N750 Exam 2 Review PDF

**[Objectives Week 6 Chest and Lungs]** - - Normal anatomy: - - - - - - - - - - - - - - - - - - - - - - - - - - From Class Slides: Chest & Lungs HPI: COUGH - - - - - - HPI:...

**[Objectives Week 6 Chest and Lungs]** - - Normal anatomy: - - - - - - - - - - - - - - - - - - - - - - - - - - From Class Slides: Chest & Lungs HPI: COUGH - - - - - - HPI: SHORTNESS OF BREATH (SOB) - - - - - HPI: WHEEZING - - - - REVIEW OF SYSTEMS (ROS) ENVIRONMENTAL & EXPOSURE HISTORY - - - PHYSICAL EXAM FOR RESP CONCERN **Purpose:** To detect abnormalities such as fluid, air, consolidation, or masses.​ **Goal:** Systematic assessment helps in diagnosing respiratory conditions early and guiding appropriate interventions.​ **Key Steps:**​ Inspection, Palpation, Percussion, Auscultation -  - - - - - - - Breath sounds: - - - Bronchial and bronchovesicular breath sounds are abnormal if heard over the peripheral lung tissue Notes: AP Diameter: width of chest straight on and then on their side/lateral portion of chest; anterior should be 2x the lateral side ; AP usually 2:1; COPD will have barrel chest 1:1 ratio ​ Pectus excavatum: \"scooping out\" or hollowness of chest; \"bowl on chest wall\"​ Pectus carinatum: \"poking out\" have hump on the chest (pigeon chest)​ Respiratory distress: e.g. sternocleidomastoid muscles being used accessory muscle use; if see these symptoms STOP & INTERVENE immediately before proceeding with rest of exam ​ ​Hyperpnea: abnormal e.g. metabolic acidosis; deeper breaths -- can occur w/ or wo inc. In RR​ Cheyne Strokes: cycle of increasing and decreasing breathing leading to temporary pause in breathing (apnea)​ Paradoxical breathing: chest wall moves inward w/ inhalation and outward w/ exhalation \[opposite of normal breathing\] - - - - - - - - - - - - - - - - - - Diaphragmatic Excursion - - Remainder of Slides was Case Studies Vocal Fremitus Article Notes​ -Tactile fremitus is palpation of chest wall to detect changes in the intensity of vibrations created with certain spoken words in a constant tone & voice indicating underlying lung pathology ​ -Pathophysiology: Transmission of spoken tones depends on state of underlying lung parenchyma in pleural space; air is a poor conductor of low sound frequencies whereas a solid or dense medium inc. Transmission of low sound frequencies. Vocal fremitus may be DECREASED in conditions affecting lung parenchyma, pleura, or chest wall. ​ Example: [Bronchial asthma, emphysema/COPD, or bronchial obstruction dt air trapping & dec. Density of lung parenchyma] ​ \--Pleural effusion & pneumothorax: air fluid accumulates in space between chest wall & lung parenchyma -\> dec. Transmission of lower frequency sound vibrations ​ \--Obesity: dec. Vocal fremitus ​ \--[Inflammation and consolidation create dense medium -\> INCREASED Vocal fremitus] w/ inc. Transmission of lower frequency sounds ​ -Vocal resonance is auscultatory counterpart of vocal fremitus; example changes in resonance: ​ \--Bronchophony: LOUDER sound over area of CONSOLIDATION ​ \--Whispering Pectoriloquy: While auscultate over lung fields, ask pt to whisper \"one, two, three\" \-- whispered words are HEARD CLEARLY in presence of CONSOLIDATION ​ \--Egophony or an \"E to A\" change: qualitative change in voice resembles \"bleating of a goat.\" Sound frequencies pass through consolidation tend to distort sound of vowel: \"E\" perceived by examiner as \"A\" or \"AAAH\" ​ -Rhonchal fremitus: palpable rhonchi ​ -Pleural fremitus: palpable pleural rub ​ **Examination for Tactile Fremitus:** ​ -Ask pt to fold arms across the chest wall to displace scapulae -- ask to repeat \"ninety-nine\" or \"one, two, three\" in constant tone while practitioner simultaneously palpates chest wall on both sides using ulnar border of hand or palmar base. Palpation begins w lung apex and moves to same location on opposite side of chest wall ​ -Compare vibrations on both sides while moving hands from apex to base of the lung ​ -Repeat maneuver on anterior and lateral chest walls ​ ***Pneumothorax*** ​ Inspection: Diminished chest movements on the affected side. ​ Palpation: Diminished chest movements on palpation. Decreased vocal fremitus on the affected side. ​ Percussion: Tympanic note on percussion of the affected side. ​ Auscultation: Diminished breath sounds and vocal resonance on the affected side. ​ ​***Pleural effusion*** ​ Inspection: Fullness of intercostal spaces and diminished chest movements on the affected side. The apical impulse may not be visualized. ​ Palpation: Diminished chest movements on palpation of the affected side. Decreased vocal fremitus on the affected side. Trachea may be shifted to the opposite. The apical impulse may not be palpable. ​ Percussion: Stony dullness on percussion of the affected side. ​ Auscultation: Diminished breath sounds and vocal resonance on the affected side. Egophony may be present on the upper border of the effusion. ​ ***Consolidation*** ​ Inspection: Diminished chest movements on the affected side. ​ Palpation: Diminished chest movements on palpation of the affected side. Increased vocal fremitus on the affected side. ​ Percussion: Dullness on percussion of the affected side. ​ Auscultation: Bronchial breathing sounds may be present. Increased vocal resonance on the affected side may be associated with bronchophony and whispering pectoriloquy. ​ ​[**Causes of increased vocal fremitus**: pneumonia, lung abscess, inflammation & consolidation] ​ ​[**Causes of decreased vocal fremitus**: pleural effusion, pneumothorax, emphysema/COPD, bronchial obstruction, bronchial asthma] ​ **Patient w/ Shortness of Breath Video**​ ​Scenario: Progressive SOB when walking reported by 65 year old Caucasian man approx 3 wks ago. Pt concerned about new onset of s/s. \"Im having difficulty breathing\"​ - - Patient reporting needing to stop halfway with stairs to catch their breath, no palpitations, chest tightness, syncope; no stents, bit of dry nonprod cough during night and day started 3 weeks as well; breathless at night laying In bed -- wake up \[paroxysmal noctural dyspnea\] needing to catch breath, put 2 pillows under head to raise it helps slightly; fullness in abdomen 3 weeks ago; swollen ankles (as day goes on) (new finding)​ Pertinent Positives: breathlessness at night, dry cough, dyspnea on exertion, peripheral edema​ - - - - - - - Physical Exam should include: General, Skin, HEENT, Resp, Cardiac, Peripheral vasc, GI​ ​HF s/s: S3 gallop, S3, JVD, Hepatomegaly, splenomegaly, Crackles (rales), wheezing peripheral edema, positive hepatojugular reflex​ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - LAB ARTICLES \-- WEEK 6 [CARDIOVASCULAR DISEASE AND RISK MANAGEMENT: STANDARDS OF MEDICAL CARE IN DIABETES---2021 \[Purple Highlighted Area Recommendations, Screening Recommendations & Primary/Secondary Prevention\]] - - - - - - - - - - - - - - - - - - - - - - - - - - - - ASSESSING AND MANAGING THE METABOLIC SYNDROME IN CHILDREN AND ADULTS - - - - - - - - - - - - - - - The 5 *A*s framework for obesity management: Do we need a more intricate model?. *Canadian family physician Medecin de famille canadien* - - - Lab Objectives: - - - - - **[Objectives Week 7 Cardiovascular and Peripheral Vascular]** - - - - - - - - - - - - - - - - - - - - - - -   - - - EKG (Vital sign), Chest pain algorithm Trop, but if suspecting, send to ED and call EMS  Also, PCP can order echo, stress test: *Algorithm for stable CP:* - - - - - - - - - - - - - - - - - - - - - - -  **Cardiac and Peripheral Vascular System** - - - - - **Respiratory System** - - - - - - - **Patterns of respiration** - - - - - - - - - - - - **Common findings** - **Abnormal findings** - - - **Cough**: describe according to it's moisture, frequency, regularity, pitch, and loudness, quality and circumstances - - - - - - - - - - - - - - Egophony: e-\>a consolidation Petroliloquy: heard more clearly w consolidation Tactile fremitus: Increased w lung consolidation (PNA, mass, thick secretions), decreased or absent w hyperinflation (emphysema, asthma, pneumo, effusion) Percussion: resonant normal. Hyperresonant = hyperinflation (emphysema, pneumo, asthma), dull w consolidation (PNA, effusion), atelectasis, and also asthma **Acute Chest Pain Article:** 1\. Prevalence and Causes: \- About 1% of primary care visits are for chest pain \- Only 2-4% of these cases are due to unstable angina or acute myocardial infarction \- Most common causes: chest wall pain (20-50%), reflux esophagitis (10-20%), costochondritis (13%) 2\. Initial Evaluation: \- Focus on determining if immediate referral to ER is needed for possible acute coronary syndrome (ACS) \- Consider age, sex, and type of chest pain to estimate likelihood of coronary artery disease \- Use validated tools like Marburg Heart Score or INTERCHEST rule to stratify risk \- Perform 12-lead ECG on all patients with suspected cardiac ischemia 3\. Further Evaluation: \- For low-intermediate risk patients: Consider exercise stress testing, coronary CT angiography, or cardiac MRI \- Cost considerations: Exercise stress test (\$171) vs. CT angiography (\$667) vs. cardiac MRI (\$1,075) 4\. Other Important Diagnoses to Consider: \- Chest wall pain/costochondritis \- Gastroesophageal reflux disease (GERD) \- Panic disorder/anxiety \- Pericarditis \- Pneumonia \- Heart failure \- Pulmonary embolism \- Acute thoracic aortic dissection 5\. Key Points for Specific Conditions: \- Chest wall pain: Often reproducible by palpation \- GERD: Trial of proton pump inhibitor can be diagnostic \- Panic disorder: Validated screening question available \- Pulmonary embolism: Use Wells criteria or Pulmonary Embolism Rule-out Criteria (PERC) **Heart Failure Article Summary:** 1\. The clinical examination (history and physical) remains fundamental in managing heart failure patients, allowing noninvasive assessment of hemodynamic state. 2\. Patients can be categorized based on volume status (wet/dry) and perfusion (warm/cold) using the Stevenson classification. 3\. Key findings for assessing elevated filling pressures include: \- Jugular venous distention (JVD) \- Hepatojugular reflux (HJR) \- Orthopnea \- Square wave blood pressure response to Valsalva maneuver \- Bendopnea (shortness of breath when bending forward) 4\. Assessing cardiac index/perfusion is more challenging, with fewer reliable clinical findings. 5\. Some traditional signs like pulmonary rales and peripheral edema have limitations in chronic heart failure. 6\. The Stevenson profiles provide prognostic information and can guide therapy. 7\. Natriuretic peptides can complement the clinical exam but have not been shown to improve outcomes when used to guide therapy. 8\. An emerging classification system categorizes congestion based on whether right-sided, left-sided, or both ventricular filling pressures are elevated. 9\. The clinical exam is more accurate for assessing elevated filling pressures than detecting low cardiac output. 10\. Further research is needed on using right vs. left-sided congestion patterns to improve risk stratification and guide treatment. **Heart Murmurs in Children** Heart murmurs are common in children, occurring in up to 80% of children at some point. Most are innocent, but some indicate underlying heart disease. In infants, 37% of murmurs are associated with congenital heart disease. Beyond infancy, only about 1% of murmurs are associated with structural heart disease. All infants should be screened for critical congenital heart disease using pulse oximetry, ideally 24 hours after birth. Key elements of evaluation include: - - - - Referral to pediatric cardiology is indicated for: - - - - - Echocardiography is not routinely needed for evaluation of innocent-sounding murmurs without other concerns. Routine use of ECG, chest x-ray, etc. is not cost-effective for evaluating murmurs without other signs of heart disease. Emerging technologies like phonocardiography and AI algorithms may aid in murmur evaluation in the future. - - - - - **Neurological Examination: Comprehensive Guide** ================================================= **Overview of Neurological Exam** --------------------------------- The neurological examination is a fundamental process for diagnosing and managing disorders affecting the nervous system. The exam focuses on localizing lesions, identifying signs of normal and abnormal neurological function, and guiding diagnostic and management decisions. **Key Objectives** ------------------ 1. - - 2. 3. - - - **Goals of the Neurological History** ------------------------------------- - - - Review of History: PRESENT ILLNESS - - - - - PMH: - - - - - - - **Indications for Neurological Examination** -------------------------------------------- - - - **Components of the Neurological Exam** --------------------------------------- ### 1. Mental Status Testing:MMSE 30 questions - - ### 2. Cranial Nerve Examination **Cranial nerve assessment includes a review of all 12 nerves (CN I - XII) considering sensory, motor, and reflex functions.** #### **Testing Overview** - - - - - - - - - - - - - - - - - - - - - - - - - ### 3. Motor System Examination #### **Muscle Bulk, Tone, and Strength** - - #### **Motor Strength Testing** - - UMN: spastic, rigid, hyperreflexive; LMN: flaccid/ hypotonic, distal muscle atrophy, ### Motor System Testing - - - ### 4. Reflex Testing #### **Deep Tendon Reflexes (DTR)** - - - ### 5. Sensory Testing - - - - ### 6. Coordination and Gait Examination #### **Coordination Testing** - - - - #### **Gait and Balance Testing** - - **Specialized Tests: HINTS Exam** --------------------------------- Used to differentiate central from peripheral causes of acute vestibular syndrome (AVS). ### Head Impulse Test (HI-test) An assessment method that checks the vestibulo-ocular reflex by moving the patient\'s head and observing for corrective saccades. ### Nystagmus Observation Identification of spontaneous nystagmus and its direction by asking the patient to gaze left and right ### Skew Deviation Test Checking for ocular misalignment by covering and uncovering one eye and observing for any corrective movements. **Diagnostic Linkage** ---------------------- ### Interpretation - - ### Clinical Conditions - - Week 8. Headache article The article is a comprehensive review of the diagnosis and management of headache disorders. It discusses the prevalence and classification of headache types, which are divided into primary and secondary headaches. Primary headache disorders include migraines, tension-type headaches (TTH), trigeminal autonomic cephalalgias (TACs), and other less common types. Secondary headaches are attributed to underlying medical conditions like vascular, infectious, or neoplastic causes. Key Points: 1\. Primary Headaches: Migraine is the most disabling and prevalent primary headache disorder, affecting 12% of people. It is treated with NSAIDs, triptans, gepants, and the newer 5-HT1F agonist lasmiditan. Tension-type Headache (TTH) affects 38% of the population and is managed with simple analgesics like acetaminophen and NSAIDs. Trigeminal Autonomic Cephalalgias (TACs), including cluster headaches, are rarer and present with unilateral pain and autonomic symptoms. 2\. Secondary Headaches: Secondary headaches are due to underlying issues and must be evaluated for possible urgent conditions such as cerebrovascular events or infections. 3\. Management: Acute treatment options include over-the-counter analgesics, triptans, and newer agents like gepants. Preventive treatments for migraines include antihypertensives, antidepressants, antiepileptics, botulinum toxin, and monoclonal antibodies targeting the calcitonin gene--related peptide (CGRP). 4\. Diagnostic Approach: Diagnosing headaches involves a thorough history and examination, focusing on distinguishing between primary and secondary causes. Diagnostic imaging or lumbar puncture is recommended in certain high-risk cases. 5\. Emerging Therapies: Neuromodulation devices and behavioral therapies are becoming increasingly recommended, particularly for patients with contraindications or who prefer nonpharmacological treatments. Concussions - - ### Key Symptoms - - - - - - - ### Mechanism of Injury - - **Pathophysiology** ------------------- - - **Initial Evaluation** ---------------------- ### On-Field Assessment - - - - ### Sideline Evaluation - - ### Hospital or Clinic Evaluation - - **Management** -------------- ### Immediate Management - - ### Gradual Return to Activity - - - - ### Prolonged Symptoms and Special Considerations - - ### Preventive Strategies - - - **[Week 9 Musculoskeletal ]** - **Examination of the Musculoskeletal System** --------------------------------------------- ### General Principles - - - - - ### Specific Joint Examinations #### **Shoulder Examination** - - - - - - - - - #### **Elbow Examination** - - - - - - #### **Hand and Wrist Examination** - - - - - - - #### **Hip Examination** - - - - - - - #### **Knee Examination** - - - - - #### **Foot and Ankle Examination** - - - - - - - - **Common Musculoskeletal Disorders** ------------------------------------ ### Case Studies and Clinical Scenarios 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Focus on history and physical exam of the following: - - - - - **[Common Childhood Orthopedic Disorders( from Article)]** ---------------------------------------------------------------------- ### 1. Metatarsus Adductus (MTA) #### **Evaluation** - #### **Risk Factors and Indications for Work Up** - #### **Treatment and Referral** - ### 2. Clubfoot **Cavus (a high arch)** **Adduction of the forefoot (toes point medial or inward)** **Varus of the hindfoot (heel directed towards the midline) and** **Equinus (foot in plantar flexion)** \- Complex deformity characterized by cavus, adduction of forefoot, varus of hindfoot, and equinus \- Incidence around 1-2 per 1000 live births \- Can be idiopathic or associated with neuromuscular conditions/syndromes \- Diagnosed clinically, radiographs rarely needed \- Treatment is with the Ponseti method of serial casting and possible Achilles tenotomy \- After casting, patients wear foot abduction orthosis full-time for 3 months, then part-time until age 4 \- Recurrence is common (25-67% rate) and may require additional casting or surgery \- Referral to orthopedic specialist familiar with Ponseti method recommended Chronic pain is common complication #### **Evaluation** - #### **Risk Factors and Indications for Imaging** - #### **Treatment** - #### **Complications** - ### 3. Calcaneovalgus Foot #### **Evaluation** - #### **Risk Factors and Imaging** - #### **Treatment** - ### 4. Vertical Talus #### **Evaluation** - #### **Risk Factors and Work Up** - #### **Treatment** - ### 5. Cavus Foot Anomaly (High-Arched Foot) #### **Evaluation** - #### **Risk Factors and Imaging** - #### **Treatment** - ### 6. Flatfeet #### **Evaluation** - #### **Risk Factors and Indications for Imaging** - #### **Treatment** - **Specific Disorders and Management** ------------------------------------- ### Kyphosis #### **Causes and Management** - - ### Slipped Capital Femoral Epiphysis (SCFE): Displacement of femoral metaphysis anteriorly/laterally on epiphysis \*Disorder the capital femoral epiphysis slips over the neck of the femur \- Displacement of femoral metaphysis anteriorly/laterally on epiphysis \- Typically occurs in adolescents, often obese \- Can present with hip, knee, or thigh pain \- Physical exam shows decreased internal rotation and abduction of hip; persistent hip pain \- Diagnosed with AP and frog-leg lateral x-rays of pelvis \- Treatment is urgent surgical fixation \- Complications include avascular necrosis and future arthritis \- Urgent referral to orthopedics or ED needed when suspected #### **Diagnosis and Management** - - ### Scoliosis **Scoliosis:** \- Defined as spinal curve \>10° on x-ray; lateral curvature \- Most common type is adolescent idiopathic scoliosis \- Screening done with forward bend test and scoliometer \- X-rays indicated for scoliometer reading \>7° \- Curves 10-25° monitored, 25-40° often treated with bracing \- Curves \>50° usually require surgical fusion \- MRI indicated for atypical curves or early-onset scoliosis \- Referral to orthopedics recommended for curves \>20-25° #### **Diagnosis and Management** - - ### Limb Length Discrepancy #### **Diagnosis and Management** - - **Developmental Dysplasia of the Hip (DDH):** \- Spectrum from mild acetabular dysplasia to complete hip dislocation \- Key risk factors are breech presentation and family history \- Screening done with physical exam (Ortolani/Barlow tests) in infancy \- Ultrasound screening recommended at 4-6 weeks for high-risk infants \- X-rays used for screening after 4-6 months of age \- Treatment depends on age and severity - may include Pavlik harness, closed reduction, or open reduction \- Goal is to maintain concentric hip reduction to allow normal development \- Referral to orthopedics needed for abnormal physical exam or imaging **Common Causes and Risk Factors for Low Back Pain (from Article)** ------------------------------------------------------------------- ### Mechanical Low Back Pain - - ### General Risk Factors - - **Identification of Red Flags in Clinical History** --------------------------------------------------- ### Age-Specific Concerns - - ### Use of Anticoagulants - ### Constitutional Symptoms - - - **Key Physical Examination Findings** ------------------------------------- ### Neurological Evaluations - - - ### Genitourinary Symptoms - **Specific Conditions Associated with Red Flags** ------------------------------------------------- ### Spinal Epidural Abscess - - ### Cauda Equina Syndrome - ### Vertebral Compression Fractures - ### Malignancies and Metastatic Disease - **Comprehensive Guide to Conducting an Office-Based Musculoskeletal Exam( from Article)** ========================================================================================= **Introduction** ---------------- A detailed musculoskeletal exam is critical for diagnosing and managing various conditions affecting the shoulder, spine, and upper extremities. This guide covers essential steps, common disorders, and red flags that necessitate immediate action. **Recognizing Potentially Life-Threatening Conditions** ------------------------------------------------------- ### Red Flags for Immediate Evaluation - - - - ### Conditions Requiring Urgent Attention - - - - - - **Evaluation Sequence for Musculoskeletal Complaints** ------------------------------------------------------ ### General Examination Steps 1. 2. 3. 4. 5. 6. 7. 8. ### Pain and Stiffness Evaluation - - - - - - - - **Shoulder Disorders** ---------------------- ### Common Conditions - - - - - - - - - - - - - - **Elbow Disorders** ------------------- ### Key Issues - - - - - - - - - - **Wrist and Hand Disorders** ---------------------------- ### Frequent Disorders - - - - - - - - - - **Spine Disorders** ------------------- ### Spine Issues - - - - - - - -