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CPD Lab Tests_MH > CPD 2 Midterm > Flashcards

CPD 2 Midterm Flashcards

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1
Q

What is the significance of visible pulsations and/or heaves over the precordium?

A

o (precordium=portion of body over heart and lower chest)

o Visible pulsations/heaves: Right ventricular enlargement

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2
Q

Know how to palpate for S1, S2, S3, S4 and thrills (palpable murmurs).

A

o S1 and S2—use firm pressure, place R hand on chest wall. With L index and middle fingers, plpate the carotid artery in lower 1/3rd of neck. Identify S1 just before the carotid upstroke and S2 just after the upstroke
o S2 and S3—apply lighter pressure at cardiac apex to determine if extra movements
o Thrills—press ball of hand on chest to check for buzzing senation from vascular turbulence. Easier to detect if lean forward.

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3
Q

Know how to assess the apical pulse for size and understand the significance of that size.

A

o 5th interspace, mid clavicular
o > 2.5 cm evidence of Left ventricular hypertrophy (LVH) (seen in hypertension and aortic stenosis)
o If pushed laterally—enlarged heart
o If pushed medially—hyper inflated lung (eg COPD)

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4
Q

Know how to differentiate S1 from S2 using palpation of the carotid.

A

• Carotid will give you systole, so more S1 ish (??)

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5
Q

Which valves make S1 and S2 sounds? Where are these sounds best heard?

A

o S1: closure of mitral valve. Best heard over apex (5th intercostal space)
o S2: closure of aortic valve. Best heard over base (2nd intercostal space)

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6
Q

When (and where) is it normal for S1 to split? What constitutes an abnormally split S1?

A

o on inspiration
o Normal: Earlier mitral (loud) and later tricuspid sound.
o abn: 60ms apart.

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7
Q

How does one differentiate a split S1 from an S4 gallop?

A

o S4 is lower frequency than S1

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8
Q

What is the significance of variations in the intensity of the S1 sound?

A

o Feature of atrial fibrillation, premature beats, atrioventricular dissociation (HR can be slow or fast), auscultatory alternans (S1 is soft and loud with alternate beats)

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9
Q

What is the normal pattern of auscultation? Be able to name regions where each heart valve is best heard.

A
  • Aortic & Pulmonic (2nd interspace)
  • Erb’s (3rd interspace, lateral to pulmonic)
  • Tricuspid (4th interspace, JUST lateral to sternum)
  • Mitral (5th interspace, MCL)
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10
Q

What is a bruit? Where and how does one listen for them during the heart exam?

A

o Turbulent blood flow in artery which supplied blood to brain
o just lateral to Adam’s apple
o use either bell or diaphragm , or both

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11
Q

What sounds do the bell and diaphragm bring out?

A

o Bell: low pitched heart sounds

o Dipahragm: high pitched heart sounds

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12
Q

What positions will help accentuate certain heart sounds, i.e., aortic regurgitation, S3, and S4?

A

o S3 and S4—pt lying on L side, partially rolled over
o S3: soft, lo pitch; walking or elevate legs will accentuate
o Aortic murmurs, esp aortic regurgitation—pt sitting up and leaning forward

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13
Q

What is physiologic splitting of S2? What is paradoxical splitting? What is fixed splitting?

A

o Physiologic splitting: inhalationincreased negative pressure, lungs expand, increases venous return
o Paradoxical splitting: exhalation. Pulmomary valve closes before aortic valve seen in aortic stenosis, left bundle branch block
o Fixed splitting: does not vary with inspiration. Usually due to septal defect

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14
Q

How common is physiologic splitting of S2?

A

o 52.1% of normal adults in a recent study.

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15
Q

How does one differentiate a split S2 from an S3 gallop?

A

o Split S2 much higher pitch and closer to onset of S2

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16
Q

What are S3 and S4 sounds? What do they signify? What makes them? Where are they best heard? What bedside maneuvers can intensify them?

A

o S3: right after S2. Associated with heart failure (may be physiologic). Caused by oscillation of blood back and forth between walls of ventricles. Best heard: cardiac apex. Maneuver: lying on left side, partially rolled over.
o S4: right before S1. Associated with failing L ventricle. Atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle. Best heard: over L or R ventricular areas. Maneuver: lying on left side, partially rolled over.

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17
Q

How does one differentiate a pathologic S3 from a physiologic S3?

A
  • path: ssx: SOB, chest pain, orthopnea, wide or displaced apical pulse, peripheral edema, takes nitroglycerin
  • phys: looks fit and asx
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18
Q

How is hypertrophic cardiomyopathy similar to, and different from MVP?

A
  • Both diminish with squat and intensify with valsalva
  • MVP—mid systolic click
  • Hypertrophic cardiomyopathy—late systolic shwoooshy
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19
Q

What kinds of findings are we looking for on inspection of the abdomen?

A
  • Skin markings: scars, striae, dilated vessels
  • Contour: flatness, distensions, 7 Fs
  • Peristalsis: increased w obstruction
  • Pulsations: from vessels, abdominal aortic aneurysm
  • Hernias: most are umbilical
  • Ecchymosis: infiltration of the extraperitoneal tissues w blood
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20
Q

What are the 7 F’s for a distended abdomen?

A

• Fat, fluid, fetus, feces, flatus, fibroid, fatal growth

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21
Q

Why do we auscultate the abdomen before palpation?

A

• Palpation and percussion may stimulate peristalsis and alter exam findings

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22
Q

Understand normal and abnormal bowel sounds.

A
  • High pitched tinkling sounds: early obstruction
  • Absent sounds: late mechanical obstruction or ileus
  • Secussion splash: air and fluid, obstruction, pyloric stenosis
  • Peritoneal friction rub: inflammation
  • Borborygmus: long prolonged gurgles: gastroenteritis
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23
Q

Be able to perform abdominal percussion using exemplary technique.

A

• You got it!

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24
Q

What is the expected liver span at the mid clavicular line?

A

• 8cm (6-12)

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25
What is the splenic percussion sign? Know how to perform it.
* Percuss lowest costal interspace in L anterior axillary line. Normally tympanic * Ask pt to take a deep breath and percuss this area again. Dullness here is sign of splenomegaly (.20 false positive with this test) * If in doubt, percuss medially to laterally in Traube’s space until dullness is elicited; normally at mid axillary line
26
Why and how do we do light palpation? What can you do about ticklish patients?
* Begin away from pain. To help pt relax, to note guarding/tenderness, hyperesthesia, rigidity * You can use their hand, or make no sudden movements.
27
What is the significance of guarding and rigidity? What are they?
* Peritonitis or appendidicitis * Guard: voluntary contraction on palpation of ab wall mm, dt anxiety or cold hands; can be fully or partially overcome by tact and persuasion * Rigid: involuntary contraction of ab mm dt peritoneal inflammation (out of pt’s control); can never be overcome by tact or reassurance * To relax pt to distinguish: reassurance, distraction, banter
28
Be able to demonstrate deep palpation of the abdomen including the liver, spleen, and kidneys.
___
29
Which arteries are important to auscultate for bruits over the abdomen?
• Bruits over aorta and renal, iliac, and femoral arteries: obstruction
30
What is Murphy’s Sign?
* Positive sign—cholecystitis | * With your hands shoved up in there, tell pt to breathe in. Positive sign is abrupt arrest of inspiration!
31
What is rebound tenderness at McBurney’s Point?
• Possible appendicitis
32
Referred rebound tenderness (Rovsing)?
• Possible appendicitis
33
Be able to demonstrate psoas sign, obturator sign, costovertebral angle (CVA) tenderness.
* PSOAS: Flexion of thigh against resistance. To test for appendicitis * OBTURATOR: internal rotation of flexed thigh. To test for appendicitis * CVA: to test for pyelonephritis
34
• Physiological S2 spilts:
o Inspiration → listen for A2 and P2 to split | o bc ↑ venous return overloads RV and delays closure of P valve
35
• What are 5 things to note when listening to heart sounds?
o Location, timing, intensity, pitch | o Effect of respiration or special maneuvers
36
What is jugular venous distention? On what side is it measured? How is that done?
* Significance: hypervolemia, RCHF, SVC obstruction, Tricuspid stenosis or regurg * On pt’s righ side * 45 deg angle- Position pt so jugular pulse seen on lower neck, tangential light to visualize * Identify highest pt pulse is seen * Measure vertical distance bw point and sternal angle * Abn: >3-4 cm * Normal: highest point is below sternal angle
37
What is kussmauls sign?
* paradoxical increase in JVP during inspiration | * conditions that interfere w RV filling: constrictive pericarditis, constrictive cardiomyopathy, RV infx
38
what is abdominojugular reflex? When is it useful clinically? Know how to use a BP cuff to exert the correct amount of P
* alt test for JV pulses * sig: pos in subclinical RCHF, neg in SVC obstruction * position pt so JVP is seen in lower neck (45 deg angle) * press firmly on partially inflated BP cuff (25-35 mmHg) around umbilicus for 15-30 sec * (+): sustained rise in JV pressure (>4cm) * Transient <10 sec rise is normal
39
What should you note when you detect a murmur?
* Timing: systolic or diastolic, early, late, mid, pan/holo * Configuration: shape of sound (plateau, crescendo, decrescendo, crescendo-decrescendo) * Location: max intensity * Radiation * Intensity: grade (I-VI) * Quality: musical, blowing, harsh, rumbling? * Pitch * Hemodynamic changes: effects of special maneuvers
40
How are murmurs graded?
* I: very faint * II: quiet * III: moderately loud, non-palpable * IV: loud w palpable thrill * V: very loud w thrill * VI: very loud w thrill, heard w/o stethoscope
41
What are the systolic, diastolic, and both sounds?
* S: ejection click, click and murmur of MVP, pericardial rub, functional murmur, AS, PS, MR * D: S3, S4, MS, TC S, AR, PR, MS * B: pericardial rub, mammary soufflé, venous hum
42
What are effects of inspiration on different heart murmurs?
* LCHF: ↓ | * PS: ↑
43
What are the effects of Valsalva on diff heart murmurs?
* MVP: earlier click and murmur * LCHF: ↑ * PS: ↓ * HOCM: louder
44
What are effects of squatting on diff murmurs?
* MVP: delays click and murmur * LCHF: ↓ * PS: ↑
45
Which maneuvers have similar effects on murmurs?
* Inspiration and squatting | * Valsalva, standing and expiration?
46
What are the maneuvers for murmurs and their effects on heart/CO?
* Inspiration: ↑ murmurs in right heart * Expiration: ↑ murmurs in left heart * Valsalva: ↓ venous return and CO * Squatting: ↑ VR and CO * Passive elevation of both legs: ↑ VR and CO
47
What is a HOCM murmur? What are relevant, statistically sig tests?
* May appear like AS, but actually ↑ w any maneuver that ↓ VR and CO * ↑ w Valsalva * ↑ from squat to stand * ↓ w passive leg raise
48
What is best position to hear S3 and S4 gallops?
* W bell (just enough pressure to get seal) | * In mitral and tricuspid area
49
What are some findings in CHF that may indicate S3 gallop?
* ↓ ejection fraction * ↑ L heart filling pressure * ↑ BNP
50
What may cause S3?
* L and R diastolic overload (MR, TR) | * ↓ ventricular compliance (CMs, CHF, IHD)
51
What may cause S4?
* S4= pre-systolic (right before S1) * Atrial contractions causing a snap * L and R ventricular overload: systemic HTN, pulm HTN, AS, PS * ↓ vent compliant: CMs, CHF, IHD * During acute ME * Mb false + w split S1, or S1 plus ejection sounds
52
• Paradoxical splitting
o RV completes systole before LV • Expiration → A2 and P2 are switched (P2 first) • Inspiration: retards P2 to coincide with A2 • Cause: Delayed onset (LBBB, RV pacing) or prolongation (AS, HCM)
53
• What causes S3 gallops?
* oscillation of blood back and forth bw walls of ventricles dt hi input from atria. * Causes: IHD → global ventricular dysfunction (DCM) → ↓ EF (resists passive filling) → S3 * Occurs in middle 1/3 of diastole * Mb dt tensing chordae tendineae during rapid filling and expansion of ventricle
54
• S4 gallop:
* Presystolic= very late diastole * Dt atria contracting forcefully to overcome stiff or hypertrophic V →turbulence * RV: PS, pulm HTN * LV: LVH, AS, HOCM
55
• MVP:
* Mid-systolic click * Valsalva/standing: enhanced; dec vol of LV → murmur occurs sooner (systole), louder, longer * Squatting: decreased, inc venous return; moves click to later systole
56
Hypertrophic Cardiomyopathy
* Mid-systolic * Valsalva: enhanced (dec LV vol more severely distorts MV)- same as MVP * Squat (↑VR) → stand (↓VR): gets louder- same as MVP * Passive leg raise: decreases; ↑ VR
57
• Aortic Regurgitation
* can hear 3 murmurs, based on location. * Systolic ejection murmur/early diastolic murmur, w diaphragm at Apex. * Bell to appreciate the diastolic Austin Flint murmur- over LV * bounding carotid (Corrigan’s) pulse (sig in AR pts)
58
Pulmonic stenosis
* Gets louder on inspiration | * Held expiration???
59
• Mitral Regurgitation timing and shape:
* Timing: holo-systolic | * Shape: rectangular (no tapering)
60
• Mitral Stenosis
* Opening Snap (OS): dt forceful opening of mitral valve * Hear at base bc where mitral valve is heard * Quality of sound changes with bell vs diaphragm * Bell: hear lo pitch murmur * Diaphragm: higher pitched S1 and OS heard
61
• Aortic Stenosis: MSM and ejection sound
* MSM: best at apex, Split S1 followed by MSM * Mid-systolic ejection sound * best heard at aortic area, R 2nd ICS, w radiation to R neck
62
• prosthetic valves? Starr?
• Starr-Edwards = world’s first prosthetic valve, made in Portland 1960
63
• Atrial septal defect?
• LA P initially exceeds R: L → R shunt
64
Understand normal and abnormal bowel sounds.
* High pitched tinkling sounds: early obstruction * Absent sounds: late mechanical obstruction or ileus * Secussion splash: air and fluid, obstruction, pyloric stenosis * Peritoneal friction rub: inflammation * Borborygmus: long prolonged gurgles: gastroenteritis * Bruits: obstruction
65
Be able to perform abdominal percussion using exemplary technique.
* Percuss all quadrants * Listen for dullness or tympany * Unusual dullness: underlying abdominal mass * Percuss outline of liver, spleen, stomach
66
What is the splenic percussion sign? Know how to perform it.
* Check size of sleep if suspect SM * Percuss lowest costal interspace in L anterior axillary line. Normally tympanic * Ask pt to take a deep breath and percuss this area again. Dullness here is sign of splenomegaly (.20 false positive with this test) * If in doubt, percuss medially to laterally in Traube’s space until dullness is elicited; normally at mid axillary line
67
What are the tests for appendicitis?
* Rovsing’s sign: referred rebound tenderness * Rebound tenderness at McBurney’s pt (1/3 from ASIS bw umbilicus): possible appendicitis * Obturator sign: internal rotation of flexed thigh (stretches mm), right ab pain = (+) * Psoas sign: flex thigh against resistance; OR in LLD, passively extend right leg at hip * Rectal exam: for occult blood; R-side tenderness/fullness w appendicitis (pelvic/retrocoecal)
68
Keep in mind when beginning abdominal exam?
* Empty bladder * Stand on R side * Trim nails, warm shands * Pt supine w knees flexed * Watch pt’s face * Examine chest, too * Consider inguinal/rectal in M, pelvic/rectal in F
69
In addition to quadrants, what is reference terminology of abdomen locations?
* Midline * Epigastrtic- bw umbilicus, xyphoid, costal margins * Periumbilical * Hypochondrium: L and R, over lower ribs, below breast * Suprapubic/hypogastric: bw umbilicus and pubic bone * Inguinal: R and L
70
What is the order of the abdominal exam?
* Inspection * Auscultation * Percussion * Light and deep Palpation
71
What are the tests for cholecystitis, peritonitis, pyelonephritis?
* Cholecystitis: Murphy’s sign= inspiratory arrest on deep inspiration (hooking hands is best) with palpation under right costal margin * Peritonitis: Blumberg’s sign= rebound tenderness over a suspected area of abdomen * Pyelonephritis: costovertebral tenderness
72
What is an exam specific for females?
• Pelvic bimanual exam
73
How do you distinguish from intra- and extra-peritoneal masses?
* Pt does a crunch, see if mass is still present * Intra: less palpable * Extra: more palpable
74
What are most common dx for acute abdominal pain/tenderness (<7d)?
* Non-specific abdominal pain (43%) * Acute appendicitis (4-20%) * Acute cholecystitis (3-9%) * Small bowel obstruction (4%) * Urinary caliculi (4%) (not kidney stones)
75
What exams should you do for RUQ or LUQ pain? Why?
* Heart- mb IHD | * Lungs- mb pneumonia
76
What exams for lower abdominal pain?
* Woman: pelvic exam (ectopic pregnancy, ovarian cyst, uterine fibroids, PID, endometriosis) * Rectal exam
77
What are significant signs in pt appearance?
* Toxic or in acute distress? * Fever: infx (but absence doesn’t r/o) * Tachycardia and orthostatic hypotension: hypovolemia
78
What may cause peritonitis? PE? Pt appearance?
* Inflammation or perforation of a viscus (visceral organ) * Perforated peptic ulcers, diverticula, appendicitis, bowel obstruction, cholecystitis * PE: guarding, rigidity, rebound tenderness (Blumberg’s sign), TT percussion, positive Cough test, negative Carnett’s sign (+ = pain doesn’t change when tensed muscles), Markel sign (heel jar test), bowel sounds (mb absent, dt paralytic ileum) * Pt: prefer to lie very still, observe face
79
How do you assess for percussion tenderness?
* Start away from painful area | * (+)= if light percussion causes pain
80
How to perform Blumberg’s sign, cough test?
B: deep pressure for 30-60 sec, sudden rebound. (+) = pain or grimace C: if pt’s cough causes grimace or brace of abdomen; can r/o (PR 0.1)
81
How to perform merkel sign, carnett’s sign?
* M: stand on toes, drop heel hard, very sensitive. (+) = peritoneal pain * C: aka abdominal wall tenderness. Locate painful area, if crunch makes palp more painful = (+). (+) suggest NO peritonitis (but extra-peritoneal)
82
What is the risk of appendicitis? Mortality? Location? Complication?
* 7% risk * W tx: mortality <1%, elderly 5-15% * 3 cm below ileoceocal valve * Prego: 2-3 tri, gravid uterus can displace app to periumbilical or RUQ
83
What are ssx of appendicitis?
* Poorly localized epigastric or periumbilical pain * Anorexia, N/V * Lo fever * McBurney’s pt tenderness (rebound or not?)
84
What is a positive Rovsing’s sign?
* For appendicitis * Do this BEFORE McBurney’s pt * Rebound from LLQ * Referred pain to RLQ
85
What are the 3 ssx for hi PLR for appendicitis?
* RLQ pn * Migration of pain (from epigastric to McBurney’s) * McBurney’s pt tenderness
86
How is appendicitis usu dx?
* When ssx suggest, do CT | * Surgical exploration is definitive
87
What are ssx of cholecystitis?
* Early: biliary colic (ab pain increases, peaks, subsides) * Acute: continuous epigastric pain, RUQ pn, fever * PE: RUQ tender, Murphy’s sign, absent Courvoisier sign
88
How to do Courvoisier and Murphy sign?
* C: palpable, non-tender GB (mass) in RUQ, usu jaundice, suspect CA, no chole * M: pressure under R costal margin, pt takes deep breath → pain
89
What are ssx of bowel obstruction?
Constipation, acute abdominal pain, visible peristalsis (rare), abdominal distension, ↑BS
90
What are ssx of pyelonephritis? CVA tenderness test? Elderly?
* Fever, dysuria, flank pain * CVA: start w CVA thumb pressure, progress to percussion of CVA (begin at upper back) * Old: mb few sx, do urinalysis to r/o UTI
91
What can cause ascites? Amount of fluid?
* Biventricular heart failure * Lo oncotic pressure (protein loss), nephrotoc syndrome, reduced synth (malnutrion, cirrhosis) * Peritoneal inflamm (neoplastic, infx) * PE can detect when 500-1000mL
92
What are 4 best tests for ascites?
* Inspect for bulging flanks * Percussion for shifting dullness (supine dull at flanks, LLD tympanic at top) (hi spec) * Fluid wave (hi sens) * Anke edema
93
What is baye’s theorem? Ex?
* Dx accuracy ↑ w combo tests w hi sens and hi spec | * Ascites good ex

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