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warning signs of skin cancer
- asymmetry, irregular border, mottled and haphazard display of color
- unusually large diameter, almost always elevated
- increase in size is most important sign of malignant melanoma
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basal cell carcinoma
- most common
- locally invasive
- slow growing, rarely metastasized
- almost translucent, dome shaped papule
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squamous cell carcinoma
- invasive malignancy
- found on hands, head, neck, tips of ears
- heals and rebreaks over and over
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fibradenomas
- ages 15-25, usually single, round or disc-like
- firm, well delineated, mobile and non-tender
- can be left alone
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Fibrocystic breast disease
- ages 30-50
- can be single or multiple, round, elastic
- well delineated, mobile and tender
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breast cancer
- 30+, most common over 50
- single, irregular, firm/hard
- not clearly delineated, fixed to skin, non-tender
- can get peau d'orange
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tactile fremitus
- increases over consolidation, anything that makes the lungs more dense- pneumonia
- decreases over air obstruction: atelectasis
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tracheal breath sounds
- high-pitched
- inspiration is less than expiration
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vesicular breath sounds
- at base of lungs
- inspiration is greater than expiration
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bronchovesicular breath sounds
- over the bronchi
- inspiration is equal to expiration
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fine crackles
- rales
- air colliding with fluid
- pneumonia, CHF
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coarse crackles
- sounds like velcro pulling apart
- bubbly, gurgly
- can hear with pneumonia
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sonorous wheezes
- ronchi, on inspiration and expiration
- like snoring, heard with bronchitis
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sibilant wheezes
- more musical, high-pitched
- heard with asthma
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stridor
- high pitched crowing noises
- croup, or something caught in the throat
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pleural friction rub
- not enough fluid in pleural space,
- can hear the layers rubbing together
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bronchitis
wheezes and ronchi as air passes through fluid
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emphysema
- decreased fremitus, hyperresonant percussion,
- decreased breath sounds, wheezes and ronchi
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asthma
- decreased fremitus and breath sounds
- sound is obscured by wheezes
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pleural effusion
- accumulation of fluid in pleural space
- fremitus is decreased or absent
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physiological split of S2
- can be normal, due to more blood on right side of heart so the aortic valve closes before the pulmonic and causes a splitting of S2
- normal during inspiration
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S3 gallop
- ventricular filling sound, during diastole, can be normal
- heard directly following S2 due to turbulent blood flow
- may disappear when sitting up
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S4 gallop
- ventricular filling sound, at end of diastole
- ventricles are resistant to turbulent blood flow from atrial kick
- heard right before S1
- will hear with hypertension, hypertrophy
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preload
- length of ventricular muscle stretch at end of diastole
- increased stretch=increased contraction is starlings law
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afterload
- opposing pressure the ventricle has to generate to open aortic valve against pressure in the aorta
- high diastolic is an afterload problem
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systolic click
- similar to aortic stenosis
- hard time getting blood through the valve
- heard right after S1, more common than pulmonic
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mid-systolic click
- associated with mitral valve prolapse in middle of systole
- valve has closed but it prolapses back into the atrium
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opening snap
- same as early systolic click, heard during systole
- opening of either of the AV valves, right after S2
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systolic murmurs
- pulmonic or aortic stenosis: heard at the base of the heart
- mitral or tricuspid regurgitation: heard at the apex
- less severe than diastolic
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diastolic murmurs
- pulmonic or aortic regurgitation: heard at base
- mitral or tricuspid stenosis: heard at apex
- more severe than systolic
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ascites
- fluid in the abdomen
- will hear tympany in the center, dullness in the flanks
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aortic aneurysms
- 95% after the renal arteries but before the iliac arteries
- decreased femoral pulses
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Rovsings sign
- test for appendicitis
- push in LLQ and they will feel pain in the RLQ
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Iliopsoas muscle test
- inserts near the appendix, tests for appendicitis
- raise leg against resistance, will feel pain at the appendix
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obturator muscle test
- also inserts near the appendix
- internal and external rotation will cause pain at site
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Murphy's sign
- for cholecystitis
- push under liver, have patient take deep breath
- push harder and patient wont be able to let breath out because its so painful
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ligaments
connect bone to bone
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tendons
connect muscle to bone
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Carpal tunnel tests
- Phalens sign: put hands back to back for 30-60 seconds and will get numbness is 2nd, 3rd and half of 4th fingers
- Tinel's sign: tap on media nerve at radius, will get numbness in same fingers
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osteoarthritis
- degenerative joint disease- cartilage destruction
- causes formation of nodules in joints
- PIP:Bouchards nodules
- DIP: heberdens nodules
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rheumatoid arthritis
- auto-immune disease
- symmetric, affects mostly PIP and metacarpophalangeal joints
- very tender, stiff and painful
- Boutonniere: flexion of PIP and extension at DIP
- Swan neck: fixed hyperextension of PIP, flexion of DIP
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Cerebral cortex
- frontal: personality, behavior
- Parietal: sensation, feeling
- occipital: vision centers
- Wernickes area: auditory reception, in temporal lobe, will hear but not understand the words
- Broca's area: speech formation, will know what they want to say but not be able to formulate it
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diencephalon
- hypothalamus: temperature, sleep, pituitary
- thalamus: main relay station from brain to body
- basal ganglia: autonomic motor movements, swinging of arms
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Brain stem
- midbrain- most anterior
- Pons: where ascending and descending tracts converge
- medulla: vital autonomic centers, decussation of motor fibers
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cerebellum
motor coordination of voluntary movements and muscle tone
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spinal cord
- medulla to L1 or L2
- motor and sensory pathways
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Corticospinal pathway
- motor pathway, also called pyramidal
- fine discrimination movements like writing
- originate in cortex
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Extrapyramidal tract
- motor fibers from cortex, any that are outside the pyramidal tract
- maintains muscle tone, gross movements like walking
- affected in parkinsons
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cerebellar system
maintains equilibrium, posture
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5 components of reflexes
- intact motor nerve
- synapse
- intact sensory nerve
- neuromuscular junction
- muscle
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ankle reflex
sacral nerves
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bracioradialis and biceps
C 5,6
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7 components of Neuro exam
- mental status
- cranial nerves
- motor system
- sensory system
- coordination
- cerebellar function
- deep tendon reflexes
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Mental status
- alert, lethargic, obtunded, stuporous, comatose
- orientation- A and O times 3
- attention: months in reverse, 6-7 numbers forwards, 4 backwards
- language- 3 step instruction, demented patients will forget 3rd step
- memory- immediate, short term and long term- repeat 3 words
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muscle tone
normal resistance as you move through passive movements
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spastic tone
- increased resistance to passive lengthening
- knife clasp phenomenon
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cogwheel rigidity
- opens a little bit at at time
- always tight, never relaxes
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fasciculation
- rapid continuous twitching of a muscle
- due to over stress
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peripheral lesion of CN VII
- will paralyze whole side of the face
- cant raise eyebrows, shut eyes, no forehead wrinkles or nasolabial fold
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central lesion of CN VII
- will affect lower 1/3 of one side of the face
- can close eye but with some weakness
- no nasolabial fold
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tic
- repetitive twitching at inappropriate times
- can be neuro or emotional problem
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introitus
- posterior portion of the opening of the vagina
- may be covered by the hymen in virgins
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cervix
- portion of the uterus that protrudes into the vagina
- middle is called the os
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cystocele or rectocele
bladder prolapse or rectal prolapse
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bartholins glands
- lubricating glands inside the vagina, will be very painful if they are infected
- infection could be caused by chlamydia or gonorrhea
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Pap smear results: Ascus
- atypical squamous cells of unknown significance
- can be from a yeast infection can still can be HPV negative
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LSIL and HSIL
- low/high grade squamous intra-epithelial lesions
- both are assumed to be HPV,
- patient needs a colposcopy
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indirect hernias
- 60% are indirect
- can be congenital in infants
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direct inguinal hernia
- goes behind and then through the external ring, rarely goes into testicles
- common in men over 40 from heavy lifting
- often no pain or discomfort
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femoral hernia
- bulging in upper thigh
- very painful
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prostate gland
- shouldnt protrude more than 1 cm into rectum, should be smooth and non-nodular, elastic and rubbery
- infection will make it very tender
- cancer will be hard, fixed
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