o MELENA: Passage of black or very dark stool, reflecting heme breakdown products in stool.
Other causes of black stool (other than occult blood): Iron-containing drugs, bismuth-containing drugs, charcoal, lots of black cherries.
o Maroon-Colored Stools are indicative of massive blood loss (2 to 3 units of blood). Usually will see unstable vital signs. Look for complications of PUD, such as perforated ulcer.
INSPECTION:
• PROTUBERANT OR DISTENDED ABDOMEN
o Partial Bowel Obstruction: Distended abdomen plus peristaltic movements heard over the distension is practically diagnostic.
o Psuedocyesis, Psudeopregnancy: Woman who wants to be pregnancy develops a distended abdomen psychogenically.
o Increased air in bowel causing abdominal distension:
Mechanical factors, carcinoma or adhesions
Adynamic paralytic ileus.
o Ascites: Most common cause is alcoholic cirrhosis leading to portal hypertension.
Fluid Wave: Press down abdomen and create a fluid wave. It is indicative of ascites.
 Puddle Sign: Have patient lie prone and then get on hands and knees, to get all ascites to go to a dependent position. Then flick and auscultate the abdomen, listening for changes in intensity of sounds. Positive test indicates ascites.
Chylous Ascites is milky (lipid) look to transudate, indicating lymphatic blockage. Occurs with intraabdominal lymphomas and Hodgkin's disease.
Ascites can be assessed by auscultation by assessing shifting dullness when patient changes position.
• GREY TURNER'S SIGN: Ecchymoses on the abdomen, an unusual place for ecchymoses. It occurs in fulminant acute pancreatitis and carries a grave prognosis.
• JAUNDICE: Most common causes
o Viral Hepatitis
o Alcoholic Liver Disease
o Drug-induced jaundice
o Chronic active liver disease
o Choledocolithiasis
o Pancreatic carcinoma
o Metastatic liver disease
• ABDOMINAL HERNIAS
o Anatomical Types of Hernias:
Inguinal Hernias: Most common hernia.
 Direct Inguinal Hernia: Hernia directly penetrates the inguinal triangle. It creates a bulge right above (superior and medial to) the inguinal ligament.
 Indirect Inguinal Hernia: Hernia passes through the inguinal canal, and creates a bulge in the right over the inguinal ligament, as it passes through the inguinal ring.
In men, often herniates into scrotum.
Femoral Hernia: Second most common. High risk of strangulation, 20% of cases.
Obturator Hernia: Unusual, occuring in elderly, thin, emaciated women. Protrusion of peritoneal sac through Obturator Foramen.
Symptom: Pain, paresthesia down anterior thigh, due to compression of femoral nerve.
Umbilical Hernia: May occur in people with chronic increased intraabdominal pressure: Multiparous women and COPD.
Spigelian Hernia: Occurs between ubilicus and pubic symphysis. Unusual.
o Reducability:
herniaReducible: The contents of the can be easily displaced.
theIrreducible, Incarcerated: The contents of hernia cannot be displaced and are stuck there.
Strangulated: An incarcerated hernia that has cut off its blood supply, resulting in tissue necrosis and gangrene.
PERCUSSION:
• Tympany: Increased tympany is heard upon percussion of the abdomen in cases of partial bowel obstruction.
• Normal Liver Span: 10-12 cm in men, 8-11 cm in women.
AUSCULTATION:
• PERISTALTIC SOUNDS:
o Absent Bowel Sounds: Ileus
o Increased Bowel Sounds: Gastroenteritis.
o Borborygmi: High-pitched bowel sounds indicating small bowel obstruction.
• SUCCUSSION SPLASH: Audible presence of increased amount of fluid in stomach.
o Normal after a large meal.
o If it occurs after fasting, then it is indicative of pyloric obstruction.
• ABDOMINAL BRUITS: Caused by calcification of aorta, celiac compression, and alcoholic hepatitis.
• PERITONEAL FRICTION RUBS: Hearing a peritoneal friction rub over the liver is indicative of liver metastasis or primary hepatoma.
PALPATION:
• LIVER:
o Hepatomegaly:
Primary or metastatic Hepatoma.
 Alcoholic liver disease (fatty liver).
Severe CHF.
diseasesInfiltrative of liver like amyloidosis.
Myeloproliferative Disorders: CML, Myelofibrosis.
• SPLEEN
o Splenomegaly:
Infections
 Leukemias
Portal hypertension
• GALLBLADDER
o Courvosier's Law: Gallbladder is palpable in 25% of cases of pancreatic carcinoma, due to painless distension.
o Murphey's Sign: RUQ pain aggravated by inspiration, indicative of acute cholecystitis.
• KIDNEYS:
o Enlarged Kidneys: Polycystic Kidney Disease, hypernephroma, renal cysts, hydronephrosis.
o Ptotic Kidney: Normal-sized kidney displaced inferiorly into abnormal position; pelvic kidney.
• AORTA: Pulsatile mass in midline is suggestive of Aortic Aneurysm.
• MASSES and BOWEL LOOPS
• FEMORAL PULSES and DISTAL AORTA: Decreased or absence femoral pulses can be found in several disorders:
o Dissecting Aortic Aneurysm
o Coarctation of Aorta
o Severe atherosclerotic peripheral vascular disease
o Leriche's Syndrome: Occlusion of the distal Aorta.
Symptom Tetrad: Absent femoral pulses, intermittent claudication, gluteal pain, impotence.
• RECTAL EXAM
ACUTE ABDOMINAL PAIN:
• LOCALIZING PAIN to INTRAABDOMINAL SITES
• INVOLUNTARY GUARDING AND MUSCLE RIGIDITY:
o Perforated ulcer
o Perforated bowel
o Peritonitis
• DIRECT AND INDIRECT TENDERNESS
o Rebound Tenderness: Tenderness on sudden release of pressure. A reliable sign of peritoneal inflammation.
o Jar Tenderness: Avoidance of sudden movements due to abdominal pain. Also a sign of peritoneal inflammation.
ABDOMINAL PAIN SYNDROMES:
• ACUTE ABDOMINAL PAIN
o Differential Diagnosis:
Infectious: Appendicitis, cholecystitis, pancreatitis, hepatitis, Gastroenteritis, Diverticulitis.
Crohn's Disease
Bowel perforation: Peritoneal signs should be present. Patient doesn't want to move.
Bowel obstruction: Patient can't stay still and keeps moving around to get comfortable.
Colic: Renal or biliary colic.
 Dissecting Abdominal Aortic Aneurysm.
o Diabetic Ketoacidosis and other metabolic disorders can simulate an acute abdomen.
• CHRONIC ABDOMINAL PAIN
o PEPTIC ULCER DISEASE: Gnawing, burning, aching.
Pain partially relieved by eating food.
Chronicity, Rhythmicity, Periodicity
o CHOLELITHIASIS and BILIARY COLIC:
oftenParoxysms of sharp colicky RUQ pain, radiating to back, right mid-abdomen.
beIntolerance to greasy foods may found.
Ultrasound is usually diagnostic.
o DELAYED GASTRIC EMPTYING:
Often accompanied by nausea, emesis, and early satiety.
Pain is worsened by eating.
o CHRONIC PANCREATITIS:
Caused by alcoholism.
May be exacerbated by eating
o PANCREATIC CARCINOMA
 Weight loss, abdominal pain, anorexia, weakness / fatigue, diarrhea common
 Pain is variable in quality, and often ameliorated by sitting in knee-chest position.
o LACTASE DEFICIENCY
o IRRITABLE BOWEL SYNDROME: Abdominal discomfort with no demonstrable organic cause.
Defecation relieves the pain.
• ANTERIOR ABDOMINAL WALL PAIN
o Neuromas, Herpes Zoster, Hernias.
o Tightening of abdominal wall should aggravate symptoms, indicating abdominal-wall pain. If tightening of abdominal wall relieved symptoms or were done as a guarding action, then that would be visceral pain.
MALE GENITALIA
SYMPTOMS:
• DYSURIA: Uncomfortable or painful urination
o Pain with urination: Urethritis, urethral obstruction, prostatitis.
o Pain felt after urination: bladder calculus, prostatitis.
• FREQUENCY of URINATION:
• URGENCY:
• NOCTURIA:
• POLYURIA:
• URINARY INCONTINENCE:
• HEMATURIA:
o Time of Hematuria:
micturition: urethral orBeginning of prostatic source. Blood is originating near the meatus.
Throughout in urine.micturitiuon: renal source. Blood is diffusely present
End of bladder.micturition: bladder source. Blood is originating from
o Painless Hematuria: Think neoplasms (renal or bladder), renal tuberculosis, acute glomerulo-nephritis.
• OLIGURIA, ANURIA: Renal failure.
o Oliguria: 24-hr urine output less than 400 ml
o Anuria: 24-hr urine output less than 100 ml
• PNEUMATURIA: Passage of air or stool through urinary tract. It indicates the presence of fistula tracts connecting the GI and UG tracts, such as after surgery or with inflammatory bowel disease.
• PROSTATISM: No direct relationship exists between voiding habits and feelings of urgency, and the size of Benign Prostatic Hyperplasia.
• PENILE PAIN, ULCERS, DISCHARGE:
o Phimosis: Constriction of the penis, causing pain in uncircumcised penises.
• LOSS of LIBIDO, IMPOTENCE:
• INFERTILITY:
• SCROTAL SWELLING, TESTICULAR PAIN: Testicular pain is usually caused by torsion, hydrocele, varicocele, or spermatocele. Testicular tumors are usually painless when they present.
PHYSICAL EXAM:
• PENIS
o Balanitis: Inflammation of the glans penis. Causes:
Diabetes mellitus
Infections: Candida, Trichomonas
Drug reactions
Reiter's Syndrome
o Peyronie's Disease: Lateral deviation of penis, caused by unilateral inflammation of a corpus cavernosum.
• SCROTUM
o Atrophic Testes: Caused by orchitis, trauma, chronic alcoholism, cirrhosis.
o Hydrocele: Transillumination of a scrotal mass will illumiunate a hydrocele. If a painful mass is present, transilluminate it.
PROSTATE
FEMALE GENITALIA
SYMPTOMS:
• PAST HISTORY:
o Gravida: Number of pregnancies
o Para: Number of live deliveries
o Number of planned and spontaneous abortions.
• ABNORMALITIES in MENSTRUATION: Normal menstrual period = about 40 mL of blood.
o Amenorrhea: No menstruation for 3 months or more.
Primary Amenorrhea: Failure of menarche
Kallman's Syndrome: Primary GnRH deficiency
Turner's Syndrome: XO
Testicular Sensitization Syndrome: Androgen insensitivity. Genotypic male may be diagnosed with testicular feminization when he presents as a teenager with primary amenorrhea.
Imperforate hymen
tract:Congenital malformations of GU Uterine agenesis, vaginal malformations.
AmenorrheaSecondary Amenorrhea: occurring any time after menarche has occurred.
Environmental Factors:
Weight-reduction amenorrhea: Anorexia and related disorders, malnutrition.
Psychogenic amenorrhea
Exercise-induced amenorrhea
 Post-pill amenorrhea
Pituitary Disease:
Prolactinoma
Sheehan Syndrome = post-partum hemorrhage causing pituitary infarct from lack of blood-flow and increased pituitary demand.
Premature ovarian failure: Menopause occurring before age 35. Can be caused oophoritis (mumps virus), or may be idiopathic.
Polycystic Ovary Syndrome
Asherman's Syndrome: Amenorrhea caused by intrauterine adhesions (synechiae) that obliterate part of the uterine cavity. This can occur subsequent to vigorous dilatation and curettage (D&C) of the endometrium.
o Hypomenorrhea: Decrease in volume of flow or duration of periods.
o Menorrhagia, Hypermenorrhea: Abnormally heavy volume of flow or abnormally long periods.
UterineMost common causes: fibroids (leiomyomas), PID, Endometriosis, IUD
o Metrorrhagia: Bleeding at mid-cycle. It is usually precipitated by the drop in estrogen that occurs after ovulation.
o Dysmenorrhea: Painful menstruation. Symptoms = lower abdominal pain, nausea, vomiting, fatigue, diarrhea.
Dysmenorrhea:Primary Unexplained, idiopathic dysmenorrhea. Believed to be caused by high uterine levels of PGE2.
imperforateSecondary Dysmenorrhea: Endometriosis, PID, hymen, uterine polyps, adhesions.
o Dysfunctional Uterine Bleeding (DUB): Abnormal uterine bleeding in which no etiologic agent can be found after history and pelvic exam.
• OTHER THINGS RELATING TO MENSTRUATION:
o MENOPAUSE:
o PRE-MENSTRUAL SYNDROME:
• NON-MENSTRUAL VAGINAL BLEEDING: Bleeding not related to menstruation. When vaginal bleeding presents, we must determine whether it is menstrual or non-menstrual.
o Post-Menopausal Bleeding: Consider uterine cancer, cervical cancer. Atrophic vaginitis if patient is not on ERT.
o Pregnancy, either intrauterine or ectopic, may cause bleeding for a variety of reasons.
o Birth control methods: IUD, breakthrough bleeding with pill.
• PELVIC PAIN:
o ACUTE PELVIC PAIN:
Mittelschmerz: to ovulation.Pelvic pain occurring at mid-cycle and related
Torsion of itself, cutting off its bloodOvary: Cystic ovary can get large and twist on supply ------> acute-onset pelvic pain.
Ruptured tubal pregnancy.
o CHRONIC PELVIC PAIN:
Dysmenorrhea, dyspareunia, infertility.Endometriosis: Often have chronic pelvic pain, associated with the location of the ectopic glandular tissue.
endometriosis tends to be constant, and tends toPain of radiate to coccyx, lower back.
Onset of disease is usually between 25 and 40. dysmenorrhea often presents younger than age 25.Undifferentiated
• URINARY TRACT INFECTIONS:
• PREGNANCY and INFERTILITY:
o Early Pregnancy: Common symptoms
Secondary amenorrhea. Patient may also see reduced flow, or slight vaginal bleeding at time of normal period.
Morning Sickness: Nausea and vomiting
Breast tenderness
orUrinary frequency: cause may be anatomical hormonal.
Constipation
earlyWeight change: weight loss is common in pregnancy, followed by weight gain later.
o Late Pregnancy:
Chloasma: Characteristic darkening of skin around eyes, nose, cheeks. Darkening also occurs in areolae, skin between umbilicus and pubic ridge.
Striae Gravidarum: Stretch marks of pregnancy.
Spider angiomas may occur in skin, because of high estrogen.
o Pelvic Changes with Pregnancy:
Chadwick's Sign: Blue or purple discoloration of the vagina.
whiteLeukorrhea: Clear or vaginal discharge with faint musty odor. It may occur during pregnancy or in other circumstances.
ofGoodell's Sign: Bluish discoloration and softening the cervix.
Braxton Hicks Contractions: Painless uterine contractions occurring after the 28th week.
whichQuickening: The first fetal movement of the patient is aware. Normally occurs at 18 weeks during first pregnancy, and at 16 weeks in subsequent pregnancies.
o Hydatidiform Mole: Signs of a molar pregnancy:
Uterus increases rapidly in size shortly after implantation.
Persistent vaginal bleeding, no fetal movement, and no fetal heart tones by 12 weeks.
Nausea and vomiting more intense than usual.
 Grape like clusters of tissues may be expelled through the vagina.
• ABNORMALITIES in SEXUAL FUNCTION:
o Vaginismus: Spasmodic, guarding contraction of vagina upon attempt of intercourse. Often occurs subsequent to rape or trauma.
• VAGINAL DISCHARGE and ITCHING
o Physiologic Discharge: Clear or white discharge occurring at midcycle.
o Trichomonas Vaginalis:
Discharge: Gray, foamy discharge having bad odor.
Mucosa: Red, strawberry cervix.
Confirm: Confirm with wet-mount (saline suspension microscopy).
o Gonorrhea:
Discharge: Profuse mucoid discharge with foul odor.
Mucosa: Red, tender mucosa.
Confirm: Confirm with culture.
o Gardnerella Vaginalis: Also called Non-specific vaginitis. Co-infection with anaerobes usually also occurs.
Discharge: Gray or white, fishy odor
 Mucosa: Normal
Confirm: Clue cells = large epithelial cells with many coccobacilli adherent to them.
o Chlamydia:
Discharge: Little, yellow, mucous and pus in cervical canal.
Mucosa: Cervical erosion.
FAConfirm: stain of smear shows elementary bodies.
o Candida Albicans: Yeast infection.
Discharge: White, cottage-cheese like
Mucosa: White patches stuck to a red base.
Confirm: KOH preparation, look for pseudohypha.
o Atrophic Vaginitis: Estrogen deficiency
Discharge: Little discharge, some blood
Mucosa: Atrophic, pale or red.
Confirm: history, age.
• PELVIC RELAXATION: Loss of pelvis support due to atrophy of muscular viscera,
o Urethrocele: Urethra herniates into the vaginal canal.
o Cystocele: Bladder herniates into the vaginal canal.
o Rectocele: Rectum herniates into the vaginal canal.
o Uterine Prolapse: Descent of the uterus into the vaginal canal. Graded from 1 (mild) to 3 (uterus descends past the vulva).
• HIRSUTISM
.
MUSCULOSKELETAL
EPIDEMIOLOGY:
• COMMON MUSCULOSKELETAL DISEASES BY AGE:
o Childhood: Juvenile RA, Rheumatic Fever
o Young adult: Reiter's Syndrome, SLE
o Middle Age: Fibrositis
o Old Age: Osteoarthritis
• COMMON MUSCULOSKELETAL DISEASES BY SEX:
o Male: Gout
o Female: SLE, RA
• COMMON MUSCULOSKELETAL DISEASES BY RACE::
o Black: Sarcoidosis, SLE
o White: Polymyalgia Rheumatica
SYMPTOMS:
• REITER'S SYNDROME:
o Symptoms: Conjunctivitis, Urethritis, Arthritis.
o Signs:
Blennorrhagia: Rash on palms and soles.Keratoderma
Circinate on penis.Balanitis: Circular rash
Sausage fingers: Swelling of the tendon sheath of the hands.
• PSORIATIC ARTHRITIS: Arthritis occurring with Psoriasis.
o Signs:
Sausage fingers: Swelling of the tendon sheath of the hands.
be inflamed unilaterally.DIP joints may
• GOUT:
o Symptoms:
pain at the base of the great toe.Podagra: Severe gouty
• RHEUMATIC FEVER:
o Symptoms:
Migratory Pain: Typical finding. Pain moving from joint to joint.
o Jones Criteria: Diagnostic criteria for Rheumatic Fever. Two major criteria, or one major and two minor criteria are required.
Major Criteria:
Myocarditis,Carditis: Pericarditis
Polyarthritis
of variousChorea: Purposeless movements muscle groups
on proximalErythema Marginatum: Pink, circular rash on trunk arms.
surfaces,Subcutaneous Nodules: Granulomatous nodules on extensor often associated with cardiac involvement.
Minor Criteria:
History, Symptoms:
History of previous rheumatic fever or rheumatic heart disease.
Arthralgia
Fever
Labs:
increasedAcute phase reactants: ESR, C-Reactive Protein, leukocytosis.
ECG abnormalities
Recent streptococcal infection.
• GONORRHEA, DISSEMINATED (Gonococcal Arthritis):
o Symptoms:
fromMigratory Pain: Typical finding. Pain moving joint to joint.
• RHEUMATOID ARTHRITIS:
o Symptoms:
stiffness:Morning Pain in the morning, which tends to loosen up as the day progresses.
Fatigue: fatigue sets in, the worse isDuring the day, fatigue sets in. The earlier the the RA.
o Signs: The proximal (PIP and MCP) joints are characteristically more involved than the DIP joints.
Thickening -- swelling ofSynovial joints.
medially.Entire phalanx may deviate laterally or
Boutonniere Characteristic deformities ofDeformity, Swan-Neck Deformity, Ulnar Deviation: hands and wrists seen in Rheumatoid Arthritis.
• OSTEOARTHRITIS: Degenerative arthritis.
o Symptoms:
usually gets worse as the day progresses,Pain leading to fatigue in the afternoon.
o Signs: The distal (DIP) joints are characteristically more involved than the PIP joints.
Distal phalanx may deviate laterally.
Heberden's Nodes: Bony overgrowths on the dorsum of the DIP joints, typical of osteoarthritis.
• SYSTEMIC LUPUS ERYTHEMATOSUS (SLE): Diagnostic Criteria. 4 of 11 at any time is diagnostic.
o Malar Rash
o Discoid rash
o Photosensitivity
o Oral ulcers
o Arthritis
o Serositis (pleuritis, pericarditis)
o Renal disorder
o Neurologic disorder (seizures, psychosis)
o Hematologic (anemia, leukopenia, lymphopenia, thrombocytopenia).
o Immunologic (elevated anti-DNA, LE-Prep, or biological false positive for Syphilis (RPR))
o Antinuclear Antibody (ANA)
TERMS:
• Kyphosis: Anterior curvature of the spine. Normally found in thoracic area, characterized by extensive flexion.
• Lordosis: Posterior curvature of the spine, normally found in cervical and lumbar areas.
• Scoliosis: Lateral curvature of the spine.
• Varus: Medial deviation.
• Valgus: Lateral deviation.
SYMPTOMS:
• PAIN:
o Generally, the deeper the musculoskeletal structure, the more diffuse the pain.
deepPain from bone is or boring pain.
Pain from periosteum is more localized.
o Referred pain: Don't forget the Ddx of CAD in shoulder pain.
o Arthralgia: Defined as joint pains without objective signs of inflammation. It is caused by many processes, both inflammatory and non-inflammatory.
o Arthritis: Joint inflammation.
• STIFFNESS:
• WEAKNESS:
o Weakness: Loss of strength, due to mechanical or neurological impairment.
o Fatigue: Poor endurance.
INSPECTION
PALPATION: May find the following abnormalities on palpation:
• Swelling
o Synovial thickening (pannus formation) is characteristic of RA.
o Swelling of tendon-sheath (sausage-shaped digit) occurs in Reiter's Syndrome and Psoriatic Arthritis.
o Effusions: Fluid is most commonly found in the knee.
• Deformity
o Ganglia: Fluid-filled cysts found along joint capsules, usually in the wrist.
o Rheumatoid Nodules: Firm nodules found on extensor surfaces of bony prominences. They contain mononuclear cells and fibrosis.
o Gouty Tophi: Joint nodules associated with urate deposits.
o Bursitis: Inflammation of the bursa in the knee or elbow.
• Erythema and Warmth: Especially in inflammatory or infectious processes.
• Limitation of Range of Motion:
• Tenderness: The subjective sensation of pain upon pressure.
o Grading:
0: No tenderness
1: Patient says it is tender
2: Patient says it is tender and winces
3: Patient says it is tender, winces, and pulls back
4: Patient will not allow palpation.
• Joint noises or locking:
AUSCULTATION:
• Crepitus: Grating or grinding sensation felt by patient, or heard by examiner. Rubbing of bones due to degeneration of articular cartilage.
• Cracking, Snapping: Snapping of joints is usually not pathologic, unless it occurs repeatedly.
• Clicking: May indicate an abnormality when it occurs in TMJ joint.
MUSCLE STRENGTH: Graded on a scale from 5 to 0.
• 5: Full strength
• 4: Strength against gravity and added resistance.
• 3: Strength only against gravity, not added resistance.
• 2: Muscle contraction occurs, but not sufficient to overcome gravity.
• 1: Muscle contracts with little or no movement.
• 0: No muscle contraction.
RANGE OF MOTION
• Active Range of Motion: Voluntary movement
• Passive Range of Motion: Examiner moves the joint.
• Goniometer: Device used to measure angles, to assess the range of motion of a joint.
• Unstable Joint: Excessive joint motion (excessive extension) of the knee may be seen in osteoarthritis.
HEAD EXAM:
• TMJ Abnormalities are caused by dental malocclusion, trauma to the jaw, RA.
NECK (CERVICAL SPINE):
• Arthritis may limit rotation or lateral flexion of the neck.
SHOULDER:
• Rotator Cuff Injury: Pain or spasm in mid-abduction is a sign of rotator cuff injury. This is due to degeneration in the subacromial bursa, resulting in friction between the supraspinatus muscle and acromial process at mid-abduction.
o Arm can't rise above about 90, the extent to which the Deltoid can abduct it.
• Adhesive Capsulitis (Frozen Shoulder): Unilateral diffuse, dull, aching pain.
o Tenderness is diffuse.
• AC Degenerative Arthritis: Maybe from trauma. It hurts upon movement of scapula.
• Bicipital Tendinitis (Impingement Syndrome): Inflammation of the tendon of the supraspinatus muscle.
• Calcific Tendinitis: Prolonged inflammation of the supraspinatus tendon, with resulting calcification.
ELBOW:
• Tennis Elbow: Tender and inflamed lateral epicondyle, resulting from repeated extension. Patient will experience pain when asked to extend the elbow against resistance.
• Golfer's Elbow: Inflammation of the medial epicondyle. Typically shows pain when asked to lift with the palms facing upward (volar aspect).
WRIST:
• Diseases:
o DEQUERVAIN'S TENOSYNOVITIS: Involves the extensor tendon of the thumb. Ask patient to apply pressure with thumb against the forefinger, and pain will result.
o GANGLION: Cyst caused by herniated synovium into soft tissues.
o CARPAL TUNNEL SYNDROME: Compression of median nerve through carpal tunnel.
Phalen's Test: Ask patient to flex each wrist at 90 for one minute. Positive test occurs if numbness and tingling over median distribution results.
nerveTinel's Sign: Tingling shots of pain over median upon percussion of the wrist.
o DUPUYTREN'S CONTRACTURE: Fibrous contraction of the palmar aponeurosis.
familial.May be found in RA, alcoholism, or
• Signs:
o Bouchard's Nodes: Swelling of the PIP joints, which is less common than swelling of the DIP joints.
o Heberden's Nodes: Bony overgrowths on the dorsum of the DIP joints, typical of osteoarthritis.
o Boutonniere Deformity: Flexion contracture of the PIP joint, with hyperextension of the DIP joint. Caused by injury or RA.
o Swan Neck Deformity: Hyperextended PIP joints and flexed DIP joints. May accompany RA.
SPINE:
• SCOLIOSIS: Lateral curvature of spine. When bending over, muscular prominences on one side of the back is more prominent than the other side.
• Straight Back Syndrome: Lack of normal thoracic kyphosis.
• Dowager's Hump: Marked kyphosis of dorsal spine in elderly women.
• Ankylosing Spondylitis: RA-like disease affecting the lower spine and sacroiliac joints.
• Lumbosacral Strain: Lower back pain from obesity and or poor posture.
• Herniated Nucleus Pulposus:
• Sciatica:
HIP:
• If one leg is shorter than the other as measured from ASIS to ankle, hip disease is likely.
• Trendelenburg Test: Have patient stand on one foot. The contralateral hip should pull upward. If it doesn't, and the same hip on which patient is standing instead pulls downward, then that is a positive test and is indicative of hip disease.
• Antalgic Gait: Walking funny (limping) in order to avoid pain in the hip.
KNEE:
• Baker's Cyst: Extension of the synovium into the popliteal space. Felt on posterior knee.
• Osgood-Schlatter Disease: Partial separation of the quadriceps femoris tendon at the tibial tuberosity, making the tibial tuberosity swollen and tender. Seen in adolescents.
• Genu Valgus: Knock kneed. Knees bend inward.
• Genu Varus: Bowlegged. Knees bend outward.
• Genu Recurvatum: Excessive extension of the knee.
ANKLE and FEET:
• Bunion: Swelling of the great toe. Usually valgus is seen too.
• Flat Foot (pes planus): Relaxation of longitudinal arches, resulting in flattening of the arch of the foot. Patients tend to wear down the soles of their shoes on the medial side.
• High Arches (pes cavus): Have excessive wear on their soles at the base of the heal and under the metatarsal heads.
• Heel Spur: Tenderness may happen at the insertion of the plantar longitudinal tendon on the calcaneous.
• Morton Neuroma: Pinching of fibrous neuromas between metatarsal heads, resulting severe burning pain.
NEUROLOGICAL
NEUROLOGIC SYMPTOMS:
• HEADACHE:
o MIGRAINE HEADACHE: Often preceded by aura, and associated with weakness, numbness, and paresthesias.
o TENSION HEADACHE: Usually is frontal or occipital. Tends to be recurrent.
o CLUSTER HEADACHE: In males, occurring at night, 2-3 hours after falling asleep. Symptoms are intense unilateral orbital pain (over one eye), with lacrimation, rhinorrhea, flushing. Usually lasts about 1 hour.
o CAUSES of SECONDARY HEADACHE:
the "worst headache ofMeningismus: Stiff neck. If it occurs with my life," then you should be suspicious of subarachnoid hemorrhage.
Projectile Vomiting: Headache with projectile vomiting, occurring in morning, usually means increased intracranial pressure.
 Transient loss of Consciousness: Headache accompanied by transient loss of consciousness should raise question of stroke.
• SYNCOPE and LOSS of CONSCIOUSNESS:
• SEIZURES:
o Types of Seizures:
Complex Partial Seizures: Patients commonly have feelings of fear or deja vu associated with complex partial seizures.
Grand Mal Seizures: Tonic-clonic, often with loss of autonomic control.
timePetit Mal Seizures: Lasting for a short period of -- only a few seconds.
o CAUSES of SEIZURE:
Adolescents (12-20): Idiopathic (Epilepsy), Trauma, Drug and alcohol withdrawal
Young Adults (20-35): Trauma, alcoholism, brain tumor
Older adults (35+): brain tumor, CVA, metabolic disorders, electrolyte imbalances (hyponatremia, hypoglycemia, uremia).
• CHANGES in VISION:
o Amaurosis Fugax: Transient, painless loss of vision in one eye, due to ischemic changes in retina. Usually due to carotid artery stenosis or some form of retinal artery occlusion.
Other symptoms, such as weakness, paresthesias, often accompany the Amaurosis Fugax.
o Retrobulbar Neuritis: Occurs in Multiple Sclerosis and may cause transient loss of vision in one eye.
• CHANGES in HEARING:
• CHANGES in SPEECH:
o Dysarthria: Difficulty in articulating words.
o Dysphonia: Difficulty speaking due to impaired phonation ability.
o Aphasia: Inability to produce (motor aphasia) or understand (receptive aphasia) meaningful speech.
• PARALYSIS or WEAKNESS: Paresis is intermittent weakness.
o CAUSES of Paresis:
Myasthenia Gravis (fatigable weakness)
Hypokalemia can result in periodic paralysis.
Transient ischemic attacks (TIA's): Recurrent Transient weaknesses in an upper extremity, accompanied by numbness and paresthesia.
Peripheral neuropathies
Polymyositis or dermatomyositis.
• NUMBNESS and PARESTHESIA:
o Hypocalcemia, hypomagnesemia
o Hyperventilation syndrome
o Paraneoplastic syndrome.
o Medications: isoniazid, metronidazole.
• CHANGES in MOOD and SLEEP PATTERN:
• ALCOHOL and DRUG USE, SEXUAL HISTORY:
o Sexual history: In the neuro exam, may inquire about it to evaluate risk of HIV encephalopathy.
o Alcoholism manifests a lot of neurological symptoms (Wernicke, beriberi, peripheral neuropathies).
NEUROLOGIC EXAM:
• ASSESSMENT of MOTOR FUNCTION: Sometimes pluses and minuses can be used for even finer grading.
o 0: No contraction; paralysis
o 1: Trace of contraction.
o 2: Moves if gravity is eliminated.
o 3: Moves against gravity.
o 4: Moves against gravity and against some resistance.
o 5: Normal strength.
• Motor Abnormalities:
o Hysteria: To test whether weakness in the leg is from hysteria or is organic, put a hand on both limbs and have the patient lift one limb against the hand's resistance.
If the cause of motor weakness is organic, then examiner should feel the other leg move the opposite direction in compensation.
If it is hysteria, then the other leg remains still.
o FasciculationsETwitchings in resting muscles. May be normal if they are occasional or precipitated by cold. They may be a sign of Amyotrophic Lateral Sclerosis (ALS) if they are accompanied by weakness.
o Tics: Normal movements of muscle groups (such as winking or grinning) occurring involuntarily, as in Tourette's Syndrome.
o Tetany: Involuntary muscle spasms.
Causes: Tetanus, hypocalcemia, hypomagnesemia, hyperventilation syndrome.
 Chvostek's Sign: Tap over facial nerve anterior to ear, and look for contraction of the facial muscles, especially shutting of eyes.
Trousseau's Phenomenon: Inflate a blood-pressure cuff to systolic pressure and maintain for 1-2 minutes. Induction of carpal-pedal spasm indicates latent tetany.
o Tremors: Oscillating movements caused by involuntary contractions of muscle groups.
• SENSORY EVALUATION
o Peripheral Neuropathies tend to occur in hand-and-glove distribution -- at the distal ends of the extremities.
o PAIN: Upon pinprick, patient may experience hypalgesia (reduced pain), hyperalgesia, or analgesia (no pain).
o LIGHT TOUCH:
Hypesthesia = Impaired light touch sensation. Also related to light-touch are hyperesthesia, paresthesia, and anesthesia (no light touch).
o Sensory Extinction: In parietal lobe lesions, if you put a pinprick on both sides of the body of a patient simultaneously, the patient will not perceive the prick on the affected side of the lesion. If the pins are placed sequentially, then the patient still retains normal sensation on both sides.
• STEREOGNOSIS: Being able to identify objects with your eyes closed.
• CEREBELLAR FUNCTION:
o Dysergia: Improper coordinated function of a muscle group.
o Dysmetria: Inability to properly guage the distance between two points. Tested with finger-to-nose movements.
o Dysdiadochokinesia: Inability to do rapid alternating movements.
o Scanning Speech: Prolonged separation of syllables, often seen with cerebellar dysfunction.
o GAIT Disturbances:
Cerebellar Lesions: Central cerebellar lesion shows unsteady gait, but conventional cerebellar signs may be normal.
Posterior Columns Lesions: Loss of proprioception results in unsteady gait when eyes are closed, but relatively normal gait when eyes are open.
Festinating Gait: Parkinsonian gait, shuffling walk.
o Romberg Test: Patient can't maintain balance with legs tight together, with eyes closed.
o Titubation: Body tremor when standing or walking, sign of cerebellar disease.
REFLEXES:
• Deep Tendon Reflexes:
o Upper Extremity:
Biceps Reflex: Elbow flexion.
 Triceps Reflex: Forearm extension.
radiusBrachioradialis Reflex: Tap distal ------> flexion and partial supination of the forearm.
o Lower Extremity:
Patellar Reflex: Contraction of Quadriceps (strongest muscles in body) and extension of leg.
Suprapatellar Reflex: Above the knee; same response.
Achilles Reflex: Causes plantarflexion of foot.
• Reflex grading:
o 0: Complete absence
o 1: Diminished
o 2: Normal Reflex
o 3: Hyperactive reflex
o 4: Clonus
• Superficial Reflexes:
o Upper Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side.
o Lower Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side.
o Cremasteric: Stroke inner thigh ------> elevation of testes.
• Brainstem Reflexes:
o Corneal Reflex
o Pupillary Light Reflex
o Gag Reflex
• Abnormal Reflexes:
o Babinski Sign: Stroke bottom of the foot ------> fanning (eversion) of big toe.
o Chaddock's Reflex: When the external malleolar skin area is irritated, extension of the great toe occurs in cases of organic disease of the corticospinal reflex paths.
o Oppenheim's Sign: Scratch inner side of leg ------> extension of toes. Sign of cerebral irritation.
o Gordon's Sign: Squeeze the calf muscles and note the response of the great toe. Fanning or extension is considered abnormal.
o Hoffman's Sign: Flexion of the terminal phalanx of the thumb and of the second and third phalanges of one or more of the fingers when the volar surface of the terminal phalanx of the fingers is flicked.
pyramidalIt is significant for tract disease when it is unilateral. If it is bilateral than the meaning is uncertain.
• Absence of Superficial Reflexes: Unilateral suppression of superficial reflexes often results from upper motor lesions subsequent to a CVA.
• Primitive Reflexes: Presence of primitive reflexes is often a sign of frontal lobe lesions.
o Suck Reflex: Gently tap or rub the upper lift ------> elicit a reflexive sucking or puckering response.
o Grasp Reflex: Stroke the patient's palm, causing him to grasp your fingers. A positive test occurs when the patient does not let go of your fingers.
o Palmomental Sign: Rub the thenar eminence ------> elicit reflexive contraction of the muscles of the chin.
CRANIAL NERVE EVALUATION:
• CN I: OLFACTORY
o TEST: Have patient identify objects by smell.
o ABNORMAL:
Head trauma with fracture of cribriform plate
meningiomaNeoplasm in anterior fossa:
• CN II: OPTIC
o TEST: Visual acuity, funduscopic exam
o ABNORMAL: Lots of causes of blindness
• CN III: OCULOMOTOR
o TEST:
Have patient move eyes through all fields of vision. Intact 3rd nerve means that eyes can move medially, superiorly, and inferiorly.
for pupillaryPupillary Reflex: Check response to light in same eye and contralateral eye.
Ptosis mayPtosis: occur due to 3rd nerve palsy.
o ABNORMAL:
Palsy:Unilateral CN-III Subarachnoid hemorrhage resulting from aneurysm, diabetes, atherosclerosis.
Horner's Syndrome: Usually occurs from bronchogenic carcinoma (Pancoast Tumor) impinging on the Superior Cervical Ganglion.
• CN IV: TROCHLEAR
o TEST:
o ABNORMAL:
• CN V: TRIGEMINAL
o TEST:
 Sensory: Check corneal reflex. Test facial sensation with eyes closed.
 Motor: Have patient clench teeth and palpate masseter muscle.
o ABNORMAL:
Lost Corneal Reflex: Tumor of the cerebellopontine angle.
Tic Douloureux: Irritative lesions of the CN V sensory roots.
musclesSpasm of of mastication: tetanus, adverse reaction to Phenothiazines.
• CN VI: ABDUCENS
o TEST: Look laterally.
o ABNORMAL:
Diabetes, atherosclerosis, increased ICP, neoplasm.
• CN VII: FACIAL
o TEST: Have patient smile, blink, frown, wrinkle forehead.
o ABNORMAL: Bell's Palsy
 Central Lesion of VII: The supratrochlear muscles are spared, as they receive bilateral innervation from both facial nerves. Below the eyes, the contralateral side will be paralyzed.
Peripheral Lesion of VII: There is an entire facial hemiplegia, with the paralysis occurring on the contralateral side.
• CN VIII: VESTIBULOCOCHLEAR
o TEST: Standard hearing and vestibular tests.
o ABNORMAL: A variety of disorders
• CN IX: GLOSSOPHARYNGEAL
o TEST: Have patient open mouth and say "Aaahhh."
o ABNORMAL: See Vagus N. below.
• CN X: VAGUS
o TEST: Have patient open mouth and say "Aaahhh."
o ABNORMAL:
Aortic Aneurysm, Bronchogenic Carcinoma may damage the recurrent laryngeal nerve.
Uvula will deviate toward the damaged side.
• CN XI: SPINAL ACCESSORY
o TEST: Have patient shrug shoulders.
o ABNORMAL: Polymyositis
• CN XII: HYPOGLOSSAL
o TEST: Have patient stick out tongue.
o ABNORMAL:
MENTAL STATUS EXAM:
• STATE of CONSCIOUSNESS: The Glasgow Coma Scale
• ORIENTATION
• ABILITY to COOPERATE
• MOOD
• THOUGHT PROCESS
• MEMORY for RECENT and REMOTE EVENTS
• ABILITY to HANDLE CONCEPTS and PROVERBS
• PRACTICAL SKILLS
• SPEECH PROBLEMS and RECOGNITION of APHASIA
PATIENTS with ABNORMAL NEUROLOGICAL STATUS:
• APPROACH to the COMATOSE PATIENT:
• APPROACH to the DELIRIOUS PATIENT:
• APPROACH to the PATIENT with PERIPHERAL NEUROPATHY:
• APPROACH to the PATIENT with SIGNS of MENINGEAL IRRITATION: