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Cardiovascular Exam
"Hi my name is ______, I.m a second year medical student. What is your
name? It.s very nice to meet you. Mr./Mrs. ______ I.ve been asked to
come in and check your pulse and blood pressure. Is that ok with you? Ok if
there is any discomfort at any time please let me know and I.ll try my best
to alleviate the discomfort.
I. Inspection
- Inspect with the patient in supine position with the arms at their sides
- Inspect from the foot of the bed, then on the right side of the patient
- Inspect the patients body from their periphery in towards their heart
- Palpate for pitting edema
o "Mr./Mrs. _____ I.m just going to be pressing into your legs
and feet, just let me know if there is any pain at allE
o Note: when palpating for pitting edema, the doctor should be looking at
the patient’s face for any signs of tenderness
o Press firmly but gently with thumb for > 5 seconds bilaterally over:
The dorsum of foot
Posterior to medial malleolus
Over the shins
- Inspect the patient’s eye
o "Can you please look up for me?E
o Pull down underneath the patients eye to be able to inspect the
conjunctival sac for signs of anemia
o "Can you please look down for me?E
o Pull up on the eyelids to be able to inspect the sclera for jaundice
- Inspect the patient’s tongue
o "Can you please open your mouth for me?E
o Checking for glossitis
o "Can you please lift up your tongue for me?E
o Checking for central cyanosis
- Inspect the patients fingers
o Bring up the patient’s fingers to eye level to check for clubbing and
splinter hemorrhages
o Capillary refill: pinch the patient’s fingers/nails for a second and look to
see the blood flow back into the nails
- "Upon initial inspection the patient is not in any distress, there is no
pitting edema, no signs of anemia and jaundice. There are no signs of
1
glossitis and central cyanosis. There is no clubbing, splinter
hemorrhages, and capillary refill is normalE
II. Pulses
- Inspect arm/hand for masses scars or
lesions
- "Mr./Mrs. _____ I.m going to
be checking your pulse nowE
- Palpate the right radial pulse with
the pads of your index and middle
finger on the patient’s lateral flexor
surface of wrist for one minute. You
are palpating for:
o Rate – beats per minute
o Rhythm
o Volume
o Character
o Palpate for tone of vessel
wall (should not be palpable):
with the middle finger of
your right hand occlude the
radial artery and then with
the index finger of the same
hand palpate for the radial
artery
- "With the patient in supine position, the right radial artery is 72
beats per minute, with regular rhythm, normal volume and character.
The right radial artery was not palpable.E
- Palpate the following bilaterally except for the carotid. Check to see that all the
pulses are present bilaterally, no differences in the rate, rhythm, volume, and
character. For this part of the exam you should only have to check the pulses for
a few seconds (5-10).
- Radial: lateral to tendon of flexor carpi radialis
- "Mr./Mrs. _____ can you go ahead and flex your arm for me against
my handE
- Brachial: medial to the biceps tendon (by giving resistance as the patient tries to
flex their arm the biceps tendon should become visible)
- "Mr./ Mrs. _____ can you turn your head to the side please... ok, now
the turn to the other side... thanksE
- Carotid: between the trachea and the SCM, sternoidcleidomastoid muscle (check
one side at a time)
2
- "Mr/Mrs._____ I.m going to be checking for your pulses in the groin
area and I.m going to be palpating for some landmarks firstE
- Femoral: distal to the inguinal ligament (ASIS, anterior superior iliac spine and
symphysis pubis)
- **Radial-Femoral Delay**:
o Palpate radial and femoral pulses simultaneously (you may want to check
for this at this point since the femoral artery has already been palpated)
o Positive sign is if the pulses are not felt simultaneously.
- "Mr/Mrs. _____ can you slide your legs up for me please, I.m going to
check your pulse under your knee...thanksE.
- Popliteal: lateral to the semimembranosus tendon (from medial to lateral,
semitendinosus, semimembranosus, and biceps femoris)
- "Ok you can go ahead and bring your legs back downE.
- Dorsalis pedis: between the 1st and 2nd metatarsals
- Posterior tibial: posterior to the medial malleolus
- **Water-Hammer**:
o "Do you get dizzy when you sit up...ok, then can you please sit up
for me pleaseE.
o Ask the patient to sit up
o "Go ahead and relax your arm for me please. I.m going to be
raising your arm over your headE.
o Palpate radial pulse the lift off the artery until you can barely feel it; then
quickly move patient’s arm over their head
- **Allen.s Test**:
o Check for patency (occlusion) of ulnar artery before puncturing the radial
artery for blood samples
o "Can you make a fist for me?E
o Take the patient’s hand using both your hands and compress both the
radial and ulnar arteries firmly between your thumb and fingers as they are
making a fist (palm up).
o "Go ahead and open your hand now and relax your hand a bitE.
o The patient’s hand should be pale and the hand should be positioned in a
slightly flexed position.
o Release pressure over the ulnar artery (this is checking for patency in the
radial artery); note time until color returns.
o "Can you make a fist for me again?E.
o Take the patient’s hand using both your hands and compress both the
radial and ulnar arteries firmly between your thumb and fingers as they are
making a fist (palm up).
o "Go ahead and open your hand now and relax your hand a bitE.
o The patient’s hand should be pale and the hand should be positioned in a
slightly flexed position.
3
o Release pressure over the radial artery (this is checking for patency in the
ulnar artery); note time until color returns.
- "All pulses are present and bilateral. There was no Radial-femoral
delay noted. Water-Hammer test was negative, and Allen.s test
showed patency of both ulnar and radial arteriesE.
III. Blood Pressure

- The patient’s arm has to be exposed up to the shoulder
- "I.m going to take your blood pressure right nowE
- "Have you ever had your blood pressure taken before?E
- "Do you remember what it was the last time you had your blood
pressure taken?E
- "Did you have any coffee/tea today? How long ago?E
- "Did you exercise today?E
- "Do you smoke?E
- Inspect the arm
- "Upon inspection, no masses, scars, lesions, tearing or interferences in
the cubital fossa are notedE
- Measure cuff: bladder width should be approximately 40% of upper arm
circumference and length should be approximately 80%.
- Confirm the presence of the brachial pulse (1 cm proximal and medial to cubital
fossa) and palpate the vascular tone for patency
- Position patient’s hand in your armpit – hands free support
- Center the bladder over the brachial artery, approximately 2.5 cm above the
antecubital fossa; secure snugly.
- "You.re going to feel some pressureE
- Determine target inflation level (estimating the systolic)
o Palpate radial pulse
o Inflate cuff until radial pulse in non palpable (palpable systolic)
o Target level is then palpable systolic + 30mmHg
o Use this target from subsequent inflation to prevent discomfort from
unnecessarily high cuff pressures; also avoids auscultory gap
- Deflate cuff to 0 mmHg
- Place bell over the brachial artery, inflate cuff to target inflation level then deflate
at a rate about 2 mmHg per second and listen for Korotkoff sounds
- To confirm disappearance of sounds, listen as pressure falls 10-20 mmHg past 5th
Korotkoff sound, then deflate cuff rapidly to zero
- Report both systolic and diastolic level to the nearest 2 mmHg (even numbers),
where measured, patient’s position
- "The patient.s blood pressure was 120/80 in the right brachial artery
with the patient sittingE
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- The first reading is the point where you hear the first sound and the second
reading is the point where you hear the last sound (4th) minus 2 mmHg. So in the
case where the blood pressure is 120/80 mmHg the last sound heard (4th) is 82
mmHg.
- Offer to take BP twice and repeat in left arm
IV. Venous System

- Jugular Venous Pressure
o Determination of right atrial pressure
o Position patient with the bed elevated 30 degrees, adjust angle to
maximize visibility of the jugular venous pulsation; ask patient to turn
head slightly away from the side being checked
o Arbitrarily the sternal angle is 5 cm above the center of the right atrium
(vertical height doesn’t change whether the patient is lying down or
inclined)
- Inspection
o Look for any masses, scars, or lesions, varicose veins, caput medusa
o "Upon inspection, no masses, scars, or lesions noted. No
varicose veins notedE
- Locate internal jugular (between bellies of sternoidcleidomastoid muscle) or
external jugular vein (post to post belly of sternoidcleidomastoid muscle)
o Use tangential lighting and valsalva maneuver if necessary to locate the
highest point where venous pulse can be seen
o Confirm it is the venous pulse
- Measure highest point (vertical height) of pulsation from the sternal angle
o Place ruler on the sternal angle in the vertical position
o Place a straight edge up or down so that it’s lower edge rests at the highest
point of pulsation
o Read vertical distance between the sternal angle and the lower edge of the
straight edge (to the nearest cm above sternal angle)
o If the highest point of pulsation lies below the sternal angle:
Place the straight edge on the sternal angle in the horizontal
position
Place long end of ruler at highest point of pulsation and
perpendicular to straight edge
Read the vertical distance between the end of the ruler and the
straight edge (cm’s below the sternal angle)
- "The JVP is 3 cm.s above the sternal angle or 8 cm above the right
atriumE
- Offer to execute and observe:
o **Hepato-jugular reflux**:
"I.m going to be pressing into your stomach nowE
Lightly press on abdomen and observe the JVP
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Normally it should see it distend for a quick second, but in
abnormal it should stay distended longer because the heart can’t
compensate the extra blood due to right-sided heart failure.
o **Kussmaul sign**:
Note the JVP as the patient inspires.
Normally it should go in. You breath in there is a pooling of blood
effect to the heart but in the abnormal (positive) it distends due to
the backing up of blood caused by right-sided heart failure.
- "The Hepato-jugular reflux and the Kussmaul sign are negative.E
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Cardiovascular Exam Secondaries
I. Inspection
Head
Temperature
Sclera for jaundice, yellowish discoloration of the skin and sclera with bilirubin
levels greater than 2.5 mg/dL.
Conjunctiva for anemia: blood loss, iron deficiency, folate/B12 deficiency,
hemolysis, infections, sickle cell, thalassemia, DIC; associated with pallor, carotid
bruits, Water-hammer, cyanosis, slow capillary refill
Tongue for glossitis:
o Causes: iron deficiency anemia, vitamin deficiency (vitamin C, niacin L
B3, riboflavin L B2, folate, cobalamin B12)
o Signs and symptoms: painful tongue, red, smooth, and no filiform papillae
Underneath tongue for central cyanosis: bluish discoloration of the skin with
reduced Hb; d/t CO anemia, R L shunts, vasoconstriction, polycythemia,
pulmonary pathology; having central cyanosis implies peripheral cyanosis, but
peripheral cyanosis can exist without central cyanosis
Chest symmetry
Pectus excavatum: depressed sternum/funnel chest that may cause murmur.
Compresses the heart and great vessels causing murmurs.
Pectus carnatum: in kids with asthma, may be caused by cardiomegaly. Pigeon
chest/ children breast deformity. Sternum is displaced anteriorly, costal cartilages
are depressed.
Palms
Temperature, moisture, pallor, jaundice, xanthomas, lesions
Nails
Clubbing: (tips of the fingers appear round and bulbous) angle

between plate and proximal fold >180 degrees, spongy (spongy, feels like the nail is
floating) nail bed; due to R L shunts, infective endocarditis, bronchogenic
carcinoma, CrohnXs disease and ulcerative colitis, liver cirrhosis, TB, chronic
bronchitis, anemia, empyema
Capillary refill (normal is 1-2 seconds): peripheral vasculature disorders (diabetes
mellitus, vasculitis)
Splinter hemorrhages: Subacute bacterial endocarditisis the most common cause.
Splinter hemorrhages appear as narrow red to reddish brown hemorrhages beneath
the nails. They run in the direction of nail growth. The hemorrhages are caused by
microscopic clots that damage the small capillaries under the nails.
Legs
Pitting edema: + depression due to pressure of thumb fluid moved into vascular
system, therefore skin takes longer to return to normal; veins distended; Scale: +1 to
+4 (worst)
o Chronic venous insufficiency: CHF, liver disease, nephrotic syndrome,
IVC obstruction; bilateral, thick skin, ulcers
o Orthostatic: prolonged sitting or standing; bilateral
Non-pitting edema: no pitting because fluid doesnXt move into vascular system;
veins are not distended. Causes:
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o Lymphedema: lymphatic obstruction; often bilateral; thick skin
o Lipedema: fat deposition in legs; not true edema; bilateral
Pulses
Radial pulse
Rate: <60 = bradycardia; >100 = tachycardia
o with caffeine, smoking, exercise, inspiration, hyperthyroidism, fever,
anemia, severe lung disease, shock, sinus tachycardia, ventricular and
supraventricular tachycardia
o with trained athlete, exhalation, 2nd/3rd degree heart block, early stages
of MI, vagal tone
Rhythm:
o Regularly irregular (heart block, atrial flutter)
o Irregular
Regular
Atrial (supraventricular) premature contractions
o Aberrant P waves
o S1 differs in intensity and S2
Ventricular premature contradictions
o Aberrant QRS and T
o Early beat with split sounds
Sinus arrhythmia
o Normal cyclical heart rate variation: with
inspiration; with expiration
Irregular
Atrial fibrillation/flutter
o No P waves
o Ventricular rhythm is totally irregular, S1 varies
with intensity; Rx: digitalis/quinidine
o Complication: stagnant blood clot
embolization
Volume
o Normal: full
o Increase: fever, anemia, hyperthyroidism, pheochromocytoma, aortic
fistula
o Decreased: hypovolemia (diuretic, emesis, diarrhea, hemorrhage), left
ventricular failure
Character
o Normal: nonbounding, brisk upstroke
o Bisferiens: double systolic peak due to aortic regurgiation with or without
aortic stenosis, hypertrophic CM
o Pulsus Alterans: pulse amplitude regularly alternates due to left
ventricular failure, heart swinging in pericardial sac
o Pulsus parvus: weak upstroke due to stroke volume, hypovolemia, left
ventricular failure, aortic or mitral stenosis
o Pulsus tardus: slow rising pulse due to aortic stenosis
o Paradoxical pulse: exaggerated inspiratory fall in systolic blood pressure
(>10mmHg less than expiratory systolic blood pressure) due to cardiac
tamponade, constrictive pericarditis, obstructive lung disease
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o Small, weak pulse: upstroke slowed and peak prolonged, tachycardia
pulse, thready; due to stroke volume (heart failure, hypovolemia, aortic
stenosis); TPR (exposure to cold and congestive heart failure)
o Large bounding pulse: due to stroke volume anemia, hyperthyroid,
aortic regurgitation, marked vasodilation; patent ductus arteriosus,
bradycardia or complete heart block; compliance ( stiffness L aging or
artherosclerosis)
Palpate tone
o Normal: not palpable
o Palpable: (chord-like) due to atherosclerosis
Peripheral pulses: increased, normal, diminished, or absent

Absent or diminished pulse: partial or complete arterial occlusion (arteriosclerosis)
distal to occlusion; arteriosclerosis most commonly obstructs in the thigh femoral
pulse absent & popliteal pulse decreased or absent
TakayasuXs arteritis: weak pulses in the upper extremities
Widened femoral pulse and popliteal pulse: femoral and popliteal aneurysm
Dorsalis pedis absent may be congenital or branch may be higher in the ankle
Absent dorsalis pedis with a femoral pulse diabetes mellitus
Radial J femoral delay: i+j if femoral pulse is smaller or later than radial pulse due to
aortic coartation after left common carotid branch
Water J hammer pulse: i+j feel knocking/ bounding pulse then falls (collapsing pulse);
due to fever, thyrotoxicosis, aortic regurgitation, anemia, PagetXs disease, AV shunt
AllenLs test:
Normal: ulnar artery patent color returns to palm in 3-5 seconds
Abnormal: > 3-5 seconds d/t occlusion of ulnar artery
Blood Pressure
Sphygomomanometers:
Mercury: more accurate
Aneroid (spring): less accurate, needs periodic calibration
Electronic: very unreliable
Reasons not to check BP: dialysis, shunt, brachial cut down (IVDA)
Abnormally high reading:
Short or high cuff
Caffeine (<1 hour before)
Exercise (<30 minutes before)
Brachial Artery well below heart level when measure BP
Patient arm is not relaxed
Abnormally low reading
Long or loose cuff
Bladder balloons outside of cuff
Hypotension: systolic blood pressure < 100 mmHg due to hemorrhage, cardiogenic
shock, hypovolemic shock
Orthostatic hypotension: check blood pressure standing and sitting (+ if systolic BP
falls >20mmHg while standing); due to ANS diseases, hemorrhage, drugs, prolonged bed
rest
Systemic hypertension
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Category Systolic (mmHg) Diastolic (mmHg)
HTN
Stage 3 (severe) 180 110
Stage 2 (moderate) 160-179 100-109
Stage 1 (mild) 140-159 90-99
High normal 130-139 85-89
Normal <130 <85
Optimal <120 <85
Essential hypertension (MCC): defect in sodium excretion, transport; variation in

genes encoding for renin-angiotensin system proteins; neurogenic vasoconstriction
Secondary hypertension: renal disease (increased renin secretion, sodium retention,
decreased vasopressin secretion, nephritic syndrome); endocrine causes
(aldosteronism, contraceptives, pheochromocytoma, hyperthyroidism, CushingXs
syndrome); vascular (coarctation of the aorta, vasculitis, renal artery stricture or
coarctation); neurogenic (psychogenic, increased intracranial pressure)
Pulmonary hypertension: dependent edema, wide S2; hepatomegaly, ascites, Graham
Steele murmer
Kortokoff sounds: 1st L systolic sound heard at least 2 consecutive beats; 2nd L3rd start-
end of auscultory gap (no sound heard); 4th muffling of sound; 5th L diastolic when
sounds disappear
Auscultory gap: absences of sound within the range of the Korotkoff sounds; may
overestimated diastolic or underestimated systolic meaurement
II. Venous System

a. Jugular Venous Pressure
i. Used to check volume overload (right atrial filling pressure),
venous return, and cardiac output
CHARACTERISTIC JVP CAROTID
Location Low in neck and lateral Deep in neck and medial
Contour Biphasic and diffuse Single-peaked and sharp
Character Undulant , NOT palpable Forceful, brisk, easily felt
Response to position Varies w/ position No variation
Response to w/ inspiration No variation
respiration
Response to Displace pulse upward and Pulse unchanged
abdominal pressure induces transient in pressure
Effect of palpation Wave visible but nonpalpable Pulse unchanged, vessel
difficult to compress
ii. Normal JVP: <4cm from sternal angle (<9cm above the RA)
iii. JVP: >4cm above the sternal angle (>9cm above the RA); atrial
pressure is (Hypervolemia); due to right heart failure, TV
stenosis, constrictive pericarditis, pericardial tamponade, SVC
obstruction, Pancoast tumor = blood flow to RA
iv. JVP: at or below the sternal angle; atrial pressure
(Hypovolemia) d/t severe burns, severe emesis, fistula, blood
volume , dehydration
v. A change in JVP is concern, not the instantaneous measurement
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b. Right atrial pressure wave (reflected in the biphasic jugular venous
pulse)
c. Hepato-jugular reflux:
i. Tests heartXs capacity to compensate for venous return (StarlingXs
Law);
ii. Normal: JVP with the increase abdominal pressure, then
iii. Abnormal: JVP doesnXt due to right-sided heart failure (RV
filling problem), cardiac tamponade
d. Kussmaul sign:
i. Normal: JVP with inspiration
ii. + JVP with inspiration: due to cardiac tamponade, right sided
heart failure, RV stiffness
11
Precordium Exam
come in and examine your heart. Is that ok with you? OK, if there is any
discomfort at any time please let me know and I.ll try my best to alleviate
the discomfort. Ok, at this time I.m going to have you uncover yourself
from the waist up.F
I. Inspection
- Inspect with the patient in supine position with the arms at their sides
- Inspect from the foot of the bed, then on the right side of the patient
o Check for signs of distress
o Masses, scars, lesions
o Apex beat
o Symmetry
o "Upon inspection, the patient is not in any distress. The
patient.s chest is symmetrical. There are no masses, scars, or
lesions. The apical beat is not visible.F
- Inspection from side of bed
o Apical beat (use tangential lighting)
o "Upon closer inspection using tangential, the apical beat is not
visible.F
II. Palpation
o Check for parasternal heave
Place ulnar surface of hand perpendicular to sternum along
parasternal edge
"Can you please breathe out for me and hold?F
Ask the patient to breath out and hold and observe any movement
of hand
o Check for thrills by placing palm of right hand over all 4 valve areas
13
o Localize apex beat
Place palm of right hand underneath the patientFs left breast
Pinpoint where it is felt with ½ finger
If you are unable to feel it, ask patient to turn to the left side,
exhale, and stop breathing for a few seconds; try to locate again
Note:
Location: use left hand to count intercostal spaces and
measure from midsternal line (cmFs)
Diameter: measure using finger width (~1.5 cm)
Duration: palpate the carotid pulse or radial pulse with
your left hand and compare to apical beat (normal,
sustained). Another way to check duration is to auscultate
for S1 and S2 and palpate the apex beat.
Amplitude: (normal, hypokinetic/hyperkinetic)
Focal or diffuse
o If you canFt find the apical beat then check for dextrocardia (heart
displaced to the right): place the palms of both hands on either side of
sternum and locate patientFs heartbeat
- "Upon palpation no thrills were felt. There was no parasternal heave.
The apical beat was located 7 cm from the midsternal line, just medial
to the midclavicular line. Amplitude was normal. The diameter was 2.5
cm and focal. Apical beat duration was less than 2/3 systole. There
was no dextrocardia (report only if the apical beat was nonpalpable)F
III. Auscultation
o "Mr./Mrs._____ I.m just going to be listening to your heart
now.F
o "Can you turn your head to the left please and breath normallyF
o Ask patient to turn their head to the left
o While auscultating palpate the carotid pulse with your left hand to find S1
heart sound (upstroke of carotid is timed with S1 and auscultate)
Start with bell from base apex (aortic pulmonary mitral
tricuspid). Auscultate the tricuspid on two spots. (Warm the
stethoscope with your shirt)
Aortic valve is 2nd IS midclavicular line
Pulmonary valve is 2nd IS midclavicular line
Tricuspid valve is 3rd and 5th IS left of the sternum
Mitral valve is 5th IS midclavicular line
Check for mitral stenosis (pitch is low and quality is rumbling)
"Can you please roll to your left please and exhale
completely and hold for three seconds?F
14
Ask patient to roll onto left side (left decubitus position)
while keeping stethoscope bell on chest
Ask patient to completely exhale and hold breath for 3
seconds (brings the heart closer to chest wall)
"Ok, go ahead and lie back down on your back
please.F
Ask patient to return to supine position
Flip to diaphragm and work back to base (tricuspid mitral
pulmonary aortic)
Check for aortic regurgitation (pitch is high and quality is blowing)
"Can you please sit up for me and lean forward
please?F
Ask patient to sit up and hunch over
"Can you exhale completely and hold for three
seconds again?F
Ask patient to completely exhale and hold breath for 3
seconds (brings the heart closer to the chest wall)
Auscultate with the diaphragm along the sternal border in
2nd, 3rd, and 4th intercostal spaces.
- "Upon auscultation S1 and S2 were heard S3 and S4 were not heard.
There were no murmurs, rubs, clicks, ejection sounds, or opening
snaps. Mitral stenosis and aortic regurgitation were not heard.F
- “MR. CEO” - (Murmurs, Rubs, Clicks, Ejection sounds, Opening snaps)
15
Precordium Exam Secondaries
I. Precordium
a. Palpation
i. Dextrocardia: heart, liver, stomach on right (situs inversus)
1. If heart on right and other 2 on left = congenital heart
disease
ii. Parasternal heave: if =+? hand will rise and tilt with each beat;
due to right ventricular hypertrophy
iii. Thrills (palpable murmurs)
1. Aortic: upper right sternal border
2. Pulmonary: upper left sternal border
3. Tricuspid: lower left sternal border
4. Mitral: horizontal across 5th IS
iv. Apex beat
1. May not be found in:
a. Obese
b. Dextrocardia
c. Emphysema
d. Pericardial effusion (fluid in the pericardial sac)
Signs and symptom is BeckSs Triad (hypotension,
elevated JVP, and muffled heart sounds). All the
chambers of the heart will have restrictive filling
throughout diastole.
e. Death
2. Apical beat: furthest down and out point. This is where
the farthest point you can feel the beat, doesnSt have to be
the strongest.
3. Point of Maximal Intensity (PMI): area of maximal
impulse; normally they are the same point
4. Location: normal = 5 IS MCL
a. Displaced because of pregnancy, high left
diaphragm, enlarged heart, thorax deformities; right
ventricular hypertrophy lateral; left ventricular
hypertrophy inferior and lateral, myocardial
infarction, aneurysm superior and medial, and
pulmonary pathology affecting the mediastinum
5. Amplitude: normal (small and gentle)
a. Hypokinetic: dilated cardiomyopathy
b. Hyperkinetic: anemia, hyperthyroidism, aortic
stenosis, mitral regurgitation, hypertension (also
increased duration), mitral regurgitation (also lateral
apical beat), anxiety, atrial septal defect (no change
in duration)
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6. Diameter: supine Y usually less than 2.5 cm; left lateral
decubitus(the position of the patient in bed lying to the
side) position - >3cm indicates left ventricular hypertrophy
a. with left ventricular hypertrophy due to volume
overload (aortic regurgitation) or pressure overload
(aortic stenosis, hypertension)
7. Duration:
a. Most useful to identify left ventricular hypertrophy;
carotid pulse
b. Normal: 2/3 systole duration (_sustainedS if greater)
c. Normal: <2 radial beats (_sustainedS if greater)
b. Auscultation:
i. Aortic: 2nd IS right sternal border
ii. Pulmonary: 2nd IS left sternal border
iii. Tricuspid: 5th IS left sternal border
iv. Mitral: 5th IS midaxillary line
II. Heart Sounds

a. S1: Mitral and tricuspid closure at beginning of systole, heard best at the
apex
i. Corresponds with carotid artery upstroke
ii. in heart rate, cardiac output, mitral stenosis
iii. in 1st degree heart block, calcified mitral valve (mitral
regurgitation) left ventricle contractility (CHF, CAD)
iv. Varying: complete heart block, irregular rhythm (atrial fibrillation)
v. A normal split is detectable along the lower left sternal border; an
abnormal split is due to right bundle branch block, premature
venticular contraction
b. S2: A2 = Aortic closure at the end of systole; P2 = Pulmonic closure at
end of systole, heard best at the base
i. Corresponds to radial pulse
ii. P2 due to severe pulmonary hypertension
iii. A2 due to systemic hypertension
iv. Physiologic splitting (A2-P2) auscultate 2nd, 3rd left IS,
accentuated by inspiration, disappears on expiration, especially
when patient sitting up. Inspiration prolongs ejection of blood
from the right ventricle but shortens ejection from the left
ventricle.
v. Pathologic splitting
1. Wide splitting: A2-P2 delay due to delay pulmonic valve
closure (pulmonary stenosis, right bundle block), early
closure of aortic valve (mitral regurgitation)
2. Fixed splitting: wide splitting that doesnSt vary with
respiration due to atrial septal defect, right ventricular
failure
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3. Paradoxical/reverse splitting (P2-A2): accentuated on
expiration and disappears on inspiration due to delay aortic
valve closure (most common cause is left bundle branch
block)
c. S3: rapid filling of left ventricle in early diastole (later than an opening
snap)
i. A left sided S3 is heard best at the apex with patient on lying on
the left side, left decubitus position, with the bell (dull and low
pitched). A right sided S3 is heard best along the lower left sternal
border with the patient supine
ii. Normal in children, common in athletes, third trimester of
pregnancy, pathologic in adults due to myocardium contractility,
congestive heart failure, left ventricular or right ventricular failure,
volume overload, or mitral/tricuspid regurgitation
iii. Gallop (Ventricular Gallop) Y ‘Kentucky’ (1-2-3)
d. S4: Atrial contraction ventricle filling occurs late in diastole

i. A left sided S4 is heard best at the apex with patient on laying on
the left side, left decubitus position, with the bell (dull and low
pitched). A right sided S4, less common is heard best along the
lower left sternal border with the patient supine.
ii. Dull pitched and heard in trained athletes
iii. Pathological due to ventricular compliance, - pressure overload
states (aortic stenosis, chronic hypertension, myocardial infarct,
CAD Y coronary artery disease); if accompanied by pain due to
ischemia
iv. Gallop (Atrial) Y ‘Tennessee’ (4th Y 2nd Y 1st)
III. Associated Sounds

a. Clicks (high pitched)
i. Ejection sounds: aortic and pulmonic valve stenosis
ii. Mid or late systolic click Y is indicative of mitral valve prolapse;
heard best with patient standing, eliminates all other clicks.
18
Standing (Valsalva or amyl nitrate) reduces left ventricular
volume). Standing brings the click closer to S1
iii. Late systolic click: papillary muscle dysfunction (i.e. post-MI)

b. Opening Snaps (high pitched): mitral valve stenosis (1 rheumatic heart
disease)
c. Rubs (high pitched)
i. Inflammation of pericardium (pericarditis Y most common viral
cause is secondary to coxsackievirus B and most common bacterial
cause is Strep and Staph)
ii. Best heard along left sternal border while leaning forward with
held expiration
iii. Scratchy, scraping quality
d. Knocks, Crunches
i. Pneumothorax: 1 in white, 20Ss, SOB, chest pain
ii. Knock: early diastolic sound heard in patients with constrictive
pericarditis
iii. Crunch: beating heart hitting emphysematous lungs
IV. Murmurs
a. If a murmur is auscultated, report on:
i. Location: murmurs originating in right side of heart tend to change
more with respiration than left sided ones
ii. Timing
iii. Intensity
1. Very faint, may not be heard at all points
2. Quiet, immediately heard with stethoscope on chest
3. Moderately loud
4. Loud
5. Very loud, heard with stethoscope partly off chest
6. Heard without stethoscope
Note: 4, 5, 6 are all thrills
iv. Radiation
v. Character
1. Rumbling: mitral stenosis
2. Blowing: aortic regurgitation
3. Musical: MV regular
4. Harsh: aortic stenosis
vi. Pitch (low, high)
b. Mechanism of murmur:
i. flow/pressure across valve: anemia, thyrotoxicosis, exercise,
fever, pregnancy
19
ii. Irregular valve surface: aortic sclerosis, endocarditis
iii. Backward flow: aortic regurgitation, mitral regurgitation
iv. Stenosis: aortic stenosis, mitral stenosis
v. Abnormal connection: ventral septal defect, atrial septal defect
vi. Flow into dilated chamber: aortitis, MarfanSs syndrome
c. Types
i. Aortic regurgitation
1. Location: left sternal border 2, 3, 4 IS
2. Timing: diastolic, decrescendo
3. Radiation: left sternum down to apex
4. Intensity: strong
5. Pitch: high
6. Quality: blowing
ii. Mitral Stenosis

1. Location: apex
2. Timing: late diastolic: crescendo
3. Radiation: none
4. Intensity: 3-4
5. Pitch: low
6. Quality: rumbling
20
iii. Mitral regurgitation
1. Location: apex
2. Timing: pansystolic, plateau
3. Radiation: axilla and behind shoulder blade
4. Intensity: 2-4
5. Pitch: high
6. Quality: musical
iv. Aortic Stenosis

1. Location: right 2nd IS
2. Timing: midsystolic, crescendo-decrescendo
3. Radiation: neck, left sternal border
4. Intensity: 3-4
5. Pitch: medium
6. Quality: harsh
v. Early Systolic murmurs
1. Acute severe mitral regurgitation
a. Timing: decrescendo
b. Location: heard at the apex or medial to it
c. Causes:
i. Papillary muscle rupture complicating acute
myocardial infarct (lateral, inferior,
posterior)
ii. Infective endocarditis: associated with fever,
peripheral embolic lesions, + blood cultures
iii. Rupture of chordae tendineae
21
iv. Blunt chest wall trauma
2. Small muscular ventricular septal defect with no
pulmonary hypertension or left ventricular volume overload
a. Location: left sternal edge
b. Intensity: 4-5
3. Large, uncorrected ventricular septal defect with
pulmonary hypertension
4. Tricuspid regurgitation
a. Causes: infective endocarditis in (injection drug
users)
b. Soft
c. Location: heard at the lower left sternal edge
d. Carvallo’s sign: inspiration may accentuate
vi. Midsystolic murmurs
1. Aortic stenosis
2. Sclerosis of aortic valve (left sternal edge)
3. Pulmonic valve stenosis (pulmonic area)
4. Hyperdynamic states (fever, thyrotoxicosis, pregnancy,
anemia) left sternal edge
5. Hypertrophic cardiomyopathy (left sternal edge, 2-3
intensity; loudest when decrease in left ventricular volume
(Valsalva, standing, amyl nitrate)
vii. Late Systolic Murmurs
1. Mitral valve prolapse: a nonejection click followed by
murmur, best heard at the apex to the left sternal edge, click
and murmur moves toward S1 when there is a decrease in
left ventricular volume (Valsalva, standing, amyl nitrate)
viii. Holosystolic (Pansystolic) Murmurs
1. Mitral regurgitation
2. Tricuspid regurgitation: intensity of 1 to 3 and at the left
lower sternal edge, and increases upon inspiration
3. Ventricular Septal Defect: louder than tricuspid
regurgitation and no change with inspiration
ix. Early Diastolic murmurs
1. Aortic regurgitation Y peripheral signs of wide systemic
pulse pressure and water hammer carotid upstroke
2. Graham-Steele murmur (pulmonic valve regurgitation):
early diastolic murmur, heard over right sternal border due
to pulmonary hypertension; incompetent pulmonary valve;
increase in intensity upon inspiration
x. Middiastolic murmurs
1. Mitral stenosis
2. Tricuspid stenosis
xi. Austin Flint murmur: mild diastolic murmur at apex due to a
chronic aortic regurgitation (hear over apex) left ventricle
22
volume overload originates at the mitral valve when blood
enters simultaneously from both the left atrium and the aorta.
xii. Carey Coombs murmur: blubbering apical mid-diastolic murmur
occurring in acute stage of rheumatic mitral valvulitis and
disappearing as valvulitis subsides
xiii. Patent Ductus Arteriosus PDA (normal is R L, abnormal is L
R): machinery murmur at 2nd left IS bilaterally, loudest around
S1
xiv. Venous hum: small murmur, origin in veins of children
(disappears when child sits up), severe anemia, pregnancy,
hyperthyroidism; continuous murmur; louder in diastole; hear
above clavicles, around root of neck; obliterate with pressure on
jugular veins; low pitch
xv. Benign pulmonary flow murmur: CV exam otherwise normal;
hear over pulmonary artery, systolic murmur
xvi. Mammary soufflé: pregnancy and lactation blood to breasts,
systolic and diastolic
xvii. Cervical systolic murmur/bruit: carotid aorta due to
atherosclerosis ventral septal defect Y early life; atrial septal defect
Y late 20s
V. Endocarditis
a. Subacute bacterial endocarditis:
i. Caused by strep. viridians, strep. fecalis, strep. bovis, hemophilus,
parainfluenza
ii. Occurs in previously diseased valves; bulky, friable vegetations
(made of fibrin, inflammatory cells, and bacteria) on valves
iii. Embolization of vegetations causes petechiae, infarcts, mycotic
aneurysms
b. Acute bacterial endocarditis:
i. Caused by staph. Aureus; seeding previously normal valves
ii. Complications include systemic pyemia; can cause death
VI. Left heart failure

a. Causes:
i. Essential hypertension Y hypertension without known cause
ii. Mitral regurgitation
iii. Aortic stenosis
iv. Myocardial infarct
v. Thyrotoxicosis
vi. CAD
vii. Constrictive pericarditis Y most common cause world wide is
tuberculosis; most common cause in the US is idiopathic; open
heart surgery; radiation of the mediastinum; neoplastic disease;
previous pericarditis
23
viii. Hypertrophic cardiomyopathy
ix. Pericardial tamponade
x. Ischemic heart disease
xi. Ventral septal defect
xii. Patent ductus arteriosus (normal R L; abnormal L R)
xiii. Bicuspid aortic valve
b. Signs and symptoms:
i. Exertional dyspnea
ii. Cough
iii. Fatigue
iv. Orthopnea Y is discomfort in breathing that is brought on or
aggravated by lying flat.
v. Paroxysmal nocturnal dyspnea Y acute dyspnea appearing at
night, usually awakening the patient after an hour or two of sleep
caused by pulmonary congestion that results from left sided heart
failure.
vi. Cardiac enlargement
vii. Pulmonary rales
viii. Crepitations
ix. Late inspiratory crackles
x. Gallop rhythm Y hearing a third heart or fourth heart sound the 3rd
or 4th heart sound, referred to as the Kentucky and Tennessee
Gallop respectively. They occur in diastole and S4 is due to atrial
contraction and S3 to rapid filling of a ventricle. There is also a
summation gallop, which is both S3 and S4 and when the rhythm
is fast they may sound as one.
xi. Nocturia Y excessive urination at night
xii. Pulmonary edema
xiii. Pulmonary hypertension
xiv. Respiratory alkalosis
xv. Hypotension
xvi. Fatigue
xvii. Weakness
VII. Right heart failure

a. Causes:
i. Left heart failure
ii. Mitral stenosis
iii. Pulmonic regurgitation
iv. Pulmonary hypertension
v. Pulmonary emboli
vi. Myocarditis Y viral infection (coxsackievirus B) is the most
common cause
vii. Right ventricle infarction
b. Signs and symptoms:
i. Elevated JVP
24
ii. Dependent edema
iii. Cyanosis
iv. Anorexia
v. Ascites
vi. Exertional right upper quadrant pain
vii. Hepatomegaly ( unconjugated and conjugated bilirubin, ALP,
AST, ALT)
viii. Oligouria (scanty urine) in day
ix. Oligouria (scanty urine) at night
x. Polyuria (excessive urine) at night
xi. Weakness or mental aberration
xii. Early satiety
VIII. Symptoms
a. Chest pain (C4-C5 dermatome) Y LevineSs sign; diagnosis Y myocardial
infarct, pericarditis, aortic dissection
b. SOB ( consciousness to respiratory effort) upon exertion; often 1st
symptom of left-sided heart failure
i. Relieved by rest Y diagnosis asthma, anemia
ii. Aggravated by exercise, anxiety, after a meal
c. Palpations Y patient aware of heart beat irregular or strong
d. Edema Y feet, sacrum (diagnosis Y renal failure, liver failure, nutrition,
obstruction)
e. Fatigue (congestive heart failure, paroxysmal tachycardia)
f. Cough Y dry, repetitive due to aortic pulmonary edema; hemoptysis
(coughing up blood) with MS, pulmonary infarct
g. Syncope
h. Abdominal pain
i. Medication
j. Nocturia Y congestive heart failure
k. Paroxysmal nocturnal dyspnea (PND) Y repetitive dry cough in PM,
subsides in 30 minutes (complication pulmonary edema)
l. Right upper quadrant pain (due to hepatomegaly with congestive heart
failure)
IX. Anatomy
a. Ventricles
i. Chronic pressure overload ( after load) = hypertrophy
ii. Chronic volume overload ( preload) = dilation and hypertrophy
iii. SV = 70 ml/beat
iv. AR = 70 beats/minute
v. CO = 5L/minute
b. Pressure: (systolic/diastolic)
i. RA = 5/0
ii. LA = 5/0
iii. RV = 25/0
25
iv. LV = 120/0
v. Aorta = 120/80 mmHg
vi. Arterioles = 35 mmHg (due to peripheral vascular resistance)
1. Kidney: up to 60 mmHg due to filtration process
2. Lung: as low as 20 mmHg because no fluid wanted in
pulmonary system; therefore low pressure system favorable
vii. Capillaries = approximately 3-5 mmHg
viii. Plasma oncotic pressure: 1º due to albumin; prevent interstitial
edema
26
Respiratory Exam
!Hi my name is ______, I.m a second year medical student. What is your
come in and listen to your lungs. Is that ok with you? Ok if there is any
discomfort at any time please let me know and I.ll try my best to alleviate
the discomfort.
I. Inspection
- Look for (with the patient sitting):
- Symmetry, masses, scars, lesions
- Signs of distress or use of accessory muscles
- Breathing quality
- !Upon inspection the patient is not in any evident respiratory distress.
There are no masses, scars, or lesion noted. The chest wall rises and
falls symmetrically during breathing, and the breathing is abdomino-
thoracal. No accessory muscles are being used during breathingH
o !Mr./Mrs. _____ I.m just going to be pressing into your legs
and feet, just let me know if there is any pain at allH
the patientBs face for any signs of tenderness
The dorsum of foot
Over the shins
o !Can you please look up for me?H
o !Can you please look down for me?H
o !Can you please open your mouth for me?H
o !Can you please lift up your tongue for me?H
27
o Bring up the patientBs fingers to eye level to check for clubbing and
o Capillary refill: pinch the patientBs fingers/nails for a second and look to
o !Upon initial inspection the patient is not in any distress, there
is no pitting edema, no signs of anemia and jaundice. There are
no signs of glossitis and central cyanosis. There is no clubbing,
splinter hemorrhages, and capillary refill is normal.H
- Check respiration rate:
o Look at stomach and at your watch (hold arm so that pt. doesnBt know and
therefore change the respiratory rate)
o Up and down of chest = 1
- A/P diameter: use hands to measure (normal 2:1)
- !The A/P diameter is 2 to 1, and the respiratory rate is 16.H
II. Palpation
- !I.m just checking your neck, ok.H
- Tracheal deviation: right index and ring on right and left sternoclavicular joints
respectively, with middle on midline over trachea
- TVF (tactile vocal fremitus): palpable vibration
o !Mr./Mrs._____ can you please say 99, 99, 99.H
o Have patient say T99V (at each area) W while placing ulnar surface of hands
over 3 places bilaterally anteriorly
i. 2nd IS midclavicular line
ii. 4th IS midclavicular line
iii. 4th IS anterior axillary line
iv. Check for symmetry and presence
- Chest Expansion
o Place hands on chest bilaterally so that thumbs bunch up skin in midline
i. 2nd IS
ii. 4th IS
iii. 10th IS
o !Can you take deep breaths for me please?H
o Have patient take deep breath at each area and confirm symmetrical chest
expansion (when fold flattens and thumbs move laterally)
o !Upon palpation, no tenderness was present. The trachea is
midline. Chest expansion is symmetrical and of normal force
and extent. Tactile vocal fremitus was present and
symmetrical.H
28
III. Percussion
- !Mr./Mrs._____ I.m going to tap on your chest now. Can you please
turn your head to the left for me please...and now the turn the other
way pleaseH
- Ask patient to turn head to the opposite side and percuss from the apex
- When percussing place only the distal portion of the middle finger on the chest
and percuss with the index finger.
- Percuss bilaterally (from left to right)
i. Apex W dorsal to clavical (above the clavicle)
ii. 2nd IS MCL
iii. 3rd IS MCL
iv. 4th IS MCL
v. 4th IS midaxillary line
vi. 6th IS midaxillary line
- !Upon percussion, normal resonance was heard in all lung fields, except
the expected dullness of the heart and liver.H
IV. Auscultation
- !Mr./Mrs._____ I.m going to be listening to your lungs now please
breath normally for me now. Can you please turn your head to the left
for me please...and now the turn the other way pleaseH
- Ask patient to turn head to the opposite side and when auscultating the lungs.
- Listen bilaterally from left to right
i. Apex (only place to use bell)W dorsal to clavicle (above the
clavicle)
ii. 2nd IS MCL
iii. 3rd IS MCL
iv. 4th IS MCL
v. 4th IS midaxillary line
vi. 6th IS midaxillary line
- !Upon auscultation, normal vesicular breath sounds were heard in all
lung fields and no adventitious sounds were heard.H
- TVF, auscultate for these:
o Bronchophoney: ask patient to say T99V spoke words are louder,
clearer (normal W muffled, indistinct); increased intensity and clarity of
voice sounds heard over a bronchus surrounded by consolidated lung
tissue.
o Egophony: ask patient to say TeeV long e changes to TaV (nasal) W
(normal W muffled e); a peculiar broken quality of the voice sounds, like
the bleating of a goat, heard about the upper level of the fluid in cases of
pleurisy with effusion.
29
o Whispered pectoriloquy: ask patient to whisper T99V words heard
louder, clearer (normal W muffled, if at all); increased transmission of the
voice sound through the pulmonary structures, so that it is clearly audible
on auscultation of the chest; usually indicates consolidation of the
underlying lung parenchyma.
V. Posterior exam
- Same as anterior exam with the following additions:
- Tracheal deviation (if not done anteriorly) W be sure to show patient your hands
first to comfort them
- Have the patient cross arms over chest moves scapula laterally to expose
thorax
- TVF W 4 places bilaterally
o 1st IS midclavicular line
o 2nd IS midclavicular line
o 6th IS midclavicular line
o 6th IS midaxillary line
- Chest expansion
- 2nd IS
- 5th IS
- 10th IS
- Percuss and auscultate
- 1st IS midclavicular line
- 2nd IS midclavicular line
- 4th IS midclavicular line
- 6th IS posterior axillary line
- 8th IS posterior axillary line
30
Respiratory Exam Secondaries
I. Inpection
a. Clubbing
i. Check in abdominal, cardiovascular, and respiratory

exams (pulmonary disease is the most common cause of clubbing).
ii. Angle between plate and proximal nail fold 180º, spongy nail
bed
iii. Due to infective endocarditis, liver cirrhosis, CrohnDs disease,
ulcerative colitis, tuberculosis, chronic bronchitis, anemia,
empyema (pus in cavity), R L shunts
iv. Pseudo clubbing from GraveDs disease
v. Pancoast;s tumor: invasion (near trachea) of brachial plexus
(usually T1-T2) and the cervical sympathetic chain by a primary
(apical) lung cancer. Destruction of the T1-T2 sensory and motor
nerves (most commonly by a primary squamous cell carcinoma of
the lung) produces unilateral arm pain (ulnar nerve distribution),
medial paresthesias, and wasting of the small muscles of the hand.
Destruction of the cervical sympathetic ganglion produces
Horner;s syndrome on same side of the lesion L triad of
ipsilateral lid lag, miosis (pinpoint pupil), and anhidrosis (lack of
sweating); hoarseness; increased JVP, and unilateral clubbing.
b. Cyanosis - deoxyHb
i. Central: due to heart or lung disease (most common respiratory
cause is bronchogenic carcinoma, chronic hypoxia); with central,
have to have peripheral
ii. Peripheral: due to frost bite, coarctation of aorta, RaynaudDs, poor
circulation; with peripheral, do not have to have central
c. Respiration
i. Normal: 14-20 breaths/minute, abdomino-thoracal
ii. Infants; normal: 44 breaths/minute
iii. Tachypnea: >20 breaths/minute ventilation will CO2
respiratory alkalosis (corrects metabolic acidosis)
1. Rapid shallow due to restrictive lung disease, chest pain,
elevated diaphragm
2. Rapid deep hyperventilation due to exercise, anxiety,
metabolic acidosis (Kussmaul breathing), anemia, early
congestive heart failure
iv. Bradypnea: < 14 breaths/minute ventilation will CO2
respiratory acidosis L corrects metabolic alkalosis L due to diabetic
coma, drug induced respiration, depression, increased brain
pressure
31
v. Cheyne-Stokes breathing: hyperpnea with apnea (deep breaths
and more rapid than normal with short periods of apnea); normal in
infants and elderly L due to heart failure, uremia, brain damage
(especially medullary level), drug induced respiratory depression
vi. Abdominal breathing: (more in males than females) L stopped in
ascites or peritonitis
vii. Ataxic breathing (Biot;s): unpredictable, shallow then stops; due
to respiratory depression, brain damage at medulla
viii. Frequent sighing (hyperventilation syndrome): dizzy, dyspnea
ix. Obstructive: prolonged expiration due to narrowing L COPD
x. Restrictive: rapid shallow breathing
d. A/P diameter
i. AP diameter: is measuring the distance of the anteroposterior to
the distance of the transverse
ii. Barrel chest - AP diameter; normal in old man; emphysema
iii. Funnel chest (pectus excavatum): depression of lower sternum;
associated with possible murmurs
iv. Pigeon chest (pectus carinatum): increased AP diameter;
depressed costal cartilage, sternum sticks out; associated with
asthma
v. Thoracic kyphoscoliosis: abnormal spinal curvatures and
vertebral rotation deform the chest
vi. Cooles; test: place 2 fingers between notch and cricoid (2 should
fit, barrel chest if < 2)
II. Palpation
a. Tracheal deviation
i. Midline: consolidation
ii. Same side (pulls): atelectasis; foreign body, tumor, fibrosis,
pressure
iii. Opposite side (pushes): thoracentesis (pleural tap), stab, rib
fracture, pleural effusion, pneumothorax/tension (Air enters the
pleural cavity and gets trapped upon expiration. The intra-thoracic
pressure increases and compress the mediastinum and causes
torsion of the Great Vessels leading to sudden death)
iv. Moving: aortic arch aneurysm
v. Descent: chronic over inflated lungs
b. TVF (tactile vocal fremitus)
i. Vibration: solid (tumor, consolidation)
ii. Vibration: air (emphysema, bronchitis, asthma, pleural
effustion, pneumothorax)
iii. No TVF: atelectasis
c. Chest expansion
i. Nonsymmetrical chest expansion: broken ribs, musculoskeletal
problems, collapsed lung, pneumothorax, pleural fibrosis, tumor,
atelectasis, effusion, consolidation
III. Percussion
32
a. Dull: lobar pneumonia (staph and strep), empyema, hemothorax,
hydrothorax, exudate
i. Fluid ususally sinks to the lowest part of the pleural space
(posteriorly in a supine patient)
ii. Only a very large effusion can be detected anteriorly
b. Resonance: normal, chronic bronchitis, asthma
c. Hyperresonance: emphysema (may totally replace cardiac dullness),
pneumothorax, asthma
d. Tympanic: large pneumothorax (especially in dyspneic newborns)
e. Stony dull or flat: (like thumping the floor) pleural effusion
f. Abscess: see air fluid level on chest x-ray; most commonly due to staph,
klebsiella, anaerobes
i. Note: apex L site of 2º tuberculosis due to V/Q
IV. Auscultation
a. Lung sounds
i. Vesicular: inspiratory sounds last longer, and louder than

expiratory (normal)
ii. Bronchovesicular: inspiratory and expiratory sounds are equal
(consolidation, normal along sternum L large bronchi)
iii. Bronchial: expiratory sounds last longer than inspiratory, gap
exists between sounds (consolidation, normal over trachea)
iv. Tracheal: inspiratory and expiratory sounds are equal gap exists
between sounds
b. Adventitious
i. Crackles: discontinuous, intermittent, nonmusical, and brief
sounds
1. Fine crackles: soft, high pitched and very brief (5-10msec)
2. Coarse crackles: louder, lower pitched and longer in
duration (20-30msec)
3. Inspiratory
a. Early: due to chronic bronchitis, LHF, COPD,
asthma
b. Late: due to pneumonia, fibrosis, early CHF,
consolidation, interstitial lung disease
c. Mid inspiration/expiration: due to bronchiectasis
ii. Continuous sounds: > 250 msec but do not usually span entire
length of respiratory cycle; musical
33
1. Wheezes: high pitched with a hissing or shrill quality
suggests narrowed airways, as in asthma (in expiration only
or expiration & inspiration), COPD, or bronchitis
2. Rhonchi: low pitched with snoring quality; due to
secretions or mass obstructing large airways
3. Stridor: a wheeze that is entirely inspiratory; heard loudest
over the neck; due to partial obstruction of the larynx or
trachea medical emergency; most common cause croup
(laryngotracheobronchitis in infants & young children
caused by parainfluenza viruses) in children or foreign
body obstruction
iii. Hamman;s sign: a mediastinal crunch/precordial crackles heard
synchronous with the beat of the heart and not respiration; best
heard in left lateral position; most common cause due to
mediastinal emphysema (pneumomediastinum) and is a medical
emergency
iv. Pleural rub: inflamed and roughened pleural surfaces grate
against each other; heard in both phases of respiration
V. Anatomy
a. Right lung (3 lobes)
i. Right upper lobe
ii. Right middle lobe L (oblique fissure L spinous process T3
midclavicular line 6th rib)
iii. Right lower lobe L horizontal fissure L midaxillary line 5th rib
midclavicular line 4th rib)
b. Left lung (2 lobes)
i. Left upper lobe
ii. Left lower lobe (oblique fissure)
c. Lobes surface anatomy
i. 2-4 cm above the clavicle
ii. 6th rib: midclavicular line
iii. 8th rib: midaxillary line
iv. Trachea bifurcates anterior L T4, 5; posterior L T4 spinous
process
d. Physiology
i. Tidal volume: amount air inspired and expired with each normal
breath
ii. Vital capacity: Tidal Volume + Inspiratory Reserve Volume +
Expiratory Reserve Volume
1. pO2: trachea 150, alveoli 100, systemic artery 100, mixed
venous 40
2. pCO2: trachea 0, alveoli 40, systemic artery 40, mixed
venous 46
iii. Oxygen Dissociation Curve: measures the % of Hb saturated with
O2 at given pressure of O2
34
1. Left shift (latches), affinity of O2 to Hb due to pO2,
pH, temperature, 2,3 DPG
2. Right shift (release), affinity due to pH, CO2,
temperature, 2,3 DPG
3. V/Q: COPD; pulmonary embolis
4. Diffuse capacity: anemia, emphsema, fibrotic disease,
polycythemia, early congestive heart failure
e. Muscles of Respiratory
i. Inspiration
1. Principal = external intercostals & diaphragm
2. Accessory = sternocleidomastoid (SCM) & scalenes
ii. Expiration
1. Passive = recoil of lungs
2. Active = internal intercostals & abdomen muscles
35
Condition Trachea & Chest Expansion Breath Sounds & Notes
TVF and Percussion Adventitious
Sounds
Normal Midline & Symmetrical and Vesicular and none
Normal Resonant
Chronic Bronchitis (COPD) Midline & Symmetrical and Vesicular and Accessory
- Clinically defined as productive cough > 3 consecutive Normal Resonant none/possible muscles used,
months >2 consecutive years crackles, wheeze, smoking stains,
- Cigarette smoking, air pollution, infection, & genetic ronchi decreased
factors diaphragm
- May lead to cor pulmonale movement
- Small alveoli/big airways; hypersecretion of mucous &
fibrosis of bronchioles (canDt inflate the lungs)
Emphysema (COPD) Midline and Symmetrical AP / absent and Accessory
- Big alveoli/small airways; deficiency in alpha1-antitrypsin normal diameter and none/possible muscles used,
(protease inhibitor that neutralizes elastase) (canDt deflate diffusely crackles, wheeze, smoking stains,
lungs) hyperresonant ronchi decreased
- Dilation of air spaces with destruction of alveolar walls diaphragm
- Cigarette smoking (inactivates alpha1 antitrypsin and movement
attracts neutrophils, macrophages, and source of elastase)
- Hereditary alpha1 antitrypsin deficiency (pi gene, chrom
14)
1. Centrilobular L respiratory bronchioles, upper part of the
pulmonary lobes
2. Pacinar L entire acinus (alveoli, alveolar ducts,
respiratory bronchioles, and terminal bronchioles),
distributed uniformly throughout lung
3. Paraseptal L distal part of acinus (alveoli, alveolar
ducts), localizes subjacent to pleura and interlobar septa.
Associated occasionally with large subpleural bullae, blebs,
which may rupture pneumothorax
4. Irregular L irregular involvement of acinus with scarring
of the walls of enlarged air spaces
Asthma (COPD) Midline and symmetry and Vesicular and Accessory
- Hyperresponsive airways to inflammatory mediators (LTDs, normal hyperresonant wheezes muscles used
histamine)
- Extrinsic asthma L type I hypersensitivity (IgE and mast
cells), begins in childhood and family history of allergy
- Intrinsic asthma L begins in adult and no history
Consolidation Midline and Normal > abnormal Bronchial and late Decreased
Bilateral L CHF, hypoproteinemia bronchophony, and dull inspiratory crackles respiratory rate
Unilateral L Xf, neoplasm (bronchogenic carcinoma), egophony,
lymphatic drainage whispered
pectoriloquy
Collapse/ Atelectasis Ipsilateral and Normal > abnormal Absent and none
Bronchus obstruction (mucus, tumor, FB), pneumothorax, absent and dull
pleural effusion, surfactant loss/absence
Pleural Effusion Contralateral Normal > abnormal /absent and
Xf (pyothorax), lymphatic drainage (chylothorax), stab and /absent and stony dull possible pleural rub
(hemothorax)
Pneumothorax Contralateral Normal > abnormal /absent and
Thoracentesis, stab, rib fracture (tension) and and hyperresonant/ possible pleural rub
/absent tympanic
36
Abdominal Exam
come in and check your stomach area. Is that ok with you? Ok if there is
any discomfort at any time please let me know and I.ll try my best to
alleviate the discomfort. Ok I.m going to need you to undress from the
bottom of your chest to the knee and you can cover your groin area.D
I. Inspection
- Inspect from the foot of the bed
- Patient is supine arms are at side
- "Are you in any discomfort right now?D
- Contour
- Hernias
- Umbilicus
- Rashes
- Pulsations
- Peristaltic waves
- Symmetry
- Significant scars and stria
- Superficial veins
- Check the patient to see if they are in shock
- "Upon inspection of the patient.s abdomen, I see no masses, scars, or
lesions. The contour is flat, there are no hernias, the umbilicus is
inverted, and there are no rashes, pulsations, or peristaltic waves.
There are no stria, superficial veins, and the abdomen is symmetrical.
o "Mr./Mrs. _____ I.m just going to be pressing into your legs
and feet, just let me know if there is any pain at allD
the patientCs face for any signs of tenderness
The dorsum of foot
Over the shins
o "Can you please look up for me?D
o "Can you please look down for me?D
37
o "Can you please open your mouth for me?D
o "Can you please lift up your tongue for me?D
o Bring up the patientCs fingers to eye level to check for clubbing and
o Capillary refill: pinch the patientCs fingers/nails for a second and look to
- "There is no pitting edema, no signs of anemia and jaundice. There are
no signs of glossitis and central cyanosis. There is no clubbing,
splinter hemorrhages, and capillary refill is normal.D
II. Auscultation
- "I.m just going to be listening to your stomach sounds.D
- Listen for bowel sounds
o Use diaphragm (done before palpation/percussion because they may alter
bowel sounds)
o Listen in all four quadrants for at least 2 minutes
- Listen for arterial bruits (turbulent blood flow)
o Use the bell
o Abdominal aorta: above the umbilicus R between the aorta and the
xyphoid process
o Renal arteries: to right and left of the abdominal aorta
o Iliac arteries: above the inguinal ligament, straight down from the renal
arteries
o Femoral arteries: below the inguinal ligament R ½ way between the
ASIS and the pubic symphysis
- Listen for friction rubs (due to inflamed capsule rubbing against the diaphragm;
due to gonorrhea, liver tumor, and chlamydia)
o Use the bell
o Auscultate over liver and spleen; 11 intercostal space left and right R
patient must breathe
- Listen for venous hum (due to collateral circulation heard in both systolic and
diastolic; liver cirrhosis is MCC, right heart failure)
o Use bell
o Auscultate over liver
- "Upon auscultation bowel sounds of normal pitch and frequency heard.
There were no bruit heard, no friction rubs, no venous hum.D
38
III. Percussion
- "Mr./Mrs._____ I.m going to tap on your stomach right now.D
- Look at the patientCs face
- While standing percuss all four quadrants
- "Upon percussion, normal tympany was heard in all 4 quadrants.D
- Offer to check abdomen for ascites (normally do this with protuberant abdomen)
- **Shifting Dullness**
- Start percussion at midline close to umbilicas and percuss laterally away from you
until dull sound is heard
- Keeping your finger at this dull point have the patient roll over to his/her side
facing you so that if there is ascites it will flow down to the lowest point (on the
patients side)
- Percuss again on the same point, if there is ascites the dullness will now be
tympanic due to the shifting of the ascites, if there were no ascites that same point
will remain dull
- Dullness tympanic, percuss down towards the umbilicus to measure where the
ascites has collected to
- **Fluid wave transmission**
- Have the patient or assistant (professor) press with ulnar surface of both hands
across the abdomen. This helps stop the transmission of a wave through fat.
- Tap on one side of the abdomen sharply with your fingertips, feel the opposite
side for an impulse transmitted through the fluid
- ^+`, If you feel fluid transmitting
- **Puddle sign**(do not do during the exam)
- Have patient put hands on knees and tap the belly
- Most sensitive
IV. Palpation
- Look at the patientCs face
- Use the right hand
- Dr should be sitting
o Light palpation
"Are you in any pain right now? I.m going to press down
on your stomach now.D
Ask the patient if any pain present before palpation
Palpate all 4 quadrants or 9 areas R work counterclockwise; start in
RLQ (or LLQ if pain is present in the RLQ)
Use breathing: Expiration push hand in 1-2 inches palpate
during inspiration
o Deep palpation
Dr should be standing
Palpate all 4 quadrants or 9 areas (start in the RLQ)
Push in 3-4 inches during expiration, palpate during inspiration
o "Upon palpation, no masses, guarding, or tenderness was notedD
39
o Appendicitis Signs
Search for areas of local tenderness (RLQ)
Ask patient to cough
Feel for muscular rigidity (voluntary guarding may be replaced by
involuntary rigidity with time)
Cutaneous hyperethesia R gently pick up a fold of skin, without
pinching, at a series of points down the abdomen
Rebound tenderness R press on McBurneyCs point, lift off quickly
viscera rebound and hit appendix
Rovsing’s sign R press deeply and evenly in LLQ then quickly
withdraw fingers
Psoas test R flex hip against resistance (put hand over patientCs
right knee and ask to flex thigh against pressure)
Obturator test R rotate leg internally at hip with knee flexed
Perform rectal exam and look for right-sided tenderness
V. Organ Palpation
- Liver
o Inspection
o Auscultation
o Percussion
"I.m going to tap on your stomach and chest right now.D
Percuss down the mid-clavicular line starting at the 2-3 intercostal
space until dullness is heard, indicating the upper border of the
liver (ask patient to mark point with fingers)
Percuss up from the RLQ in the mid-clavicular line until dullness
heard.
Measure span of dullness (measure by finger/hand width)
o Palpate
Starting at the ASIS, move the hand superiorly and deep on
expiration
"Mr/Mrs._____ I.m going to press down on your stomach
now.D
Feel for the liverCs edge as it shifts caudally on inspiration
Scooping method R with the side of the hand and work up
to the costal margin
Hooking technique R place hands side by side below area
of liver dullness; pull in and up with fingers
o Gallbladder
**Murphy’s sign**
Hook fingers or thumb on right hand under costal margin at
border of lateral rectus and costal margin (9th IS)
Have the patient take a deep breath in
40
"Upon examination, the liver span is 8 cm, the liver
edge was smooth and non-tender. There was a
negative Murphy.s sign.D
- Spleen
o Inspection
o Auscultation
o Percussion
"Mr/Mrs. _____ I.m going to tap on your stomach now.D
Percuss along TraubCs space from medial lateral (area of
tympany between lung resonance above and costal margin below)
Percuss 11th IS in left anterior axillary line (normal = tympanic)
Ask patient to breath in and hold; percuss again (normal =
tympanic)
"Upon percussion a negative splenic sign was noted.D
o Palpation
"I.m going to pressing into your stomach now.D
Not palpable in normal patient
Start at the right ASIS and progress to left costal margin because
the spleen enlarges comma shaped
Ask the patient to inspire deeply as you approach the left costal
margin
Feel for the spleenCs edge as it shifts position on inspiration
Roll patient onto their right side facing you and repeat palpation
(the patientCs left hand goes on your left shoulder, your left hand
goes over the patientCs back, and you can use that hand to push
behind the ribs to help push the spleen forward while you palpate
with your right hand).
"Upon examination the spleen was not palpable.D
- Kidney
o Inspection
o Auscultation
o Palpation
Sandwich technique: with the patient in supine position attempt to
trap the kidney between your hands at the peak of the patientCs
inspiration. Left hand push from back, right hand examines from
abdomen.
Check the other kidney
o **Murphy’s Test ** R Assessing kidney tenderness
Patient should be sitting
Ask the patient if he or she is having any lower back pain
Place your palm over the patientCs kidney (costalvertebral margin
between 11th & 12th intercostal space on posterior chest)
Strike the back of your hand firmly with a closed fist
Repeat with the other kidney
41
"Upon examination the kidneys were non-palpable and
non-tender.D
42
Abdominal Exam Secondaries
I. Inspection
Inspection:
CHURPPSS
Contour: flat, round/protuberant, (fat, feces, flatus, full, fluid, fibroid, bladder,
tumor), scaphoid (lean). Note: fat will hang over the belly, ascites will droop to the
sides
Hernias (Possible to hear bowel sounds; Will not be able to feel above a hernia; If
possible, have the patient cough)
o Femoral hernia: lateral to pubic tubercle, deep to inguinal ring; F>M
o Direct inguinal hernia: acquired, does not descend, in older men usually.
Goes only through the external inguinal ring.
o Indirect inguinal hernia: congenital, most common, descends into the
scrotum. Goes through both internal and external inguinal ring.
o Ventral hernia: in the abdominal wall H have patient raise head and
shoulders off the table and look for an abdominal bulge.
o Diastasis recti hernia: separation of two rectus abdominus muscles through
which abdomen contents bulge to form midline ridge when patient raises
head H midline hernias; may be noticeable in latter trimester of pregnancy
o Lipoma hernia: most common benign fatty tumors located in subcutaneous
anywhere including abdominal wall; soft lobulated (press down H bulge
slips from beneath your finger)
Umbilicus: inverted (obesity, normal), everted (ascites, hernia)
Rashes
Pulsations: abdominal aortic aneurysm, pulse pressure
Peristalitic waves:
o Hyperperistalsis: early sign of bowel obstruction (late-sign will be silent
abdomen)
o Five things that cause obstruction: feces, flatuss (gas), fetus (pregnancy),
fluid (ascites), tumor
Symmetry: abnormal H large organ, mass
Significant scars and stria: pregnancy (linea nigra H brownish-black pigmented line
following the midline of the abdomen), normal, CushingLs disease H purple stria
Superficial veins: portosystemic circulation due to cirrhosis, IVC obstruction H
Caput Medusa (varicose veins radiating from the umbilicus)
Shock: will be cyanotic, low pulse due to bleeding from peptic ulcer, ectopic pregnancy
Jaundice: due to hepatitis; cirrhosis
Clubbing:
o Due to infective endocarditis, liver cirrhosis, CrohnLs disease, ulcerative
colitis
Abdominal Pain:
Colic pain will build up (spasms) H typical of biliary obstruction
Acute salpingitis: bilateral, motion of uterus causes pain
43
Tendor peritoneum: rigidity with tenderness throughout general peritonitis
(involuntary rigidity guarding) due to:
o Acute cholecystitis: RUQ, check MurphyLs sign
o Acute pancreatitis: epigastric, rebound tenderness
o Acute appendicitis: RLQ (umbilical) H check flank (lumbar)
o Acute diverticulosis: LLQ sigmoid colon (mimics appendicitis on left)
Auscultation
Bowel Sounds:
Normal frequency: 5-34 bowel sounds/minute, pitch (high/low)
bowel sounds: diarrhea, early intestinal obstruction
bowel sounds: adynamic/paralytic ileus, peritonitis, late intestinal obstruction,
recent abdominal surgery
Borborygmi: loud, prolonged gurgle of hyperperistalsis (growling)
Arterial bruits: turbulent blood flowing through a vessel, hepatic carcinoma, (partial
occlusion)
Friction rubs: inflammation of liver capsule peritoneal surface rubs with
diaphragm H due to gonorrhea, liver tumor, chlamydia, recent liver biopsy, splenic
infarct
Venous Hum: soft humming noise heard during both systolic and diastolic, indicating
increased collateral circulation between portal system and systemic (liver cirrhosis, is
most common cause, right heart failure)
Percussion
Dull sounds: ascites, mass, enlarged organ
Tympanic: gas in GIT, normal
1) Ascites: accumulation of fluid in the peritoneal cavity (pus, exudate, blood, transudate)
>500ml in pertoneal cavity = evident
Alcoholic cirrhosis
Congestive heart failure
Hepatic vein obstruction (Budd-Chiari syndrome)
Nephrotic syndrome
Kwashiorkor
2) Portal hypertension
Prehepatic: narrowing of portal vein H thrombosis, massive splenomegaly with
shunting of blood into splanchnic circulation
Intrahepatic: cirrhosis, schistosomiasis, diffuse fibrosing granulomatous disease,
nodular regenerative hyperplasia
Posthepatic: severe right sided heart failure, constrictive pericarditis, hepatic vein
outflow obstruction (Budd-Chiari syndrome)
Palpation
Light palpation
44
If feel mass, have patient lift head off table (flex ab muscles)
If you still feel it H the mass is in the wall or is superficial
If you donLt feel it H the mass is intrabdominal
Rigid Abdomen = acute abdomen
Guarding: chronic or old pathology
Deep palpation
Masses: pulsating (aneurysm), movement with breathing (organ), physiologic
(pregnant uterus), inflammatory (diverticulus), vascular (abdominal aortic aneurysm),
neoplastic (colon cancer), obstructive (dilated bowel loop)
Appendicitis signs: McBurneyLspoint ½ way between ASIS and symphysis pubis and
1/3 of distance from this point to the ubilicus
Classically pain begins near umbilicus then shifts to RLQ
+ Cough: pain
+ Cutaneous hyperesthesia: localized pain in RLQ
+ Rebound tenderness: peritoneal inflammation due to appendicitis
Mimic on left: diverticulitis, salpingitis
Mimic on same side: Yersinia, tumor of appendix
+ RovsingQs sign: pain in RLQ when press on LLQ
+ Psoas test: abdominal pain due to psoas muscle irritating inflamed appendix
+ Oburator test: abdominal pain due to obturator muscle irritating inflamed appendix
Surgery: ultimate way of knowing about appendicitis
Lab: left shift, WBC, fever, becomes ischemic area so there is nothing there to fight
it (canLt get there)
If there is a slight problem remove it
Diagnosis RLQ pain: salpingitis, acute appendicits, ovaria cysts, mesenteric adenitis,
MeckelLs Diverticulum, ectopic pregnancy
Liver
Percussion
Normal: midclavicular line = 6-12 cm; midsternal line = 4-8 cm
Dullness displaced inferiorly without enlargement due to COPD
False increase in liver span dullness due to pleural effusion or consolidation
False decrease in liver span due to gas in the abdomen
(pneumoperitoneum), gas in bowels
Palpate
Normal liver: smooth, large, and non-tender
Large, irregular liver: cirrhosis (late stage shrunken), malignancy
Alcohol (most common cause) H hepatocellular damage and liver failure
Viral hepatitis
Heart failure H In CHF, long standing right sided heart failure or constrictive
pericarditis or tricuspid insufficiency nutmeg liver (centrilobular is dark red,
congested and the portal areas are poor) centrilobular fibrosis
45
Biliary obstruction H extrahepatic biliary obstruction, which leads to dilation and
pressure within intrahepatic bile ducts and cholangioles ductal injury ductal and
periductal inflammation fibrous tissue formation
Hemochromatosis
o Idiopathic H familial defect of iron absorption. Neglect triad of cirrhosis,
diabetes mellitus, and hbronze diabeticsi ( skin pigmentation).
o Secondary H caused by iron overload, ineffective erythropoiesis and
multiple transfusions.
WilsonQs disease H (hepatolenticular degeneration) an autosomal recessive disorder of
copper metabolism, serum ceruloplasmin, accumulation of copper in parenchymal
cells
Large, smooth and tender liver:
Hepatitis
Venous congestion
CHF H In CHF, long standing right sided heart failure or constrictive pericarditis or
tricuspid insufficiency nutmeg liver (centrilobular is dark red, congested and the
portal areas are poor) centrilobular fibrosis
Budd-Chiari H caused by thrombotic occlusion of the major hepatic veins
Hepatosplenomegaly:
CHF
schistosomiasis
Clinical signs of liver cirrhosis/failure:
Portal hypertension: development of venous collaterals with the submucosal veins of
the esophagus (seen in 65% of advanced cirrhosis), splenomegaly, caput medusa,
hemorrhoids
Hypoalbuminemia: anasarca (hydrothorax), edema, ascites
Jaundice: Check eyes, palms, dark urine, pale stools
Hyperestrogenism (canQt break down): palmar erythema, spider telangiectasia,
feminization of male sex organs H gynecomastia, testicular atrophy
Coagulopathies: synthesis of coagulation factors, bruises, bleeding (petechiae)
Hepatic encephalopathy, asterixis, putrid breath: ammonia in blood CNS
liver enzymes (AST, ALT)
Hepatorenal failure: BUN, creatine, urine output, hyperosmolar urine
Gall Bladder
1. Acute cholecystitis: (N/V/F) nausea, vomiting, & fever,
RUQ pain, + MurphyLs sign
2. Sharp in tenderness with a sudden stop of inspiratory
effort
3. + CourvoisierQs sign: oval mass palpable below liverLs
edge, no pain (cancer head of pancreas H obstructs common
bile duct)
ii. Jaundice
1. Pre-hepatic (unconjugated)
46
a. Overproduction (intra or extravascular hemolysis,
ineffective erythopoesis)
2. Hepatic (unconjugated)
a. Decreased bilirubin conjugation (decreased
glucouronyltransferase activity)
i. Hereditary transferase deficiency
1. GilbertQs syndrome H modest
elevation of unconjugated bilirubin,
no clinical consequences
2. Crigler-Najjar I or II - levels of
unconjugated bilirubin, one for leads
to early death by kernicterus, damage
to the basal ganglia and parts of the
CNS
ii. Neonatal jaundice
iii. Acquired [hepatocellular diseases H viral or
drug induced hepatitis, cirrhosis, drug
induced cholestasis (oral contraceptives,
androgens, chlorpromazine), alcoholic liver
disease, sepsis, postoperative state,
parenteral nutrition, biliary cirrhosis
(primary or secondary)]
3. Post-hepatic (conjugated)
a. Impaired hepatic excretion (intrahepatic defects)
i. Familial
1. Dubin-Johnson syndrome H
autosomal recessive defect in
transport, brown to black
discoloration of liver caused by
deposition of granules of very dark
pigment.
2. Rotor syndrome H defect in
transport
3. Recurrent intrahepatic cholestiasis -
4. Cholestatic jaundice of pregnancy
b. Extrahepatic biliary obstruction
i. Intraductal:
1. Gallstones
2. Biliary malformation H stricture
3. Atresia
4. Choledochol cyst
5. Infection
6. Malignancy
7. Inflammation-pancreatic
c. Hepatitis, yellow fever, pancreatic neoplasm,
transfusion, etc.
47
iii. Anatomy
1. Embryological origin: foregut
2. Blood coming to liver:
a. Hepatic Artery H 30-40% of volume of hepatic
blood flow & 80% of oxygenated blood
b. Portal Vein H 60-70% of volume of hepatic blood
flow
b. Spleen
i. Percussion
1. + Splenic percussion sign (dullness): splenomegaly
ii. Causes of Splenomegaly
1. Congestive heart failure
2. Portal hypertension, cirrhosis, portal thrombosis, right
sided heart failure
3. Early sickle cell anemia in young: (chronic
autosplenectomy H multiple small infarct fibrosis over
time)
4. Leukemia (hairy cell leukemia, CML)
5. Shistosomiasis, malaria
6. Lymphomas, myelomas, leukemias, hemolytic anemias
(extravascular)
7. Immunologic inflammatory conditions: SLE, rheymatoid
arthritis, FeltyLs syndrome
8. Storage disease: GaucherLs, Neiman Pick,
mucopolysaccharidosis
9. Amyloidosis, neoplasm, cysts
10. Mono-EBV (heterophile +) > 50% lymphos
11. CMV (heterophile -) < 50% lymphos
iii. Splenectomy - risk for S. pneumo, H influenza, Neisseria
therefore vaccinate
iv. Anatomy:
1. 1,3,5,7,9,11 (1i thick, 3i wide, 5i long, 7 oz, between ribs
9-11)
2. Anterior medial border notch
3. Extends beyond midline
4. Dullness upon percussion
5. Fingers cannot get between spleen and costal margin
6. Moves with respiration
c. Kidney
i. Enlarged Kidney
1. Masses or lumps (cancer, cysts)
2. Hydronephrosis, pyelonephrosis, renal cell cancer,
polycystic kidney disease, WilmLs
3. Kidney tumor sign & symptoms H M>F, hematuria, flank
mass, pain, paraneoplastic syndrome
ii. Small Kidney
48
1. Congenital hypoplasia
2. Chronic pyelonephritis
3. Unilateral renal artery stenosis
iii. MurphyQs punch
1. h+i Sign = musculoskeletal problem, pyelonephrosis,
kidney infarcts
iv. Calculus: block ureter sudden, severe paroxysomal renal colic
pain, chills, F, hematuria, frequency of urination
v. Anatomy
1. Tympanic upon percussion
2. Fingers can get between kidney and costal margin
3. Right kidney is usually lower than the left
4. Retroperitoneal
49
Breast Exam
Hi my name is ______, I-m a second year medical student. What is your

name? It-s very nice to meet you. Mrs. ______ I-ve been asked to come in
and do a breast exam. Is that ok with you?
1. Have you ever had a breast exam done before?
2. Have you ever done a self-exam?
3. Do you notice any pain/tenderness or nodules?
4. What was the first day of your last menstrual period? (<7 days do not
do exam – may get abnormal results; best time to do exam is between 7 and 14
days)
5. Do you know of any breast cancer in your family? I-m going to leave
the room and I-m going to need you to undress from your waist up. If
you would like, you can have a family member or someone else in the
room and there will also be a female assistant in the room during the
exam. Ok if there is any discomfort at any time please let me know
and I-ll try my best to alleviate the discomfort.
I. Inspection
a. Patient sitting at the edge of the bed and arms at her side
b. Breast
i. Size
ii. Symmetry
iii. Contour
iv. Shape
v. Color
vi. Masses/scars/lesions
c. Nipples/ Areola
Upon initial inspection there are no visible masses, scars, or lesions. The
contour is round, and the breasts are of equal size and symmetrical. The
nipples are everted, and there are no signs of dimpling or nipple discharge.
d. Changes with movement
i. Ask the patient to:
1. Raise hands above her head
2. Lean forward with hands above her head
3. Squeeze hands on her hips
Upon further inspection there are no signs of dimpling and there were no
contour changes with movement
51
II. Palpation
a. Always check the good side first
Go ahead and lay down on your back for me now with your head resting on
your right/left hand. I-m going to place this pillow underneath your shoulder.
b. The patient should be supine with her hand (ipsilateral to breast being
examined) behind head and pillow underneath shoulder blade.
I am going to squeeze around the nipple area now, please let me know if you
feel any pain. Ok, now I-m going to place my hands on your breasts, let me
know if there is any pain.
c. Check for nipple discharge by squeezing areola – Do not touch nipple
d. Palpate in light circles all around breast and axilla
i. Best to use both hands, the non-palpating hand should be on the
opposite side of the breast holding it in position while palpating in
light circles with the palpating hand.
ii. Repeat bilaterally and do not forget to palpate the axilla
Upon palpation there was no nipple discharge and there was no masses and
tenderness noted.
III. Axilla
Please sit up on the edge of the table for me.
Upon inspection there are no rashes nor pigment changes.
a. Inspection
I-m going to place my hands underneath your arms in the armpit area, let me
know if there is any pain.
b. Examine the lymph nodes (bilaterally at the same time to compare)
c. Place the hands in axilla – make sure the arms are down over the patient’s
hands
d. Palpate and report at each lymph node (normally < 1cm, non-painful)
i. Central (axillary): palpate along chest wall between axillary folds

(drains into infraclavicular, receives from pectoral, lateral to
subscapular)
ii. Subscapular: ventral to post axillary fold (drains posterior chest
wall, part of arm)
iii. Lateral: along upper medial humerus (drains most of the upper
arm)
52
iv. Pectoral: lower border of pectoris major caudal to anterior axillary
fold (drains anterior to chest)
v. Infraclavicular: lateral to SCM – inferior to clavicle (receives
from central)
vi. Supraclavicular: lateral to SCM – superior to clavicle (receives
from infraclavicular)
Upon palpation of the lymph nodes no enlargement noted and no tenderness
noted.
53
Breast Exam Secondaries
I. Inspection
a. Tanner’s Stage of Development
Stage 1 Stage 2 Stage 3 Stage 4 Stage 5
i. Preadolescent % elevated nipples only

ii. Breast bud % elevation of breast, nipples as small mounds,
enlarged areolar diameter
iii. Further enlargement of elevation of breast and areola % no
separation of contours
iv. Projection of areola and nipple % Secondary mound on top of
breast
v. Mature % projection of nipple only, areola has receded to general
contour of breast
b. Contour:
i. Normal % convex
ii. Dimpling or flattening of the breast suggests CA
c. Shape:
i. Normal % normal if one is bigger than other
ii. Thick skin with enlarged pores (Peau d’ orange) due to lymphatic
blockage
d. Color:
i. Same compared to rest of the body (redness with infection)
e. Nipples:
i. Inverted: if it has been inverted since birth or childhood then it is
normal variant but if it is a recent occurrence then there may be
underlying CA
ii. Nipples pointing in alternate direction suggests CA
iii. Rashes or ulcerations % PagetIs disease (underlying CA)
iv. Ectopic breast (polymastia)
v. Ectopic nipples (polethelia)
f. Cracking of skin/discharge:
i. Discharge
1. Milky (nonpuerperal galactorrhea) = hyperprolactinemia
(prolactin producing tumors)
2. Bloody = intraductal papilloma
3. Can be caused by medications (methyldopa, birth control
pills)
ii. PagetIs disease of breast: cracking, eczema, scaly, weeping, crusty.
Paget's disease is a benign appearing eczematoid lesion of the
54
nipple caused by large malignant cells (Paget's cells) which arise
from the ducts and which invade the surrounding nipple
epithelium. In the absence of an underlying mass, this is usually
due to an intraductal carcinoma. An underlying palpable mass
usually indicates invasive ductal carcinoma in which case the
prognosis is the same as that for any other invasive ductal
carcinoma and is reflected by the status of the axillary lymph
nodes.
g. Changes with movement:
i. Dimpling or retraction suggests CA pulling Ashley Cooper
ligaments; DDx fatty necrosis
II. Palpation
a. Reporting a mass:
i. Where: quadrant, or clock face
ii. Size: diameter (cmIs)
iii. Distance: cmIs from nipple
iv. Shape: round, regular, irregular
v. Consistency: firm, soft, hard
vi. Mobility: freely mobile or fixed to chest wall
vii. Delimitation: well circumscribed or not
viii. Tenderness
b. Enlarged axillary nodes due to (be sure to check other lymph nodes):
i. Infection of hand/arm
ii. Recurrent immunizations
iii. Skin test in arm
iv. Part of general lymphadenopathy
v. Malignant: firm, adhesive to each other or underlying tissues
III. Axilla
a. Rash: due to deodorant
Hidradenitis suppurativa Acanthosis Nigricans
b. Hidradenitis suppurativa: sweat gland infection with pus

c. Acanthosis Nigricans: deeply pigmented axillary skin; associated with
underlying malignancy
IV. Secondaries
a. Lumps/Nodules:
i. Fibroadenoma:
1. Firm % like the tip of the nose
2. Mobile
55
3. Non tender
4. Round % benign
5. Well circumscribed
6. Single
7. No retraction
8. <35
ii. Tumor
1. Hard % like back of the mastoid
2. May be fixed
3. Non tender
4. Stellate
5. Non % mobile
6. Retraction
7. 30 % 90
8. Breast tumors metastasize bone (osteoclastic)
9. Diagnose % FNA (+) blood
iii. Cyst:
1. Soft (like air in cheeks)
2. Mobile
3. Tender
4. Round
5. Diagnose % FNA serous fluid do cytology
6. Single/multiple
7. No retraction
8. Well outlined
9. 30 % 60
iv. Fibrocystic change: do nothing for treatment % feels like rice
v. F/U:
1. Mammogram
2. FNA and cytology
3. Biopsy and histology
4. Lumpectomy, chemotherapy, radiation (not radical
mastectomy because no difference in 10 years)
vi. Most common % fibrocystic change (40% breast CA)
vii. Fibroadenoma % Rx resection
viii. Most common breast cancer % infiltrating ductal CA
ix. CA that metastasizes to bone (primary osteoclastic)
1. Thyroid, lung, breast, prostate, kidney
x. Risk factors for breast CA
1. Familial
2. No children (nulliparity)
3. Age 40-50
4. Early menarche/late menopause (exposed to more
hormone)
5. Combo BCPIs
6. Obesity
56
7. Any other CA (especially in opposite breast)
8. Exposure to ionizing radiation
xi. Breast Cancer (fibrotic shortening retraction)
1. Skin dimpling
2. Abnormal contours (compare two sides)
3. Nipple retraction
xii. Males: 2/3 of adolescent males develops gynecomastia due to
gland enlargement, imbalance of estrogen, drugs, liver failure
bilateral enlargement (unilateral may be cancer)
V. Anatomy
a. Position:
i. Between 2nd and 6th ribs % between sternal edge and midaxillary
line
ii. 2/3 superior to pec major
iii. 1/3 superior to serratus anterior
iv. Nipples and areola % lateral to midline of breast
b. 3 components:
i. Glandular tissue
1. 12-14 lobules of glandular tissue make up breast
2. Produce milk after delivery of infant
3. Organized in lobes that radiate around nipple
4. Fibrous tissue % Ashley Cooper ligaments; suspensory
ligaments that are connected to both skin and fascia
underlying the breast
5. Fat % surrounds the breast; both superficially and
peripherally
ii. Surface Areola: has elevations that mark locations of sebaceous
glands (of Montogomery)
1. Axillary hair: ~ 2 years after pubic
iii. Aging:
1. Breast size (glandular tissue atrophies, replaced with fat)
2. Total fat , proportionately of fat/glandular
3. Loss of axillary hair
4. Breast: flabby, hangover on chest
57
Cranial Nerves
I. Olfactory
A. Check if both nasal passages are open by closing one nostril and have
patient breathe (in and out)
B. Check one nostril at a time to see if patient to smell and ID familiar odors
with their eyes closed (coffee packet)
-Nasal passages conduct air and familiar odor is noted
bilaterally9
II. Optic
A. Visual Acuity (report Yaeger score)
i. Ask patient
1. Can you read?
2. Do you wear contacts?
3. Are you wearing them right now?
ii. If they can@t read or can@t see, use fingers and ask:
1. How many fingers am I holding up?
iii. Use Snellen chart to measure distance (14G from chin)
iv. Ask patient to cover one eye and read lowest line possible on
Snellen chart
v. Ask patient to cover other eye and read the same line backwards
vi. If patient is unable to read line, read the next one up
The visual acuity is +1 bilaterally (report Yaeger score so
patient doesn@t know results)
B. Confrontation test
i. Align yourself with patient so that you are at eye level
ii. Place your hands 2 feet apart, lateral to patient@s ears in their visual
field
iii. Wiggle your fingers over visual field
Please point to the moving fingers as soon as you can see
them and tell me if you stop seeing them at any time.
Make sure you can see your own fingers because you are
comparing your visual field (assumed to be normal) to
your patients.
iv. Move hands toward midline
v. Repeat exam and test lower visual field
vi. If defect is found, test one eye at a time (i.e. you cover your right
eye and patient covers left eye)
1. Move fingers from defect area toward normal vision
2. Cover other eye and do it again to define borders
vii. Upon confrontation test, no visual defect was noted.
116
C. Pupillary light reaction (turn off lights, crack door)
i. Turn off lights, crack door
ii. Shine light on wall and ask patient to fixate on this point
iii. Direct: bring light from behind ear to eye and observe constriction
iv. Consensual: bring light to same eye but observe opposite eye with
oblique lighting (enough light to see pupil but not cause consensual
miotic reactions in opposite eye)
v. Repeat bilaterally
vi. The pupils are equal and round, they are reactive to light
and accommodation is intact.
D. Opthalmoscopic exam (fundoscopy) (turn off lights, crack door)
vii. Turn off lights, crack door
viii. Use right hand and eye, look at patient@s right eye
ix. Place left thumb on patient@s eyebrow (to open eye if necessary)
x. Shine light on wall and ask patient to fixate on this point
xi. Start 15 lateral to patient@s line of vision, shine light on pupil
1. Note orange glow in pupil (red reflex)
xii. Move inwards keeping your index finger on focus dial at all times
(start with 0 diopters)
xiii. Observe optic disc (follow A@s centrally) and physiologic cup
viii. Repeat in patient@s left eye V using your left eye and left hand to
hold the opthalmoscope
Red reflex is present, the retina is visible, the optic disc
is clear and pinkish. The physiologic cup is clean and half
the size of the disc. The A-V crossings are normal.
III. Oculomotor
A. H test (III, IV, VI): ask patient to follow pen while making a wide H
a. Extreme right
b. Right and up (pause to check nystagmus)
c. Right and down
d. Without pause extreme left
e. Left and up
f. Left and down
B. Accommodation
a. Hold pen 10cm from patient@s nose
b. Ask patient to look at point on wall (dilate), then look at pen (constrict)
C. Convergence and lid lag
a. Convergence: ask patient to follow pen as move it toward bridge of nose
b. Lid lag: ask patient to follow pen as you move it slowly from up to down
in midline
D. Strabismus (if DDx) check using the cover – uncover test V have the patient
look at the pen, cover one eye and the other will realign (+)
117
IV. Trochlear
a. Extreme right
c. Right and down
e. Left and up
f. Left and down
V. Trigeminal
A. Motor V while palpating ask patient to:
a. Clench teeth (masseter and temporalis)
b. Move jaw to sides against resistance (pterygoid)
c. Push down against resistance (temporalis)
d. Normal strength of temporalis, masseter, and pterygoid
bilaterally
B. Sensory
a. Test 6 sites: forehead, cheeks, and jaw bilaterally
i. Light touch: (don@t brush/drag) use a cotton swab
ii. Pain: test sharp vs. dull
iii. Temperature: test cold (tuning fork) vs. warm (hand)
b. Corneal reflex
i. Ask patient to look up and away from you, approach from other
side, out of patient@s line of vision. Touch the cornea lightly with
wisp of cotton (avoid eyelashes) V not done in exam
c. Jaw jerk reflex
i. Place finger on tip of chin and hit with hammer; + jaw jerks
posterior
d. Sensory system is intact, corneal reflex is present, and jaw
drop reflex is present
VI. Abducens
a. Extreme right
c. Right and down
e. Left and up
f. Left and down
VII. Facial
A. Inspection
a. Assess facial symmetry (especially nasal labial folds for CN lesion)
B. Motor
118
a. Raise eyebrows
b. Frown
c. Close eyes tightly (pull up on eyelids to test strength)
d. Show teeth
e. Smile
f. Blow out cheeks
g. Corneal reflex
C. -Upon inspection of the face, there are no masses, scars, lesions, or
deformities and symmetry is noted. Full muscular force and strength
is noted bilaterally. The corneal reflex is intact.9
VIII. Acoustic
A. Inspection
a. -Upon inspection there are no masses, scars, or lesions and
symmetry is noted.9
B. Test acuity
a. -Do you have any hearing problems/devices?9
b. -Can you close your eyes?9
c. Rub your fingers together.
d. -Do you hear this?9
e. If hearing is diminished, try to distinguish between conductive and
sensorineural hearing loss
f. -Sound was heard equally in both ears.9
C. Offer Weber-Rinne
a. Weber (lateralization)
i. Tap the tuning fork (512 Hz) against a knuckle so that it begins to
vibrate
ii. Place fork firmly on patient@s forehead
iii. -Which side do you hear better?9
b. Rinne
i. Place the vibrating tuning fork on the mastoid bone behind the ear,
level with the ear canal (bone conduction)
ii. Ask the patient when sound can no longer be heard place the
fork close to the ear canal and ask the patient if the sound is still
audible (air conduction).
iii. U of the fork should be facing forward to maximize vibration
iv. Place fork next to your ear to confirm sound presence
c. -Auditory acuity is normal bilaterally. Sound was heard equally
in both ears. Air conduction was greater than bone conduction.9
D. Check for nystagmus V ask patient to follow pen without moving head; move pen
side to side then to extreme side
119
IX. Glossopharyngeal
A. Test CN IX and CN X since functions overlap
X. Vagus
A. Motor
a. Ask the patient to say dahG and note position of soft palate and uvula
b. Ask patient to swallow
c. Gag reflex: stimulate back of the throat lightly on each side in turn V not
asked to do in exam
d. Check hoarseness V ask patient to say their name
e. Ask patient to blow out their cheeks
B. -Motor system is intact. The gag reflex is noted. The uvula is
midline.9
XI. Accessory
A. Inspect (from behind) for symmetry, muscle bulk, fasiculation
B. Motor V ask patient to:
a. Shrug against resistance (trapezius V ipsilateral)
b. Turn head to sides against resistance (SCM V ipsilateral)
C. -Upon inspection, normal muscle bulk and symmetry noted. Full force
and strength bilaterally.9
XII. Hypoglossal
A. Inspect tongue
B. Motor V ask patient to:
a. Move tongue to sides
b. Stick out tongue
C. Put hands over cheek and ask patient to push tongue against cheek
D. -No atrophy or fasiculations of the tongue as it lies in the floor of the
mouth. With the patient[s tongue protruded, there is normal
symmetry, on atrophy, and no deviation from the midline. Full force
and strength bilaterally9
120
Cranial Nerve Secondaries
I. Olfactory
a. Function: special sense = smell
b. Olfactory pathway:
i. Olfactory receptor cells (1st order neurons)
ii. Mitral cells (+ glutaminergic) of olfactory bulb
iii. Olfactory tract
iv. Lateral olfactory stria
v. Primary olfactory cortex (piriform cortex that lies over the

parahippocampal uncus) and the amygdala; primary olfactory
cortex is BA 34
c. Olfactory hallucinations [uncinate fits (seizures) with deja vu]: lesions

involving the parahippocampal uncus
d. Ipsilateral anosmia (loss of smell): lesion of the olfactory pathway;
olfactory groove meningioma (compress the olfactory tract and bulb),
esthesioneuroblastoma (olfactory neuroblastoma), head trauma (cribiform
plate damage), anterior fossa meningioma, smoking, cocaine, congenital,
deviated septum, frontal lobe lesion
e. Foster Kennedy syndrome (FKS): ipsilateral anosmia, ipsilateral optic
atrophy, and contralateral pailledema (cause: anterior fossa meningioma)
II. Optic
a. Function: special sense = vision and pupillary light reflex (afferent limb)
b. Visual Pathway:
i. Ganglion cells of the retina: forms the optic nerve
ii. Optic chiasm: optic nerve projects to the lamina cribrosa of the
scleral canal through the optic canal; nasal hemiretina fibers cross
iii. Optic tract: contains ipsilateral temporal hemiretina and nasal

hemiretina fibers and projects to
iv. Lateral geniculate body: 6 layered nucleus (layer 1, 4, 6 contra

fibers & layers 2, 3, 5 ipsi fibers)
v. Geniculocalcarine tract
121
vi. Primary visual cortex (BA 17): divided by calcarine sulcus;
lesions macular sparing
1. Cuneus: the upper division, input from superior retinal
quadrants inferior visual field quadrants
2. Lingual gyrus: the lower division, input from inferior
retinal quadrants superior visual field quadrants (Lpie in
the skyM); loops through the MeyerOs loop
c. Pupillary Light Reflex Pathway

i. Ganglion cells of the retina: bilaterally to
ii. Pretectal nucleus of the midbrain: Crossed (posterior

commisure) and uncrossed fibers of CNII
iii. Edinger-Westphal nuclus of CNIII: preganglionic

parasympathetic fibers and CNII exit to
iv. Ciliary ganglion: postganglionic parasympathetic fibers to
v. Sphincter muscle of Iris
d. Pupillary Dilation pathway:

i. Hypothalamus
ii. Ciliospinal center (T1-T2) of the intermediolateral cell column

of the spinal cord: projects preganglionic sympathetic fibers to
iii. Superior cervical ganglion: projects postganglionic sympathetic

fibers through perivascular plexus of the carotid system to
iv. Dilator muscle of Iris
e. SEE HEAD AND NECK EXAM
III. Oculomotor
a. Function:
i. Special sense = pupil control/lens focus
ii. Motor = move eye up, down, and medially
b. Near Reflex and Accommodation Pathway
i. Cortical Visual Pathway: Primary visual cortex (BA 17) to
ii. Visual association cortex (BA 19): projects through the

corticotectal tract to
iii. Superior colliculus and pretectal nucleus
122
iv. Oculomotor complex (midbrain)
1. Rostral Edinger-Westphal nucleus: pupillary constriction
2. Caudal Edinger-Westphal nuclues: contraction of the
ciliary muscle increases refractive power
3. Medial rectus subnucleus of CNIII: convergence
c. SEE HEAD AND NECK EXAM

d. Levator palpebrae superioris \ innervates skeletal portion
e. PNS component:
i. Ciliary muscle
ii. Sphincter pupillae
f. SNS component:
i. Dilator pupillae
ii. Superior tarsal muscle
g. CNIII palsy: transtentorial herniation (tumor, subdural and epidural
hematomas) supratenotorial pressure forces the hippocampal uncus
throught the tentorial notch and compresses CNIII; aneurysms of the
carotid and posterior communicating arteries compress CNIII within
the cavernous sinus or interpeduncular cistern; diabetic oculomotor palsy
affects CNIII unlike others it spares the pupilloconstrictor fibers
i. Pupilloconstrictor fibers: affected first dilated and fixed pupils
ii. Somatic efferent fibers: affected last external strabismus
iii. Ptosis: due to denervation of levator palpebrae muscle
iv. “Down and out”: denervation of the extraocular muscles
h. Light reflex: II afferent, III efferent
IV. Trochlear, VI Abducens

a. Funtion: motor to superior oblique depresses, intorts, and adducts the
eye
b. Pathway:
i. Trochlear nucleus (caudal midbrain)
ii. Crosses at superior medullary velum (midbrain)
iii. Exits at the brain stem (dorsal surface, caudal to the inferior
colliculus)
iv. Encircles the midbrain
v. Passes through cavernous sinus
vi. Orbit (through superior orbital fissure)
vii. Superior Oblique Muscle
123
c. CNIV Palsy: Extorsion of the eye and weakness in looking down and in
i. Vertical Diplopia: increases when looking down
ii. Head tilting: to compensate for the extorsion
iii. Head trauma: CNIV is vulnerable because it wraps around the
midbrain
iv.
d. Strabismus (eye deviations)
i. Nonparalytic strabismus \ imbalance in oculomotor tone
1. Esotropia \ convergent strabismus
2. Extropia \ divergent strabismus
3. Nystagmus: fine rhythmic oscillation of eyes (few beats
with extreme lateral gaze is normal; defined by the fast
phase (in left horizontal nystagmus, the eye drifts slowly to
the right and jerks back to the left); can be vertical,
horizontal, or rotary; due to disorders of labyrinth,
cerebellum, drug toxicity
V. Trigeminal
a. V1 – opthalmic nerve: innervates the forehead, dorsum of the nose, upper
eyelid, orbit (cornea and conjunctiva), and cranial dura
b. V2 – maxillary nerve: innervates the upper lip and cheek, lower eyelid,
anterior portion of the temple, oral mucosa of the upper mouth, nose,
pharynx, gums, teeth and palate of the upper jaw, and cranial dura
c. V3 – mandibular nerve: GSA innervates the lower lip and chin, posterior
portion of the temple, external auditory meatus, and tmpanic membrane,
external ear, teeth of the lower jaw, oral mucosa of the cheeks and floor of
the mouth, anterior 2/3 of the tongue, temporomandibular joint, and
cranial dura. SVE innervates the muscles of mastication, mylohyoid,
anterior belly of the digastric, and tensores tympani and veli palatini. It
innervates the muscles that move the jaw, the lateral and medial
pterygoids.
d. Function: Motor = mastication, lateral jaw movement, initiate
swallowing, auditory dampening
i. Temporalis (elevate/retract), masseter (elevates), pterygoid
(protrude, side to side)
ii. Spasm of muscles of mastication = tetanus and adverse reaction to
phenothiazines
iii. Corneal reflex: a consensual disynaptic reflex (afferent V-1/
efferent VII); abnormal \ patient doesnOt blink
iv. Jaw Jerk reflex: a monosynaptic myotatic relex (afferent V-3/

efferent V-3)
1. Muscle spindle from masseter muscle
2. Mesencephalic nucleus (primary neuron)
124
3. Motor nucleus of CNV (secondary neuron)
4. Masseter muscle
v. Trigeminal neuralgia (tic douloureux): recurrent paroxysms of

sharp, stabbing pain in one or more branches of the trigeminal
nerve on one side of the face.
e. Pathway of Ventral trigeminothalamic tract (pain and temperature)

i. Trigeminal ganglion: are where the first-order neurons are and
descend in the
ii. Spinal trigeminal tract: to the
iii. Spinal trigeminal nucleus: where the second-order neurons are

and decussate and terminate at the
iv. VPM: contralateral ventral posteromedial nucleus of the thalamus

where the third-order neurons are and project to the
v. Posterior limb of the internal capsule
vi. To the somatosensory cortex (BA 3, 1, 2) \ face area
f. Pathway of Dorsal trigeminothalamic tract (discrimination and

pressure sensation)
i. Meissner’s and Pacini’s corpuscles
ii. Trigeminal ganglion: are where the first-order neurons are and
synapses at
iii. Principle sensory nucleus of CNV: are where the second-order

neurons to project to the
iv. VPM nucleus of the thalamus (ipsilateral): are where the third-
order neurons are located and projects to the
v. Posterior limb of the internal capsule
vi. To the somatosensory cortex (BA 3, 1, 2) \ face area
125
VI. Abducens
a. Function: motor to lateral rectus muscle abducts the eye
b. Pathway:
i. Abducent nucleus: found in the dorsomedial tegmentum of the
caudal pons
ii. Corticospinal tract: goes through the
iii. Pontine cinstern and cavernous sinus: to the
iv. Orbit (through superior orbital fissure)
c. CNVI palsy: most common isolated palsy; seen in patients with

meningitis, subarachnoid hemorrhage, late-stage syphilis, and trauma
i. Esotropia: convergent (medial) strabismus with inablitiy to abduct
the eye [Extropia \ divergent strabismus]
ii. Horizontal diplopia: double images are farther apart when
looking towards the affected lateral rectus muscle
VII. Facial
a. Function:
i. Special sense = taste anterior 2/3
ii. Motor = facial movements, close eye, corneal reflex, salivation,
lacrimation, general sensation from the external ear
b. Lower motor neuron lesion (Bell’s palsy) \ parotid tumor, middle ear
infection, lyme disease
i. Paralysis of ipsilateral entire face
c. Upper motor neuron lesion \ stroke, multiple sclerosis, tumor
i. Paralysis to contralateral lower face
VIII. Acoustic
a. Function: special sense
i. Vestibular nerve: maintains equilibrium and balance
1. Kinetic labyrinth: three semicircular ducts respond to
angular acceleration and deceleration of the head. Hair
cells respon to the flow of endolymph
2. Static labyrinth: utricle and saccule (contains hair cells
whose cilia are embedded in the otolithic membrane)
respond to the position of the head with respect to linear
acceleration and the pull of gravity
3. Pathway:
a. Hair cells of the semicircular ducts and utricle are
innervated by bipolar cells
126
b. Vestibular ganglion (located in the fundus of the
internal auditory meatus)
c. Vestibular nerve to vestibular nuclei and to
d. The flocculondoular lobe (cerebellum)
e. Nuclei also projects to:

- CNIII, IV, VI through MLF
- Spinal cord through lateral vestibulospinal
tract
- Ventral posteroinferior and posterolateral
nuclei of the thalamus postcentral gyrus
ii. Cochlear nerve: mediates hearing
1. Pathway:
a. Vibration of the basilar membrane stimulates
b. Hair cells of the organ of Corti (innervated by

peripheral processes of bipolar cells of the spiral
ganglion
c. Bipolar cells of the spiral (cochlear) ganglion

project centrally as the cochlear nerve to the
d. Cochlear nuclei
e. Projects contralaterally to the superior olivary

nucleus (sound localization) and projects to
f. Lateral lemniscus projects to
g. Nucleus of inferior colliculus projects through the

brachium of the inferior colliculus to
h. Medial geniculate body projects to through the

internal capsule as the auditory radiation to
i. Primary auditory cortex (transverse temporal gyri

of Heschl \ BA 41 & 42)
2. Sensorineural (perceptive or nerve) deafness: is caused

by disease of the cochlea, cochlear nerve (acoustic
neuroma), or central auditory connections.
127
3. Conduction deafness: is caused by interruption
(obstruction \ wax, otosclerosis, or otitis media) of the
passage of sound waves through the external or middle ear.
4. Tinnitus: irritative lesions causing ear ringing
5. Aoustic neuroma: is a schwann cell tumor of the cochlear
nerve that causes deafness
b. DollOs eyes: if damage to CN8 when doctor moves patientOs head side
to side the eyes move with head (normal = eyes move opposite of head
rotation); due to lesion of midbrain or pons
IX. Glossopharyngeal
a. Function: special sense = taste posterior 1/3
b. Afferent
i. Carotid sinus (baroreceptor)
ii. Carotid body (chemoreceptor)
X. Vagus
a. Function: motor = pharynx, larynx, palate
b. Lesion in vagus
i. Dysphagia: pharyngeal or palatal weakness
ii. Palate:
1. Fails to rise: bilateral
2. Abnormal side fails to rise, uvula deviates to normal side:
unilateral
3. Nasal voice
iii. Vocal cord paralysis: aortic aneurysm, bronchogenic CA = damage
recurrent laryngeal nerve
iv. Gag reflex (afferent \ IX/efferent \ X) abnormal \ patient doesnOt
gag
XI. Accessory
a. Function: motor = SCM, upper trapezius
b. Ipsilateral muscle control right SCM turns head to right
c. Lesion XI
i. Weakness, atrophy, fasiculations \ peripheral nerve disorder
ii. Paralyzed trapezius: shoulder drop, scapula displaced down and
laterally
iii. Paralyzed SCM: difficulty raising head off pillow
XII. Hypoglossal
a. Function: motor = tongue
b. Lesion XII
i. Atrophy, fasiculations
ii. Tongue deviates to same side when protruded
iii. Force is greater to unaffected cheek
iv. Cerebellum dysfuntion: spasticity, paralysis
128
- Bulbar Palsy: palsy affecting cranial nerves of medulla (V, VII, IX, X,
XII); reflexes (jaw jerk, gag)
- Pseudo Bulbar Palsy: same cranial nerves but upper motor neuronOs;
reflexes
- Jugular Foramen syndrome: IX, X, XI; ipsilateral weakness of
pharyngeal, laryngeal, trapezius, SCM muscles; ipsilateral loss of
sensation of pharynx
- Wallenberg Syndrome: (posterior inferior cerebellar artery occlusion) \
V, IX, X ipsilateral; spinothalamic (contralateral)
129
Head & Neck Exam
I. Head
a. Patient sitting
b. Inspection
i. Symmetry
ii. Masses, scars, lesions
iii. Fasiculations, abnormal tics
iv. Hair ; quantity, distribution, texture, lice/nits
The patient.s hair is of normal quantity, texture and distribution. There are
no lice or nits. The skull and face are symmetrical with no masses, scars, or
lesion. There is no movement or edema and the skin is normal in pallor and
texture.
II. Eyes
a. Inspection
i. Eye symmetry
ii. Eyebrows
iii. Eyelashes
iv. Eyelids: have patient close eyes
v. Lacrimal glands and apparatus
vi. Conjunctive and sclera
vii. Cornea and lens: use oblique lighting from the top to inspect
opacities
The patient.s eyes are symmetrical. Eyebrows are of normal thickness. No
lesions or periorbital edema. Lacrimal apparatus is functional. No
conjunctivits, anemia, or jaundice noted. No opacities noted.
b. Visual acuity
i. Ask patient
1. Can you read?
2. Do you wear contacts?
3. Are you wearing them right now?
ii. If they canJt read or canJt see, use fingers and ask:
1. How many fingers am I holding up?
iii. Use Snellen chart to measure distance (14O from chin)
iv. Ask patient to cover one eye and read lowest line possible on
Snellen chart
v. Ask patient to cover other eye and read the same line backwards
vi. If patient is unable to read line, read the next one up
76
The visual acuity is +1 bilaterally (report Yaeger score so patient doesnJt know
results)
c. Pupil size
i. Compare to pupil size chart
Upon inspection, pupil size is 4 bilaterally.
d. Confrontation
i. Align yourself with patient so that you are at eye level
ii. Place your hands 2 feet apart, lateral to patientJs ears in their visual
field
iii. Wiggle your fingers over visual field
Please point to the moving fingers as soon as you can see them and tell me if
you stop seeing them at any time. Make sure you can see your own fingers
because you are comparing your visual field (assumed to be normal) to your
patients.
iv. Move hands toward midline
v. Repeat exam and test lower visual field
vi. If defect is found, test one eye at a time (i.e. you cover your right
eye and patient covers left eye)
1. Move fingers from defect area toward normal vision
2. Cover other eye and do it again to define borders
Upon confrontation test, no visual defect was noted.
e. Iris ; shine light from temporal side
No crescentric shadow noted.
f. Accommodation
i. Hold pen 10cm from patientJs nose
ii. Ask patient to look at point on wall (dilate), then look at pen
(constrict)
g. Pupillary light reaction
ii. Shine light on wall and ask patient to fixate on this point
iii. Direct: bring light from behind ear to eye and observe constriction
iv. Consensual: bring light to same eye but observe opposite eye with
oblique lighting (enough light to see pupil but not cause consensual
miotic reactions in opposite eye)
v. Repeat bilaterally
The pupils are equal and round, they are reactive to light and accommodation
is intact.
h. Extraocular muscles
i. H test: ask patient to follow pen while making a wide H
1. Extreme right
2. Right and up (pause to check nystagmus)
3. Right and down
4. Without pause extreme left
5. Left and up
77
6. Left and down
ii. Lid lag: ask patient to follow pen as you move it slowly from up to
down in midline
iii. Convergence: ask patient to follow pen as move it toward bridge
of nose
iv. Corneal reflection: hold light 2 feet from patientJs eyes
1. Ask patient to look at light
2. Observe location of reflection
Eyes show good use of extraocular muscles. There is no lid lag and
convergence is normal. Corneal reflection is symmetrical
i. Ophalmoscope exam (fundoscopy)
ii. Use right hand and eye, look at patientJs right eye
iii. Place left thumb on patientJs eyebrow (to open eye if necessary)
iv. Shine light on wall and ask patient to fixate on this point
v. Start 15 lateral to patientJs line of vision, shine light on pupil
1. Note orange glow in pupil (red reflex)
vi. Move inwards keeping your index finger on focus dial at all times
(start with 0 diopters)
vii. Observe optic disc (follow AJs centrally) and physiologic cup
viii. Ask patient to look into the light last (to observe the macula)
ix. Repeat in patientJs left eye ; using your left eye and left hand to
hold the opthalmoscope
Red reflex is present, the retina is visible, the optic disc is clear and pinkish.
The physiologic cup is clean and half the size of the disc. The A-V crossings
are normal.
III. Ear
a. Inspection
i. Patient sitting
ii. Look for masses, scars, lesions, deformities, and symmetry
Upon inspection, no masses, scars, or lesions noted. Symmetry is noted
b. Palpation
i. Palpate preauricular and posterior auricular lymph nodes
ii. Pull up, back, down on alae
iii. Palpate tragus
iv. Palpate mastoid process
No tenderness, or masses noted on palpation
c. Hearing
i. Test acuity
1. Do you have any hearing problems/devices?
2. Can you close your eyes?
3. Rub your fingers together.
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4. Do you hear this?
5. If hearing is diminished, try to distinguish between
conductive and sensorineural hearing loss
Sound was heard equally in both ears
ii. Weber (lateralization)
1. Tap the tuning fork (512 Hz) against a knuckle so that it
begins to vibrate
2. Place fork firmly on patientJs forehead
Which side do you hear better?
iii. Rinne
1. Place the vibrating tuning fork on the mastoid bone behind
the ear, level with the ear canal (bone conduction)
2. Ask the patient when sound can no longer be heard
place the fork close to the ear canal and ask the patient if
the sound is still audible (air conduction).
a. U of the fork should be facing forward to maximize
vibration
3. Place fork next to your ear to confirm sound presence
Auditory acuity is normal bilaterally. Sound was heard equally in both ears.
Air conduction was greater than bone conduction.
d. Otoscope exam
I am going to look into your ear, you may feel some discomfort, but tell me if
you have any pain.
i. Pull patientJs alae up and back (to straighten ear canal), rest hand
on zygomatic arch, insert ear speculum (left hand/left ear; right
hand/right ear); use largest ear speculum that ear canal can
accommodate
ii. Inspect for discharge, foreign bodies, inflammation, cerumen
iii. Inspect ear drum (color/contour)
1. Describe tympanic membrane
2. ID cone of light (anterior ; inferior to handle of malleus)
3. ID The handle of malleus, and incus if possible
Upon inspection, no inflammation or foreign bodies present, the ear drum is
pink and smooth. The cone of light and the handle of malleus are visible.
IV. Nose and Paranasal Sinuses

a. Inspect anterior and inferior surfaces of nose
I.m going to look into your nose, if you feel any pain please tell me
b. Test for nasal obstruction
Please occlude one nostril and breathe in and out through your nose. And
with the other.
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c. Gently press on nose with thumb (widens nostrils) inspect nasal orifices
with pen light
d. Ask patient to tilt head back, insert speculum (without touching nasal
septum) and observe:
i. Nasal mucosa: color, swelling, bleeding, exudate, polyps, ulcers
ii. Nasal spetum: deviation, inflammation, perforation
Upon inspection, there are no masses, scars or lesion on the nose. The nasal
mucosa is red and there is no bleeding, ulcers, or polyps. The septum is
intact. The inferior and middle conchae are visible.
e. Palpate maxillary, frontal sinuses with thumbs ; noting any tenderness
Upon palpation there was no tenderness in the paranasal sinuses
f. Offer to illuminate sinuses
ii. Frontal: place light snugly deep under each brow, close to nose,
and shine up; look for dim glow of forehead
iii. Maxillary: ask patient to lie supine and open mouth; shine light
downward from just below inner aspect of each eye; look through
mouth for dim glow of hard palate
V. Mouth and Pharynx

a. Inspect
i. Use pen light and tongue depressor
ii. Lips
iii. Oral mucosa
iv. Gums
v. Teeth
vi. Tongue and floor of mouth
vii. Soft palate
viii. Anterior and posterior pillars
ix. Uvula
x. Tonsils
xi. Pharynx
xii. Not the color, symmetry, inflammation, ulcers, lesions, and any
other abnormalities
Upon inspection the lips are not dry and there are no lesions, ulcers or
cracking. There are no masses, scars, or lesions on the oral mucosa. The
teeth are intact. The gums are pink. There are no lesion on the tongue and
there is no glossitis. There are no lesions on the floor of the mouth. The
pharynx is not inflamed, and there are no ulcers or visible lesions.
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VI. Neck
a. Inspection: look for masses, scars, or lesions, symmetry
b. Palpate parotid and submandibular glands
Upon inspection, the patient.s neck is symmetrical with no masses, scars, or
lesions. The parotid and submandibular glands are not enlarged
c. Palpate lymph nodes using pads of index and middle fingers
i. Ask patient to slightly flex head forward
1. Preauricular (front of ear)
2. Postauricular (front of mastoid)
3. Occipital (base of skull posteriorly)
4. Tonsillar (mandible angle)
5. Submandibular (1/2 way between angle and tip of
mandible)
6. Superficial cervical (above SCM)
7. Post cervical (along anterior edge of trapezius muscle)
8. Deep cervical (deep to SCM)
9. Supraclavicular (dorsal to clavicle where it meets the SCM)
10. Infraclavicular (caudal to clavicle where it meets the SCM
11. Note: shape, size, delimitation, mobility, consistency, and
any tenderness
12. If enlarged node, the reexamine the area it drains
Upon palpation, the patient.s lymph nodes are not hard or enlarged, and no
tenderness is noted.
VII. Thyroid
a. Patient sits
b. Inspection
i. Ask patient to extend neck back slightly
ii. Use pen light directed down from patientJs chin
iii. Inspect the region below the cricoid cartilage for the gland
iv. Ask patient to take a sip of water but not to swallow until you are
ready to observe; when patient swallows, observe cricoid cartilage
and thyroid gland movement (normal ; rise and fall symmetrically)
Upon inspection the thyroid gland is not enlarged and it is symmetrical. It
elevates and then returns to normal position upon swallowing.
c. Palpate
i. Stand behind patient
ii. Place your fingers (use both hands) on the patientJs neck just
below the cricoid cartilage
iii. Show hands to patient before placing them on neck patient
comfort
iv. Palpate the thyroid, cricoid cartilage and thyroid gland
v. Note the size, shape, and consistency of gland
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vi. If gland is enlarged, listen for a bruit with bell of stethoscope
Upon palpation, the thyroid gland is normal size, shape, and consistency.
There were no nodules, and no tenderness was noted.
d. Associated exam
i. Palpate the hair
ii. Inspect for thinning of the eyebrows
iii. Convergence
iv. Lid lag
v. Exopthalmos
vi. Check for sweaty palms
vii. Tremors (place a piece of paper over patientJs hands)
viii. Pulse
ix. Myxedema ; periorbital edema
Upon further examination the hair is of normal texture, there is normal
convergence of the eye. No lid lag, no exopthalmos. No sweaty palms, no
tremors. The eyebrows are of normal thickness. There is no periorbital
edema. The pulse is 72 beats per minute, the rhythm is regular, the
character is normal and the volume is normal.
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Head and Neck Exam Secondaries
I. Head
a. Cushing8s syndrome: ACTH; patient resembles a lemon on a stick;
moon (round) face, red cheeks; excess facial hair lips and chin; buffalo
hump
b. Parkinson8s disease: decreased facial motility (mask-like face @ less
blinking, seems to peering forward), oily skin, drooling may occur
c. Facial fractures: nose (most common fractured bone in the body); jaw
d. Enlarged skull: PagetEs disease of bone; hydrocephalus
e. Asymmetrical face: CN7 lesion
f. Hair: fine due to hyperthyroidism
g. Seborrheic dermatits: inflammatory skin disease; round, irregular lesions
covered with yellow or brown-gray greasy scales (dry or weeping)
h. Pilar cysts
i. Psoriasis: erythematous papules, plaques with distinct borders
j. Nits: eggs of lice @ ovoid, granular, white, adhere to hair
k. Down syndrome: low set ears
l. Fontanelle8s:
i. Anterior: closes at 12 months, delayed in hydrocephalus, early in
craniosynostosis;
ii. Posterior @ closes at 2 months, check for dehydration
II. Eyes
a. Inspection
i. Eye position: exopthalmos @ Graves disease (bilateral); ocular
tumors
ii. Eye brows:
1. Hypothyroidism thin laterally
2. Seborrheic dermatitis scaly
iii. Eyelashes (direction they point)
Ectropion Entropion Stye (hordeolum)
1. Ectropion: margin of lower lid is turned outward exposing

palpebral conjunctiva; strabismus associated; most
common in elderly
2. Entropion: inward turning of lid margin lashes irritate
the cornea; ask patient to squeeze lids together, then open
them @ may reveal it; most common in elderly
83
3. Sty (acute hordeolum): painful, tender, red inflammation
around the hair follicle of the eyelash
a. External hordeolum @ caused by staph infection of
superficial accessory glands of Zeis or Moll located
in the eyelid margin
b. Internal hordeolum @ occurs after suppurative
infection of the oil secreting meibomian glands with
in the tarsal plates of eyelid
iv. Eyelids
Epicanthus Blepharitis Ptosis
Chalazion Xanthelasma Pinguecula
1. Epicanthus: vertical fold of skin over medial eye; Asians,

Down syndrome, convergent strabismus (floating eye)
assoc.
2. Blepharitis: inflammation of the eyelids along the margins,
often with crusting or scales. Most common form occurs in
association with acne rosacea or seborrheic dermatitis
3. Ptosis: down and out eye due to aneurysm, herniation,
Myasthenia Gravis; HornerEs syndrome; CN3 damage;
Lambert-Eaton syndrome (canEt release Ach)
4. Chalazion: chronic inflammatory lesion involving a
meibomian gland (upper lid). Produces pea-like nodule
within the eyelid
5. Xanthelasma: slightly raised, yellowish, well
circumscribed plaques in the skin along the nasal portion of
the eyelid; sign of hypercholesterolemia
6. Pinguecula: yellowish nodule in the bulbar conjunctiva on
either side of the iris; appear frequently in aging
v. Lacrimal apparatus
1. Epiphora: tearing
2. Dry (keratoconjunctivitis sicca): SjorgrenEs, MiKulicz
disease, sarcoidosis; test by Schirmer strip (measures tear
production)
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3. Dacryocystitis: inflammation of the lacrimal sac (swelling
between the lower lid and nose)
a. Acute: painful and red
b. Chronic: obstruction of a nasolacrimal duct
4. Excessive tears:
a. Conjunctival inflammation
b. Nasal lacrimal duct obstruction
c. Ectropion: impaired drainage of tears
vi. Conjunctiva and sclera
Corneal Scar Bitot8s spots
1. Jaundice
2. Episcleritis: local noninfectious inflammation of the
superficial tissues of the sclera; the thin layer of connective
tissue between the conjunctiva and the sclera
3. Conjunctivitis: diffuse redness, watery eyes due to
bacterial, viral (most common is adenovirus), allergy
4. Allergic conjunctivits:
a. Hay fever conjunctivitis @ seasonal, IgE mediated
activation of mast cells cause itching, redness, &
edema
b. Vernal conjunctivitis @ seasonal, unknown cause
itching, photophobia, epiphora, and mucous
discharge
c. Atopic conjunctivitis @ occurs with atopic dermatitis
or asthma
5. Corneal injury or infection: red just around iris; watery,
abrasions, infections
6. Acute iritis: red just around iris; non-watery, decreased
vision; with ocular and systemic disorders
7. Acute glaucoma: red just around iris; intense itching,
cloudy cornea; an emergency: acute increase in intraocular
pressure; pain is due to the stretch of the cornea (chronic
glaucoma no pain, tunnel vision is 1st sign)
8. Subconjunctival hemorrhage: pure red, less vessel
demarkation @ just blood (rupture of blood vessels bridging
the potential space between the episclera and the
conjunctiva; from eye rubbing, vigorous cough, trauma or
bleeding disorders; resolves without treatment
9. Bitot8s spots: foamy soap suds appearance early sign of
keratomalacia vitamin A deficiency
85
vii. Cornea and lens:
1. Cornea:
Herpes virus Corneal arcus Pterygium
a. Dryness: cobblestone appearance on red reflex

b. Glaucoma: cloudy corneal edema
c. Trauma: permanent scar
d. Vitamin A deficiency: opacification
e. Sjogren8s
f. Keratitis: impairs vision by corneal clouding,
scarring, and perforation blindness (trachoma
and vitamin A deficiency world leading cause)
g. Herpes virus: major cause of blindness from
keratitis; unilateral follicular blepharoconjunctivitis;
dentritic tree pattern of corneal epithelial ulceration
h. Corneal arcus: thin gray arc at edge of cornea;
suggests hyperlipoproteinemia; associated with
elderly, African Americans
i. Corneal scar: superficial opacity of cornea from
old injury (DDx-cataract is deeper = opacity of the
lens); best seen with fluorescein strips and slip lamp
using cobalt blue light
j. Pterygium: bulbar thickening of conjunctiva that
slowly grows across the edge of the surface of
cornea, fleshy material; removed if signs and
symptoms of irritation or blurring recurrence is
common problem
2. Lens:
a. Cataract (most common): milky whiteness in
pupil, dark spot on red reflex background; most
develop slowly as a result of aging visual
impairment; occurs more rapidly in patients with
history of ocular trauma, uveitis, or diabetes
mellitus; acquired in myotonic dystrophy,
neurofibromatosis type 2, galactosemia.
b. Nuclear cataract: gray with flashlight @ looks back
against the red reflex
c. Peripheral cataract: spot-like shadows that grow
inward
b. Visual acuity (Snellen chart) refractive error
86
Myopia Hyperopia Presbyopia Astigmatism
i. CanEt tell if patient is near-sighted with pocket Snellen

(Rosenbaum card); testing vision through a pinhole aperture is a
useful way to screen quickly for refractive error, if visual acuity is
better through pinhole than unaided eye refraction needed to
correct visual acuity
ii. Emmetropia (20/20): parallel rays from infinitely are focused
perfectly up on the retina; distance from chart/distance normal eye
can be read line from
iii. Hyperopia: impaired near vision; globe is too short; Rx
converging (convex) lens
iv. Myopia: impaired far vision; globe is too long; Rx diverging
(concave) lens
v. Presbyopia: impaired near vision due to loss of refractive power
to accommodate near objects; in middle and old age @ Rx convex
lens; if previously hyperopia bifocals to see near objects; if
previously myopia take off glasses to see near objects
vi. Astigmatism @ corneal surface is not perfectly spherical, need
cylindrical corrective lens or LASIK (laser in situ keratomileusis)
or PRK (photoreactive keratectomy)
c. Pupil size:
i. Anisicoria: pupillary inequality <0.5 mm (benign; normal in 20%
of pupil); ok as long as the asymmetry of pupil is constant with
light changes
1. Inequality >0.5 mm in HornerEs syndrome @ caused by;
oculomotor paralysis; tonic pupil; open angle glaucoma
2. If anisicoria increases in dim light: indicates a sympathetic
paresis of the iris dilator muscle 1 of the pupils is not
dilating because of the paresis. Brainstem stroke, carotid
dissection, or neoplasm impinging on sympathetic chain
HornerEs syndrome (miosis, ptosis, & anisicoria)
3. If anisicoria increases in bright light: indicates a
parasympathetic paresis
ii. Miosis: constriction of the pupils
iii. Mydriasis: dilation of the pupils
1. Contraindications for mydriatic drops @ head injury, coma,
narrow angle glaucoma
2. Acute mydriasis occurs with damage to the ciliary
ganglion; infections (herpes zoster & influenza), trauma
87
(blunt, penetrating, surgical), or ischemia (diabetes &
temporal arteritis)
iv. Tonic pupil (Adies Pupil): large pupil unilateral; reaction to light
/slowed; near reaction is slowed; deep tendon reflexes due to
PNS lesion (nerve or ciliary ganglion)
v. Argyll Robertson: small pupil unilalteral, accomomodation
normal, but doesnEt react to light; due to neurosyphilis, diabetes,
lesions of the dorsal midbrain (obstructive hydrocephalus, pineal
region tumors), aberrant regeneration (oculomotor nerve palsy,
AdieEs tonic pupil)
vi. Horner8s syndrome: small pupil, ptosis, anhidrosis; normal
pupillary light reaction and accommodation due to SNS lesion
vii. Uveitis: pain with constriction; inflammation of the uveal tract
(iris is part of uveal tract), always unilateral
viii. Marcus Gunn: (swinging flashlight test) direct and consensual in
normal eye, then see dilation of both when shine light in abnormal
eye (due to relaxation from light in normal), light shined in the
abnormal eye causes no reaction in either eye, no pupillary reflex
due to afferent optic nerve lesion
ix. Weber8s syndrome: CN3 paresis with contralateral hemiplegia
due to midbrain stroke
x. Parinaud8s syndrome: midbrain lesion no upward gaze, no
pupillary light reflex, but normal accommodation
xi. Oculomotor nerve paralysis ptosis; pupil is dilated and not reactive
to light (often with lateral deviation)
xii. Unilateral blindness does not cause anisicoria as long as the
sympathetic and parasympathetic innervation is intact; light in the
good eye causes constriction in both eyes, light shined in the blind
eye causes no reaction in either eye
d. Confrontation
i. Normal: fingers seen in visual fields
ii. Visual defects:
1. Legal blindness @ constricted visual field of 20 or less in
good eyes; 20/200 or less in the good eye with glasses on
2. Horizontal defect (central retinal artery)
3. Blind eye (optic nerve lesion)
4. Bitemporal hemianopsia (nasal ½ of retina, lesion of optic
chiasm)
5. Homonymous hemianopsia (contralateral optic tract, also
seen with occipital radiation lesion)
6. Homonymous quadratic lesion (partial lesion of
contralateral optic radiation)
7. Tunnel vision: 1st sign of chronic glaucoma, retinitis
pigmentosa, papilledema, migraine (transient)
8. Scotoma: 1 retinal diseases affecting macula due to
diabetes mellitus, hypertension, vitamin B12 deficiency,
88
retrobulbar neuritis (most common), vascular lesion of
ocular pole., methanol
9. Strabismus: signs and symptoms diplopia (brain cuts off
image from bad eye normal vision, eventually leads to
blindness of bad eye); Diagnose @ cover test (tests
alignment) @ patient fixes on point, cover fixed eye,
gloating eye realigns
10. Note: Names are from the patients visual field
e. Iris
i. + crescentric shadow due to narrow angle glaucoma @ the iris
bulges too far forward creating a narrow angle between the iris and
the cornea in intraocular pressure due to aqueous humor
drainage is blocked
ii. Hypopyon: pus in anterior chamber in front of iris (with corneal
ulcers)
iii. Hypehema: blood in anterior chamber in front of the iris due to
blunt trauma
f. Accomodation
i. Pupillary constriction with near effort, eyes move medially, ciliary
muscle contracts tension on suspensory ligament of the lens
convex lens (near vision)
g. Pupillary light reaction
i. Afferent @ CN2; efferent @ CN3; mediated by input to pretectal
olivary nuclei in the midbrain projects output to ipsilateral and
contralateral Edinger-Westphal nuclei of the oculomotor nuclear
complex (cells here provide parasympathetic innervation to the iris
sphinctor via interneuron in the ciliary ganglion).
ii. Direct reaction: pupillary constriction of the same eye as
stimulated by light
iii. Consensual reaction: pupillary constriction in the opposite eye
h. Extraocular muscles
i. Convergence: poor due to hyperthyroidism
ii. Lid lag: rim of sclera seen between upper lid and iris due to
hyperthyroidism (normal: upper lid slightly overlaps the iris)
iii. Corneal reflection: (tests ocular alignment) normal @ reflection is
slightly nasal to center of pupils; cover test is more precise @ have
patient look at distant object, cover eye while observing other eye;
any shift means misaligned; repeat with other eye
iv. Corneal reflex: afferent @ CN5; efferent @ CN7
i. Opthalmoscope exam
i. Red reflex not seen if: detached rim, absent eye, retinoblastoma,
cataracts (black spots on red background); = DARC; red reflex test
looking at the retina
ii. Optic disc
1. Clarity of disc outline
2. Color: normal @ yellowish orange to creamy pink
89
3. Central physiologic cup: Normal @ white and < ½
diameter of disc
4. Character and size of arteries and veins (see retina
below); pulsatory veins suggest CSF press is normal
5. Normal optic disc variations
a. Rings and crescents @ seen around discEs temporal
border (pigment)
b. Medulated nerve fibers @ white patches where the
vessels are occluded; obscures the edge of the disc
6. Abnormalilities of the optic disc
a. Optic atrophy: less of disc vessels, whitish in color
b. Papilledma: vessel stasis leads to engorgement,
disc swollen, margins blurred, due to intracranial
pressure (meningitis)
c. Acute glaucoma: pressure in the eye leads to
backwards depression of the disc; the base of the
cup is enlarged; pink hyperemic, disc vessels more
numerous and swollen at borders, stony hard eye;
size of optic cup > ½ size diameter of disc
7. Optic nerve disorder: glaucoma, acuity, optic neuritis
(in MS), methanol, thrombosis of retinal vein sudden
loss of vision, emboli in central retinal artery sudden
loss of vision
iii. Retina
1. Arteries: light red, smaller, and brighter light reflex
2. Veins: dark red, larger, and absent light reflex
3. Hypertension:
a. Copper wiring: artery becomes tortuous and light
reflex giving a ncopperE appearance
b. Silver wiring: narrowed artery becomes completely
opaque
c. Superficial hemorrhages: small, linear, flame-
shaped red streaks in the fundus due to severe
hypertension, papilledema, and occlusion of the
retinal vein
d. Cotton wool patches: white or grayish, ovoid
lesion with irregular borders; most commonly due
to infarcted nerve fibers
e. Hard exudates: small, round yellowish, with well
defined borders, often in clusters or circular, linear
patterns (also in diabetic retinopathy)
f. A-V crossings
i. Tapering: vein appears to taper down on
either side of the artery
ii. Nicking: vein appears to stop abruptly on
either side of the artery
90
iii. Banking: vein twists on the distal side of
the artery and forms a dark, wide end
4. Diabetic Retinopathy:
a. Non-proliferative:
i. Deep retinal hemorrhages: small rounded
irregular red spots that occur deep in the
retina
ii. Microaneurysms: tiny, round, red spots
seen most commonly around macular
region; consist of minute dilations of tiny
retinal blood vessels
iii. Hard exudates
b. Proliferative:
i. Neovascularization: formation of new
blood vessels that are more numerous,
tortuous, narrower than the other vessels;
most commonly seen in late stage diabetes
ii. Bands of white fibrous tissue that develop
iii. Vitreous hemorrhages: newer blood vessel
grow into vitreous because of CHO, more
friable than other blood vessel
5. Drusen: small yellowish round spots, haphazardly
distributed, concentrated at the posterior pole; seen with
aging and macular degeneration
6. Healed chorioretinitis: a well defined irregular patch of
white sclera marked with dark pigment, due to
toxoplasmosis, laser surgery
7. Coloboma of the choroid and retina: developmental
abnormality, large to moderate size white oval of sclera,
well demarcated, pigmented borders
j. Blindness
i. Most common cause in US diabetes
ii. Most common cause in World chlamydia; others = cataract,
glaucoma (chronic open angle intracellular pressure @
bilaterally), Chlamydia trachomatis (old most common cause),
onchocerciasis @ Rx ivermectin
iii. Childhood most common cause of blindness measles
(keratoconjunctivitis), xerophthalmia (due to deficiency in vitamin
A cornea drying and rupture), ophthalmia neonatum (affected in
birth canal), retinopathy of prematurity (retrolental fibroplasia),
congenital cataract
k. Color Vision
i. Red, green, & blue cones
1. Red & green @ X chromosome
2. Blue @ chromosome 7; mutations are rare
ii. Can be 20/20 with hue discrimination impaired
91
iii. Ishihara plates @ detects red-green color blindness
iv. Color blindness @ disease of macula and optic nerve, bilateral
strokes involving the ventral portion of the occipital lobe (cerebral
achromatopsia)
v. Color anomia @ can discriminate colors, canEt name colors;
infarcts of the dominant occipital lobe
l. Anatomy
i. Aqueous humor is made by ciliary body (posterior chamber
pupil anterior chamber canal schlemm)
ii. Posterior chamber: cornea iris
iii. Anterior chamber: iris lens
III. Ear
a. If they ask to do ear exam inspect the face first
b. Inspection
i. Position of ears (DownEs syndrome @ low set)
ii. Scars (mastoidectomy)
iii. Lesions
1. Chondrodermatitis helices: painful inflammatory purple
papule on helix or antihelix ulceration and crusting;
biopsy needed to distinguish from a carcinoma; most
common in older men
2. Cauliflower ear: inflammation of auricle cartilage
(perichodritis) due to pseudomonas aeruginosa Xf
3. Squamous cell carcinoma: most common on helix, but
check behind the ear as well; confirm with biopsy;
occasional metastasis to regional lymph nodes
4. Basal cell carcinoma: raised nodule with lustrous center
and telangiectatic vessels, slow growing, rare metEs; most
common in light skinned people with frequent exposure to
the sun
5. Cutaneous cyst: benign, closed sac on dermis @ blackhead
maybe visible on surface
6. Epidermoid cyst: common on the face and neck, may
become inflamed
7. Pilar (trichilemmal) cyst: common on the scalp
8. Tophi deposit of uric acid crystals: hard nodules on the
helix or antihelix; may discharge white, chalky crystals
(also seen near joints, hands) due to chronic tophaceous
gout
9. Rheumatoid nodules: small lumps on the helix or
antihelix; may come before the arthritis; check for other
nodules on the body (ulnar surface of arm, heels, knees);
ulcerations may result from repeated small injuries; DDx
tophi
92
10. Keloid: firm, nodular, hypertrophic mass of scar tissue
extending beyond the area of injury; most common on
shoulder or upper chest (appears in pierced skin); darker
skinned people are predisposed; recurrence likely
11. Lepromatous leprosy: multiple papules and nodules on
the auricle
12. Referred pain to the ear (five TEs)
a. Throat, TMJ, Tonsil, Teeth (cutting in babies),
Tongue
c. Palpation
i. Tragus and auricle movement tenderness due to otitis externa
@ inflammation of ear canal
ii. Mastoid process: tenderness
1. Upper: due to mastoiditis @ swollen, red, swollen pre- and
postauricular lymph nodes death if untreated
2. Lower: furuncular otitis externa (boil communicates with
abscess in middle ear); otitis media/interna
d. Weber-Rinne
i. Weber
1. Unilateral sensorineural hearing loss: sound is heard in
good ear
2. Conductive hearing loss: sound is heard in impaired ear
ii. Rinne
1. Normal: air conduction is better than bone conduction
2. Conductive hearing loss: sound is heard through bone as
long as or longer than it is through air
3. Senorineural hearing loss: sounds is heard longer through
air
iii. Hearing disorders
1. Conduction loss: no air conduction; due to obstruction of
ear canal (foreign body, cerumen), otitis media, perforation,
otosclerosis
2. Sensorineural loss: no air/bone conduction; due to
sustained exposure to loud noise, drugs (neomycin
quinine), inner ear infections (syphilis, mumps, rubella),
trauma, tumors, congenital disorders, aging (presbycusis)
3. Hyperacusis (excessive acuteness of hearing): paralysis
of stapedius or tensor tympani
4. Otosclerosis: abnormal bone deposition around the stapes
conductive loss
5. Presbycusis: damage to organ of Corti with old age
iv. Acoustic dampening
1. Nerve to stapedius (CN VII)
2. Tensor tympani (CN V)
e. Otoscope exam
i. Ear Canal
93
1. Acute otitis externa: canal is swollen, narrowed, moist,
tender, red
2. Chronic otitis externa: skin of canal is thickened, red,
itchy
3. Exostoses: nontender nodular swellings in ear canal
4. Excess cerumen: Rx
a. Put metal syringe up against roof of ear canal at
border of tympanic membrane; gently let stream of
water flow through, which will bounce off tympanic
membrane and push cerumen out; keep small dish
under ear to collect water and cerumen
b. H2O2 (2-3 days later)
c. Baby oil
ii. Tympanic membrane
1. Normal: pinkish/gray, translucent, no opacities
2. Otitis media: red, bulging, purulent (may rupture drum
relief of pain)
a. Due to Hemophilus influenza, S. Pneumonia
b. Rx: analgesics to temperature, decongestant to
open tube, if not healing within 2 weeks, antibiotics
3. Perforated Eardrum: holes in the eardrum resulting from
infections:
a. Central perforations @ not extended to margins of
the drum; more common
b. Marginal perforations involve the eardrum
margins
c. Rx: ear toilet @ swab for pus until no more, then
gentamicin drops @ will heal but membrane may be
extremely thin and transparent; at 12 years old,
tympanoplasty
4. Tympanosclerosis: chalky white patch with irregular
margins due to deposition of hyaline materials within the
layers of the eardrum; may follow otitis media
5. Amber drum: serous effusion caused usually by viral
upper respiratory tract infection or sudden change in ATM
pressure air completely absorbed into the bloodstream
from the middle ear and serous (containing serum)
accumulates there instead
6. Prominent handle, short process of malleus and incus:
retracted drum due to otitis media with effusion (OME);
movement of drum with pneumatic otoscope
7. Bullous myringitis: bullae on ear drum,
painful/hemorrhagic; due to viral infection
8. Translucent: healed perforation
f. Auditory procedure
94
i. Audiometry: device procedures auditory stimuli of different
frequencies
ii. Tympanometry: positive, normal, negative air pressure in
external auditory meatus; monitor resulting energy flow; energy
flow will be increased if fluid in middle ear or is ear drum is
retracted by negative pressure in the middle ear cavity
iii. Myringotomy: insert needle into middle ear to drain fluid
IV. Nose and paranasal sinuses

a. Viral rhinitis: mucosa reddened and swollen
b. Allergic rhinitis: mucosa pale and bluish or red
c. Polyps: pale, semi-translucent mass, most commonly on middle meatus
d. Ulcers: due to cocaine use
e. Septal perforation: due to trauma, surgery, intranasal use of cocaine and
amphetamines
f. Nose fracture: can get septal hematoma septal perforation
g. Acute sinusitis, fever, pain, nasal discharge; Dx @ transilluminate
V. Mouth and Pharynx

a. Lips
i. Cyanosis: purple color
ii. Ulcers (herpes)
iii. Cracking: angular cheilitis @ nutritional deficiency or over closure
of mouth
iv. Scaliness: actinic cheilitis @ lips are thickened, everted, loss of
redness
v. Lip carcinoma: (most common bottom lip) ulcer with/without
crust or nodular lesion; sun risk
vi. Angioedema: non-pitting swelling, no itch, usually allergic,
associated with hives
vii. 1 syphilitic chancre: ulcerating button like lesion
viii. Hereditary hemorrhagic telangiectasia: dilated red capillaries;
associated nosebleeds and GI bleeding
ix. Peutz-Jeghers syndrome: intense freckling directly on the lips;
associated with intestinal polyps
b. Oral mucosa
i. Ulcers
ii. White patches (leukoplakia)
iii. Chancres
iv. Karposi8s sarcoma: purple color mucosal lesion; associated with
AIDS
c. Gums
i. Pregnancy tumors (epulis, pyogenic granuloma) originates 1 in
interdental papilla
ii. Lead line: bluish, back line on the gums due to chronic lead
poisoning; absent where no teeth
95
iii. Swollen interdental papilla @ gingivitis
1. Marginal gingivitis: reddened and swollen bleeding gums,
plaque covers teeth, most common teens
2. Acute necrotizing ulcerative gingivitis: fever, malaise,
enlarged lymph nodes, ulcers develop in the interdental
papilla and spreads along the gums, bleeding; most
common young adults, teens
3. Chronic gingivitis may progress to periodontitis (deep
tissues that holds teeth in place)
4. Gingival hyperplasia: heaped up masses that even cover
the teeth due to Dilantin therapy, puberty, pregnancy, and
leukemia
iv. Teeth
1. Dental Caries: x-ray needed for early detection @ starts as
white chalky plaque
2. Attrition of teeth (and recession of gums): elderly,
chewing surface worn down; dentin exposed
3. Erosion of teeth: chemical erosion from regurgitation (i.e.
bulimia, etc.)
4. Hutchinson8s teeth: small, wide spacing; sides tapered to
biting edge; sign of congenital syphilis
5. Abrasion of teeth: notching of biting surfaces due to
holding nails or bobby pins in teeth
v. Tongue and floor of mouth
1. Fissured tongue: (scrotal tongue) little significance; seen
with age
2. Hairy tongue: elongated papilla on back of tongue @
yellowish to brown black (harmless)
3. Geographic tongue: dorsum of the tongue has smooth red
areas (no papilla), map-like pattern; benign with unknown
cause
4. Smooth tongue (atrophic glossitis) @ due to deficiency in
B12, folic acid, pyridoxine, niacin, iron
5. Hairy Leukoplackia: most often affects side of tongue,
cannot be scraped off (unlike candida); associated with
HIV
6. Candidiasis: may cause redness with/ without coating;
AIDs associated
7. Mucous patch of syphilis: slightly raised and oval with
grayish membrane due to secondary syphilis
8. Aphthous ulcer: small whitish ulcer surrounded by reddish
halo; heals in 7-10 days; recur
9. Varicose veins: (caviar lesions) purplish/blue black
swellings under tongue; not significant
10. Carcinoma: most common side of tongue, floor of the
mouth; surrounded by reddened area
96
11. Tori mandibulares: bony protuberances from inner
surface of teeth of the mandible
12. Nerve damage: CN12 tongue deviates to side of lesion
13. Carcinoma @ most common side of tongue, floor; 2nd most
common cancer of mouth
14. Lou Gehrig8s Disease: tongue is atrophied
vi. Pharynx
1. CN10 paralysis: ipsilateral soft palate does not rise, uvula
deviates to the contralateral side
2. Pharyngitis: reddened pharynx with exudate; sore,
scratchy throat; fever; cervical lymphadenopathy due to
group A strep, EBV
3. Exudative tonsillitis: due to Strep A @ enlarged anterior
cervical nodes, mono @ enlarged posterior cervical nodes
4. Diptheria: gray, exudative pseudomembrane; uvula,
pharynx, tongue
5. Thrush: candida @ thick white plaques; due to antibiotic
treatment, AIDs
6. Torus palatinus: bony growth of the hard palate (common
in adults)
7. Kaposi8s sarcoma: deep purple lesions, palate is common
site; associated with AIDs
8. Koplik8s spots: small white specks on red background due
to rubeola measles
9. Fordyce spots: normal sebaceous glands that appear as
small yellowish spots on buccal mucosa or lips; normal
10. Petechiae: on buccal from biting cheek, infection,
decreased platlets, or trauma
11. Leukoplakia: thickened white and dull (not candida); due
to tobacco
VI. Neck
a. Enlarged parotid gland
i. Chronic bilateral (obesity, diabetes, cirrhosis)
ii. Unilateral enlargement suggests neoplasm
iii. Acute enlargement suggests mumps
b. Virchow8s node: enlarged supraclavicular node (left) suggests
thoracic/abdominal metastasis
c. Lymph nodes
i. Infection/fever: easy to press; feel pain in swollen node
ii. Cancer: no pain; node is hard
VII. Thyroid
a. Goiter (hyper/hypothyroid): the general name for an enlarged thyroid
gland; compensatory hyperplasia of follicular epithelium 2 to impaired
production of thyroid leads to elevated TSH levels;
97
i. Diffuse enlargement of thyroid: includes isthmus and lateral
lobes; Graves, Hashimotos, I2 deficiency, pregnancy
ii. Multinodular goiter:
1. 2 or more nodules suggests metabolic problem (not
neoplastic);
2. Radiation/family history suggests malignancy
3. Single nodule: cyst, benign tumor, possible malignancy
4. Dx of nodule:
a. FNA @ cytology
b. Isotype I131
c. Cold: due to thyroid adenoma, DeEquervainEs
thyroiditis
d. Hot: due to thyrotoxic adenoma, Graves, follicular
CA
5. Hashimoto8s Thyroiditis: goitrous hypothyroidism due to
defective function of thyroid specific CD-8 T cells,
resulting in the emergence of CD-4 T cells directed at the
thyroid and auto-Abs to various components of thyroid
such as thyroid peroxidase, TSH receptors, and
thyroiglobulin
6. Graves disease: goitrous hypothyroidism due to a defect in
thyroid specific CD-8 T cells the production of:
a. TSH Ab
b. Thyrotropin binding inhibitor Ab activity of
thyroid epithelial cells TSH
c. Long acting TSH fat deposition behind eye
exopthalamos
b. Hyperthryoridism
i. Signs: tachycardia/a fib; hyperkinetic pulse (may be collapsing @
Water hammer); systolic/ diastolic; warm, moist skin;
tremor/weak proximal muscles; stare, lid lag; diplopia,
exopthalamos (bilateral = Graves Disease); fine hair, poor
convergence; localized/carotid bruit; pretibila edema; general
myxedema, brisk reflexes bilateral, heat intolerance,
hyperglycemia
ii. Symptoms: nervousness, weight loss, sweating, palpitations,
diarrhea, muscles/tremors, menstrual irregularities, appetite
c. Hypothyroidism
i. Signs: bradycardia; systolic/ diastolic; dry, coarse, cool skin;
nonpitting myxedema (dull puffy face @ pronounced around eyes);
coarse thin hair; thinning of eyebrows lateally; amenorrhea;
hoarseness, slow relaxation of reflexes (seen in ankle reflex),
ascites
ii. Symptoms: fatigue, lethargy, weight gain, cold intolerance,
constipation, weak, cramps, parasthesias, amnesia, appetite,
libido
98
d. Treatments:
i. Surgery: pre-treat with iodine to decrease chances of bleeding and
thyroid storm during surger
1. Complication: recurrent laryngeal nerve (left @ loops
down; right goes straigher); lesion hoarseness
ii. Iodine: inhibits release of T3/T4
iii. Propylthiouracil: inhibit iodination of MIT-DIT and inhibit
coupling to form T4/T3
iv. Pechlorate/thiocyanate: inhibits iodine transport
v. Radioactive I2: uptake = hyperthyroid; uptake = hypothyroid
e. DDx:
i. Acromegaly: excess growth hormone; prominent forehead, nose
and lower jaw; generally coarsened facial features; soft tissue of
nose, lips, and ears enlarged
ii. Nephrotic syndrome: pale edematous face, usually around the
eyes in the morning (eyes become slit like as the edema gets
worse)
f. Pemberton8s sign if thyroid is retrosternal, have patient raise arms
thyroid moves upwards hits carotid artery faint
g. Good prognosis papillary thyroid CA, medullary CA
h. Anatomy
i. Thyroid hormones synthesis
1. Eat iodine, becomes iodide in stomach; iodide trapped in
thyroid, oxidized to iodine by thyroid peroxidase;
complexed with tyrosine molecules in thyroglobulin (MIT
or DIT); DIT + MIT tri-iodothyronine
2. DIT + DIT thyroxine; thyroid hormones transported in
vascular system bound to albumin, trans-thyrectin, etc.; T3
is more potent, T4 is present in higher quantities
ii. TSH: stimulates: I-uptake, oxidase, iodinase, coupling enzyme,
protease
VIII. Tracheal deviation: due to telectasis, mediastinal mass, tenison

pneumothorax
99
Male Genitalia Exam
I. Inspection
a. Exposed patient from waist down
b. Penis
i. Skin
ii. Prepuce (foreskin)
iii. Glans
iv. Location of urethral meatus
v. Inspection for discharge
c. Scrotum
i. Inspect skin, contours (lumps/swelling)
ii. Lift scrotum to examine posterior surface
II. Palpation
a. Between thumb and first two fingers
b. Shaft of penis (not done on asymptomatic young patients)
c. Testis, epididymis, spermatic chord
i. Palpate between thumb and first two fingers
ii. Note size, shape, tenderness
d. Hernias
i. Tell patient to strain down and look for bulges (inguinal/femoral
areas)
ii. Push finger up into scrotum into external inguinal ring and have
patient cough – see if masses touch fingers (inguinal)
iii. Put finger on thigh – have patient cough (femoral)
73
Male Genitalia Secondaries
I. Tanner Stages
a. Hair
i. None (preadolescent)
ii. Sparse, curly, base of penis
iii. Darker, coarser, over pubic symphysis
iv. Coarse, curly, covers more area
v. Hair spread to thighs
b. Penis
i. Same as in childhood
ii. Slight increase
iii. Increase length
iv. Increase length, width, glans developed
v. Adult in shape and size
c. Scrotum
i. Same as in childhood
ii. Testes/scrotum increase
iii. Increase size
iv. Increase size, skin dark
v. Adult in size and shape
II. Penis
a. Skin
i. Induration along ventral surface: cancer, urethral stricture
ii. Peyronies’ disease: hardening of corpora cavernosa nontender
hard plaques beneath skin on dorsum of penis; crooked, painful
erection
iii. Lice (“crabs”): excoriation, itchy, small, red maculopapules
b. Prepuce (foreskin)
i. Phimosis: canIt be retracted
ii. Paraphimosis: retract but wonIt go back edema
c. Glans
i. Balanitis: inflammation of glans
ii. Balanoposthitis: inflammation of glands and prepuce
d. Location of urethral meatus:
i. Hypospadius: urethral meatus on inferior surface of penis
ii. Epispadius: urethral meatus on superior surface of penis
e. Discharge
i. Gonorrhea: profuse and yellow
ii. Non-gonococcal (1˚ chlamydia): scanty, clean
iii. Dx: gram stain, culture
f. Lesions of penis:
i. Genital herpes (most common cause – HSV2): shallow painful,
small ulcers
74
ii. Syphilitic chancre (1˚ syphilis): round, dark, red, painless ulcer;
non-tender inguinal lymphadenopathy
iii. Condyloma Accuminatum (most common cause – HPV Types
6 and 11): rapidly growing; moist, malodorous
III. Scrotum
a. Testis and epididymis
i. Painless nodule: testicle cancer M 20 to 30 years; curable
ii. Cryptochism: undescended testicle; cancer risk of testicles
b. Spermatic cord (cystic means hydrocele of cord)
c. Examine swellings using light M shine light behind scrotum
i. Transmits light
1. Chylocele
2. Hydrocele: serous fluid in tunica vaginalis; can get fingers
above mass
3. Cyst of epididymis (no sperm)
4. Spermatocele (contains sperm)
ii. DoesnIt transmit light
1. Tumor of testicle: painless; suspect malignancy
2. Varicocele: varicose veins of spermatic cord (feels like bag
of worms separate from testis); collapse when patient is
supine; infertility may be associated
3. Scrotal edema: congestive heart failure or nephrotic
syndrome
4. Scrotal hernia (1˚ indirect) M canIt get finger above mass
iii. Pain with swelling:
1. Acute epididymitis
2. Acute orchitis (with mumps)
3. Torsion of spermatic cord (emergency because blood in
but not out)
4. Strangulated inguinal hernia
IV. Hernias
a. Indirect: internal inguinal canal out external inguinal ring; all ages,
both sexes; into scrotum; cough hernia comes down and touches
fingertip
b. Direct: less common; only through external inguinal ring; > 40 years;
rarely into scrotum; cough hernia bulges forward and pushes hand
c. Femoral: least common; F>M; below inguinal ligament more lateral than
inguinal; never into scrotum; coughs nothing touches (canal is empty)
d. Complications
i. Incarcerated M canIt be returned to abdomen
ii. Strangulated M blood supply to contents comprised; suspect
especially if tender surgery
iii. Scrotal hernia M fingers canIt get above mass (indirect)
e. Femoral canal contents: NAVEL (lateral to medial M nerve, artery, vein,
empty space, lymphatics)
75
Musculoskeletal Exam
!Hi my name is ______, I.m a second year medical student. What is your
come in and check your muscles and joints. Is that ok with you? Ok if there
is any discomfort at any time please let me know and I.ll try my best to
alleviate the discomfort.
I. Head and Neck (patient sitting)

a. Temporomandibular joint (TMJ)
i. Look
1. Inspect for masses, lesions, scars, swelling
2. !Upon inspection, there are no masses, scars or
lesions visible. There is no visible swelling present.
There are no visible deformities or nodules, and
the muscles show no signs of atrophy.J
ii. Feel
1. Palpate with the tips of 2nd and 3rd fingers over
temporomandibular joint
2. !Upon palpation, there was no tenderness, nodules,
or masses felt. There was no palpable bogginess or
swelling in the joints.J
iii. Move
1. !Can you please open your mouth and close your
mouth for me?J
2. Ask the patient to open and close his mouth while palpate
TMJ for:
a. Tenderness
b. Swelling
c. Range of motion
d. Some crepitations is normal
3. !Upon movement, there was no pain or crepitations.
The range of motion was normal.J
b. Neck
i. Look
1. Inspect for masses, scars, lesions, deformities, abnormal
posture
2. !Upon inspection, there are no masses, scars, or
lesions visible. There is no visible swelling present.
There are no visible deformities or nodules, and
the muscles show no signs of atrophy.J
100
ii. Feel
1. Palpate the cervical processes and surrounding musculature
for tenderness
a. Spinous process
b. Levator scapula
c. Upper trapezius
d. Sternocleidomastoid
2. !Upon palpation, there was no tenderness, nodules,
or masses felt. There was no palpable bogginess or
swelling in the joints.J
iii. Move (cup your hand over the back of the patients neck) - AROM
1. !Can you bring your chin to your chestJ N Flexion
(between skull and C1)
2. !Can you look over your left shoulder... your right
shoulderJ - Rotation (C1, C2)
3. !Can you bring your ear to your shoulder... and the
otherJ - Lateral bending (C2-C7)
4. !Can you look up to the ceilingJ - Extension (between
skull and C1)
II. Spine M patient standing
a. Look
i. Inspect the cervical, thoracic, and lumbar curvatures
ii. Look for differences in height of the shoulders, iliac crests, and
skin creases below the buttocks
iii. !Upon inspection, there are no masses, scars, or lesions
visible. There is no visible swelling present. There are no
visible deformities or nodules, and the muscles show no
sign of atrophy.J
b. Feel
i. Palpate the spinous process with your thumb and the
paravertebral muscles for tenderness or spasm
ii. Palpate the rhomboids and quadratus lumborum
iii. !Upon palpation, there was no tenderness, nodules, or
masses felt. There was no palpable bogginess or swelling
in the joints.J
c. Move (cup hand over the lumbar spine) - AROM
i. Stand on side of patient to be able to catch
ii. !Try touching your feet with both handsJ N flexion (lumbar
curvature should flatten out)
101
iii. !Slide your right hand down the side of your leg... and
your leftJ N lateral bending (support by holding patientUs waist)
iv. !Lean backwardsJ N extension (stand behind the patient to
support)
v. !Twist to your right... your leftJ N rotation (hold the patient at
the hips)
vi. !Upon movement, there was no pain or crepitations. The
range of motion was normal.J
III. Shoulders (patient sitting)
a. Look
i. Inspect for any swelling, deformities, or muscular atrophy of the
shoulder and shoulder girdle both anteriorly and posteriorly
ii. !Upon inspection, there are no masses, scars, or lesions
sign of atrophy.J
b. Feel
i. Palpate:
1. Sternoclavicular joint
2. Acromioclavicular joint
3. Subacromial joint
4. Bicipital groove
5. Pec major and minor
6. Biceps and triceps
7. Upper trapezium
8. Levator scapula
9. Supra and infraspinatous
10. Rhomboids
11. Teres groups
ii. !Upon palpation, there was no tenderness, nodules, or
in the joints.J
c. Move (cup hands over the patientUs shoulder) N PROM and AROM
i. !Raise your hands over your head in front of youJ M
flexion
ii. !Raise your hands over you head out to the side... bring
your hands back downJ N abduction and adduction
iii. !Bring your hands behind your neck with your elbows outJ
N external rotation
iv. !Place both your hands behind your backJ N internal rotation
102
v. !Upon movement, there was no pain or crepitations. The
IV. Elbow (patient sitting)
a. Look
i. Inspect the elbow, olecranon proces and ulnar extensor for:
1. Swelling
2. Nodules
sign of atrophy.J
b. Feel
i. Palpate the olecranon process and the grooves between the
medial & lateral epicondyles of the humerus for:
1. Tenderness
2. Thickening
3. Swelling
ii. Palpate:
1. Biceps
2. Triceps
3. Wrist extensors
4. Wrist flexors
iii. !Upon palpation, no tenderness, nodules, or masses were
felt. There was no palpable bogginess or swelling in the
joints.J
c. Move (cup the elbow with your hands)- PROM and AROM
i. !Can you flex your arm... and backJ N flexion and extension
ii. !Can you show your palms... now show me the top of your
handsJ N supination and pronation
iii. !Upon movement, there was no pain or crepitations. The
V. Hands and Wrists (patient sitting with hands
on thigh)
a. Look
i. Inspect for any swelling, inflammation, nodules, deformities, or
muscular atrophy
ii. !Upon inspection, there are no masses, scars or lesions
sign of atrophy.J
103
b. Feel
i. Palpate:
1. Wrist joint with your thumbs on the dorsum of the wrist
and fingers beneath it
2. Distal interphalangeal (DIPS), proximal
interphalangeal (PIPS), & metacarpophalangeal
(MCPS) joints between your thumb and index finger
3. Radial styloid, Ulnar styloid, wrist extensors & flexors,
thenar and hypothenar eminence
4. Squeeze the patientUs hand (not too firmly) to check for a
tenosynovitis
in the joints.J
c. Move - AROM
i. Ask patient to (doctor can hold patientUs hand to feel for
crepitation during movement):
1. !Make a fist... flex your wrist... extend your wrist
backJ N wrist flexion and extension
2. !Open your fingers...close your fingersJ N abduction
and adduction
3. !Bend your wrist towards your midline... bend your
wrist away from your midlineJ N ulnar and radial
deviation of wrist
5. **De. quervain.s tenosynovitis**
a. Ask the patient to flex the fingers over the flexed
thumb and ulnar deviate N will elicit pain
6. **Phalen.s test**
a. Ask the patient to press the back of both hands
together to form right angles
b. This maneuver compresses the median nerve
7. **Tinel.s sign**
a. Percuss lightly over the course of the median nerve
in the carpal tunnel
VI. Hips (supine position)
a. Look
i. Inspect for any deformities, muscle atrophy or scars, shortening of
limbs, position, fasiculationUs
104
signs of atrophy.J
b. Feel
i. Palpate:
1. Iliac tubercle, iliac crest, ASIS, PSIS, greater
trochanter, ischial tuberosity, ischial tuberosity, pubic
symphysis
2. Quadriceps femoris muscle (rectus femoris, vastus
lateralis, vastus intermedius, vastus medialis),
Hamstrings (semimembranosus, semitendinosus, biceps
femoris)
3. 3 bursas:
a. Iliopectineal N anterior to joint, lateral to femoral
artery
b. Trochanteric N posterior on femur; patient lying on
side (decubitus position)
c. Ischial bursa N patient lying on side with hip and
knee flexed
in the joints.J
c. Move
i. Put hand on opposite side to stabilize N PROM and AROM
1. Lift heal off table and leave the other leg extended (flexor
and psoas)
2. Lie patient on side and extend hip (gluteus maximus)
3. Adduct leg (until opposite buttocks comes off table)
4. Abduct leg
5. Rotation N flex leg to 90, stabilize thigh; left hand over
rectus femoris; grab ankle with right hand and external and
internal rotate leg
6. Never touch calf muscle due to DVT
ii. !Upon movement, there was no pain or crepitations. The
VII.Knee (supine position)
a. Look
i. Inspect for swelling, scars, inflammation, deformities
visible deformities or nodules present and the muscles
show no signs of atrophy.J
b. Feel
i. Palpate
105
1. PatientUs knees flexed at 90 with feet flat on the table
2. Tibial tuberosity, medial and lateral tibial plateau,
condyles (tibial and femoral)
3. Medial/lateral collateral ligaments
4. Patellar tendon, patella, quad tendon
5. Feel for heat
in the joints.J
c. Move N (cup hand over the knee to feel for crepitations) N PROM and
AROM
i. !Slide your foot towards your buttJ - Slide leg up table,
while keeping foot on the table N go as far as possible
ii. !Upon movement, there was no pain or crepitations. The
d. Ligaments
i. Lateral collateral
1. Have leg slightly bent, apply pressure to medial aspect of
joint (the thigh) with left hand while adducting lower leg
with right hand
ii. Medial collateral
1. Have leg slightly bent, apply pressure to lateral aspect of
joint (the thigh) with left hand while abducting lower leg
with right hand
iii. Cruciate ligaments
1. **Drawer test**
a. PatientUs knee flexed to 90, and the foot flat on the
table, sit on foot. Grab hold of the leg just below
the knee joint (thumbs on tibial tuberosity and
fingers behind joint line N no on calf due to DVTUs)
b. To test of a competent ACL, pull the leg towards
you
c. PCL N push the leg away from you
d. If the leg moves more than what is considered
normal, than respective cruciate ligament is torn and
gives a + drawerUs sign for that ligament
2. **Lachman.s**
a. PatientUs leg slightly bent, left hand just proximal to
joint and right hand just distal to joint, push on
thigh and pull up on calf (ACL)
b. Pull on thigh and push on calf (PCL) N [+ if
movement]
e. Meniscus
i. **McMurray.s Test**
1. Medial meniscus
106
a. Right Leg - Grasp the heel and flex the knee with
the right hand.
b. Cup the left hand over the knee joint with the
fingers over the anterior-medial and the thumb over
the posterior aspect.
c. From the heel slowly rotate the leg externally while
slowly extending the leg. Simultaneously, push
with the left hand medially, applying a valgus stress
on the medial side of the joint.
2. Lateral meniscus N same but, rotate internally and push
laterally
f. **Bulge sign ** (for minor effusions)

i. With the knee extended, milk the medial aspect of the knee
(suprapatellar pouch) firmly downward 2-3 times to displace any
fluid in the medial aspect of the knee to the lateral side.
ii. + Bulge sign will show a bulge on the lateral side of the patella
(normally indented in)
g. **Balloon sign** (for major effusions)
i. Right leg - place the thumb and index finger of your right hand on
each side and caudal to patientUs patella
ii. With the left hand, milk the suprapatellar pouch down towards the
patella 2-3 times with the last stroke holding the knee firmly just
above the patella compressing the suprapatellar pouch against the
femur
iii. + Ballooning, feel for fluid underneath the your thumb and fingers
in the right hand next to the patella
iv. Fluid returning to the suprapatellar pouch confirms an effusion or
v. !BallotteJ (push) the patella - if the fluid is seen filling the joint
space and/or feel the fluid underneath your thumb and fingers than
with the index finger of your right hand, press the patella
backwards against the femur to confirm
VIII. Ankles and Feet (patient sitting)
a. Look
107
i. Inspect for signs of swelling, inflammation, scars, lesions, warts,
calluses, corns, or deformities
signs of atrophy.J
b. Feel
i. Palpate:
1. Achilles tendon
2. Anterior and posterior aspects of the ankle joint
3. Each metatarsophalangeal joint of foot
4. Plantar surface of foot, plantar fascia
5. Calcaneus, Navicular
in the joints.J
c. Move N PROM and AROM
i. Dorsal and plantar flex ankle (talocrural joint)
ii. Invert and evert ankle (subtalar joint)
iii. With the heel stabilized, invert and evert ankle joint (transverse
tarsal joint)
iv. Ask the patient to wiggle toes (metatarsophalangeal joints)
v. !Upon movement, there was no pain or crepitations. The
range of movement was normal.J
108
Musculoskeletal Exam Secondaries
I. Head and Neck

a. Temporomandibular Joint
i. Decreased range of motion 1 arthritis, inflammation, fibrosis,
ankylosis, arthrodesis
ii. Increased range of motion 1 instability of the joint
iii. Arthritis 1 swelling, tenderness, bogginess
b. Neck
i. Kyphosis head back, neck forward
ii. Stiff neck 1 lots of causes 1 lasts 1-4 days; local muscle tenderness
and pain
iii. Aching neck 1 may be related to sustained muscle contraction,
local muscle tenderness, also elsewhere in body
iv. Cervical sprain 1 more severe and longer lasting than stiff neck;
often precipitated by whiplash injury, heavy lifting, sudden
movements; no dermatomal distribution
v. Neck pain with dermatomal radiation 1 compression of nerve
roots via herniated disc or degenerative disease; limited range of
motion, tenderness, pain
vi. Neck pain with symptoms of compressed cervical cord 1 due to
herniation, spurring or trauma muscle weakness
vii. Ankylosing spondylitis 1 chronic inflammatory joint disease of
the vertebra and the sacroiliac joint; usually in men;
immunogenetic origin with antibody directed towards joint
elements; head and neck thrust forward
II. Spine
a. Flexures: 1 - thoracic and sacral (in fetus); 2 - cervical and lumbar;
cervical and lumbar concave, thorax convex
b. Lumbar curve: due to herniated lumbar disc or ankylosing spondylitis;
concavity persists with flexion; look also for muscle spasms in the lumbar
area and for decreased spinal mobility
c. Lumbar lordosis: accentuation of the normal lumbar curve (develops to
compensate for protuberant abdomen of pregnancy, obesity, kyphosis, or
flexion deformities of the hips); deep midline furrow may be seen between
the lumbar paravertebral muscles
d. Kyphosis: rounded thoracic convexity seen in aging, especially in women
(osteoporosis)
e. Scheuermann’s disease: kyphosis; 1 male adolescents
f. Scoliosis: lateral curvature of the spine (plumb line drops through gluteal
cleft)
i. Structural scoliosis associated with rotation of the vertebra upon
each other 1 rib cage is accordingly deformed 1 seen best when
patient flexes forward
109
ii. Functional scoliosis compensates for other abnormalities (unequal
leg length, no vertebral rotation); disappears with forward flexion
g. Gibbus: angular deformity due to collapsed vertebra [due to metastatic
cancer (osteoclastic cancer) of from tuberculosis of the spine (PottMs
disease)]
h. List: lateral tilt of the spine; most common cause 1 herniated disc or
paravertebral muscle spasm
i. Torticollis: lateral deviation of the head; due to contraction of SCM
j. Spondylolisthesis: forward slippage of vertebra on one below 1 may
compress spinal cord
k. Sciatica: sharp pain shooting down posterior thigh; movement pain;
due to herniated disc, osteoarthritis, inflammation (metabolic, toxic or
infectious); sciatic nerve lies midway between trochanter and ischial
tuberosity and exits through sciatic notch
l. Valgus: distal part away from midline; i.e. knock knees
m. Varus: distal part toward midline; i.e. bowlegs
n. Unequal iliac crests: due to uneven lengths of legs, scoliosis, hip
deformities (adduction/abduction of lower limb)
o. Herniated discs: most common cause between L4/L5 or L5/S1;
tenderness of the spinous process, intervertebral joints, or paravertebral
joints
p. Spina bifida: associated with birthmarks, port-wine stains, hairy patches
or lipoma overlying defect
q. Neurofibromatosis: cafe-au-lait spots, skin tags, fibrous tumors
III. Shoulders
a. Axioscapular muscles: traps, rhomboids, serratous 1 rotate and fix
scapula; pull shoulder back
b. Axiohumeral muscles: pecs and lats 1 internal rotation shoulder
c. Rotator cuff muscles: S-I-T-S supraspinatus, infraspinatus, teres
minor, and subscapularis; all insert onto the greater tubercle of the
humerus except subscapularis which inserts onto the lesser tubercle
d. Rotator cuff tears:
i. Repeated impingement may weaken the rotator cuff and cause
tears and deposition of calcium salts
ii. Usually > 40 year old male (pitcher, gymnast, swimmer)
iii. Manifestations: weakness, atrophy, supra- and infraspinatus
muscle pain, tenderness
iv. Incomplete tear (suprispinatus tendon) there is limited abduction
compensates by shrugging shoulder to raise arm
e. Calcific tendonitis:
i. Degenerative process of the tendon 1 associated with deposition of
calcium salts
ii. Most commonly involves supraspinatus tendon (acute, disabling
attacks of shoulder pain)
110
iii. Arm is held close to side, tenderness is maximal below the tip of
the acromion (subacromial bursa inflammation)
iv. Usually in women ~30 years old
f. Bicipital tendonitis:
i. Inflammation of the long head of the biceps tendon causing
anterior shoulder pain resembling rotator cuff tendonitis (may
coexist)
ii. Tenderness is maximal in the bicipital groove
iii. By externally rotating and abducting you can easily palpate and
separate this area from the subacromial tenderness of supraspinatus
tendonitis
iv. Confirmed by supinating (elbow at 90) against resistance causing
pain in bicipital groove
g. Acromioclavicular arthritis: (uncommon) direct injury to the shoulder
girdle with resulting degenerative change (localized over the
acromioclavicular joint); movement of the scapula (shoulder shrug) is
painful
h. Adhesive capsulitis: (frozen shoulder) fibrosis of the glenohumeral joint
capsule; diffuse, dull, aching pain in the shoulder and progressive
restriction of motion (not localized); unilateral; MC 50-70 years of age;
chronic course lasting months to years, but may resolve spontaneously
i. Dislocation of the shoulder:
i. Anterior 1 most common (route inferior anterior superior)
ii. Posterior 1 anterior aspect of shoulder flattened
IV. Elbow
a. Rheumatoid nodules: subcutaneous nodules that are firm, non-tender,
and not attached to the overlying skin. Most common 1 along the extensor
surfaces of the ulna
b. Epicondylitis:
i. Lateral epicondylitis (tennis elbow) occurs after repetitive
extension of the wrist or pronation 1 supination of the forearm and
results in pain when the patient extends the wrist; swelling;
tenderness
ii. Medial epicondylitis (golfer’s elbow) occurs after repetitive
flexion of the wrist and results in wrist pain upon flexion; swelling;
tenderness
c. Olecranon bursitis: swelling/inflammation of the olecranon bursa from
trauma, rheumatoid or gouty arthritis; swelling is superficial to the
olecranon process
d. Arthritis of the elbow: synovial inflammation or fluid felt best in the
grooves between the olecranon process and the epicondyles on either side;
palpate for a boggy, soft, or fluctuant swelling and tenderness
e. Ulnar nerve: between olecranon and medial epicondyle
f. Median nerve: through cubital fossa
111
g. Radial nerve: anterior to lateral epicondyle then wraps to posterior
forearm
V. Hands and Wrist

a. Gonococcal arthritis: Neisseria gonorrhea commonly infects the wrist
joint or tendon sheath and present with pain, tenderness, and decreased
range of motion (Rx = ceftrizxone, doxacycline)
b. Osteoarthritis: progressive, deterioration of the articular cartilage, mainly
in weight bearing joints, leading to subchondral bony thickening and bony
overgrowths (osteophytes) about the joint margins; Heberden
nodes:(DIP) and Bouchard’s nodes (PIP) 1 hard, painless; Rx NSAIDS
(Indomethacin)
c. Rheumatoid Arthritis: (PIP, MCP) a chronic, severe synovitis that leads
to destruction and ankylosis of affected joints while also affecting blood
vessels, heart, eyes, nerves, skin, and lungs; bilateral with swelling,
tenderness, or bogginess; Pannus formation of the joint is characteristic in
RA and leads to the bony ankylosis. Boutonneire and Swan Neck
deformities with chronic RA due to inflammation fluid lifts and
shifts tendons
d. Caplin’s nodes: intrapulmonary nodules (histologically similar to
subcutaneous rheumatoid nodules): associated with RA, pneumoconiosis
in coal workers
e. Rheumatoid nodules are seen in both acute and chronic RA; feel warm
and tender
f. Bacterial arthritis: affects only one joint
g. Dupuytren’s Contracture: flexion contracture of the fingers due to
thickening of the flexor tendon of the ring finger or 5th digit at the level of
the distal palmar crease (fibrosis of Palmar Fascia)
h. Acute tenosynovitis: extreme pain upon compression due to inflammation
of the flexor tendon sheath 1 may follow injury (even minor); swelling
along course of tendon may spread to involve thenar space and adjacent
facial spaces in palm not in joint
i. De’quervain’s tenosynovitis: inflammation of extensor and abductor
tendons of thumbs as they cross the radial styloid pain
j. Tophaceous (gouty) nodules: mimic osteoarthritis and rheumatoid, no
symmetric sometimes ulcerate and discharge white chalky urate crystals
k. Ganglion cysts: round nontender swellings on tendon sheaths or joint
capsules: frequent on dorsum of wrist; best seen on wrist flexion
l. Felon: infection in the closed facial spaces of finger pad from a pucture
wound
m. Trigger finger: caused by painless nodule in flexor tendon in the palm 1
nodule is too big to enter tendon sheath for extension (extends with a
snap)
n. Hypothenar Atrophy: ulnar nerve disorder
o. Thenar atrophy: median nerve disorder
p. Carpal Tunnel Syndrome
112
i. Causes: acromegaly, obesity, pregnancy, trauma, idiopathic
ii. Carpal Tunnel occurs most commonly in secretaries
iii. Carpal Tunnel contents: median nerve, flexor digitorum
superficialis (4 tendons), flexor digitorum profundus (4 tendons)
iv. Signs and symptoms: numbness and tingling in 1st, 2nd, 3rd, ½ of
4th fingers (median nerve)
v. Dx:
1. Tinels’ sign 1 press/tap on median nerve; + if tingling is
felt
2. Phallen’s sign 1 flex both wrists and hold dorsum of hands
together for 30 seconds; + if get tingling
vi. Rx: incision in flexor retinaculum to relieve pressure on median
nerve and tendons
q. Colles’ fracture: tenderness over ulnar styloid
r. Scaphoid fracture: tenderness in csnuff boxd
VI. Hips
a. Bursitis: tenderness over bursa
b. Joint pain:
i. Congenital: dislocation
1. Ortolani’s maneuver in newborn
ii. Inflammation: septic arthritis, RA, osteoarthritis ( most
commonly restricted rotation, abduction)
iii. Trauma: fracture due to fall
iv. Neoplastic
v. Metabolic: SSA, gout
c. Sciatica: pain in the lower back and hip radiating down the back of the
thigh into the leg, initially attributed to sciatic nerve dysfunction, but now
known to usually be due to herniated lumbar disk compromising the L5 or
S1 root.
VII. Knee
a. Normal flexion = 135-140
b. Signs of inflammation are:
i. Tenderness (arthritis, tendonitis, bursitis)
ii. Heat (tender and heat RA)
iii. Red (septic/gouty arthritis)
iv. Synovial membrane (synovitis, effusion, thickening of membrane)
v. + Bulge, balloon test
c. Synovial fluid
i. Normal amount is 1mL
ii. Hemophiliac blood in knee
iii. Bulge sign (2-40 mL in knee)
iv. Balloon sign (>40 mL)
d. Baker’s cyst: herniation of knee joint capsule and synovium into the
popliteal space due to increased intra-articular fluid exudate as seen in RA
113
e. Bursa
i. Suprapatellar: proximal patella
ii. Infrapatellar: deep to patella
iii. Prepatellar: superficial to patella
f. Clergyman’s knee: infrapatellar bursitis
g. Housemaid’s knee: prepatellar bursitits
h. Patellofemoral disorders present with pain and crepitaitons along with a
history of knee pain
i. Cruciate ligaments
i. ACL
1. Origin: anterior tibia
2. Insertion: posteriolateral surface of lateral femoral condyle
ii. PCL
1. Origin: posterior tibia
2. Insertion: anterolateral surface of medial femoral condyle
j. Most common tear: anterior collateral ligament, medial meniscus and
medial collateral (these are joined commonly injured together)
k. +McMurray’s: pain in joint line; due to torn meniscus
l. Osteoarthritis: Rx 1 NSAIDMs indomethacin, gold salts, penicillamine
i. Aging degeneration
ii. Bony ridges felt along joint margins
m. Rheumatoid arthritis
i. Systemic disease, autoimmune
ii. Most common in females
n. Osgood-Schlatter disease: aseptic necrosis of tibial tuberosity
osteochodrosis; leg pain; most common in adolescents
VIII. Ankles and Feet

a. Rheumatoid nodules on tendon
b. Tendor tendon: tendonitis or bursitis
c. Gout
i. Wine, meat eater
ii. Most commonly in big toe (50%), ankle, knee
iii. Occurs when blood concentration of uric acid is >7 mg/dL
iv. Drugs: allopurinol 1 inhibitis xanthine oxidase; probenecid -
excretion
d. Acute gouty arthritis: metatarsophalangeal joint = (big toe) is usually the
first painful, tender, hot, dusky, red swelling, also dorsum of foot affected
e. Pseudogout:
i. Similar to gout but any joint can be affected (most commonly the
knee and intervertebral discs)
ii. Due to the deposition of calicum pyrophosphate crystals and no Rx
exists to date
f. Hallux valgus: big toe is abnormally abducted and metatarsal itself is
deviated medially and bursa may become inflamed
114
g. Flat foot: only seen when standing, sole touches floor; due to loss of
longitudinal arch
h. Ingrown toenail: sharp edge of toenail may dig into and injure the lateral
nail fold 1 inflammation and infection (most commonly the big toe)
i. Hammer toe: most commonly involves the second toe; hyperextension at
the metatarsophalangeal joint and flexion at the proximal interphalangeal
joint (frequently with a corn)
j. Corns: painful conical thickening of skin that results from recurrent
pressure on normally thin skin (apex of the corn points inward)
i. Pain characteristically occurs over bony prominences (most
commonly 5th toe)
ii. Soft corn 1 located in moist area (most commonly between 4th and
5th toe)
k. Calluses: thick skin developing in entire region of recurrent pressure;
involves skin that is normally thick (sole) and is painless
i. If it is painful, suspect underlying plantar wart
l. Plantar wart: (verruca vulgaris) located in the thickened skin of the
sole; characteristically small dark spots 1 stippled appearance
m. Neuropathic ulcer: (via diabetic neuropathy) 1 formed when pain
sensation is diminished or absent 1 develop at pressure points on the feet 1
often deep, infected, and indolent, but they are painless
i. Callus formation around ulcer is diagnostically helpful since it also
results from chronic pressure
115
Pelvic Exam

name? It-s very nice to meet you. Mrs. ______ I-ve been asked to come in
and do a pelvic exam. Is that ok with you?
1. Have you ever had a pelvic exam before? It entails placing 2 gloved,
lubricated fingers into your vagina. You may feel slight discomfort
but let me know if you feel any pain.
2. When was the first day of your last menstrual period? (>2 weeks, pap is
not accurate; Do even on period 7 not Cx. Note ovulation is fixed at 14 days
before end of cycle, not beginning)
3. Are you in any pain or discomfort?
4. Are you sexually active?
5. Have you ever been pregnant before? (To know strength of walls and how
easy it is to insert finger)
6. Could you be pregnant right now?
7. Have you had any vaginal discharge?
8. Can I supply you with a mirror and flashlight to watch the exam?
I-m going to leave the room and I-m going to need you empty your bladder if
you haven-t already done so and to undress from your waist down. If you
would like, you can have a family member or someone else in the room and
there will also be a female assistant in the room during the exam. Ok if
there is any discomfort at any time please let me know and I-ll try my best
to alleviate the discomfort.
I. Position Patient
A. Pull out the stirrups
The stirrups are cold so you can leave your socks on.
B. Pull up the bed to 60
C. Slide the patient all the way to the edge of with their butt a little off the
table, guide heels to stirrups.
D. Drape the patient so that you can still see patientLs face and she can see
yours 7 from the pubis to knees
II. Prepare
A. Offer to perform abdominal exam
B. Put on glove
C. Ask for some water as lubrication (use water so you donLt contaminate
cytology)
63
III. Inspect
A. Dr. Sits
B. Assess stage of maturity: Tanner stages
I-m going to put my hands on your inner thighs now...
C. Ask patient feels any pain/discomfort, put fingers on inner thigh; inspect
(LUMP):
a. Labia majora
b. Urethral meatus
c. Mons pubis
d. Perineum
Upon inspection of the labia major, urethral meatus, mons pubis, and
perineum, there were no visible masses, scars, or lesions. There were no
excoriations or inflammation.
D. Separate the labia majora and inspect (LUCI):
a. Labia minor
b. Urethral meatus
c. Clitoris
d. Interoitus
I am going to touch you now.
Upon inspection of the labia minora, urethral meatus, clitoris, and interoitus,
no masses, scars, or lesions were visible.
E. Inspect and milk BartholinLs glands (insert index finger into vagina on
the posterior end of the introitus and place thumb on outside of labium
majorus) and SkeneLs Glands (same as before but at anterior end of
interoitus)
Upon inspection of Bartholin-s and Skene-s glands, no tenderness,
inflammation, or discharge noted.
F. Milk urethra gently from inside outward
Upon milking the urethra, no tenderness, inflammation, or discharge noted.
G. Insert index finger into vagina and locate cervix (do this to know what
size speculum to use)
The cervix is midline and 4cm deep.
H. Assess support of vaginal walls: as you withdraw your finger open the
labia folds with middle finger and index finger and tell patient to bear
down, note any bulging of walls
No cystocele, rectocele, cystourethrocele noted.
I. Tell patient to cough and check for urinary incontinence.
No incontinence noted.
IV. Do speculum Exam

A. Not asked to do in oral, but do understand how to operate speculum.
64
V. Bimanual Exam
A. Dr. Stands
B. Look at the patientLs face
C. Put lubrication (not water because done with Pap) on your index finger
and middle fingers without letting bottle touch your fingers (this will
contaminate the gloves and bottle)
D. Insert fingers downward at a 45 angle into vagina (keep thumb
abducted and 4th and 5th fingers flexed into palm)
The vaginal walls are non-tender and no masses or lesions noted.
E. Palpate cervix: note size, shape, position, tenderness, mobility
F. Do cervical excitation (Chandelier test): tap cervix on each side
G. Palpate the fornices:
a. Left lateral
b. Anterior
c. Right lateral
d. Posterior
The cervix is midline, round, firm, and mobile. All four fornices are palpable
and no masses or lesions were noted. Chandelier test is negative.
H. Palpate the uterus: push up on cervix so the uterus moves anteriorly 7
feel with left hand on abdomen about midway between the umbilicus
and the symphysis pubis as you push down and in.
a. Note shape, consistency, mobility, masses, and tenderness.
The uterus is firm, smooth and mobile. There are no masses or tenderness
present. It was felt through the anterior fornix indicating normal
positioning.
I. Palpate the adenexae: press the abdominal hand (left hand on RLQ and
LLQ) in and down, trying to push the adenexal structures toward the
pelvic hand (2 fingers in respective fornix)
There were no masses or lesion palpable in the right and left adenexa.
J. Take fingers out part ways and ask patient if she can feel your fingers
a. If she can, ask patient to squeeze your fingers together
Can you feel my fingers? Can you try to squeeze my fingers?
Pelvic muscle strength is normal. The fit was snug, and lasted for more than
three seconds.
65
Pelvis Exam Secondaries
I. Indications
a. Delayed puberty: (>15 years) due to chronic disease, abnormal hypo-ant
pituitary ovary axis
b. Precocious puberty: <10 years
c. Amenorrhea: absence of menses
d. Dysmenorrhea: painful menses (common in young girls who are starting
menstruation)
e. Menorrhagia: syn hypermenorrhea
f. Hypermenorrhea: excessively prolonged or profuse menses
g. Polymenorrhea: occurrence of menstrual cycle greater than normal
frequency
h. Intermenstral bleeding
i. Unexplained abdominal pain
j. Vaginal discharge:
i. Yellowish-green (trichomonas), painful urination, malodorous: do
a wet mount
ii. White and curdy (candida), vaginal soreness, painful urine,
pruritus (itching): KOH prep for hyphae
iii. Grey or white (gardnerella), fishy/musty odor with KOH: saline
wet mount for Lclue cellsM
k. Vulval area discomfort
l. Assessment of infertility
m. Assess pelvic capacity for delivery: if you can feel the sacral promontory
she cannot give birth vaginally
n. Contraceptives: not necessary anymore for initial contraceptive
prescription
o. Injury and Rape: only for female practitioners; special training required
II. Contraindications (consider a rectal exam which may be just as informative)
a. Incompetent os during pregnancy fetal loss >20 weeks
b. Bleeding in the last trimester; placenta covers internal os
c. Painful situations (PID)
d. Severe limitation of movement in the hip joints
e. Intact hymen
f. Menstruation is not a contraindication (pap smears are more accurate in
the absence of menstruation; IUD insertion is preferred during
menstruation)
III. Common stresses of exam
a. Genital exposure
b. Pain with exam
c. Loss of control
66
d. Possible malignancy finding
IV. Inspection
a. Materials needed (on tray):
i. Gloves, speculum in warm water, swabs, warm water, mirror,
flashlights, jelly, Ayre[s spatula, culture plates, Papanicolaou
slides and fixative, endocervical swab, cervical brush (for pregnant
woman),
b. Tanner Stages:
i. No pubic hair
ii. Sparse long hair along labia
iii. Darker, coarser spreading over pubis
iv. Coarse and curly covering more surface area
v. Hair on medial thighs ^ not on abdomen
c. Lice (LcrabsM) excoriations, itchy, small, red maculopapules
d. Clitoris is enlarged in masculinizing conditions
e. Lesion of the vulva:
i. Genital herpes (MCC by HSV2): shallow, painful, small red
ulcers
ii. Syphilitic Chancre (primary syphilis): round, dark red painless
ulcers (most chancres go unnoticed because they are internal); non-
tender inguinal lymph nodes, most common ^ postmenopausal
iii. Condyloma Latum (secondary syphilis): raised, flat papules
covered with gray exudate, contagious
iv. Condyloma Accuminatum (venereal wart) (most common
cause – HPV types 6 and 11): cauliflower-shaped in vestibule,
malodorous
v. Extrammary Paget’s Disease: red, crusty, sharply demarked on
labia majora
vi. Vulvar Dystrophy (Lichen Schlerosis and Squamous
Hyperplasia, epidermoid cysts)
vii. CA of vulva: in elderly, ulcerated or raised vulvar lesion
f. Urethra:
i. Caruncle: benign lesion just inside urethra ^ non-tender, non-
nodular (vs. CA), check inguinal lymph node
ii. Most sensitive part of vagina ^ urethra (not clitoris)
iii. Urethral prolapse (procidentia of urethra)
iv. Most common cause of urethritis: Neisseria gonorrhea and
Chlamydia trachomatis
g. Bartholin’s gland: infection/cyst = most common chlamydia or
gonorrhea
h. Discharge: urethritis, vaginitis, cervicitis, PID, CA
i. Bulging of vagina walls (due to weak vaginal musculature):
i. Cystocele: bladder bulges into vaginal canal
ii. Rectocele: rectum bulges into vaginal canal
iii. Cystourethrocele: both bladder and urethra bulge into vaginal
wall
67
j. Incontinence:
i. Stress: void with cough (weak bladder sphincter, multiparous
female)
ii. Overflow: could lead to urethrocele, cystocele; painless, small
frequency voidings (overfill or pathologically volume due to
obstruction, usually CA)
iii. Urge: involuntary contraction, completely empty of bladder
[Parkinson[s, after stroke, infection (UTI)]
iv. Drugs make it worse ^ i.e. caffeine, antidepressants
V. Do Speculum Exam
a. Normal uterus: posterior fornix depth
b. Retroverted uterus: anterior fornix depth
c. Pap smear
i. Endocervical Swab: moisten applicator stick with saline; insert
into cervical os; roll it back and forth between finger and thumb;
remove and smear glass slide with swab
ii. Cervical scrape: place scraper into cervical os; scrape in full
circle... be sure to include squamocolumnar junction
iii. Cervical brush: used primarily for pregnant woman
VI. Bimanual Exam
a. Cervix:
i. Shape: round
1. Nodules ^ myoma
2. Enlargement:
a. Pregnancy ^ elongates
b. Carcinoma of the cervix (most common Squamous
Cell CA)
i. Begins with metaplasia, CIN I ^ mild
dysplasia, CIN II ^ moderate dysplasia, CIN
III (CIS); cauliflower like growth
ii. risk with: multiple partners, HIV virus,
sexually active at early age, smoking (i.e.
prostitute)
c. Cervical Polyp (benign but may bleed) usually
arises from the endocervical canal; bright, red, soft,
fragile
ii. Size: 2-3 cm in diameter
iii. Position: anterior, midline, 3-5 cm deep
iv. Tenderness: PID, mucopurulent Cervicitis (most common cause by
Neisseria gonorrhea, Chlamydia trachomatis)
v. Mobility: with PID
b. Cervical Excitation + with:
i. PID: most common cause by Neisseria gonorrhea and Chlamydia
trachomatis; salpingitis or salpingooophoritis that causes extreme
tenderness and pain of pelvic region; resolves leaving tubal
adhesion that may cause infertility or an ectopic pregnancy
68
ii. Ectopic pregnancy: fertilized egg implants in the fallopian tube
rather than the uterine wall (most common in the ampulla). If the
tube ruptures, patient will present with:
1. Faintness
2. Syncope
3. Nausea and vomiting
4. Tachycardia
5. Shock due to severe hemorrhage
6. Abdominal pain
c. Uterus
i. Normal uterus: midline, 3-4 cm below umbilicus
ii. Mass: most common tumor fibroid (fibroma), myoma
iii. Check for pregnant uterus (gravid)
1. 12-14 weeks: above the pubic symphysis
2. 20 weeks: to umbilicus
3. 36 weeks: to sternum (xiphoid process)
iv. If uterus is non-palpable, it may retrodisplaced (retroverted and
retroflexed) ^ if this is the case, then place pelvic hand into the
posterior fornix and feel for the uterus pushing against your
fingertips.
d. Adenexa (ovary, broad ligament, fallopian tubes)
i. No ovaries are normally felt (exception on thin female)
ii. Mass: swollen fallopian tubes of PID, nodule, ovarian cyst, tubal
pregnancy
iii. Extreme tenderness in uterosacral ligaments DDx endometriosis
e. Pelvic muscle strength: full strength hold for >3 seconds, and compresses
fingers snugly; weak ^ DDx ^ endometriosis, past vaginal delivery,
neurological deficits, old age; associated with urinary incontinence
VII. Anatomy
a. Blood supply of uterus: uterine artery ^ main branch of internal iliac
b. Vaginal blood supply:
i. Upper third: cervico-vaginal branches of uterine arteries
ii. Middle third: inferior vesical arteries
iii. Lower third: middle rectal, internal pudendal arteries
c. Extensive venous plexus: drain into internal iliac veins
i. Lymphatics:
1. Lower third of vagina and vulva ^ inguinal lymph nodes
2. Middle third ^ internal iliac nodes
3. Upper third ^ iliac nodes
d. Perineum
i. Pelvic diaphragm
1. levator ani muscles
2. Cocccygeus muscles and fascial coverings
ii. Urogenital diaphragm
1. Deep transverse perineal muscles
2. Constrictor of urethra
69
VIII. Secondaries
a. Gynecology
i. Terminology
1. Amenorrhea: absence of flow for >90 days
2. Menorrhagia: excessive amount and duration, regular
intervals
3. Metrorrhagia: normal amount, irregular intervals
4. Menometrorrhagia: excessive in amount and duration
5. Oligomenorrhea: >35 days between menses, usually
irregular
6. Polymenorrhea: <21 days between menses, regular or
irregular
7. Hypermenorrhea: >7 days, or excessive amount
8. Hypomenorrhea: low in amount
9. Dysmenorrhea: painful menses
b. Menopause:
i. Period of permanent cessation of menses (normal = 35-58 years
old)
ii. HRT (hormone replacement therapy) tender breasts, nausea,
cramps, weight gain, biliary tract disease, bleeding, depression, hot
flashes, sleep disturbances, osteoporosis
iii. Cx: estrogen dependent breast tumor
c. Problem of penetration:
i. Hymen
ii. Mutilation
iii. Vaginismus: reflex contraction of muscles around lower vaginal
sphicter/introitus; usually psychological problem
iv. Atrophic vaginitis
d. Dyspareunia:
i. Bleeding after sex (polyps, STD, PID, forced sex, fibroids, CA)
e. Family planning:
i. Oral contraceptives (estrogens with progesterone, progesterone
only)
ii. Injectable contraceptives (progesterone only no period)
iii. IUD
iv. Natural (thermal ^ sustained basal temperature for 3 days =
ovulation); fertile period ^ shortest = 2 days, longest = 10 days
v. Breast feeding: on demand; < likely to get pregnant
vi. Emergency: morning after pill
f. Pregnancy:
i. Signs and Symptoms:
1. Amenorrhea
2. Morning sickness
3. Breast: venous patterns, areola darker with first
pregnancy
70
4. Chadwick’s sign: soft, cyanosed cervix; early in
pregnancy and continuous throughout pregnancy
5. Hegar’s sign: sign of early pregnancy; fundus moves
independently (softening of lower part of uterus - isthmus)
6. Goodall sign: cervix feels like lips due to edema at 8
weeks
7. Naegele’s rule: to find EDC (expected date of
confinement): 1st day of LMP (Last menstrual period) +7
days ^ 3 months + 1 year; i.e. Sept. 8th, 1999 = LMP, June
15th, 2000 = EDC.
ii. Terminology
1. Still birth (birth of dead fetus)
2. Neonatal death (death of child less than 28 days old)
3. Term (gestation age 38-42 weeks)
4. Pre-term (less than 38 weeks)
5. Post-term (greater than 42 weeks)
6. Primipara: delivered once and fetus who reached viability
7. Multipara: completed 2/more pregnancies to viability
8. Nulligravida: woman who is not now and has never been
pregnant
9. Gravida: woman who is or has been pregnant irrespective
of the pregnancy outcome: primigravida; multigravida
10. Nullipara: woman who has never completed a pregnancy
beyond abortion
11. Parturient: woman in labor
12. Puerpera: woman who has just delivered
g. Problems in pregnancy:
i. Pelvic capacity
ii. Abortion
iii. Sheehan’s syndrome: most commonly due to postpartum,
hemorrhage, shock; test visual field for bitemporal hemianopsia
iv. Ectopic Pregnancy
v. Molar Pregnancy
1. LFalse pregnancyM due to hydatidiform carcinoma of uterus
s/s of pregnancy ( HCG, size of belly, amenorrhea)
2. Dx ^ US
h. Infertility:
i. Ignorance of physiology of reproduction
ii. Chemicals and substances: medications, douching
iii. High temperature (hot baths)
iv. Health problems (STDs)
v. Anatomic problems
vi. Hormonal problems
vii. Genetic problems
i. Pelvic Pain/Backache:
71
i. Chronic: common with dysmenorrhea, PID, chlamydia, gonorrhea;
often exacerbated with period microbe medium
F/discharge (can lead to peritonitis)
ii. Acute: ruptured ectopic pregnancy or threatened abortion (blood
loss in early pregnancy); check external os (if no dilation no
abortion, or threatened; if dilated inevitable)
j. Exposure to diethylstilbestrol (DES) as fetus
i. Most of cervix is covered by columnar epithelium
ii. Vaginal adenosis
iii. Circular collar between cervix and vagina
k. Abnormal bleeding:
i. Early menarche - <9 years old, delayed - >15 years old (may be
due to imperforate hymen ^ complete closure of vaginal orifice)
ii. Disturbance in pituitary ovarian axis (most common cause)
iii. Fibroids, polyps
iv. Dysfunctional menstrual bleeding: (Anovulatory cycle) young
females shortly after menarche; painless
v. 2 Amenorrhea: anorexia, hypothyroidism, DM, CA, chronic
disease; DDx = Amenorrhea of pregnancy
vi. Dysmenorrhea: females in late 20s and 30s, cause is obscure ^ in
older females, possible endometriosis (endometrium pieces get
outside birth canal, deposit on ovaries, in peritoneal cavity and
during period, enlarge in response to hormones; can get into
pleural cavity pneumothorax)
vii. Postmenopausal bleeding: indicates CA or use of estrogen
viii. Retained production: i.e. incomplete abortion (not all production of
conception are out and os has closed up) or i.e. not everything is
out after pregnancy
ix. Early pregnancy: threatened abortion or pregnancy
72
Peripheral Nervous System
Upper Limb * Compare bilaterally

I. Motor
a. Inspection
i. Look for masses, scars, lesions, symmetry, fasiculations
ii. 4The patient8s body position is normal, there are no
involuntary movements, there is no atrophy, hypertrophy,
or fasiculations.@
b. Muscle tone
i. PROM ; assess resistance while flex/extend/adduct/abduct ; wrist,
elbow, shoulder
ii. Note spasticity or floppiness
iii. 4Muscle tone is normal.@
c. Muscle strength ; ask patient to:
i. Shoulder
1. Shrug up/down
2. Abduct/adduct
3. Internal and external rotation with arms at side
ii. Elbow
1. Flex (biceps ; musculocutaneous nerve C5, C6)
2. Extend (triceps ; radial nerve C6 ; C8)
iii. Wrist
1. Flex (medial nerve C5 ; T1)
2. Extend (radial nerve C6, C7, C8)
3. Abduct (radial nerve C5 ; T1)
4. Adduct (ulnar nerve C8 ; T1)
iv. Fingers
1. Abduct ; (ulnar nerve C8 ; T1) 4Don8t let me close your
fingers@
2. Adduct ; (ulnar nerve C8 ; T1) 4 Don8t let me open
your fingers@
3. Opposition flexion ; thumb and pinky together (median
nerve C8 ; T1) 4Don8t let me break this apart@
4. Grasp fingers ; (median nerve C8 ; T1) WDonYt let me pull
my fingers outZ
5. 4Muscle strength is grade 5 bilaterally@
II. Reflexes
a. Look at muscle for reflex
b. Biceps: place thumb or finger over tendon and hit with point of hammer
(C5, C6)
130
c. Triceps: hit with base of hammer (C6, C7)
d. Brachioradialis: proximal to radial styloid ; hit with base of hammer
(C5, C6)
e. No response (3x), reinforce by clenching teeth for upper limb; only last for
approx. one second, therefore do during test
f. Hoffman sign: flex middle finger, flick it
g. Clonus: keep arms straight out, flex wrist then rapidly extend wrist and
hold
h. 4Reflexes are present and normal@
III. Sensory
a. PatientYs eyes are closed and start the exam from the periphery and
continue proximally
b. Light touch: (brush from neurological hammer ; donYt brush/drag)
c. Pain: sharp vs. dull (broken wood ear swab)
d. Temperature: test cold (tuning fork) vs. warm (hand)
e. Vibration
i. Vibrate (128 Hz) tuning fork and place on patientYs sternum, then
stop and put on sternum again ; exemplifies the difference to
patient
ii. Place vibrating fork on distal phalange of large toe
iii. Ask patient what they feel (vibration or touch)
iv. If impairment noted, move proximal
f. Position sense:
i. Hold edges of interphalangeal joint of big toe, and show patient
what is up and down
ii. Test patient with eyes closed
iii. Move up and down, then hold and ask patient for position
iv. If impairment noted, move to proximal joints
g. Offer these tests
i. Graphesthesia
1. Ask patient if he/she can read/write
2. Demonstrate by tracing a # on palm (handle of reflex
hammer)
3. Test with eyes closed
4. Ask patient to identify # traced
ii. 2 point discrimination (use paper clip)
1. Find minimal distance that two points can be distinguished
from one on pads of patients finger (open paper clip)
2. Normal < 5mm
iii. Stereognosis: put a object in hand (coin) and ask patient to
identify
iv. Extinction: simultaneously touch opposite, corresponding areas of
patientYs body and ask patient where touch is felt
h. 4Sensory system is intact@
131
Lower Limb * Compare bilaterally
IV. Motor
a. Inspection
i. Look for masses, scars, lesion, symmetry, muscle bulk,
fasiculation
ii. 4The patient8s body position is normal, there are no
involuntary movements, there is no atrophy, hypertrophy,
or fasiculations.@
b. Muscle tone
i. PROM ; asses resistance while:
1. Rotate leg internally then externally
2. Relax leg and pull leg up quickly (normal ; heel stay son
the table; upper motor neuron lesion ; leg lifts off table)
3. Flex/extend/abduct/adduct hip, knee, and ankle
ii. 4Muscle tone is normal@
iii. Muscle Strength
1. AROM ; ask patient to:
2. Hip
a. Flexion (psoas nerve L2, L3)
b. Extension (inferior gluteal nerve L5 ; S2)
c. Abduction (superior gluteal nerve L4 ; S1)
d. Adduction (obturator nerve L2 ; L4)
3. Knee
a. Flex (sciatic nerve L4 ; S2)
b. Extend (femoral nerve L2 ; L4)
4. Ankle
a. Dorsi flexion (deep peroneal nerve L4 ; S1)
b. Plantar flexion (tibial nerve L5 ; S2)
5. 4Muscle strength is grade 5 bilaterally.@
V. Reflexes
a. Look at muscles for reflex
b. Patella: flex knees bilaterally- base of hammer (L2 ; L4)
c. Achilles: bend one leg, suspend it over the other, dorsi flex ankle ; hit
with base of hammer (S1)
d. Clonus: hold and flex knee so foot is off table, plantar flex anke then
rapidly dorsi flex and hold
e. Babinski’s sign: use handle of reflex hammer; run along plantar surface
of foot from heel along lateral edge of foot across to big toe
f. No response (3x) ; reinforce by tightly pulling hands apart (Jendrassik
maneuver); only lasts for approximately one second, therefore do during
test
g. 4Reflexes are present and normal@
132
VI. Sensory
a. PatientYs eyes are close and start the exam from the periphery and continue
proximally
b. Light touch: (brush from neurological hammer ; donYt brush/drag)
c. Pain: sharp vs. dull (broken wood ear swab)
d. Temperature: test cold (tuning fork) vs. warm (hand)
e. Vibration
i. Vibrate (128 Hz) tuning fork and place on patientYs sternum, then
stop and put on sternum again ; exemplifies the difference to
patient
ii. Place vibrating fork on distal phalange of large toe
iii. Ask patient what they feel (vibration or touch)
iv. If impairment noted, move proximal
f. Position sense:
i. Hold edges of interphalangeal joint of big toe, and show patient
what is up and down
ii. Test patient with eyes closed
iii. Move up and down, then hold and ask patient for position
iv. If impairment noted, move to proximal joints
VII. Cerebellum
a. Test patientYs coordination, each side separately
b. Observe for speed, rhythm, smoothness
c. Rapidly Alternating movements
i. Disdiadokokinesia
1. Ask patient to strike palm then dorsum of hand repeatedly
in palm of opposite hand
d. Point to point
i. Heel to shin
1. Have patient rub heel up and down opposite shin
2. Go over movement with patient 2-3 times then have patient
close eyes and do it alone
ii. Finger to nose
1. Have patient touch finger to your finger, then touch their
nose repeatedly
2. Do it with eyes open a few times, then have patient close
eyes and repeat
e. Gait
i. Heel to toe
1. Walk heel to toe on straight line (follow the patient)
f. Stance
i. Romberg
1. Patient stands up with feet together, arms out in front
(pretend catching a ball)
2. Eyes open the closed (20-30 seconds)
ii. Pronator Drift
133
1. Ask patient to close eyes, put arms out, palms up
2. Slap hands down
3. Observe movements of arms
iii. 4Cerebellar function intact@
134
Peripheral Nervous System Exam Secondaries
I. Motor
a. Inspect
i. Pseudohypertrophy: Duchenne muscular dystrophy 6 increase in
size by not strength
ii. Weakness: paresis
iii. No strength: paralysis
iv. Symmetrical weakness of proximal muscles: myopathy
b. Muscle tone
i. Dystonia: limb moves as one with passive range of movement
ii. Hypertonia
1. Clasp knife: initial resistance with movement, then
2. Lead pipe: resistance remains constant with movement
3. Cogwheel: ParkinsonIs due to underlying tremor
iii. Spasticity: upper motor neuron lesion (corticospinal tract);
increased tone that is rate-dependant (tone is greater with fast
moves)
iv. Rigidity: lesion of extrapyramidal system (basal ganglia)
increased resistance throughout the movement lead pipe
rigidity; Cogwheel rigidity
v. Flaccidity: lower motor neuron or anterior root; hypotonia causes
limb to be loose and floppy and hyperextensible; cause: Guillain-
Barre syndrome, spinal cord injury, stroke; DDX 6 cerebellar
disorder
vi. Paratonia (lesion in both hemispheres – usually in frontal
lobes): sudden loss of tone, increases the ease of motion 6
common cause is dementia
c. Muscle strength
i. 0 6 no muscular contractions detected
ii. 1 6 barely detectable flicker or trace of contraction
iii. 2 6 active movement with gravity eliminated
iv. 3 6 active movement vs. gravity
v. 4 6 active movement vs. gravity and some resistance
vi. 5 6 active movement vs. full resistance (normal)
II. Reflexes
a. Reflex Grades
i. 0 6 no response
ii. 1 6 diminished, low normal
iii. 2 6 average, normal
iv. 3 6 brisker than average, not necessarily abnormal
v. 4 6 hyperactive (with clonus)
b. + Hoffman’s sign: if pointer finger moves toward thumb 6 due to upper
motor neuron lesion
c. + Clonus: hand spasmodically flexes/extends; must have hyperreflexia
135
d. + Babinski sign: toes fan out and towards patient due to upper motor
neuron lesion; 1-2 years old, unconscious, (drug, alcohol, intoxication)
e. 6 Babinski sign: toe curls down
III. Sensory
a. Do pain/temp/touch on:
i. C4 6 shoulders
ii. C6 6 lateral forearm
iii. T1 6 medial forearm
iv. C6 6 thumb (web)
v. C8 6 little finger
vi. L2 6 anterior thigh (quad area)
vii. L4 6 medial leg
viii. L5 6 lateral leg
ix. S1 6 little toes or heal
x. S2 6 post thigh
xi. S3 6 medial buttocks
b. Sensory loss
i. Anesthesia: absence of touch
ii. Hypersthesia: increased sensitivity to sensory stimuli
iii. Analgesia: absence of pain
iv. Hyperalgesia: excessive sensitivity to pain
v. Hypalgesia: lessened sensitivity to pain
vi. Lesion of DC/ML: agraphesthesia, loss of 2 point, astereognosis
vii. Peripheral neuropathy: 3 syphilis (Tabes Dorsalis), diabetes,
trauma
viii. “Glove and stocking” sensory loss: symmetrical distal sensory
loss of a polyneuropathy seen in alcoholism and diabetes
ix. Loss of vibration sense: most commonly the 1st sensation lost in
the polyneuropathies of alcoholism and diabetes; DC/ML disease
in 3 syphilis and vitamin B12 deficiency
x. Syringomyelia: chronic, progressive disease of spinal cord
cavities lesion spinothalamic tracts
xi. Cortical and subcortical:
1. Loss of discriminative sensation and specific cortical
function (i.e. agraphesthesia, astereognosis, sensory
extinction, no 2 point, R/L disorientation, agnosia) due to
CVA, MS, space occupying lesions, degenerative disease
(Alzheimer, PickIs), subcortical dementia (i.e. ParkinsonIs)
affecting posterior right parietal lobe
xii. Suprathalamic: deficit in sensation requiring cortex (2 point,
proprioception, stereognosis); 1 parietal affected due to CVA;
little defect in pain, temperature, vibration, touch
xiii. Thalamic 6 contralateral loss of all modalities; PCA occlusion;
partial recovery Thalamic syndrome (burning sensation on
contralateral)
xiv. Mononeuropathies
136
1. Median nerve: carpal tunnel syndrome 6 pain, paresthesia
in thumb and 1st 2 fingers, weakness, wasting of arms due
to idiopathic, pregnancy, myxedema, RA, old scaphoid Fx,
amyloidosis
2. Radial nerve: paresthesia 6 dorsum of hand and forearm;
wrist drop (KlumpkeIs paralysis), weakness of finger and
thumb extensors, supinator; most common cause humerus
Fx
3. Ulnar nerve: paresthesia 6 medial hand and fingers; no
flexion of distal phalanges of 4th and 5th, no
abduction/adduction of fingers; claw hand (flexed MP joint
of 4th and 5th fingers due to paralysis of 3rd and 4th lubicles,
flexion of IP joint); most common cause medial
epicondylar Fx of humerus
4. Peroneal nerve: foot drop, paresthesia over anterolateral
lower leg and dorsum of foot and webspace between 1st and
2nd metatarsals
5. Multiple mononeuropathies: Fx of fibula, Charcot Marie
Tooth syndrome; collagen vascular disease (PAN, SLE)
sarcoidosis, metabolic (DM, amyloidosis), infectious
disease (Lyme, HIV, leprosy), drugs, metals
6. Peripheral polyneuropathies: (multiple modalities
affected 6 motor, sensory, ANS) peripheral tingling,
numbness, burning pain 6 worsens at p.m., reflexes,
atrophy; MI (DM, chronic uremia), toxic (Pb, Isoniazid),
inflammation (Guillan Barrre syndrome), Xf (leprosy), met
(B12, Thiamine deficiency), neoplasm
IV. Cerebellum
a. Cerebellar disease: incoordination that gets worse with eyes closed;
clumsy movements; vary in speed/force
b. Disdiadochokinesia:
i. Dominant hand usually better
ii. Abnormal: slow, clumsy movement
c. Heel to shin
i. Cerebellar disease: clumsy unsteady movements with possible
overshoot (dysmetria); with eyes closed
ii. Proprioceptive abnormal: only abnormal with eyes closed
d. Finger to nose
i. Cerebellar disease overshoot (dysmetria)
e. Heel to toe
i. Instability: UMN lesion, ataxia DDx 6 cerebellar, intoxication,
proprioception abnormal
ii. If +, have patient hop in place/ do a shallow knee bend; DDx 6
muscle weakness, cerebellar, DC/ML
f. Romberg (Dorsal column test)
i. Fall to one side (vestibular 6 ipsilateral to lesion)
137
ii. Eyes closed and fall: DC/ML, vestibular, proprioceptive loss
iii. Eyes open and fall: Cerebellum problem/ ataxia
g. Pronatory Drift
i. Contralateral corticospinal problem one side drifts down and
pronates
ii. Slap hands: normal 6 come back to the same level; overhoot 6
cerebellar disease; donIt come back or poorly 6 position sense
abnormal (DC/ML)
V. Secondaries
a. Spinal cord tracts:
i. Posterior column: (DC/ML) carries fibers for tactile
discrimination, vibration sensation, form recognition, and joint and
muscle sensation (proprioception)
1. Fasciculus cuneatus 6 (lateral): C2-T6 6 upper extremities
2. Fasciculus gracilis 6 (medial): T6-S5 6 lower extremities
3. Both give rise to internal arcuate fibers decussate in
lower medulla
ii. Spinothalamic: carries fibers for pain and temperature sensation 6
decussate at level of spinal cord entry
iii. Corticospinal: carries fibers for voluntary skilled motor activity 6
decussate in pyramids of medulla (90%); decussate at level of SC
exit (10%)
b. Cerebellum:
i. Structure
1. Flocculonodulus: vestibulocerebellar
2. Vernis, parvernal: spinocerebellar
3. Lateral hemisphere: cerebrocerebellar
ii. Functions:
1. Vestibular nuclei flocculonodular fastigial (and back
to vestibluar nuclei)
a. Balance, posture, and vestibular reflexes
2. Spinocerebellar tracts vermis fastigial reticular
system
a. Execution and coordination of movement in axial
and proximal muscles
3. Spinocerebellar paravermal interposed nuclei
lateraal descending tracts
a. Execution and coordination of movements in distal
muscles
4. Cortical tracts lateral hemispheres dentate cortex
a. Planning, timing, initiation, terminate motor action
138
Rectal Exam

name? It-s very nice to meet you. Mr./Mrs. ______ I-ve been asked to
come in and do a rectal exam. Is that ok with you?
1. Have you ever had a rectal exam?
2. Do you know what it entails? It entails inserting a gloved, lubricated
finger up your back end. You will feel slight discomfort but let me
know if you feel any pain.
3. Do you have any pain right now?
4. Did you empty your bladder before you came in here/ Would you like
to empty your bladder right now.
I-m going to leave the room. I-m going to need you to undress from the waist
down.
Mr./Mrs.______ lie on the table for me on your left side for me please. I
need you to flex your hips and knees. Also bring the top leg slightly over to
the front of the bottom leg. Make sure the butt is hanging over the table.
Female patients:
- Examine in lithotomay position (after examine genitals)
- Feel cervix through anterior rectal wall
- Palpate retroverted uterus or retroflexed
I. Inspect
a. Put gloves on and spread buttocks apart
b. Look for lumps, ulcers, inflammation, rashes, hemorrhoids, dilated veins,
cracking (STDFs), scars, bleeding, eczema, sentinel tags, carcinoma,
nodules (HSV2) or warts
Upon inspection of the peri-anal area and anus, there are no masses, lesions,
or ulcerations. No swelling or discharge noted.
II. Exam
a. Look at the patientFs face
You may feel as if you are going to move your bowels, but you won-t. Bare
down for me please.
b. Have the patient bare down and note any lesions hemorrhoids, rectal
prolapse
There are no signs of rectal prolapse or hemorrhoids.
c. Rest the pad of your lubricated gloved index finger over the index
Bare down again and there may be discomfort but if you feel pain please let
me know.
d. Have the patient bare down
58
e. Gently insert the fingertip into the anal canal in the direction of the
umbilicus (Pad of finger in the anus should be facing you 1st).
i. Posterior wall
Bare down again
ii. Right Wall Q with finger inserted as far as possible, rotate hand
clockwise to get right side
Bare down again
iii. Left Wall Q turn finger counterclockwise
I-m going to palpate the prostate, you may feel as if you-re going to urinate
but you won-t. Bare down
iv. Anterior wall and prostate gland Q twist body around so that back
is to patient and arm is pronated
f. Everytime you check a wall, have the patient bare down
g. If excruciating pain, pull out
h. Palpate prostate lateral lobes and median suclus between them, noting
size, shape, and consistency of prostate
Upon palpation of the rectal walls, no masses, or lesions were noted. The
patient demonstrated no signs of tenderness. Upon palpation of the
prostate, no tenderness or masses were noted. The median sulcus is
palpable.
i. Check rectal shelf if possible Q higher than prostate
j. Gently withdraw finger and check for blood or fecal matter; wipe finger
over slide to do Guiac test and send for cytology (not required in test)
k. Offer patient a tissue to clean himself
59
Rectal Exam Secondaries
I. Indications for exam

a. Frequent urination, dribbling, hesitancy, poor stream, retention with
overflow incontinence, hematuria, hemospemia, sexual problems, enlarged
prostate
b. Pay close attention to GIT (constipation, diarrhea, abdominal pain,
bleeding-melena, and hematechesia)
II. Inspection
a. Pilonidal cyst: congenital abnormality in midline superficial to coccyx or
lower sacrum; ID by open sinus tract; may have small tuft of hair and halo
of erythema; generally asymptomatic; slight drainage; abscess sinus
tracts
b. Anorectal fistula: inflammatory tract/tube one end opens into
anus/rectum, other end onto skin surface; abscess before fistula
c. Polyps: vary in size and number; can develop stalk (pedunculated) or on
mucosal surface (sessile); soft, difficult to feel; proctoscopy to diagnose;
biopsy for malignancy
d. External Hemorrhoids: dilated veins originating below pectinate line and
covered with skin due to venous obstruction; asymptomatic without
thrombosis; acute local pain - with defecation, sitting; tender, blue,
swollen, ovoid mass visible at the anal margin; Rx I nick veins
e. Internal Hemorrhoids: enlarged vascular cushions above pectinate not
usually palpable; may be bright red; bleeding on defecation; may prolapse
= red, moist, protruding mucosa
f. Cracking: STDLs
g. Anal fissure: a painful longitudinal/oval ulceration of the anal canal;
found MC in the midline posteriorly; inspection may show a OsentinelL
skin tag just below the anal opening; sphinctor is spastic and the exam is
painful
h. Nodules: HSV2
III. Exam
a. Sphincter:
i. Tight due to anxiety, inflammation, scarring
ii. Loose due to neurological disease
b. Induration: due to inflammation, scarring or malignancy
c. Rectal Prolapse: prolapse of rectal mucosa on straining for bowel
movement
i. Prolapse of only mucosa = small, radiating folds
ii. Whole bowel prolapse = large, concentrically circular folds
d. Prostate:
i. Normal: rubbery, non-tender
ii. Abnormal:
1. Cancer of the prostate:
60
a. Hardened, non-tender, irregular shaped enlarged
gland; starts peripherally; median sulcus may be
obscured
b. Metastic to spine via posterior intervertebral plexus
(osteoblastic)
c. Lithotomy position: may help you reach a CA thatLs
higher up
d. Dx:
i. PSA: prostate specific antigen
ii. PAP: prostate acid phophatase
iii. FNA cytology
e. Rx:
i. Most common resect prostate (worry about
impotence if you cut nerves)
ii. Flutamide (estrogen), leuprolide (anti-
testosterone)
2. Prostatitis:
a. Acute, febrile condition due to bacterial infection;
gland is very tender, swollen, firm, and warm
b. Chronic prostatitis does not produce consistent
physical findings and may not be tender or warm to
the touch
3. Benign Prostatic Hypertrophy: Most common >50 years;
gland symmetrically enlarged, smooth, firm, slightly
elastic; median sulcus may be absent to palpation; enlarged
gland may obstruct urinary outflow; Rx I prazosin
4. Hard areas: DDx I CA, prostatic stones, chronic
inflammation
5. Prostatic Urethral Obstruction: signs and symptoms =
nocturia, poor stream force, start/stop/start pee, polyuria,
pain because bladder expands
e. Rectal Shelf: metastases from peritoneal reflection anterior to the rectum
(in females I recto-uterine pouch (of Douglas) behind cervix and uterus)
f. Perianal abscess: painful, tender, indurated, red mass
g. Puritis ani: swollen, thick, fissured skin with excoriate
h. Pale stool (clay colored): conjugated bile (no stecobilin) due to CA head
pandreas, CA ampulla of Vater, gallstones obstruct common bile duct
i. Bleeding per rectum: diverticulitis, IBD, CA
IV. Anatomy
a. Prostate (normal 2-5 cm); heart shaped (only palpate posterior wall)
b. Anorectal junction (pectinate, dontate line): Anal canal demarcated from
rectum superiorly by serrated line marking change from skin to mucous
membrane, denotes boundary between somatic and visceral nerve supplies
not palpable
c. Anterior to rectum: males = prostate; females uterus
61
d. Valves of Houston = 3 inward foldings of rectal wall; can feel lowest on
left; can feel peritoneal inflammation or nodularity of peritoneal
metastases above the rectal shelf
e. Prostate gland; small in boyhood; 5x size in puberty and adulthood; size
due to hyperplasia in 50Ls
62

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Cardiovascular Exam

III. Blood Pressure

IV. Venous System

Clubbing: (tips of the fingers appear round and bulbous) angle

Peripheral pulses: increased, normal, diminished, or absent

Essential hypertension (MCC): defect in sodium excretion, transport; variation in

II. Venous System

II. Heart Sounds

d. S4: Atrial contraction ventricle filling occurs late in diastole

III. Associated Sounds

iii. Late systolic click: papillary muscle dysfunction (i.e. post-MI)

ii. Mitral Stenosis

iv. Aortic Stenosis

VI. Left heart failure

VII. Right heart failure

i. Check in abdominal, cardiovascular, and respiratory

i. Vesicular: inspiratory sounds last longer, and louder than

Hi my name is ______, I-m a second year medical student. What is your

i. Central (axillary): palpate along chest wall between axillary folds

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

i. Preadolescent % elevated nipples only

Hidradenitis suppurativa Acanthosis Nigricans

b. Hidradenitis suppurativa: sweat gland infection with pus

ii. Mitral cells (+ glutaminergic) of olfactory bulb

iii. Olfactory tract

iv. Lateral olfactory stria

v. Primary olfactory cortex (piriform cortex that lies over the

c. Olfactory hallucinations [uncinate fits (seizures) with deja vu]: lesions

iii. Optic tract: contains ipsilateral temporal hemiretina and nasal

iv. Lateral geniculate body: 6 layered nucleus (layer 1, 4, 6 contra

c. Pupillary Light Reflex Pathway

ii. Pretectal nucleus of the midbrain: Crossed (posterior

iii. Edinger-Westphal nuclus of CNIII: preganglionic

iv. Ciliary ganglion: postganglionic parasympathetic fibers to

v. Sphincter muscle of Iris

d. Pupillary Dilation pathway:

ii. Ciliospinal center (T1-T2) of the intermediolateral cell column

iii. Superior cervical ganglion: projects postganglionic sympathetic

iv. Dilator muscle of Iris

e. SEE HEAD AND NECK EXAM

i. Cortical Visual Pathway: Primary visual cortex (BA 17) to

ii. Visual association cortex (BA 19): projects through the

iii. Superior colliculus and pretectal nucleus

c. SEE HEAD AND NECK EXAM

IV. Trochlear, VI Abducens

ii. Crosses at superior medullary velum (midbrain)

iv. Encircles the midbrain

v. Passes through cavernous sinus

vi. Orbit (through superior orbital fissure)

vii. Superior Oblique Muscle

iv. Jaw Jerk reflex: a monosynaptic myotatic relex (afferent V-3/

2. Mesencephalic nucleus (primary neuron)

v. Trigeminal neuralgia (tic douloureux): recurrent paroxysms of

e. Pathway of Ventral trigeminothalamic tract (pain and temperature)

ii. Spinal trigeminal tract: to the

iii. Spinal trigeminal nucleus: where the second-order neurons are

iv. VPM: contralateral ventral posteromedial nucleus of the thalamus

v. Posterior limb of the internal capsule

vi. To the somatosensory cortex (BA 3, 1, 2) \ face area

f. Pathway of Dorsal trigeminothalamic tract (discrimination and

iii. Principle sensory nucleus of CNV: are where the second-order

v. Posterior limb of the internal capsule

vi. To the somatosensory cortex (BA 3, 1, 2) \ face area

ii. Corticospinal tract: goes through the

f. Bulge sign (for minor effusions)