Gen Dia

• Onset
• this is attribute to symptom of present illness that would be taken at the time of history

• Palliative/Provocative
• this is attribute to symptom of present illness that would be taken at the time of history

• quality of pain
• this is attribute to symptom of present illness that would be taken at the time of history

• Radiating/ Referral such as from the nerve roots, facet joints
• this is attribute to symptom of present illness that would be taken at the time of history

• Site, Setting, Severity
• this is attribute to symptom of present illness that would be taken at the time of history

Timming

• Serios Illnesses
• Previous injury
• Hospitalizations
• Surgeries
• medications
• allergies

it is the occurence within the family of any medial condition that may affect thier medical condition.

• Chief hx
• oast health hx
• personal and social hx
• review of systems

• CAGE Questionare
• C- Cutting down (have you ever felt the need to Cut down)
• A- Annoyedby others criticisms
• G- Guilty feeling
• E- Eye opener

• Height and weight
• pulse
• Respiratory Rate
• Bp

• Oral - 98.6
• Axilla- 97.6
• Rectal and Tympanic- 99.6
• Range 96-99.5F or 35-37.5C

• Adults 60-100
• NewBorn 120-160
• Elderly 70-80

• Adults 14-18
• Newborn 44

90-120/60-80

Auscultory gap in palpatory systolic reading

loss and reappearance of the pulsatile sound while listening with stethascore while cuff is deflating

low pirch sounds produced by turbulent blood flow in the arteries

"Subclavian Steals" Bp reading 20% higher than in the lower extermities

• Barre-Lieou
• DeKleyns
• Hallpike
• Hautants
• Underberg
• Georges Test
• not if any of these are positive refer to cardiovascualr specialist

lid turned outward

lid turn inward

not seen in cataract pts and newborns

Opacities in the eyes seen in diabetics and elderly

newborns

• grayish opaque ring around the cornea.
• Elderly >50yo -normal

trianglular thickening of the biulbar conjunctive that grows across the cornea and is brought on by dry eyes

infection of sabaceous glands causing a pimple or boil on the eyelid

Infection of miebomian gland causing a nodule which points inside the lid

yellowish triangular nodule in the bulbar conjunctiva that is harmless and indicates aging

Fatty plaques on the nasal surface of the eyelids that is normal or indicates hyoercholesterolemia

• bilateral small and irregular pupils that accomidate but do not react to light
• seen with syphillis (prostitutes pupil)

dilated pupil with ptosis and lateral deviation. DOesnt react to ligjt or accomidation

• Ptosis
• Miosis
• anhydrosis
• PAM is HORNEy

Cervical sympathetic

Cupping of optic disc due to intrsocular pressure

• Tunnels vision ( blurring of peripheral field)
• Cresent sign of the cornea

Choked disc

• swelling of the disc due to Increased Intercranial Pressure.
• there is NO visual loss.

painLESS sudden onset of blindness.

curtain closing over vision and lightning flashes and floaters

Macular Degeneration

• ealrt sign if Macular Degneration
• Describe as yellow deposits under retina

damage to retinal vessels.

cotton wool soft exudates.

affects viens more than arteries

microanyueryms, hard exudates, and neovascularization

Inflammation of the iris

Ankylosing Spondylitis

Normal vision

Near sighted

Loss of the elaasticity due to aging

Farsighted

• Tinnitus
• Presbycussis
• Acute Otitis Externa
• Acute Mastoiditis
• Purulent Otitis Media AKA Bacterial Otitis Media
• Serous Otitis Media
• Vertigo
• Meniere's Disease
• Benign Paroxysmal Positional Vertigo
• Acoustic neuroma
• Eustachian Tube Block

• outer ear infection qith pain and inflammation.
• Tugging of the pinna will be painful

• Bacterial infection, commonly associated with hearing loss.
• presents the same as acute otitis media

• Bacterial or viral infection of the middle ear.
• tympanic membranes present with a red appreance
• Purulent = bactrial = buldging

• effusion in the middle ear usually from incomplete resolution of acute otitis media or obstruction of Eustachian tube
• if chronic is amber with bubbles

Endolymphatic Hydrops

disorder characterized by recurrent prostrating vertigo, sensory hearing loss, tinnitus and feeling fulness in the ear.

Retraction of the tympanic membrane

equal sound heard bilaterally

Lateraization to bad ear

Lateralizaton to good ear

AC>BC (Rinne+)

• AC<BC or =
• (rinne -)

AC>BC with less TIME in bad ear

• Angualr Stomatitis aka Cheilosis
• Candidiasis aks Thrush(Tongue)
• Leukaplakia (Tongue)
• Atrophic Glossitis
• Fissured Tongue aka scrotal tongue

• Furros ont he surface
• can be considered normal

• vit B deficiency or iron
• tongue is smooth and glossy

• PreCA lesions of white patches adherent to the surface
• not easly removed

• thick white fungal patches
• they are easly scraped off.

excessive growth hormone prior to skeletal maturity

excessive growth hormone after skeletal maturity

• MC caused by Graves disease (autoimmune)
• TSH decreased
• T3/T4 increased

Hashimotos mc cause

Cretism

• Intolerance to heat
• weight loss
• Exophthalmos (bilat)
• Increased T3 and T4
• Decreased TSH

• Macroglossia and loss of lateral 1/3 eye brows
• Decrease T3 and T4
• Increased TSH

Adrenals

• Photophobia, throbbing (worse behind the eye)
• nausea

• Aura
• will also incl characteristics of common migraine

• Throbbing
• wake up with a HA

Alcohol

band like

over 50 yo females

• stiff neck
• excruiciating pain like never before

• slow bleed following trauma
• sxs evident days-week post injury

• Loss of memory
• visual disturbance

• Inspection
• Palpation
• Percussion
• Ausculatation

• Barrel Chest
• Pectus Excuvatum
• Pectus Carinatum

• AP= lateral diameter
• seen with COPD and cystic fibrosis

marked depression noted in the sternum

forward protusion of the sternum

• Tachnypnea
• Bradypnea
• Biot's Breathing
• Cheyne Stokes
• Kussmaul's

Rapid shallow breathing

Slow breathing

characterized by groups of quick, shallow inspirations, followed irregular periods of apnea (no pattern)

• Breathing pattern characterized by alternating periods of apnea and hyperpnea (has a pattern)
• Respiratory acidosis

• first rapid and shallow but as metabolic asidosis worsens,
• breathing gradually becomes deep, slow, labored and gasping
• "air hunger breathing"

• Pitted
• Splinter Hemmorage
• Beau's lines
• Paronychia
• Clubbing
• Koilonychia aka Spoon nail

Seen with Psoriasis also look for silver scales

Subacute bacterial endocarditis (strep organism -red dots)

Transverse ridging associated with acute severe disease

Onflammation of the nail fold near the cuticle

nail base has an angle > 180 degrees and may indicate hypoxia/COPD

Iron deficiency anemia

second part Palpation

Place hands over the posterior ribs and have the pt take a deep breath

• Palpable vibration
• pt says 99
• Increased with fluid (pneumonia)
• decreased air (emphysema, pneumothorax)
• decreased with atelectasis and plerisy bc sound barrier is created

Tones and Diaphragmatic Excursion

are normal

• during Percussion
• 1. Inspect
• 2. Palpation
• 3. Percussion
• 4. Auscultation

Increased air in the chest (emphysema and pneumothoax)

Increased density (pneumonia and atelectasis)

• Vesicular
• Bronchovesicular
• Bronchial
• Tracheal

Insp longer than Exp

versicular

• Insp and exp
• location: Ant 2-3 ribs bt scapula at apex

• Exp longer than Insp
• over the Manubrium

• Insp equal Exp
• Over trachea in neck

when air opens closed air spaces

Air is blocked or becomes rough through the large airways.

Rales

wheezes

• Asthma in young
• Emphysema in older

• Bronchophany
• Egophany
• Whispered pectriloquy

• Percussion: Resonant
• Fremitus: Decreased
• Breath Sound: Wheezing

• Percussion: Dull/Flat
• Fremitus: Decreased
• Breath Sound: Absent

• Percussion: Resonant
• Fremitus:Normal
• Breath Sound: Ronchi

• Percussion: Resonant
• Fremitus: Normal
• Breath Sound: rales (crackles)

• Percussion: Hyperresonant
• Fremitus: Decreased
• Breath Sound: Wheezing

• Percussion: Resonant
• Fremitus: Decreased
• Breath Sound: Crackles (Friction Rub)

• Percussion: Hyperresonant
• Fremitus: Decreased
• Breath Sound: Decreased

• Percussion: Dull
• Fremitus: Increased
• Breath Sound: Egophany, Bronchophony, Whispered Pectoriloquy, Crackles

• Lobar Pneumonia
• Friedlander Pneumonia
• Pneumocystis Carinii
• Cytomegalovirus
• Tuberculosis
• Pluerisy
• Pneumothorax
• Atelectasis
• Bronchiectasis
• Chronic Bronchitis/COPD
• Asthma
• Emphysema
• Bronchogenic Carcinoma
• Costochondritis aka Tietze Syndrome
• Herpes Zoster aka Shingles
• Sarcoidosis
• Hodgkins
• Cystic Fibrosis

• Consolidation of the lung
• 10 days Rusty brown Sputum
• silhoutte sign and air bronchogram

Productive/ Current red jelly sputum

• Low grade fever, night swears
• Ghon Lesions on film
• starts in apices of lungs
• tine test/mantoux test
• positive purified protein derivitive
• most definitive test- Sputum culture

• rupture lung causing air to become trapped in the pleural space.
• Unilateral darkening of chest film due to collapse lung
• Tracheal shift AWAY from lesion .

• Inflammation of the pleura
• stabbing chest worsened by respiration and cough
• Dull on percussion
• N. productive cough
• positive friction rub

Schepelmann's +

• Collapse lung
• tracheal deviat toward collapesed lung

• Long term cough and mucus
• Shortness of breath and wheezing
• Cigarette smoking main cause

• airways constricted, bronchspasm
• Type I hypersensitivity rx
• IgE rise

• Curshmann's Spiral
• Charcott Laden Crystals

• loss of elasticity of pulmonary connective tissue = Permanent dilation of avioli air sacs and caused by defiency alpha 1 anti trypsin
• Hyperresonant percussion
• decreased breath sounds
• prolonged experation with expiratory wheeze
• Fluid accumulates in costophrenic recess

• Primary malignant lung tumor
• starts in bronchus

• long term hx of smoking
• n. productive cough MORE than 30 DAYS
• dyspnea
• weight loss
• and clubbing of nails.

bronchogenic CA --> n. productive cough longer than 30 days

Pneumonia --> rusty brown sputum and 10 days duration

Both have cloudy white density of film

Tietze Syndrome

• Inflammation of cartilage connection bt ribs and sternum
• worsens with physical activity and deep breaths
• palpable tenderness at COSTOsternal Articulation

painful rash following CN V dermatome

• MC in African descent
• disease in which abn collection of inflam cells
• most often lungs or lymph nodes

Bilateral hilar lymphadenopathy "angel wings, potato nodes"

biopsy, looking Reed Sternberg Cells

Causcasion males

CA of lympahtic systems that can spread to the spleen

• CHronic Progressive
• loss of excessive amounts of salt
• COPD
• Barrel Chest
• Pranceatic insufficiency
• meconium ilues

intestines and lungs

Measures the pressure of the right side of the heart.

• when congestive heart failure is present
• Apply pressure to the liver (hepatojugular reflex)

peripheral pulses and thrills

• Pulsus Magnus
• Pulsus Parvus
• Pulsus Alterans
• Pulsus Bisferiens
• Pulsus Paradoxus
• Water Hammer Pulse

• Bounding; increased cardiac output
• exercise
• anxiety
• fever
• hyperthyroidism

• weak or thready; decreased stroke volume
• hypovolemia (blood loss)
• aoritc stenosis
• chf

• Alternate in amplitude
• left ventricular failure

• two strong systolic peaks seperated by mid systolic dip (best felt at carotid art)
• aoritc regurgitation
• aortic stenosis

• decreased amplitude on inspiration
• increased with expiration (>10mmHg amplitude change)
• COPD
• bronchial asthma
• emphesema
• pericardial effusion

jerky pulse that is rapidly increasing anf the collapsing due to aortic insufficiency

Vibration produced by turbulent blood flow within the heart (murmurs)

ventricle contraction

Ventricular relaxation

closure of AV (mitral and tricuspid) valves

Closure semilunar (pulmonary and aortic) valves

• Ventricular Gallop
• normal in kids, young adults and athletes

>40 yo earliest sign of CHF

• Atrial Gallop
• similar to S3 and is related to stiffness of the ventricular myocardium to rapid filling

• Aortic Valve - Right sternal border at 2nd intercostal space.
• Best when pt is seated, leaning fwd, and exhaling
• Pulmonic Vales - Left sternal border 2nd intercostal
• Erbs point - Left sternal borderat 3rd intercostal space
• Tricuspid Valve - Left sternal border at the 4th or 5th intercostal space
• Mitral Valve - Mid-clavicular line at the 5th intercosal space Best auscultated in the left lateral decubitus position

• A P
• R R
• M T
• S S

• valve has trouble opening and the blood swirls through a narrow opening
• Murmur has low pitch and best heard with the bell of a stethoscope

Valve is insufficient and blood seeps or squirts back into chamber. THis murmur has a high pitch and is best heard with the diaphragm of stethoscope.

• Aortic - Stenosis
• Mitral - Regurgitation
• Pulmonic - Stenosis
• Tricuspid - Regurgitation

• Patent Ductus Arteriosus
• Tretralogy of Fallot (DRIP)
• Coarcatation of the Aorta
• Subclavian Steal Syndrome

• Failure of shunt to close bt the aorta and left pulmonary artery
• Continuous/machinery like murmur that can be heard in both phases (diastole and Systole) of the heart cycle

• Dextraposition of the aorta
• Right ventricular hypertrophay
• Interventricular Septal Defect
• Pulmonic Stenosis

loud ejection murmur in systole and severe cyanosis

• Constriction of descending aorta (DISTAL left subclavian)
• causes higher Bp in upper extremity than than lower by 20 mm Hg

Marfans Syndrome

• Narrowing proximal to the vertebral artery
• Subclavian steals from vertebral
• Seen young females who faint while exercising.

• Left sided heart failure
• Right sided heart failure
• Aortic Dissection
• Angina Pectoralis-coronary vasospasm
• myocardial infarction
• aneurysm

• MC cause of left sided heart failure is Hypertension
• 2nd mc cause aortic stenosis

• Pulmonary edema (fluid in the lungsO causing shortness of breath (exertional dyspnea
• Orthopnea
• Fluid collects at costophrenic angles

• MC cause of left sides heart failure
• MC cause of mitral stenosis - rheumatic fever (ASO titer

• when right side fails by itself
• (lung condition that causes right sided heart failure)

• stasis dermatitis
• ascities
• portal hypertension
• caput medusa/spider angioma
• pitting edema

exertional dyspnea

tearing pain

• comes on with exertion
• Printzmetal angina comes on with rest (atypical)

• Acute failure womes with rest caused by atherosclerosis
• CK-MB is elevated i
• increased SGOT
• Increased LDH

Early intestinal obstruction

• late intestinal obstruction
• adynamic (paralytic) ileus

vomiting of blood

coughing of blood

blood in stool

• GGT
• SGPT/ALT

LDH

Yellowing skin, sclera. and mucous membranes

• Jaundice - includes sclera
• increased beta Carotene - only skin
• Stasis dermatitis - ankles only

• Alcoholism is the MC cause of liver destruction
• thiamin deficiency

• seen with cirrohosis
• alcoholics

Beri beri

(area of brain affected) Thiamin dificiency leading to dementia

• enlarged but edge remains soft and smooth
• from food through fecal/oral route, self limiting not a carrier

• Enlarged tender but edge remains smoothe and soft
• dirty needles and sexual contact, carrier for life, MC to become liver CA

• enlarged tender smooth and soft edges
• blood transfusion

• MC site for metastatic disease
• liver is enlarged irregular border

• watersoluble gallstone (duct obstruction)
• may cause urobilinogen

• not water soluble
• heilytic anemia - coombs test

• Cholecystitis
• Porcelin Gallbladder

to right shoulder or tip of right scapula (viscerosomatic)

• MC over weight >40yo
• MC cause of cholelithiasis (gallstones)
• Severe upper right quadrant pain

Increased amylase and lipase

Calcification that can become malignant due to chronic inflammation

• Pancreatitis
• Pancreatic CA
• Diabetes mellitus
• Diabetes Insipidus

Epigastric pain straight through the back T10-T12 like a knife

bleeding into the flank seen in pancreatitis

• Bruising/ pery umbilical ecchymosis
• seen in etopic pregnancy and pancreatitis

Increased amylase and lipase

• Glucose Tolerance Test
• Fasting Plasma Glucose
• HbA1C

Dish

• DM - Polydypsia, Polyphagia, polyuria
• DI- Poly dypsia and polyuria

• Includes Duodenal and gastric ulcers
• caused by H. Pylori bacteria
• coffee ground emesis
• burning epigastric pinpoint pain

• Pain occurs two hours after eating
• BLACK/Tarry stool
• MC type of peptic ulcer

Guaiac Test-Occult blood in the stool

Stomach CA

Lesser curvature and left supraclavicular lymph node (virchows Node)

Epstien Bar Virus 18-25 yo

• Spleen
• Atypical lymphocytes (downy Cells)

• Heterophile Aggulation
• Paul Bunnel Test

Peri Umbilical

• Adynamic Ileus
• Regional Ileitis aka Crohns Dz
• Ulcerative Colitis
• Irritable Bowel Sundrome aka Spastic Colon
• Appendicitis
• Diverticulitis

• Right side of the intestines (RLQ)
• Patchy Inflammation (cobblestone appearance) does not absorb B12
• chronic diarrhea

sigmoidoscopy

malabsorption syndrome: tropical sprue/ celiac Sprue (gluten allergy)

Ulerative colitis

Dull periumbilical with radiation to lower right quadrant

Appendicitis - increased WBC

CT scan

• small outpuching within the colon
• LLQ pain

• Cushings Dz (aka Hyperadrenalism, hypercortisolism)
• Addison Dz
• Pheochromocytoma

• Moon pie face
• buffalo hump
• purple striae in pendulous abdomen
• hypertension

• Hypoadrenalism; Hypocortisolism (decreased aldosterone)
• decreased Bp
• hyperpigmented mouth and face (bronze)

• Grey Cell Tumor of Adrenal Medulla
• Increased epinephrine production (catecholamine)
• Tachycardia, extreme hypertension

Pheochromocytochroma