymis are usually behind the mass.
o Mass transilluminates.
Spermatocele
o Painless, cystic mass, usually in head of epididymis.
o Translucent.
Solid tumor
o Rarely occurs.
o Opaque masses.

Question 7

What is a varicocele? How does one confirm the diagnosis?

Answer 7

= Varicosities of the pampiniform plexus of veins of the spermatic cord.
o Forms a soft, irregular mass.
o Feels like a bag of worms.
o Most commonly on the left side due to pressure of left venous outflow.
o Collapses slowly when scrotum is elevated in supine patient.

Question 8

What’s difference between acute orchitis and acute epididymitis?

Answer 8

Acute orchitis
o Painful, tender, swollen.
o Associated with mumps or other infectious disease.
o May be simultaneous epididymitis.
o Need to rule out testicular torsion (which may follow a rigorous workout).
Acute epididymitis
o Usually from trauma or infection.
o Painful, tender, swollen with fever and increased WBCs.

Question 9

What is the size of a normal prostate?

Answer 9

The prostate gland is about the size of a chestnut. It lies 2 cm posterior to the symphisis pubis with the posterior surface of the gland in close contact with the rectal wall.

Question 10

What’s the difference between BPH, prostatic cancer, and acute prostatitis on digital rectal exam (DRE)?

Answer 10

BPH - smooth, symmetrical, elastic/rubbery/firm & NT
PrCA - palpable hard, NT nodule(s),
Prostatitis - enlarged, tender, asymmetrical edema

Question 11

What information can be derived from transilluminating a scrotal mass?

Answer 11

DDX solid vs. fluid-filled masses

Question 12

What is Peyronie’s disease? What are the findings on PE?

Answer 12

formation of plaques on the shaft of the penis

found on palpation

Question 13

Inguinal lymph nodes - horizontal

Answer 13

just below inguinal ligament. It drains the skin of the lower abdominal wall, external genitalia (except testis), anal canal, lower vagina, and gluteal area

Question 14

Inguinal lymph nodes - vertical

Answer 14

located beside the upper segment of the great saphenous vein and drains that area of the leg. It is often palpable

Question 15

Unilateral LAD

Answer 15

may indicate possible infection of scrotum, epididymis, urethritis, chancroid, or lymphogranuloma. The testes drain deep into pelvic nodes, so lymphadenopathy due to a testicular issue won’t be palpable

Question 16

BL LAD

Answer 16

may indicate gonorrhea or syphilis

Question 17

Mental status exam sections

Answer 17

appearance
thought processes, content, perception
cognitive function
language and motor skills
higher intellectual functions

Question 18

MSE: Appearance

Answer 18

LOC
Posture and motor behavior
Personal hygiene
Facial expression
Manner/affect
Speech
Mood

Question 19

MSE: Thought processes, content, and perception

Answer 19

Logic, relevance, organization, coherence
Thought content
Perceptions
Insight

Question 20

MSE: Cognitive functions

Answer 20

Orientation
Attention
Memory
New learning ability

Question 21

MSE: Language and Motor Skills

Answer 21

Comprehension
Writing
Naming/identifying

Question 22

MSE: Higher intellectual functions

Answer 22

hobbies, job, school

Question 23

Never OMIT

Answer 23

O - orientation x 3
M - memory: recent and remote
I - intelligence: calculating, fund of knowledge, abstract reasoning
T - talk: speech rate, quantity, fluency, articulation

Question 24

CN 1

Answer 24

Olfactory

sensory: smell

Question 25

CN 2

Answer 25

``` Optic sensory: visual acuity Snellen/Rosenbaum Visual fields by confrontation Ophthalmoscopic exam - disc/cup, atrophy, papilledema, spontaneous venous pulsations ```

Question 26

CN 3

Answer 26

Oculomotor motor: pupil, eyelid, extraocular muscles (sup/med/inf rectus and inf oblique) PERRLA EOM

Question 27

CN 4

Answer 27

Trochlear motor: superior oblique muscle - primarily downward and internal rotation of the eye

Question 28

CN 5

Answer 28

``` Trigeminal sensory: face motor: muscles of mastication Light touch in ophthalmic, maxillary, and mandibular regions Have pt clench jaw while palpating ```

Question 29

CN 6

Answer 29

Abducens | motor: lateral rectus

Question 30

CN 7

Answer 30

Facial sensory: taste on ant 2/3 of tongue motor: facial muscles ask pt to raise eyebrows, frown, close eyes tightly, smile, puff out cheeks, attempt to elicit a spontaneous smile

Question 31

CN 8

Answer 31

Vestibulocochlear sensory: hearing and balance gross hearing test, then Weber/Rinne if necessary Romberg for balance

Question 32

CN 9

Answer 32

Glossopharyngeal sensory: pharynx, taste on posterior 1/3 of tongue stimulate gag reflex with swab; response should be symmetrical

Question 33

CN 10

Answer 33

Vagus motor: pharynx ask pt to swallow, phonate

Question 34

CN 11

Answer 34

Spinal Accessory motor: trapezius, SCM ask pt to shrug against resistance test SCM if trap is abN

Question 35

CN 12

Answer 35

Hypoglossal motor: tongue ask pt to protrude their tongue in case of deficit, tongue will deviate toward side of lesion

Question 36

How do we rate muscle strength? How do we test muscle tone?

Answer 36

Tone - flaccidity, rigidity, spasticity Strength 0/5 = no muscle contraction or mvmt 1/5 = visible contrax w/out strength to move joint 2/5 = can move joint but not overcome gravity 3/5 = can move vs gravity but not active resistance 4/5 = can move against gravity and some resistance 5/5 = normal strength, active mvmt vs resistance w/out fatigue

Question 37

Neuro Exam

Answer 37

``` MSE CN Motor system Coordination Sensory system Reflexes ```

Question 38

What is cogwheel rigidity?

Answer 38

jerky resistance to passive movement as muscles tense and relax caused by Parkinsons

Question 39

What is spasticity?

Answer 39

a special form of rigidity, present only at the start of passive movement. It is rate-dependent and only elicited upon a high-speed movement present in motor d/o, like parkinsons

Question 40

What tests check coordination?

Answer 40

Rapid, alternating movements (arms and fingers - finger tapping test) Point-to-point testing Forearm rolling test Heel-to-shin test

Question 41

How do you test sensation in the spinal tracts? Which tests evaluate which tracts?

Answer 41

``` LSTT (lateral spinal thalamic tract) -- sharp v. dull -- temp ASTT (anterior spinothalamic tract) -- light touch PC (posterior column) -- vibration using 128 Hz tuning fork -healthy 40 yo should perceive vibe for: 11 sec at med malleolus; 15 sec at lat malleolus, 15 sec at ulnar styloid -- proprioception ```

Question 42

How are deep tendon reflexes rated? When are deep tendon reflexes abnormal?

Answer 42

``` 0/4 = areflexia (LMN lesion) 1/4 = reduced or weak reflex or only with Jendrassik reinforcement 2/4 = average, normal reflex 3/4 = brisk reflex, in upper half of normal range 4/4 = hyperreflexia with clonus (UMN lesion) ```

Question 43

How are the DTRs tested?

Answer 43

``` Biceps (C5, 6) Triceps (C6, 7) Brachioradialis (C5, 6) Patellar (L2, 3, 4) Achilles (S1, 2) - slow return suggests hypothyroid Plantar (L4, 5; S1. 2) ```

Question 44

What is clonus?

Answer 44

a series of involuntary, rhythmic, muscular contractions and relaxations. mb a sign of UMN lesions involving descending motor pathways mb accompanied by spasticity (another form of hyperexcitability) Unlike small, spontaneous twitches known as fasciculations (usually caused by LMN pathology), clonus causes large motions that are usually initiated by a reflex

Question 45

Describe a Babinski reflex. What does a positive Babinski sign indicate in a 21-year old patient versus an 18-month old child?

Answer 45

positive (in adults) = dorsiflexion of the big toe | indicates lesion in corticospinal tract or LOC d/t drugs/alcohol/seizure

Question 46

What are the tests for meningeal irritation?

Answer 46

Brudzinki's - flexion of supine patient's neck causes hip/knee flexion BL Kernig's - with pt's hips/knees flexed, pt resists knee extension Neck stiffness - involuntary resistance to neck flexion

Question 47

What does “glove and stocking distribution” mean in terms of sensory testing?

Answer 47

pattern of peripheral neuropathy involving the hands and feet often is suggestive of DM

Question 48

How are discriminative sensations tested? What part of the nervous system is responsible for sensory discrimination?

Answer 48

Depends on normal cortical function Stereognosis = ability to recognize common objects 90% of the time in 5 sec Graphesthesia = ability to ID numbers or letters (1 cm tall on fingertips, 6 cm tall elsewhere) 2-point discrimination = ability to distinguish 2 sharp points simultaneously applied to skin (3 cm for hand/foot and 6 mm for fingertips)

Question 49

What is a dermatome?

Answer 49

area of skin innervated by a single spinal nerve

Question 50

What is the normal ROM of the TMJ? What other findings will you encounter?

Answer 50

3 cm btw upper and lower incisors (3 fingers width) | Note any swelling, crepitus, or deviation

Question 51

What is Adson’s test? When is it positive (as discussed in class!)?

Answer 51

Check radial pulse as you ABduct, Extend, and Externally Rotate the pt's arm. Have the pt valsalva and turn head towards the side being tested. Positive can be: absent/diminished pulse = compression of subclavian A repro of peripheral neuropathy = TOS

Question 52

What is Finklestein’s test?

Answer 52

Pt makes a fist with thumb grasped by fingers, then ulnar deviates severe pain = tenosynovitis

Question 53

What are the best exams for ruling in, or ruling out Carpal Tunnel Syndrome?

Answer 53

to rule in = Hand sx diagram and hypalgesia | to rule out = hand sx diagram and weak thumb adduction

Question 54

What are the findings in tennis elbow?

Answer 54

TTP distal to lateral epicondyle

Question 55

Know how to assess ROM for the shoulder.

Answer 55

``` Abduction: 180º Adduction: 45º Flexion: 90º Extension: 45º Internal rotation: 55º External Rotation: 40º ```

Question 56

Define crepitus

Answer 56

grating, crackling or popping sounds and sensations experienced under the skin and joints or a crackling sensation due to the presence of air in the subcutaneous tissue

Question 57

What are the tests for “non-organic” low back pain?

Answer 57

Flip test - pos with SLR is pos, but pt can sit up with leg extended w/out pain Hoover's test - hold pt's heel off the table and ask him to raise other leg. Should feel pressure as pt uses straightened leg for leverage. If not --- malingering

Question 58

What is the term for gout on the great toe?

Answer 58

podagra

Question 59

What part of the leg is affected in Osgood-Schlatter disease

Answer 59

Knee, specifically tibial tuberosity

Question 60

Which test is most sensitive for detecting a meniscal tear? Detecting an anterior cruciate ligament tear?

Answer 60

``` meniscal = Thessaly at 20* flexion ACL= Lachman's ```

Question 61

How does one test the knee for effusion? Where would you expect to find tenderness to palpation in a meniscal tear?

Answer 61

Ballottement | Tibial plateau

Question 62

ligamentous stability in the knee: Valgus and Varus stress

Answer 62

valgus - stresses MCL | varus - stresses LCL

Question 63

ligamentous stability in the knee: Apley's compression/distraction

Answer 63

tests meniscus and collateral ligs

Question 64

ligamentous stability in the knee: McMurray's test

Answer 64

assess meniscus - -apply valgus stress to flexed knee while slowly externally rotating the leg and extending the knee (medial meniscus) - -apply varus stress to flexed knee while slowly internally rotating leg and extending knee (lateral meniscus)

Question 65

ligamentous stability in the knee: Lachman's

Answer 65

detects ACL deficiency with knee flexed 20-30*, tibia is displaced anteriorly soft endpoint of > 4 mm of displacement = positive

Question 66

Patrick - FABERE test

Answer 66

assess flexion, abduction, ext rotation at hip | pos = repro of pain

Question 67

Gaenslen's Test

Answer 67

assesses hip extension, psoas tenderness, SI disease allow leg to fall off the edge of the table pos = repro of pain

Question 68

SLR

Answer 68

active and passive | pos = pain shooting down the leg, past the knee

Question 69

Bragard's

Answer 69

SLR until painful, lower until pain stops, then dorsiflex the foot pos = pain

Question 70

Tests to evaluate LBP

Answer 70

SLR Crossed SLR Bragard's Valsalva

Question 71

Findings of DJD in the hands

Answer 71

Bouchard's and Heberden's nodes

Question 72

Findings of RA

Answer 72

PIP involvement | swan-necking

Question 73

Hallux valgus?

Answer 73

bunion