GI, GU, MSK, & Neuro Exam 2025 Lecture 3 PDF

Poll Everywhere Question 1 Match the physical exam technique to its correct description: 1. Percussion A. Feeling areas of the body with the hands 2. Auscultation B. Listening to sounds that arise from the body 3. Inspection C. Tapping to assess the density of u...

Poll Everywhere Question 1 Match the physical exam technique to its correct description: 1. Percussion A. Feeling areas of the body with the hands 2. Auscultation B. Listening to sounds that arise from the body 3. Inspection C. Tapping to assess the density of underlying structur 4. Palpation D. Observing visually 4 This question connects to Objective #1 (determine how to assess PE systems using IPPA techniques)  Abdominal (Abd) Exam & Regions All 4 IPPA techniques used Conducted at the patient’s side with the patient lying supine (on back) Need to know abdominal anatomy, landmarks, and reference points General Abdominal Regions: Epigastric – upper central abdominal Epigastric area Umbilical Umbilical – area around the umbilicus Suprapubi c Suprapubic/hypogastric – lower  See Table 4-12 in Tietze Abdominal Structures & Quadrants LU Q RU Q RL LLQ Q Some structures are too deep to be palpated Report your findings by quadrant (e.g., “RUQ Abdomen: Inspection Inspect appearance of skin, umbilicus, and abdominal contour (scaphoid - concave appearing [e.g., due to malnutrition] vs. protuberant - bulging [e.g., due to central obesity, pregnancy); note any surgical scars, spider angiomas Striae Abnormal: o Striae - discolored stripes of skin resulting from ruptured elastic fibers; causes include rapid growth/weight gain (e.g., puberty, pregnancy, bodybuilding) o Distention - buildup of abdominal fluid or gas; causes include constipation, ascites (due to ↑hydrostatic pressure Distention due to ascites Abdomen: Auscultation of Bowel Sounds (BS) Note: there is also a “BS” abbreviation from lungs/chest BS : tinkling sounds produced by peristaltic movement of fluid and air Auscultate all four quadrants o Place diaphragm of stethoscope just above and to the right or left of the umbilicus Normal finding: o NABS (hearing BS every 10 seconds) Abnormal findings: o hyperactive or hypoactive BS Abdomen: Abnormal Bowel Sounds Hypoactive Hyperactive Common Constipation Diarrhea Abnormality Constipating diseases Hypothyroidism ( s l o w t h i n g s d o w n ) Irritable bowel syndrome (IBS) Drug-induced causes 1st generation antihistamine (e.g., Causes diphenhydramine) Opioids (e.g., oxycodone) Iron supplements (e.g., ferrous sulfate) 10 Abdomen: Percussion Percuss all four quadrants Normal: o Tympanic note (high-pitched, drum-like sound) Abdominal from air-filled loops of bowel percussion Abnormal o Shifting dullness (associated with ascites) Ascites causing shifting dullness air filled ➜ Tympany; dense fluid ➜ Dullness Abdomen: Percussion - Liver Span resonant To assess liver span: above o Percuss down the right midclavicular line, beginning above the rib margin and ending below the rib margin resonant or tympanic below o Quality should change from resonant ➜ dull ➜ tympanic Normal liver span ~10 cm (range: 6-12 cm) Abnormal finding: Hepatomegaly (enlarged liver); causes include hepatitis, cirrhosis Abdomen: Palpation Light palpation: use pads of the fingertips to apply light pressure in all 4 quadrants; note any tenderness or rigidity Deep palpation: use significant downward pressure with both hands in all 4 quadrants; note tenderness, masses, abdominal structures if needed (liver’s edge, enlarged spleen, etc.) Normal: NTND Abnormal findings: o Suprapubic region tenderness: commonly associated with urinary tract infection (UTI), kidney stones o Rebound tenderness: common cause – peritonitis (inflammation of the peritoneum often c au se d b y in fe ct io n ) Abdomen: Fluid Wave Test Fluid wave test Press one hand on right side of abdomen Sharply tap the left wall of abdomen with the other hand If (+), a fluid wave is transmitted to right side of abdomen and felt by pressed hand Normal: (–) fluid wave Fluid wave test Abnormal finding: (+) fluid wave (diagnostic of ascites) Poll Everywhere Question 2 What physical exam technique is used to identify hepatomegaly? A. Inspection B. Percussion C. Palpation D. Auscultation This question connects to Objective #1 (identify how to assess abdominal system using IPPE  Poll Everywhere Question 3 Physical Exam (PE): VS: BP 115/70 HR 103 RR 18 T 101.6 °F Wt 60 kg Ht 5’ 6” BMI 21 kg/m2 Pain Score 4 ABD : abdomen distended with shifting dullness; ascites and spider angiomas present hepatomegaly present; (+) fluid wave test, rebound tenderness Which findings suggest the presence of peritonitis? [Select All That Apply] A. Tachycardia ° B. Bradypnea C. Fever D. Hepatomegaly E. Ascites l iv e r fa il in g ( n ot hi ng to d o w ith in fe ct io n F. Rebound tenderness in fe ct io n of p e r it o n e u m. 16 d This question connects to Objective #4 (interpret physical exam findings)  Genitourinary Exam Inspection and palpation techniques are used Generally, an exam is not performed unless abnormalities are detected/suspected, the patient presents with GU complaints, or the patient is seeing a pertinent specialist (e.g., obstetrician, gynecologist, urologist, gastroenterologist) It is important for clinicians to: o Create a safe and trusting environment o Use language & maneuvers that enhance patient autonomy & affirm choice 18 Elisseou S, Potter J. Performing a Trauma-Informed Physical Examination. In: Keuroghlian AS, Potter J, Reisner SL. eds. Transgender and Gender Diverse Health Care: The Fenway Guide. McGraw Hill; 2022. Accessed January 22, 2022. https://accessmedicine-mhmedical- Genitourinary: Inspection (External) External exam: o Inspect sacrococcygeal and perianal areas for lumps, ulcerations, rashes, swelling, external hemorrhoids, and excoriations o Inspect external genitalia for above abnormalities and discharge color/odor 19 Genitourinary: Abnormal Findings - Lesions Lesions: o Chancre: found on skin/mucous membrane of genitalia; commonly caused by Treponema pallidum (syphilis) infection o Vesicle: small, circumscribed, elevated lesion containing serous fluid; commonly caused by herpes simplex virus Chancre (HSV) Vesicles 20 Genitourinary: Abnormal Findings - Discharge Purulent urethral or rectal discharge o Common cause: STI (e.g., Neisseria gonorrhoeae, Chlamydia trachomatis) BRBPR B r ig h t re d b lo od p e r re ct um o Common causes: hemorrhoids (dilated veins in walls of anus/rectum), Crohn's disease, GI bleed Vaginal Discharge o Normal: clear/white, odorless o Abnormal: thick white “cheesy”, odorless Suggests vulvovaginitis cause by fungal Candida (“yeast infection”, “candida vulvovaginitis”) Common cause: uncontrolled diabetes, drug-induced causes: antibiotics, SGLT2 Inhibitors (e.g. empagliflozin) o Abnormal: gray/yellow-green, malodorous 21 Genitourinary: Inspection (Internal) Inspect vaginal wall/cervix for color and lesions c o Normal cervix- smooth, pink; if patient has intrauterine device (IUD), strings should be visible extending from cervical os o Abnormality: cervical petechiae “strawberry cervix” from microscopic hemorrhages of the cervix caused by trichomoniasis o Cervical cells may be collected for cytologic evaluation Pap test Cervical petechiae  Genitourinary Exam: Palpation (Internal) Palpate cervix, uterus, and ovaries for size, shape, consistency, masses, tenderness, and mobility o Technique: “bimanual exam” o Normal uterus - firm, smooth, freely movable, “pear shaped” o Normal ovaries - slightly tender, very mobile, “almond shaped” o Abnormality: cervical or uterine inflammation & tenderness often associated with pelvic inflammatory disease (PID) caused by STI Bimanual pelvic exam 23 Genitourinary Exam: Palpation (External) Palpate penis for indurations; scrotal structures (testis and epididymis) for size, shape, and tenderness o Abnormality: epididymitis - inflammation/tenderness of the epididymis commonly caused by STI (Neisseria gonorrhoeae, Chlamydia trachomatis) Palpate inguinal and femoral areas for bulges o Abnormality - findings indicating hernias Genitourinary Exam: Palpation (External) Palpate prostate for size & tenderness; palpate anus & rectal wall for tone & tenderness o Technique: digital rectal exam (DRE) o Abnormality: prostatitis - painful swelling and/or inflammation of the prostate caused by STI or UTI o Abnormality: prostatic hypertrophy may be associated with benign prostatic hypertrophy (BPH), a condition causing urinary frequency or incomplete emptying Normal Prostate Enlarged Prostate Poll Everywhere Question 4 What is/are the most likely cause(s) of thick white “cheesy” odorless vaginal discharge? [Select All That Apply] A. Uncontrolled diabetes B. Sexually transmitted infection C. Benign prosthetic hypertrophy D. Dapagliflozin [SGLT2 inhibitor] 26 This question connects to Objective #4 (identify common causes of Musculoskeletal (MSK) System Assessed via inspection and palpation Areas examined: o Mandible o Shoulders o Elbows o Wrists/hands o Spine o Hips o Knees o Feet Musculoskeletal: Inspection Inspect: o Symmetry, proportion, muscular development o Curvature of spine o Gait, stance, movement, grasp Abnormal findings: o Shuffling gait - associated with Parkinson's disease Don’t skip “leg day” Muscular atrophy (LLE) o Muscle atrophy - decreased muscle mass caused by disuse Associated with immobilized/paralyzed limbs, elderly o Scoliosis - lateral curvature of the spine Associated with muscular dystrophy, cerebral palsy o Kyphosis - convex backward curvature of the spine Associated with osteoporosis o Lordosis - accentuated curvature of spine Poll Everywhere Question 5 What is the meaning of the acronym ROM? [fill in the blank] 30 This question connects to Objective #3 (define common acronyms) Musculoskeletal: Palpation Palpate large and small joints. Assess for abnormalities such as tenderness, warmth, crepitation (_________________________________), deformities Assess for strength and ROM via flexion & extension Abnormal findings: ↓grip strength - associated with osteoarthritis, carpel tunnel syndrome ↓joint ROM - associated with arthritis, tissue inflammation around joint ↑joint ROM - indicates increased joint mobility; associated with joint instability Neuro Exam Assesses mental status, cranial nerve function, sensory & motor function, cerebellar function, and reflexes Standard IPPA techniques are not used Generally, a comprehensive exam is not performed unless abnormalities are detected/suspected 33 Neuro: Mental Status (MS) Determine if the patient’s affect (____________________) is appropriate o Abnormalities: Flat: severe reduction in emotional expressiveness; monotone, face expressionless, immobile body (e.g., caused by depression) Labile: emotional instability/dramatic mood swings (e.g., caused by bipolar disorder) Observe the patient’s speech throughout exam o Abnormalities (both could be caused by stroke, brain tumor): Dysphasia  Neuro: Mental Status (MS) Determine patient's level of consciousness/alertness o Normal: awake, alert Abnormal: confused, unresponsive Determine orientation to person, place, and time o “What is your name?” “Where are you?” and “What is today's date?” o Normal finding: A&Ox3 = alert and oriented to 1. person, 2. place, and 3. time Abnormality o Abnormal Definition example: “A&O x2 (person & place)” Common Causes Encephalopath y Delirium Dementia Validated Tools - Cognitive Screening & Stroke (FYI) Mini-Cog MIS - Memory Impairment Screen MMSE - Mini Mental Status Exam MoCA - Montreal Cognitive Assessment NIH Stroke Scale 36 Click on name of tool to learn more Neuro: Sensory Function Exam Assesses patient’s ability to detect a variety of stimuli o Pain, light touch, and vibratory sensations Sensory function exam technique: o Ask patient to close their eyes; start distally and work proximally, comparing left/right sides of body o Ask patient to identify when and where they are touched using: 1. Light touch - gauze/tissue, soft end of Q-tip 2. Pain - sharp object, blunt end of broken Q-tip 3. Vibration - vibrating tuning fork over a bony prominence Neuro: Sensory Function - Monofilament Foot Exam Monofilament foot exam o Assesses sensory function in feet o Often conducted in patients with diabetes or taking neurotoxic drugs Technique: o Inspect feet for lesions or ulcers o Direct patient to close their eyes and say “yes” when they feel monofilament o Touch pads of toes plus several locations on plantar surface o Use 10 g monofilament, press until it bends, hold for about 1.5 seconds Normal: (+) sensation on all locations 38 Abnormal: any loss of sensation, denoted with (-) on diagram Neuro: Sensory Function Abnormalities Hypoesthesia - loss of sensation Parasthesia - abnormal sensation such as numbness, tingling, pricking, burning Neuropathy - nerve dysfunction o Certain types of neuropathies impact the sensory pathway; symptoms may include hypoesthesia and/or parasthesia o Causes include: Diabetes, vitamin B12 deficiency, drug-induced: certain chemotherapies (e.g., cisplatin, oxaliplatin, docetaxel, paclitaxel, vincristine), certain antibiotics (e.g., isoniazid, linezolid, metronidazole) Varicella zoster virus (Shingles) 39 Neuro: Motor Function Observe for involuntary muscle movements o Abnormalities: Asterixis (“liver flap”) often caused by hepatic encephalopathy Dystonia often caused by birth injury, trauma, stroke Drug-induced: antipsychotics, antidepressants, antiemetics Resting tremor often caused by Parkinson’s disease Intention tremor often caused by stroke, multiple sclerosis (MS) Assess muscle tone - resistance to passive stretch Asterixis o Instruct the patient to relax the extremity; support and stabilize joint o Provide passive flexion, extension, abduction, and adduction o Abnormalities: Rigid tone - found in Parkinson’s disease Flaccid tone - found in comatose patients Neuro: Motor Function Assess muscle strength o Hold extremity; instruct patient to push then pull against resistance; rate on scale o Normal finding: “Muscle strength = 5+” o Abnormal: any score < 5; found in stroke, Multiple sclerosis, hemi-, para-, and quadriplegia Muscle Strength Rating Scale: Scor Meaning e 0 No muscle contractility (complete paralysis) 1+ Barely detectable muscle contractility 2+ Active muscle contractility; unable to work against gravity 3+ Active muscle contractility; able to work against gravity Active muscle contractility; able to work against gravity and some 4+ resistance  normal Neuro: Reflexes DTR Includes biceps, triceps, brachioradialis, patellar, Achilles o Strike the tendon briskly with a reflex hammer; rate reflex according to scale o Normal findings: “DTR = 2+; “Biceps reflex = 2+” Reflex Rating Scale: o Abnormal findings: Scor Meaning e Hyporeflexia (0, 1+) 0 Complete absence of movement found in stroke, hypothyroidism Diminished reflex, movement with Normal  1+ Hyperreflexia (3+, 4+) reinforcement found in Huntington’s disease, hyperthyroidism 2+ Average, normal response 3+ Brisker than average response Neuro: Reflexes Plantar reflex: o Stroke sole of foot from heel to ball with reflex hammer Normal finding: (-) Bab (toes curl downward) Abnormal finding in adults: (+) Bab Reflex in which big toe extends itself (or remains extended) when the sole of the foot is stimulated Abnormal finding except in young infants Causes in adults include stroke, Multiple sclerosis Normal Toe Flexion Positive Babinski’s Refl  Poll Everywhere Question 6 When performing the neurologic exam, which of the following are considered abnormal findings? [Select All That Apply] A. Muscle strength score: 5+ B. A&O x1 (person) : C. DTR score: 2+ D. (+) asterixis 44 This question connects to Objective #2 (identify abnormal findings)  Poll Everywhere Question 7 What is the most likely cause of a neurologic exam revealing “diminished sensation in bilateral LE”? A. Diabetic neuropathy 0 B. Parkinson’s Disease C. Empagliflozin (SGLT2 - diabetes medication) D. Shingrix (zoster vaccine) 45 This question connects to Objective #4 (identify common causes of Poll Everywhere Question 8 What is the most likely cause of neurologic findings of “A&O x1 and (+) asterixis”? A. Stroke B. Dementia C. Hepatic encephalopathy D. Delirium ^ 46 This question connects to Objective #4 (identify common causes of Correlating Physical Exam Findings with Pulmonary Diseases COPD Pneumonia Asthma Exacerbation Pleural Effusion Shallow breaths Tachypnea Tachypnea Dullness or flatness Tachypnea Tachycardia Use of accessory to percussion Cyanosis of skin and Fever muscles Shifting dullness to nails Asymmetrical chest Reduced breath percussion Clubbing of nails expansion sounds Asymmetrical chest Increased Dullness or flatness Wheezes expansion anteroposterior to percussion Diminished or absent diameter (i.e., barrel Diminished or absent breath sounds chest) breath sounds Hyperresonance to Wheezes percussion Crackles Decreased diaphragmatic excursion Reduced breath sounds Wheezes Correlating Physical Exam Findings with Cardiovascular Diseases Peripheral Arterial Stroke Heart Failure Hypertension (HTN) Disease (PAD) Facial asymmetry Hypotension or S4 Diminished/reduce Nystagmus Hypertension Elevated blood d popliteal, Carotid bruit Bradycardia or pressure posterior tibial, and Tachycardia dorsalis pedis Dysphasia/Aphasia Cold extremities pulses Dystonia Resting tremor Edema ￬ muscle strength Crackles Hyporeflexia Elevated JVP (+) Bab Displaced apical impulse or PMI S3 Correlating Physical Exam Findings with Other Diseases Anemia Hypothyroidism Hyperthyroidism Cirrhosis Pallor of skin Hypotension Hypertension Jaundice Conjunctival Bradycardia Tachycardia Scleral icterus pallor Goiter Exophthalmos Clubbing of nails Koilonychias (iron Dry skin Goiter Gynecomastia deficiency) Cool skin Thyroid bruit Spider angioma Murmur Hypoactive BS Warm skin Nail clubbing Hyporeflexia Bounding Ascites peripheral pulses Shifting dullness Murmur Hepatomegaly Hyperactive BS Fluid wave Hyperreflexia Hepatic encephalopathy Asterixis Correlating Physical Exam Findings with Other Diseases Opioid Use Parkinson’s Dehydration Infection Disorder/ Opioid Disease Overdose Pallor of skin Hypotension Blunted Bradycardia Conjunctival Tachycardia expression/ Bradypnea pallor Tachypnea “masklike” face Hypoxemia Koilonychias Fever Shuffling gait Miosis (iron deficiency) Lymphadenopat Dementia Cyanosis Murmur hy Resting tremor Hypoactive BS Warm skin Rigid tone Delirium (esp. in elderly) Descriptor: MO is a 58 yo female with PMH of cirrhosis admitted to ER with confusion, abdominal distention and complaints of vaginal discharge. This is hospital day 1. Subjective: MO complains of a “huge belly” that has gotten progressively larger and more painful over the past few days, as well as pain and itching of her vaginal area. Objective: Case 2: MO Allergies: no known drug allergies (NKDA) Medications prior to administration (PTA): Practice translating the Furosemide 40 mg PO once daily for cirrhotic ascites [loop diuretic] acronyms in the physical Spironolactone 100 mg PO once daily for cirrhotic ascites [aldosterone receptor examination antagonist] Metformin ER 500 mg PO BID for diabetes [biguanide] Based on the physical Dapagliflozin 10 mg PO once daily for diabetes [SGLT2 inhibitor] exam: Ibuprofen 400 mg PO Q6hours PRN ”joint pain” [NSAID] Determine whether the Past Medical History (PMH): alcoholic cirrhosis, poorly controlled diabetes Social History (SH): (+) alcohol (EtOH) use, reports drinking 1-2 bottles of vodka every findings 3 days x 15 years; (-) tobacco use; (-) illicit drug use are normal or abnormal. Family History (FH): unknown Vaccination History: up to date For abnormal findings, list Physical Exam (PE): what these findings could VS: BP 115/70 HR 103 RR 18 T 101.6 °F Wt 60 kg Ht 5’ 6” BMI: 21 kg/m2 Pain score be associated with. 4/10 General: WDWN female in mild distress How could these findings MSK: decreased ROM and grip strength in both hands; (+) Heberden’s nodes in DIPs; provide objective (+) Bouchard’s nodes in PIPs; no pain with extension or flexion of other joints Neuro: Normal affect; A&Ox1 (person); sensory. Function: decreased sensation to light information touch on bilateral LE to mid-shin; motor function: (+) asterixis; normal muscle tone; to support a need for muscle strength score: 5+; DTR score: 2+ additional ABD: abdomen distended with shifting dullness, caput medusae and spider angiomas present; NABS; hepatomegaly present; (+) fluid wave test, rebound drug therapy or to monitor 52 tenderness the