Final Flashcards
(353 cards)
1
Q
•With the arm at _______, center the inflatable bladder over the ____________
A
heart level, brachial artery
2
Q
•Posterior tibial A palp
A
–Curve your fingers behind and slightly below medial malleolus of the ankle
tom dick an harry
3
Q
Palpation
Left sternal Border –Right Ventricle
A
Patient supine position at 30 degrees
Place your curved fingers in the 3rd,4th and 5th interspaces at the left sternal border and try to feel the systolic impulse of the right ventricle
You can ask patient to breath out and then briefly stop breathing to improve your exam
Feel for a right sided S3 and S4 in 4th and 5th interspaces
If impulse felt- assess location, amplitude and duration
4
Q
In order to measure the JVP in a patient who is extremely hypovolemic you may need to:
a) raise the head of the bed to 90 degrees
b) lower the head of the bed to 0 degrees
A
lower the head of the bed to 0 degrees
5
Q
Venous congestion causes what for bp’s?
A
–falsely low systolic and high diastolic readings
6
Q
Read both systolic and diastolic levels to
A
•nearest 2 mm Hg
7
Q
While performing abdominal auscultation on the same patient, you hear a bruit. You proceed to palpate the area and you feel a >3cm pulsatile mass.
You are concerned that you are feeling an:
A
Abdominal Aortic Aneurysm
8
Q
Diastolic murmurs
A
b/w s2 –> s1
9
Q
A 39 year old woman presents to your office with fatigue. Which of the following patient responses during the General History would warrant further investigation?
- She goes to bed at 1 am and awakens at 4 am each day for work.
- She is frequently awakened during the night by her husband’s snoring.
- She works 12-15 hour days during the week and brings work home on the weekend.
- She has lost 15 lbs unintentionally in the last 6 months and is experiencing night sweats.
A
1.She has lost 15 lbs unintentionally in the last 6 months and is experiencing night sweats.
10
Q
A patient presents with a chief complaint of shortness of breath. During the interview you ask, “How does the shortness of breath affect your daily activities?”. This information belongs in:
a) Review of systems
b) Physical exam
c) History of present illness
d) Assessment
A
a)History of present illness
11
Q
•General Survey: Physical Exam (objective)
A
–Part of the “Physical Examination”
–Physician examines elements that relate to the patient’s general state of health- Physical Findings
•The physician’s “assessment/observation” of the patient
12
Q
•Challenges of pain management
A
–Treatment complex
- Requires knowledge of multiple types of analgesics
- Behavioral therapy
- Physical therapy
–Risk of overdose
–More than 40% of patients report that their pain is poorly controlled
13
Q
•Electronic thermometer methods
A
–Place the disposable cover over the probe
–Insert under the tongue
–Have the patient close both lips
–Watch for digital readout
–Takes about 10 seconds
–Preferred due to risk of breakage, mercury exposure with glass thermometer
14
Q
A 68 year old female presents with a productive cough and fever. During pulmonary auscultation you hear the following on inhalation of the right middle lobe. These sounds are consistent with:
a) Rhonchi
b) Crackles
c) Wheezes
d) Stridor
e) Pleural rub
A
Crackles
15
Q
Which of the following is correct?
A.The appearance of the first “Korotkoff” sound is the diastolic blood pressure
B.The lower border of the blood pressure cuff should be placed about 2.5 cm above the ante-cubital crease/fossa
C.The systolic blood pressure is defined by the “disappearance point”
A
A.The lower border of the blood pressure cuff should be placed about 2.5 cm above the ante-cubital crease/fossa
16
Q
To determine how high to raise the cuff pressure… stes
A
1.palpation
- feel radial A –> rapidly inflate cuff until pulse disappears
- add 30mmHg to it
- use as target for subsequent inflations
–prevents discomfort from unnecessarily high cuff pressures
–avoids the occasional error caused by an auscultatory gap
17
Q
ORTHOSTATIC HYPOTENSION
A
- A fall in systolic BP > 20 mmHg upon standing
- A fall in diastolic BP > 10 mm Hg upon standing
- With symptoms and tachycardia
–Lightheaded or dizzy
18
Q
•Bradycardia
A
–<60 beats per minute
19
Q
When auscultating, you hear split heart sounds. Which of the following is correct?
•
A.In general, split heart sounds are pathological
B.A2 heart sound is often heard louder than P2 due to the high pressure in the aorta
C.P2 heart sound is often heard louder than A2 reflecting the higher pressure in the pulmonary artery
D.Only S2 is split into A2 and P2, S1 heart sound does not split as it does not vary with respiration
A
A.A2 heart sound is often heard louder than P2 due to the high pressure in the aorta
20
Q
types of crackles sounds
A
fine:
- beginning of fluid buildup/atelectasis
- Often high pitched
- Very brief
coarse:
greater volume of fluid buildup
- •Louder
- •Lower in pitch
- •Often described as velcro being pulled apart
- •Louder in inspiration
21
Q
Evaluation of Swelling or Edema
A
- Unilateral or bilateral?
- Grade? (pic)
- How far up the leg?
- Location of edema suggests site of occlusion
•Measure the calves 10 cm below the tibial tuberosity
- Normal difference in calf circumference <3cm
22
Q
A 24 year old male with no significant past medical history presents with 1 week of severe vomiting and diarrhea. He is unable to keep down any liquids or solids. He appears pale, weak, ill and lethargic. You suspect that he is severely dehydrated. Which of the following would you expect to find on exam?
A.Bradycardia
B.Orthostatic hypotension
C.A normal general survey
D.An increased (widened) pulse pressure
A
23
Q
stare of hyperthyroidism
A
Sustained and unblinking
24
Q
Distinguishing Between
S1 and S2
A
palp carotid while listening to heart sounds
S1 will occur just before the carotid upstroke
S2 will follow the carotid upstroke
S1 normally heard louder than S2 at the apex
S2 normally heard louder than S1 at the base
S1 is the “lub” S2 is the “dub”
25
Glass thermometer method
Shake down to \<35oC (96oF)
Insert under tongue
Have patient close both lips
Wait 3-5 minutes
Read
Reinsert for 1 minute and read again
If still rising repeat until stable
26
–Iliofemoral vein occlusion = presentation
* painful, pale swollen leg
* tenderness in the groin
27
Displacement of the apical impulse may seen in
Êpregnancy, cardiac enlargement
28
A 68 year old man with a history of hyperlipidemia, diabetes mellitus, and hypertension complains of pain in his right calf whenever he walks one block. He states that the pain resolves with 10 minutes of rest. He has a 40 pack year smoking history.
Which of the following would be most likely found on exam?
1. Marked peripheral edema
2. An ulcer over the left lateral malleolus
3. An ulcer over the left great toe
4. Homan’s sign
●
An ulcer over the left great toe
29
Physiologic Splitting of S2
* Made up of Aortic closure and Pulmonic Closure (A2 P2)
* Left sided events in the heart precede right sided events
* aortic during exhale = slightly earlier than pulm
inhal = increase venous return --\> delays pulm closure
= decrease SV --\> early closure of aortic
[https://www.easyauscultation.com/cases-waveform?coursecaseorder=3&courseid=22](https://www.easyauscultation.com/cases-waveform?coursecaseorder=3&courseid=22)
30
Jugular Venous Pulsations and Waveforms
look for pulsations right behind SCM or suprasternal notch
observe R IJ
pt supine @ 30degrees
turn head to opp side --\> pen light
* if volume depleted = lower head
* if volume overloaded = raise head
31
Rhonchi: charavteristics
* Low pitch with snoring quality
* Can be heard throughout inspiration and expiration
* Louder than crackles due to larger secretions
32
MEASUREMENT BASED CARE OF CHRONIC PAIN
1. Pain intensity and interference with daily activities
2. Mood (depression, anxiety)
3. Effect of pain on sleep
4. Risk of co-occurring substance abuse
5. Opioid dose and calculate dose equivalency
33
The timing of this murmur is:
a) holosystolic
b) late systolic
c) early diastolic
d) systolic ejection
e) presystolic
holosystolic
34
•Tachypnea (adult abnorm)
–~\>20 breaths per minute in an adult
35
Regarding the apical impulse:
a) It is normally the size of a dime
b) It is normally located at about the second intercostal space at the mid-clavicular line
c) It normally can be felt through the first two thirds of systole
d) It is normally high, slow and rumbling in amplitude
It normally can be felt through the first two thirds of systole
## Footnote
a = nickel
b = 5th IC space, 1/2in medial of mid-clav line
d = small, brisk and tapping in amp
36
temp methods: axillary
–Lower than oral temperatures by 1o C
–Takes 5-10 minutes to register
37
JNC 7/8 BLOOD PRESSURE CLASSIFICATION FOR ADULTS
38
Ankle-brachial Index (ABI)
Noninvasive Diagnosis of PAD
39
Deep Venous Thrombosis
•Palpate for venous tenderness or cords
* inguinal area, medial to femoral pulse
* calf: pt's knee flexed and relaxed - gentle compress M aga tibia with fingerpads
absence of tenderness/cords does NOT rule out DVT
homans!!
* •Discomfort behind the knee with forced dorsiflexion of the foot
40
Midsystolic murmur
This occurs after S1
slight gap after S1 before the murmur starts
ends before S2
Aortic and Pulmonic Stenosis.
41
normal RR in adults =
12-20
look when pt isn't looking to not affect it
42
S4 Gallop
end of diastole: contraction of atria "atrial kick"
* •Atria ejects stream of blood into stiff hypertrophic ventricle causing reverberation
* Pathologic:
* Failing, hypertrophic left ventricle
* Hypertension
* Severe Aortic Stenosis
* Hypertrophic Cardiomyopathy
[http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=25](http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=25)
43
Upon palpation of the precordium you notice a prominent pulsation in the left second interspace. Which of the following could explain your finding.
a) Left Ventricular Hypertrophy
b) Aortic Aneurysm
c) Pulmonary Artery dilation
d) Dextrocardia
Dextrocardia
44
if there is irregular ryhtym, listen at the \_\_\_\_\_\_\_\_
cardiac apex
45
Isometric Hand Grip
increase intensity of systolic murmurs Mitral regurgitation, and Ventricular septal defect
increase intensity of diastolic murmurs of pulmonic stenosis, mitral stenosis and Aortic regurgitation
46
heart P chart
47
S2
semilunar: aortic \> pulm
splitting = during inspiration
48
IDIOPATHIC PAIN
•Pain without an identifiable etiology
49
f/u Q about productive cough
Quality
Quantity of sputum
Presence of blood ( hemoptysis verses other sources of blood)
50
A 35 year old female presents for a comprehensive evaluation. Her vital signs are: Temperature: 98.7oF, Heart Rate: 112 bpm, Respiratory Rate: 16 bpm, Blood pressure: 120/65 mm Hg. This patient has which of the following?
A.Hypertension
B.Bradycardia
C.Tachypnea
D.Tachycardia
E.Bradypnea
A.Tachycardia
51
•Normal response to standing
–Blood pools in the LE and abd & slight drop in cardiac output
–SBP: No change or slight decrease
–DBP: No change or slight increase
–HR: NL increase of 5-20 bpm
52
Numeric Grading System for Peripheral Pulses
* Bounding pulses may indicate aortic insufficiency
* Asymmetric pulses occur in arterial occlusion
53
•Tachycardia
–\>100 beats per minute
54
what is the least accurate temp taking
Axillary
55
Great saphenous
dorsum of food
anterior to medial malleolus
up medial aspect of leg
joins femoral vein below inguinal ligament
56
murmurs by location: erb's point
aortic regurg
57
what is this sound?
Friction Rub
58
A 35 year old female presents for a comprehensive evaluation. Her vital signs are: Temperature: 98.7oF, Heart Rate: 98 bpm, Respiratory Rate: 30 bpm, Blood pressure: 120/65 mm Hg. This patient has which of the following?
A.Hypertension
B.Bradycardia
C.Tachypnea
D.Hypotension
E.Bradypnea
A.Tachypnea
59
Apical Impulse
the 5th intercostal space in the mid clavicular line
VISIBLE! = usually PMI
60
Physiologic (innocent) Murmurs:
* Caused by increased blood flow across normal valve anatomy
* Due to conditions that are outside of heart
61
OTHER THINGS TO LOOK FOR WHEN ASSESSING RESPIRATORY RATE AND RHYTHM
•Effort
–Signs of increased work of breathing
* Accessory muscle use
* Supraclavicular retraction
* Distress
–Diaphoresis, anxiety, altered mental status
•General survey and skin findings
–Nail clubbing, cyanosis, pallor
62
Oral temp can be affect by
not recommended if
higher/lower than core body temp?
–Not recommended if: unconscious, restless, can’t close mouth
–Affected by: hot/cold liquids, smoking
–Lower than core body temp
63
[http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=29](http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=29)
Patent Ductus Arteriosus
continuous murmur - loudest in systole
–Loud
–Harsh, machinery like
–Medium pitched
64
palp pop A
flex knee with leg relaxed, place fingertips of both hands so that they meet in the midline behind knee
DEEP! and more diffuse --\> diff to find
–Alternative: patient is prone, knee is flexed to 90o, lower leg is resting against your shoulder or upper arm, press both thumbs deeply into popliteal fossa
65
A 12 Yo male presents for a pre-participation sports physical. He has no complaints. His family history includes 2 relatives that died suddenly in their late teens from "heart problems". On examination you hear a systolic murmur and suspect hypertrophic cardiomyopathy. You would like to distinguish the murmur of hypertrophic cardiomyopathy from the murmur of aortic stenosis. Which of the following will increase the loudness of the murmur of hypertrophic cardiomyopathy :
a. Squatting position
b. Performing Valsalva maneuver
c. Release of the Valsalva
d. Sitting up and leaning forward
●
a.Performing Valsalva maneuver
66
A 64 year old male with a history of tobacco use (60 pack year) presents for an evaluation. On General Survey, you note clubbing of his nails. Upon auscultation, during exhalation, you hear the following diffusely throughout the entire thorax. This sound is consistent with a:
a. Normal finding
b. Wheeze
c. Crackle
d. Friction Rub
Wheeze
67
A 24 year old male with no significant past medical history presents with 1 week of severe vomiting and diarrhea. He is unable to keep down any liquids or solids. He appears pale, weak, ill and lethargic. You suspect that he is severely dehydrated. Which of the following would you expect to find on exam?
A.Bradycardia
B.Orthostatic hypotension
C.A normal general survey
D.An increased (widened) pulse pressure
A.Orthostatic hypotension
68
what is a –Normal response to hard work, sustained stress/grief
Fatigue
69
what is this sound
Characteristics:
Creaking, leathery sound
End of inspiration and beginning of expiration
Etiology:
Caused by rubbing of inflamed pleural surfaces against lung tissue
Clinical Causes:
–Pleural effusion
–Pleuritis
70
technique for Tactile Fremitus
unar base of hand
Have them repeat “ninety-nine” or “one-one-one.”
71
–Popliteal vein occlusion = presentation?
swollen lower leg/ankle
72
Poor sound transmission during auscultation might be due to
–Pleural effusion
–Pneumothorax
–COPD
73
bradycadia (adult abnorm)
less than 60 bpm
74
normal upstroke of carotid pulse
brisk, smooth, immediately follows S1
75
pulse pressure
difference between systolic and diastolic pressures
## Footnote
•“Normal” is approximately 30-40 mmHg
76
Pulsatile mass in the abdomen suggests
•abdominal aortic aneurysm
77
ØDecreased Tactile Fremitus: bilateral
copd
chest wall thickening
78
This patient’s femoral, popliteal, dorsalis pedis and posterior tibial pulses are each 1+ bilaterally. You would describe these pulses as:
a) bounding
b) brisk
c) diminished
d) absent
a)diminished
79
Positioning of the Patient During the Cardiac Exam
80
special maneuvers of auscultation
left lateral
lean forward and exhale --\> listen at apex
81
diaphragm: shape and what kind of sounds
Diaphragm (flat across)High pitched sounds
82
•If you find an auscultatory gap
–record your findings completely (e.g., 200/98 with an auscultatory gap from 170–150).
83
Heaves or lifts-
§Movement of the thorax and ribs as a result of forceful ventricular contraction, or Hyperdynamic muscle
84
Gradations of Murmurs
85
Pain and cramping in the legs during exertion that is relieved by rest is termed?
Intermittent claudication
pain and/or cramping in the lower leg due to inadequate blood flow to the muscles
86
Location of edema suggests site of \_\_\_\_\_\_\_\_\_
occulusion
87
What is the correct order of the examination of the Thorax and Lungs?
a) Inspection, palpation, percussion, auscultation, special tests
b) Percussion, auscultation, special tests, inspection, palpation
c) Palpation, inspection, percussion, auscultation, special tests
d) Special tests, Inspection, palpation, percussion, auscultation
●
a)Inspection, palpation, percussion, auscultation, special tests
88
how to measure A.Orthostatic hypotension
* Measure BP and HR supine (after pt. has rested for 3-10 minutes) and then within 3 minutes after the pt. stands up
* Defined as
–Drop in Systolic BP \> 20 mm Hg
or
–Drop in Diastolic BP \> 10 mm Hg
89
To enhance the auscultation at the apex, which important maneuver should you perform?
a) Place the patient in the supine position with the head elevated at 30 degrees
b) Have the Patient sit and lean forward
c) Place the patient in the left lateral decubitus position
d) Place the patient in the supine position with the head of the bed at 60 degrees
●
a)Place the patient in the left lateral decubitus position
90
Systolic murmurs
b/w s1-s2
## Footnote
•Can be further categorized as early, mid, late or holosytolic
91
SOMATIC (NOCICEPTIVE) PAIN •Modulated by
–Psychological processes
–Neurotransmitters (endorphins, histamines, acetylcholine, serotonin, norepinephrine and dopamine)
92
Measuring the JVP:
normal?
what's the point?
highest oscillation pt of IJ --\> sternal angle in centimeters
Normal is \< 3cm above the sternal angle or \< 8cm above the right atrium
The JVP provides a rapid estimate of the CVP (central venous pressure) useful in assessing volume status, especially for congestive heart failure
93
murmurs by location: mitral
normal S1, S2, (S3, S4)
MVP
mid systolic clikc
OS
mitral regurg
94
symptoms of peripheral artery disease being....
one level below level of arterial narrowing
95
THE FOUR CARDINAL VITAL SIGNS
* Blood pressure (BP)
* Heart rate (HR)
* Respiratory rate (RR)
* Temperature (T)
96
how to tell the difference b/w if you are palp the internal jugular vein or carotid artery?
if you press down on it, pulsations should go away with the vein
97
Pericardial Friction Rub
2 layers of inflammed pericaridum rubbing together
"velcro"
high pitched: heard best with diaphragm
[http://www.easyauscultation.com/cases-waveform?coursecaseorder=6&courseid=28](http://www.easyauscultation.com/cases-waveform?coursecaseorder=6&courseid=28)
98
A 55yo male presents with a complaint of “shortness of breath”. Upon further expansion of the chief complaint using the OPPQRSST+ AA you find that he has been waking up in the middle of the night, usually about 2 hours after going to bed with sudden shortness of breath. You would record this symptom as:
a) Paroxysmal nocturnal dyspnea
b) Orthopnea
c) Angina
d) Dyspnea
a)Paroxysmal nocturnal dyspnea
99
Lower border of the cuff should be about
•2.5 cm above the antecubital crease
100
Allen test
* Test for occlusive disease of the ulnar and radial arteries
* Should be done before any procedure that punctures the radial artery
* Procedure:
1. Patient makes tight fist with one hand
2. Compress both radial and ulnar arteries firmly between thumb and fingers
3. Ask patient to open hand into relaxed, slightly flexed position, the palm is pale
4. Release pressure over the ulnar artery – if patent, palm flushes within about 3-5 seconds
5. Test patency of radial artery by releasing pressure over radial artery while ulnar artery still compressed
101
A 32-year-old male with no past medical history presents for an evaluation. During the cardiac examination, you auscultate at the pulmonic area and hear the following during inspiration :
This is due to:
a) splitting of S1 and increased preload
b) splitting of S1 and decreased preload
c) splitting of S2 and increased preload
d) splitting of S2 and decreased preload
a)splitting of S2 and increased preload
102
Palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking are called:
a) Retractions
b) Tactile fremitus
c) Percussion
d) Transmitted voice sounds
a)Tactile fremitus
103
SOMATIC (NOCICEPTIVE) PAIN
•Linked to tissue damage (afferent A-delta, C-fibers)
* –Skin
* –Musculoskeletal
* –Viscera
Sensitized by inflammatory mediators
Sensory nervous system intact
* –Examples
* •Arthritis
* •Spinal stenosis
•Acute or chronic
104
Bell: shape and what kind of sounds
Bell (concave in shape) Low pitched sounds
105
Heart Murmurs
•Sounds that occur when blood flows across valves in the heart
sound created is loud enough to be detected with a stethoscope
106
STEPS TO ENSURE ACCURATE BP MEASUREMENT
1. avoid exercise, smoking, caffeine for 30 min prior
2. exam room = quiet, comfortably warm
3. pt sits quietly in chair with feet on floor for 5min
4. no clothing, scarring, lymphedema (breast ca)
5. palp brachial A for pulse
6. position arm so brachail A @ heart lvl (4th intercostal)
7. rest arm on table, above pt's waist, support arm @ mid chest lvl
107
Broncho-vesicular or Bronchial Breath Sounds Heard in Distant Locations means
air-filled lung has been replaced by fluid-filled or solid lung tissue.
108
A 47 year old female with a BMI of 42 presents for evaluation. You suspect that your standard adult blood pressure cuff will not fit on her arm. Which of the following is the correct way to size her blood pressure cuff?
A.The width of the inflatable bladder should be about 80% of the upper arm circumference
B.The width of the inflatable bladder should be about 40% of the upper arm circumference
C.The length of the inflatable cuff should be about 20% of the upper arm length
D.The length of the inflatable cuff should be about 50% of the upper arm length
E.The length of the inflatable cuff should be about 60% of the upper arm circumference
A.The width of the inflatable bladder should be about 40% of the upper arm circumference
109
Distinguishing
Percussion Notes
•In general air filled tissues are “resonant”
–Such as lung tissue
•Fluid filled or solid tissues are dull.
110
•White Coat Hypertension
–the office blood pressure is high but ambulatory pressures are normal
–cardiovascular risk is low
–constituting roughly 15% to 20% of Stage 1 hypertensives
111
murmurs by location: pulmonic
innocent
ASD
PDA
splitting s2
pulmonic regurg/stenosis
112
•Axillary temperatures
─Lower than oral temperatures by approximately 1°
─Generally considered less accurate than other measurements.
113
cough: Subacute
3-8 weeks
## Footnote
causes:
* post infectious cough
* Bacterial sinusitis
* asthma
114
•Review of Systems (subjective)
–Part of the “Health History”
–Physician asks questions that are related to the patient’s general state of health
–Patient reports the their answers to the questions
–Include: Weight changes? Fatigue and weakness? Fever, chills, night sweats? Pain?
115
A 35 yo female with history of tobacco use (40 pack years) presents with cough for the past 5 weeks.
While performing the physical examination you:
* press your left 3rd finger distal inter-phalangeal joint firmly on her posterior chest
* Then, strike that joint with your right third finger with a quick, sharp taps and relaxed wrist motion, at right angles to your left third finger
What physical exam technique is this?
Percussion
116
–Wide Pulse Pressure (increased)
(\>50mm Hg)
•Pulse will feel strong and bounding on palpation
* •Increased stroke volume
* •(Coarctation of the aorta)
* •(Aortic Regurgitation )
117
tips for handling bp in Obese patient
•use a 16 cm cuff, thigh cuff or very long cuff
use cuff on forearm and palpate radial pulse
118
Pitch of the Murmur
Determined by auscultation
**bell** = low pitch
**Diaphram** = medium to high
119
how to improve palp of apical impulse?
left lateral decubitus
ask pt to stop breathing
120
Palpation of the
Anterior Chest – Expansion
normal =
–Normal expansion is about 2”-5“
same circling hand technique as posterior chest wall
121
Abdominal Aortic Aneurysm (AAA)
* \>3 cm suggestive
* Risk factors
* –Older age
* –Male
* –Smoking
* –Family history
122
clinically significant weight loss
• \>5% of usual over 6 months
123
In order to measure the JVP in a patient who is extremely hypovolemic you may need to:
a) raise the head of the bed to 90 degrees
b) lower the head of the bed to 0 degrees
•
lower the head of the bed to 0 degrees
124
Hemoptysis
•Coughing blood from the lungs
uImportant to distinguish from non pulmonary sources of blood
125
•Epitrochlear lymph nodes
medial surf of arm - approx 3cm aove elbow
–Drain ulnar surface of forearm and hand, 4th and 5th fingers, adjacent middle finger
126
•“Four A’s”
–Analgesia
–Activities of daily living
–Adverse effects
–Aberrant drug-related behavior
•Drug seeking, use despite harm, compulsive use, craving
127
[http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=30](http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=30)
aortic stenosis
128
You note that Mr. C’s JVP measurement is 5cm above the sternal angle. This finding is:
a) normal
b) below normal
c) above normal
above normal
: \> 3cm above the sternal angle is considered elevated
129
clinical causes of rhonchi
Pneumonia
Bronchitis
Chronic Obstructive Pulmonary Disease ( COPD)
130
Early diastolic decrescendo Murmur
immediately after s2, fades before s1
Aortic and Pulmonic Regurgitation
131
Korotkoff sounds are ___ in pitch, and better heard with the \_\_\_\_
low, bell
132
Bruit
–turbulent blood flow
–blood flows through an artery that is narrowed
133
You would like to examine the Jugular Venous Pressure (JVP) in your patient. The usual starting point for the assessing the patient’s JVP is to elevate the head of the bed to:
a) 60 degrees
b) 180 degrees
c) 30 degrees
d) 90 degrees
30 degrees
134
Radiation of murmurs
* Direction that the sound moves away from the area of greatest intensity
* Rule of thumb: radiation of sound is in the direction of the blood flow away from the point of maximal intensity
135
•Measure BP and HR in 2 positions....
what is the effect that is normal
–Supine – after resting 3-10 minutes
–Standing – within 3 minutes after patient stands up
•Normal
–Systolic pressure drops slightly or remains unchanged
–Diastolic pressure rises slightly
136
what methods of temp taking use –Infrared thermometry
Tympanic, temporal A
137
•Hyperpyrexia
1. –Extreme elevation \>41.1oC (106oF)
138
S4
atrial contraction
patho in adults --\> change in ventricular compliance
139
To further evaluate the clinical suspicion of lower extremity arterial occlusive disease on this same patient, you would perform:
a) measurement of the ankle-brachial index (ABI)
b) bilateral femoral palpation
c) an assessment for pitting edema
d) measurement of the calf size bilaterally
a)measurement of the ankle-brachial index (ABI)
140
ERRORS LEADING TO INACCURATE BP MEASUREMENT
•Cuff too small (narrow)
–BP will read high
•Cuff too large (wide)
–BP will read low on a small arm and high on a large arm
•Brachial artery 7-8 cm below heart level
–Pressure 6 mm Hg higher
•Brachial artery 6-7 cm higher
–Pressure 5 mm Hg lower
•Loose cuff or bladder
–Falsely high readings
141
how to count for HR?
normal rhythm, rate = 30s x 2
unusually fast/slow = 60s
142
Mr. Smith comes to your office for a rash on his chest. He describes the quality of the pain as “burning”, “lance like” and “shock-like” in quality. On examination, you note a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. You suspect that he is suffering from shingles. What is the most likely source of Mr. Smith’s pain?
A.Somatic pain
B.Neuropathic pain
C.Nociceptive pain
D.Psychogenic pain
E.Central sensitization pain
A.Neuropathic pain
143
Superficial Inguinal Lymph Nodes
•Horizontal group
–High in anterior thigh below inguinal ligament
•Vertical group
–Clusters near upper part of saphenous vein
144
•“True blood pressure”
–Average BP measured over days to weeks
–Concern: may not correlate with office readings
* Observer/measurement error, physiologic fluctuations, anxiety, situation
* Errors affect clinical decision making
145
•Once you have palpated the systolic pressure, deflate the cuff promptly and completely, wait....
15-30s
146
Inspection and Palpation of the Epitrochlear Lymph Nodes
groove b/w bicep and tricep - 3cm above medial epicondyle
•Difficult or impossible to identify in healthy people
–Enlarged in local or distal infections, associated with generalized lymphadenopathy
147
Signs of Distress: depression
–Inexpressive or flat
–Tearful
–Poor eye contact
–Psychomotor slowing
148
auscultatory gap is associated with
arterial stiffness and atherosclerotic disease.
149
ISOLATED SYSTOLIC HYPERTENSION
* Systolic BP \>140 mm Hg
* Diastolic BP \<90 mm Hg
* Tx in pt \>60 years reduces mortality and complications from cardiovascular disease
150
Delayed carotid upstroke occurs in
aortic stenosis
151
An 87 year old male with a history of heart failure who is taking multiple medications presents for evaluation. You observe that he has periods of deep breathing alternating with apnea. What type of breathing is this:
A.Obstructive Breathing
B.Ataxic (Biot’s breathing)
C.Hyperventilation
D.Sighing Respiration
E.Cheyne-Stokes Breathing
A.Cheyne-Stokes Breathing
152
Inspect Color : bronchitis v emphysema
153
TYMPANIC MEMBRANE TEMPERATURE: METHODS
* Make sure external auditory canal (EAC) is free of cerumen
* Place the disposable cover over the probe
* Position probe in EAC so infrared beam pointed at tympanic membrane
* Wait 2-3 seconds until digital reading appears
* More variable than oral or rectal temp
154
Squatting (release of Valsalva):
–Increased venous return to the heartà increased left ventricular volume
–Increased arterial blood pressure, increased peripheral vascular resistance àincreased vascular tone
155
Pathologic Murmurs:
* Caused by alterations in valve anatomy
* Due to leaking or narrowing of blood flow
* Blood flow through abnormal passages in or near the heart may also cause audible pathologic heart sounds
156
Kentucky: heart sound
diastole: lub du bub
s3
–Kids/young adults: rapid deceleration of blood against ventricular wall
–Older adults: pathologic change in ventricular compliance (CHF)
157
where to palpate for carotid A?
lower third of neck, medial to SCM
158
palpable S2 @ aorta palp spot =
pulsation?
sys htn
dilated/anuerysm
159
An unrecognized auscultatory gap may lead to
–an underestimation of systolic pressure or an overestimation of diastolic pressure
160
Adventitious (Added)/ABNORMAL Sounds
•Adventitious sounds include:
–Crackles
•formerly called rales
–Wheezes
–Rhonchi
–Stridor
161
Which of the following jugular venous pulsation waveforms represents atrial filling?
a) c
b) y
c) v
d) a
e) x
v
162
Continuous Murmur
Patent Ductus Arteriosus.
163
palp doralis pedis
dorsum of foot, distal to navicular, b/w extensor hallucis longus and extensor digitorum
164
Sequence of the Cardiac Physical Exam
ÊBlood Pressure and Heart Rate measurement
ÊInspection (Neck and Precordium)
ÊPalpation
ÊPercussion (largely replaced by Palpation)
ÊAuscultation
ÊSpecial Tests/Maneuvers
165
Diameter and duration of the Apical Impulse
supine: diameter \< 2.5 cm
* may be larger in the left lateral decubitus position
\> 3cm indicates left ventricular enlargement
duration: first 2/3rd of systole
166
what IS THE LEADING CAUSE OF DISABILITY AND IMPAIRED PERFORMANCE AT WORK
chronic pain
167
•Hypotension (adult abnorm)
–Variable. Generally defined as \<90/60 mm Hg
168
Palpate the Aorta
•Press firmly in the epigastrium, slightly to the left of the midline
**•Normal width of the aorta is no more than 3 cm**
A widely dilated artery or pulsatile mass may indicate aneurysm!!!!
169
•Masked Hypertension
–the office blood pressure is normal but the ambulatory blood pressure is high
–indicating high risk of cardiovascular disease
–Approximately 10% of the general population
170
•When the artery is fully compressed & fully open will soudns be heard?
no sounds will be heard
171
Auscultation of the
Posterior Chest
same technique as percussion
listen at least 2 full breath @ each location
172
When performing a cardiac exam on a patient, you place the patient in the supine position with the head of the bed at 30 degrees. You place your index and middle finger on the patient’s right carotid artery in the lower third of the neck to feel for the carotid upstroke while you auscultate the patient’s chest. The sound following the carotid upstroke is:
a) S1
b) S2
c) S3
d) S4
s2
173
Inferior mesenteric artery supplies
descending and sigmoid colon, proximal rectum
174
A 43 year old Hispanic female presents to the emergency department with the complaint of chest pain of 1 week duration. There is no cognitive or language barrier. Which of the following is correct?
A.The severity of her pain should be assessed using the “Wong-Baker” scale
B.This is most likely somatic pain
C.The physician must be aware that health care disparities exist in pain treatment and delivery of care
D.This is considered chronic pain
A.The physician must be aware that health care disparities exist in pain treatment and delivery of care
175
tips to handle White coat HTN
•relax patient and re-measure BP later in visit
176
Signs of Distress: chronic/respirtoary
•Cardiac or respiratory
–Clutching chest
–Pallor
–Diaphoresis
–Labored breathing
–Coughing
•
177
Palpation of Femoral A
deep, below inguinal ligament
midway b/w ASIS and pubic symphysis
may need 2 hands, one on top of the other, in obese patients
178
When performing palpation, percussion and auscultation of the lung, it is essential to progress in which of the following patterns (particularly for palpation, percussion and auscultation).
a) Staircase
b) Vertical
c) Ladder
d) Inner to outer
•
Ladder
179
pt's arm should be slightly ________ @ elbow while using a bp cuff
flexed
180
A 58 year old male presents for evaluation. His vital signs are: T: 98.6 F, BP: 120/70 mm Hg, HR: 72 bpm, RR: 15 bpm.
Height: 6’ Weight: 199 lbs Waist Circumference: 42 inches
Which of the following is correct?
## Footnote
A.His BMI is normal
B.He is obese
C.He is at high risk for diabetes, hypertension and cardiovascular disease
D.He is underweight
A.He is at high risk for diabetes, hypertension and cardiovascular disease
181
Precordium
portion of the body over the heart and lower chest.
182
Peripheral Venous Disease
183
Superficial veins are
subcutaneous, with poor support
great and small saphenous
184
Deflate bp cuff slowly at a rate
•2-3 mm Hg per second
185
when should carotid A ausculation preceded palpation?
if plaque concern
bruit = narrowing of carotid A
Prevalence of patients with asymptomatic bruits increases with age
186
patient presents for evaluation. This is your first time seeing the patient. She does not bring any of her medical records. Her BMI is “normal” (her arm is not overly large or small). You obtain her blood pressure. It is 145/95 mm Hg. She states that she takes her BP at home daily and it is never above 120/70 mm hg. Which of the following is correct?
A.The patient may have masked hypertension
B.The BP cuff that the patient is using at home is too small
C.The patient may have white coat hypertension
D.You should diagnose the patient with stage 2 hypertension
E.You may have incorrectly positioned the patient’s arm significantly above heart level
A.The patient may have white coat hypertension
187
True or False: Either the bell or the diaphragm of the stethoscope may be used when auscultating a blood pressure
True. Use of either part is correct.
188
obesity: heart
htn
cad
afib
heart failure
cor pulmonale
varicose veins
189
Normally, there may be a difference in pressure of _______ b/w right and left arms
5-10
## Footnote
•Subsequent readings should be made on the arm with the higher pressure
190
Auscultation of Abdominal Arteries for Bruits
* 4-20% of healthy people have abdominal bruits
* Presence of both systolic and diastolic components = turbulent blood flow
–Stenosis
–Atherosclerotic disease
191
If the cuff is too small (narrow)...
If the cuff is too large (wide)...
BP = too high
BP = too low on a small arm and too high on a large arm
192
tips for handling Arrhythmias
average several measurements; ambulatory monitoring
193
Wong-Baker
•FACES Pain Rating Scale
–children as well as patients with language barriers or cognitive impairment
194
PAIN description
•“an unpleasant sensory and emotional experience” associated with tissue damage
sensory, emotional, cog processing
•May lack a specific physical etiology
195
Summation Gallop
196
S3
blood rushing from atria -\> ventricle
heard in children
abnorm in adult heart
197
Fremitis is decreased or absent in which of the following conditions:
A.Thin chest wall
B.Pneumonia
C.Pneumothorax
•
Pneumothorax
198
Bruits
•turbulence of blood
199
realistic goals for wt loss recomm
5-10% = reduces DM and other obesity-assoc health problems
0.5-2lb/wk
deficient 500cal/day: 800-1200 total - healthy eating
200
AORTIC REGURGITATION
•A high pitched decrescendo murmur starting immediately after S2 and continuing throughout the first half of diastole.
best heard at Erb’s point
accentuated when the patient sits, leans forward, holds breath after exhalation.
[http://www.easyauscultation.com/cases-waveform?coursecaseorder=12&courseid=31](http://www.easyauscultation.com/cases-waveform?coursecaseorder=12&courseid=31)
201
percussion of posterior chest wall only penetrates
5-7cm : not help with deep-seated lesions
202
once first sound is heard on bp, continue to lower until sounds become \_\_\_\_\_\_\_\_\_\_\_\_\_\_
then what?
* sounds become muffled and then disappear
* confirm disappearance, listen as the pressure falls another 10-20 mm Hg
deflate rapidly to 0
= diastolic P
203
Bradypnea (adult abnorm)
–\<12 breaths per minute
204
Signs of Distress: anxiety
–Facial expression
–Fidgeting
–Cold hands
–Moist palms
205
chronic A v V insufficiency chart
206
You are seeing an 8mo male with no significant past medical history. He has been admitted to the hospital with pneumonia. You are asked to report on his most recent temperature. Upon review of the chart you see that the rectal temperature is reported as 99 degrees F. If the temperature had been taken orally at the same time it would have registered as about:
A.101 degrees F
B.100 degrees F
C.99 degrees F
D.98 degrees F
E.97 degrees F
A.98 degrees F
rectal usually 1 degree higher than anywhere else in body
207
–Narrow Pulse Pressure (diminished)
–(\<30 mmHg)
•Pulse will feel weak and small
* •Hypovolemia
* •Decreased stroke volume
* •(Aortic Stenosis)
208
TEMPERATURE: NORMAL
* Average: 37oC (98.6oF)
* Varies throughout day by approximately 1oC
–Lowest in early morning
–Highest in late afternoon/evening
209
Chronic pain is defined as...
not associated with cancer or other medical conditions that persists for more than 3 to 6 months
lasting more than 1 month beyond the course of an acute illness or injury
recurring at intervals of months or years
210
•Bronco phony
–Increased transmitted spoken word when lung tissue has lost air, i.e., pneumonia
–Have patient say, "ninety-nine“
* **normally the transmitted sounds are muffled and indistinct.**
–High pitched sounds mean lung tissue has lost air.
211
clinical causes of crackles
–Pneumonia
–Fibrosis
–Early congestive heart failure
–Bronchitis
–Bronchiectasis
212
A 35 yo female with history of tobacco use (40 pack years) presents with cough for the past 5 weeks. You would classify her cough as:
a) acute
b) subacute
c) persistent
d) chronic
b) subacute
213
High dull sounds of percussion
* Pleural effusion
* High Diaphragm
* Atelectasis
* Diaphragmatic paralysis
214
signs of
Respiratory Disease
215
Dual headed stethoscopes
Some come with 2 diaphragms in place (adult size and pediatric size). The pediatric diaphragm must be converted into to a bell by changing the cover.
216
–Patients prefer this to rectal temp measurement
oral
217
config of chest
218
Waist circumference is measured
just above the hips (iliac crest)
219
MITRAL REGURGITATION
•Mitral area ( R )to the Axilla.
Rectangular pan systolic murmur,
1. S3 Gallop
2. Dilated LV and LA
3. MVP
[http://www.easyauscultation.com/cases-waveform?coursecaseorder=13&courseid=31](http://www.easyauscultation.com/cases-waveform?coursecaseorder=13&courseid=31)
220
Palpating the Right Ventricle in patients with increased Anteroposterior diameter
pts with obstructive pulm disease = hyperinflated lung --\> may prevent palp of enlarged RV
* impulse felt in epigastrium/subxiphoid
hands flattened with index finger just under rib cage and up to L shoulder
221
The “disappearance point” represents
diastolic BP
222
Which of the following sounds can be heard during systole?
a) an ejection sound
b) S3
c) S4
d) opening snap
a)an ejection sound: aortic/ pulmonic
223
Which of the following is the most appropriate “General Survey” objective assessment for this patient? The patient walked into the office without difficulty.
## Footnote
A.An awake, ill appearing individual who appears to be in emotional distress. She appears to be pale, somewhat unkempt and slender.
B.Patient admits that she is losing weight and feels ill. She denies pain, fever, chills and weakness.
C.Her vital signs are T:98.2, BP: 110/60 mmhg, HR: 92 bpm, RR: 18 bpm.
D.Patient is awake, alert, well appearing and in no distress
A.An awake, ill appearing individual who appears to be in emotional distress. She appears to be pale, somewhat unkempt and slender.
224
Buerger test
* Chronic arterial insufficiency
* Raise both legs to about 90o for up to 2 minutes until there is maximal pallor of feet
–Marked pallor suggests arterial insufficiency
•Ask patient to sit up with legs dangling
–Normal: Skin pinkness returns in \<10 seconds, veins of feet and ankles fill in ~15 seconds
–Abnormal: persistent pallor followed by persisting dependent rubor (dusky redness)
225
You note that the murmur was heard with the stethoscope partly off the chest and with a palpable thrill. This murmur as:
a) 1/6
b) 2/6
c) 3/6
d) 4/6
e) 5/6
5/6
226
numeric, verbal, visual analogue scale
227
Nocturnal htn
•lack of physiologic fall, an excessive fall, or a rise in night time BP
–associated with adverse cardiovascular outcomes
228
In addition to the significant difference in calf circumference you note that this patient’s left calf to be erythematous, warm and tender. Homan’s sign is positive. The most likely diagnosis is a:
Deep Vein Thrombosis
229
The difference between the inspiration and expiration levels represents diaphragmatic motion: normal =
5-6cm
230
A 55 Yo female with a past medical history of hypertension presents for an evaluation. You hear the following murmur at the apex:
This is most likely is due to:
a) aortic regurgitation
b) pulmonary regurgitation
c) tricuspid stenosis
d) mitral regurgitation
a)mitral regurgitation
231
obesity class
I: 30-34.9
II: 35-39.9
III: 40+
232
Late Diastolic crescendo Murmur
Mitral stenosis, tricuspid stenosis. And MVP (Mitral valve prolapse)
233
which is correct?
## Footnote
A.The auscultatory gap is the true systolic blood pressure
B.When the artery is fully compressed (occluded), the Korotkoff sounds will be heard
C.Blood pressure difference of up to \>25 mm hg between the right and left arms is normal
D.“Estimation of systolic BP” (by palpation of the radial artery) provides a target for how high to inflate the BP cuff when obtaining the actual BP
E.When obtaining the BP, the pressure in the BP cuff should be lowered at a rate of 10 mm hg per second to minimize discomfort to the patient
A.“Estimation of systolic BP” (by palpation of the radial artery) provides a target for how high to inflate the BP cuff when obtaining the actual BP
234
murmurs by location: tricuspid
tricuspid stenosis/regurg
vsd
235
Celiac trunk arteries supply
esophagus, stomach, proximal duodenum, liver,
236
A 50 Yo male is brought to the emergency room after passing out. This is associated with dyspnea and chest pain. Upon auscultation you hear a loud harsh systolic crescendo-decrescendo murmur at the right second interspace which radiates to the carotids. This is most likely due to:
a) mitral regurgitation
b) aortic regurgitation
c) aortic stenosis
d) mitral stenosis
aortic stenosis
237
•Calculating the BMI
238
egophany
–When spoken word intensity increases through the lungs & has a nasal or bleating quality
say "eee“;
* “aye" = loss of air in lung tissue and possible lung consolidation.
239
Midsystolic Crescendo-Decrescendo murmur
Aortic Stenosis and Innocent flow murmurs
240
•Medication may mask fever
–Aspirin, acetaminophen, NSAIDS, steroids
241
•factors influence the patient’s report of pain
–Psychiatric
* Anxiety
* Depression
–Personality/coping style
–Cultural norms
–Social support systems
242
ØDecreased Tactile Fremitus: unilateral
Pneumothorax
Pleural Effusion
Bronchial Obstruction
Atelectasis
243
•Hypothermia
–\<35oC (95oF) rectally
244
When you palpate the carotid artery you should:
a) Press at the lateral border of the sternocleidomastoid muscle
b) Use your left fingers or thumb to palpate the left carotid
c) Press at the level of the thyroid cartilage
d) Assess the amplitude and the contour of the pulse wave
a)Assess the amplitude and the contour of the pulse wave
245
Width of the bladder of the cuff should be about
average adult:
40% of upper arm circumference
## Footnote
Average adult: 12-14 cm
246
when does fatigue warrant further investigation?
when it is unrelated to life circumstances
247
WEAK/INAUDIBLE KOROTKOFF SOUNDS
•Technical problems
–error stethoscope placement
–Failure to make full skin contact
–Venous engorgement of arm from repeated cuff inflations
•Consider
–Shock
–Vascular disease
248
Length of the bladder should be about
80% of upper arm circumference
249
A 68 year old patient describes pain in the R knee. It is dull and aching in nature, rated as 5 out of10, has been present for several years and is worsened by walking up or down stairs. The pain does not radiate. There is minimal swelling in the knee but no redness. Anti inflammatory medications improve the pain. X-ray demonstrates osteoarthritis.
What type of pain is this?
A.Somatic (nociceptive)
B.Neuropathic
C.Psychogenic
D.Central sensitization
E.Idiopathic
A.Somatic (nociceptive)
250
what is this sound?
characterstics
Stridor
high-pitched wheeze produced by turbulent airflow through a partially obstructed **upper airway**
can be louder in neck than chest wall
251
Warning Signs of Peripheral Arterial Disease
•Fatigue, aching, numbness or pain in legs that limits walking or exertion
–Where?
–Associated erectile dysfunction?
* Poorly healing/nonhealing wounds of the legs or feet
* Pain in the lower leg or foot present at rest and changes when standing or supine
* Abdominal pain after meals with associated food avoidance, weight loss
* Any first degree relatives with abdominal aortic aneurysm (AAA)
252
Grading Pitting Edema
* Depression caused by pressure from the examiner’s thumb
* Severity graded on 4 point scale
253
S3 Gallop
diastolic: rapid ejection atria --\> ventricles
* Physiologic:
* Young children
* Trained athletes
* Pregnant women
* Pathologic:
* Congestive Heart Failure
* Mitral regurgitation
[http://www.easyauscultation.com/cases-waveform?coursecaseorder=1&courseid=25](http://www.easyauscultation.com/cases-waveform?coursecaseorder=1&courseid=25)
254
Pansystolic (Holosystolic) Plateau murmur
s1 --\> s2
no gap b/w murmur and heart sound
mitral/tricuspid regurg
255
256
Palpating for S1 and S2
When palpating for S1 and S2 place your right hand on the chest wall and your left index and middle fingers on the right carotid artery in the lower third of the neck
S1 occurs just before the carotid upstroke
S2 occurs after the carotid upstroke
257
Palpation of the Brachial Arteries
make sure to flex pt's elbow slightly
palp medial to biceps tendon in AC, also in groove b/w bicep and tricep
258
If the first 2 readings differ by ....
then....
\> 5 mm Hg
take additional readings
have to ave 2 bp's
259
•Trachea deviation could indicate
–pneumothorax, mass, etc.
260
To test that it is in the “bell position”:
Tap the bell. You should hear the sound very loudly. Tap the diaphragm. You should not hear very much sound. If it sounds louder when you tap the diaphragm, the chest piece is open to the diaphragm and not the bell.
261
is there a commonly used scale for quant dyspnea?
no scale from 1-10
determined by pt's activities
262
Hypertrophic cardiomyopathy (HOCM): Physical Exam Red Flags
–Systolic murmur
•Intensity increases with standing (decreased preload) and decreased with squatting
263
•the level at which sounds of two consecutive beats are heard means...
systolic P
264
HYPERTENSION (HTN)
–\>140/90 mm Hg in clinic
–Home automated \>135/85
–Ambulatory automated: 24 hr average \>130/80, day average \>135/85, night average \>120/70
–Average of 2 BP readings on 2 or more occasions
265
•Tympanic membrane temperatures
─Measures core body temperature and tends to be higher than the oral by ~1.4° F
─Cerumen can impair reading
─More variable than rectal
266
Peripheral Arterial Disease
* Dependent rubor
* Ulcers on the toes or points of injury
267
temp methods: temporal A
–Lower than core temp by 0.5oC
–Like oral temp, correlates with core temp
268
mitral valve prolapse (MVP)
[https://www.easyauscultation.com/cases-waveform?coursecaseorder=4&courseid=30](https://www.easyauscultation.com/cases-waveform?coursecaseorder=4&courseid=30)
mid-sys click followed by crescendo decrescendo murmur
increases with standing
decreases with lifting legs
269
accessory M used in respiratory distress
–Sternocleidomastoid
–Scalene muscles
–Supraclavicular retraction?
270
Rectal temperatures
─Higher than oral temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F)
─This difference is variable
271
Causes of orthostatic htn
drugs, moderate-severe blood loss, prolonged bed rest, dehydration, diseases of autonomic nervous system
272
Opening snap
* Occurs in early diastole: extra heart sound
* High pitched sound heard best with the diaphragm
* Most commonly due to opening of stenotic mitral valve indicating pathology
273
ask pt's to do what while listening for bruits?
hold breath
274
A patient presents with a fever and a cough. You suspect pneumonia. During the pulmonary examination you ask a patient to say “ee” while you listen with the stethoscope. You hear this as “aye”. This is an example of:
a) Egophony
b) Adventious breath sounds
c) Fremitus
d) Resonance
Egophony
275
Which of the following statements reflects the correct way to use the sphygmomanometer to check blood pressure?
## Footnote
A.The cuff should be repeatedly inflated to get an accurate BP
B.The lower border of the cuff should be 2.5 cm above the antecubital crease
C.The cuff should be deflated rapidly once 2 beats are heard
D.Once you have palpated the systolic pressure, rapidly inflate the cuff again
A.The lower border of the cuff should be 2.5 cm above the antecubital crease
276
Quality of neuropathic pain
* burning, lancinating, shock like
* May persist even after healing
–Due to pain signal processing changes (“neuronal plasticity”)
277
Which of the following BMI values falls into the overweight category?
1. \> 30 kg/m2
2. 25.0-29.9 kg/m2
3. 18.5-24.9 kg/m2
4. \< 18.5 kg/m2
2.25.0-29.9 kg/m2
278
A 12 Yo male presents for a pre-participation sports physical. He has no complaints. His family history includes 2 relatives that died suddenly in their late teens from "heart problems". On examination you hear a systolic murmur and suspect hypertrophic cardiomyopathy. The following will increase the loudness of a hypertrophic cardiomyopathy murmur:
a. Increase preload
b. Decrease preload
a.Decrease preload
279
Clinical Causes of wheezes
Asthma
- Bronchitis
- Chronic Obstructive Lung Disease( COPD)
280
Which of the following findings are most consistent with chronic arterial disease as compared to chronic venous disease?
A.brown pigmentation on ankles
B.presence of edema
C.non healing ulcers on the toes or points of trauma
D.non healing ulcers on medial side of ankles
A.non healing ulcers on the toes or points of trauma
281
During percussion of this same patient you find that her breast tissue is overlying one of the areas that you need to examine. Which of the following is the correct approach to the patient exam?
a) Skip this part of the exam
b) Ask the patient to displace her breast tissue so that you can access the underlying thorax
c) Perform the exam over the breast with the gown covering the breast
d) Perform the exam over the breast with the gown off the breast
a)Ask the patient to displace her breast tissue so that you can access the underlying thorax
282
palp carotid A one at a time to avoid...
carotid sinus @ level of thyroid cartilage
carotid A = @ level of cricoid cartilage, medial to SCM
283
Deep veins carry
•carry 90% of venous return from lower extremities,
well supported by surrounding tissues
284
normal HR
60-100 bpm
285
•Abdominal pain after meals...
–food fear”, weight loss, dark stools
286
Rectal temps...
–More reliable if rapid respiratory rate
287
Superior mesenteric artery supplies
–jejunum, ileum, cecum, ascending and transverse colon, splenic flexure
288
tips for handling Very thin patient
•pediatric cuff
289
Lymphatics of the Upper Extremity and Breast
•Pectoral nodes
* –Anterior, along lower border of pectoralis major inside anterior axillary fold
* –Drain anterior chest wall, breast
•Subscapular nodes
* –Posterior, along lateral border of scapula, deep in posterior axillary fold
* –Drain posterior chest wall, portion of arm
•Lateral nodes
* –Along upper humerus
* –Drain most of arm
Central axillary nodes
* drain to supraclavicular and infraclavicular nodes
290
Raynaud’s Disease
* Wrist pulses are typically normal
* Spasm of distal arteries
* Sharply demarcated pallor of the fingers
291
objective portion of general survey =
## Footnote
A.Includes the physician’s assessment of the patient's overall appearance
B.Includes the patient’s report of “fatigue, fever, chills and change in weight”
C.Includes the patient’s temperature
D.Includes the patient's reported alcohol intake
E.Is part of the History of Present Illness
A.Includes the physician’s assessment of the patient's overall appearance
* Includes the patient’s report of “fatigue, fever, chills and change in weight”
* –Subjective, “General Survey” review of systems questions
* A.Includes the temperature
* –Objective, but a vital sign
* Includes the patient's reported alcohol intake
* –Subjective, part of the social history
* Is part of the History of Present Illness
* –Subjective, part of the history
292
Tennessee: heart sound
s4 - belub dub
diastole
–immediately precedes S1:
marks atrial contraction
can be pathologic change in ventricular compliance (stiff left ventricle)
293
•Tactile fremitus
–Palpable vibrations transmitted via the bronchopulmonary tree to the chest wall as patient speaks
•Provides information about lung tissue and chest cavity density
294
•Mechanismsof neuropathic pain
–CNS brain or spinal cord injury
* Stroke
* Trauma
–Peripheral NS disorders
* Entrapment
* Pressure
–Referred pain syndromes
•Increased/prolonged response to stimuli
295
what would an elevated/low JVP indicate?
high = CHF -\> R side heart failure RV
low = dehydration
296
Fremitus is usually decreased or absent over
precordium
297
innocent murmur
early systolic that occurs in non cardiac conditions that increase blood flow over normal cardiac anatomy
## Footnote
. Examples: anemia, hyperthyroidism, pregnancy and exercise
murmurs disappear when conditions are treated
[https://www.easyauscultation.com/cases-waveform?coursecaseorder=1&courseid=26](https://www.easyauscultation.com/cases-waveform?coursecaseorder=1&courseid=26)
298
Cheyne-Stokes Breathing
mechanism?
periods of deep breathing --\> periods of apnea
children, aging people --\> usu in sleep
•Proposed Mechanism
–apnea--\> increased CO2 --\> compensatory hyperventilation --\> decreased CO2 --\>apnea
* restart the cycle.
299
A 65 Yo male with a history of Coronary Artery Disease presents with a two day history of shortness of breath. You measure his JVP to be 7cm. This finding is:
a) normal
b) abnormal and elevated
c) abnormal and low
abnormal and elevated
300
Four Steps to Promote Optimal Weight and Nutrition
1.Measure BMI and waist circumference
–Identify risk of overweight and obesity
–Establish risk factors for heart disease, obesity related disease
2. Assess dietary intake
3. Assess the patient’s motivation to change
4. Provide counseling about nutrition and exercise
301
what is this sound?
characteristics?
why?
crackles
Characteristics:
* •Intermittent
* •Discontinuous
* •Non-musical
* •Heard at the end of inspiration
Etiology:
* From collapsed or narrowed alveoli that could also contain fluid, pus, secretions or edema
302
Wheezing
* Musical audible respiratory sounds
* Suggests partially obstructed airway
* Possible Causes
excess secretions
foreign body
asthma
303
what can happen if the breast is not displaced?
abnorm percussion note of a right middle lob pna
304
A 4 year old is brought in by his mother due to a respiratory infection. He is irritable, anxious and breathing through his mouth due to severe nasal congestion. Which is the most comfortable and accurate way to measure his temperature?
A.Electronic oral thermometer
B.Glass oral thermometer
C.Electronic tympanic membrane thermometer
D.Electronic rectal thermometer
E.Glass axillary thermometer
A.Electronic tympanic membrane thermometer
305
what is this showing?
Pitting
306
Auscultation- 4 Key Cardiac Areas-
Inching your Stethoscope
Start at the base and inch to the apex
* Aortic- Pulmonic – Tricuspid – Mitral
Start at the apex and inch to the base
* Mitral- Tricuspid- Pulmonic – Aortic
307
A 65 Yo male with a history of hypertension presents for an evaluation. Upon auscultation of his heart you hear an extra heart sound. Upon listening closely it sounds as if you are hearing the word Tennessee. This sound is most consistent with the presence of an:
a) opening snap
b) S3
c) Ejection sound
d) S4
e) systolic click
S4
308
Palpation of the Posterior Chest to Test for Expansion
Technique:
* Place your thumbs at the 10th ribs, with your fingers loosely grasping and parallel to the lateral rib cage.
* Have patient inhale deeply.
* Watch the distance between your thumbs as they move apart during inspiration.
* As the rib cage expands and contracts, feel for the range and symmetry.
•
309
During the examination you attempt to locate the apical impulse with the patient in the supine position with the head of the bed at 30 degrees but you are not successful. Which of the following would you do next to help you locate the apical impulse:
a) Place the patient in the supine position with the head elevated at 180 degrees
b) Have the patient sit and lean forward
c) Place the patient in the left lateral decubitus position
d) Place the patient in the supine position with the head of the bed at 60 degrees
a)Place the patient in the left lateral decubitus position
310
RECTAL TEMPERATURE: METHODS
* Patient lies on one side with hip flexed
* Lubricate rectal thermometer (stubby tip)
–Or electronic probe cover
* Insert it 3-4 cm into anal canal, direction pointing toward the umbilicus
* Remove after 3 minutes
–10 seconds for electronic
•Read
311
murmurs by location: aortic
aortic stenosis
fixed splitting of S2
312
•Fever (pyrexia)
–Elevated body temperature
–Causes: infection, trauma, malignancy, blood disorders, drug reactions, immune disorders
313
•Night sweats
–Normal body temp rises during day and falls at night
–Fever exaggerates this swing and causes night sweats
314
what nodes are accessible on physical exam: cervical, axillary, arms and legs
superficial
* Oval or bean shaped structures
* Vary in size depending upon location
–Very small and difficult to palpate (ex. preauricular)
–1-2 cm in an adult (ex. Inguinal)
315
Hypertrophic cardiomyopathy (HCM)
* Leading cause of sudden death in pediatrics and young adults
* Thickening LV --\> outflow obstruction
* decreased blood flow
* MI
* arrhythmia
* death
* Often first sign is sudden collapse and possible death
* Detect this during periodic exams and pre-sports screening exams!
316
MITRAL STENOSIS
Opening snap followed by a diamond shaped ow pitched murmur in diastole.
Best heard with the bell over the mitral area with the patient laying on left side
[http://www.easyauscultation.com/cases-waveform?coursecaseorder=14&courseid=31](http://www.easyauscultation.com/cases-waveform?coursecaseorder=14&courseid=31).
317
ØIncreased Tactile Fremitus =
Pneumonia
318
•Intercostal Retractions
–Muscles between the ribs pull inward
–Due to reduced air pressure inside your chest
–Seen best at the lower interspaces
–Sign of ↑work of breathing-respiratory distress
319
chronic aterial insufficiency, chronic venous insufficiency
320
4 potential uses of palpation of anterior chest
–Identifies tender areas
–Assess observed abnormalities
–Further assesses chest expansion
–Assess tactile fremitus
321
•Hypertension (abnormal)
–JNC Guidelines ≥140/90 mm Hg
322
Axillary lymph nodes
drain most of arm
323
Hypertrophic cardiomyopathy (HOCM): hx red flags
–Family Hx of sudden death below the age of 50
•Inherited disease with variable penetrance
324
Posterior Percussion Points: locaton technique
pt cross arms --\> like a ladder
compare symmetry
325
Standing (Valsalva strain phase)
decrease venous return
decreased left ventricular volume.
decreased vascular tone
decreased arterial blood pressure
326
Distinguishing Internal Jugular and Carotid Pulsations
327
Upon observation of the patient’s neck you know that you are observing the carotid artery as opposed to the jugular vein because the
a) height of the carotid pulsation is unchanged by position whereas the height of the jugular pulsation changes with position
b) height of the carotid pulsation changes with position
whereas the height of the jugular pulsation is unchanged with position
c) height of the carotid pulsation rises with inspiration whereas the height of the jugular pulsation falls with inspiration
d) height of the carotid pulsation falls with inspiration whereas the height of the jugular pulsation rises with inspiration
a)Height of the carotid pulsation is unchanged by position whereas the height of the jugular pulsation changes with position
328
tips for handling Hypertensive patient with unequal pressure in arms and legs
compare BP in arms and legs (5-10 mm Hg higher in arms)
compare volume (force) and timing of radial or brachial and femoral pulses (equal and simultaneous)
329
Measure the calves ... where?
normal difference?
•10 cm below the tibial tuberosity
–Normal difference in calf circumference \<3cm
330
Measuring the Jugular Venous Pressure
This distance measured in centimeters above the sternal angle is the JVP.
Normal JVP is 3cm- 4cm above the sternal angle
The JVP provides a rapid estimate of the CVP ( central venous pressure) useful in assessing volume status, especially for congestive heart failure
331
technique for percussion of posterior chest wall
Technique:
* Place the 3rdfinger (pleximeter) of your left hand firmly against the surface to be percussed.
* Hyperextend your left hand middle finger: the “pleximeter” finger.
* Press its DIP joint firmly on the surface to be percussed.
* Note that the thumb and 2nd, 4th, and 5th fingers are not touching the chest
strike DIP with tip of finger with quick, sharp, but relaxed wrist motion @ right angles
* avoid damping of vib by quickly withdrawing striking finger
* press HARDER with DIP with fatter pts
332
A 35 year old female presents for examination of new onset swelling of her left leg. Upon observation, you note that the left leg looks larger than the right leg. To confirm that there is actual edema you measure each calf 10 cm below the tibial tuberosity. Which of the following difference in measurements is suggestive of edema?
a) her left calf measures 0.5 cm more than her right calf
b) her left calf measures 3.0 cm more than her right calf
c) her left calf measures 2.0 cm more than her right calf
d) her left calf measures 1.0 cm more than her right calf
her left calf measures 3.0 cm more than her right calf
333
Small saphenous
lateral side of foot
passes posterior calf
joins deep venous sys in pop fossa
334
•Hypokinetic Apical Impulse can indicate
type of amplitude and duration?
dilated cardiomyopathy
low amp, long duration
335
PVD is more visible when...
pt stands - veins fill with blood
## Footnote
•Palpate along varicosities to check for thrombophlebitis
336
anterior posterior (AP) diameter of chest may ↑ with
–Normal aging
–COPD
–Emphysema
337
Sitting, Leaning forward positioning of pt When
Auscultating the Heart enhances....
detection of aortic insufficiency
338
cough: chronic
\> 8 wks
## Footnote
causes:
* postnasal drip
* gastroesophageal reflux
* chronic bronchitis
339
BMI categories
underwt: \<18.5
normal 18.5-24.9
overwt: 25-29.9
ovesity: 30 or more
340
Gallop
•presence of an S3 or S4 cadence similar to gallop of a horse
Summation gallop: at rapid heart rates S3 and S4 may sound like a single sound
341
appearance of the first two “Korotkoff” sounds represent the
–systolic blood pressure
342
A 20 month old male is brought to the ER for cough and fever. On examination, he is drooling and has a whistling sound when he breaths. Upon auscultation you hear the following. This sound is consistent with:
a) Rhonchi
b) Crackles
c) Wheezes
d) Stridor
e) Pleural rub
Stridor
343
cough: acute
\<3 weeks
causes:
* viral URI
* Asthma
* Left heart failure
344
A 71 year old male with a history of smoking comes to your primary care office complaining of cramping in his legs during exertion. The pain is relieved by rest within 10 minutes. These symptoms have been slowly increasing for the last few months. There is no swelling, erythema or tenderness on examination of his calves but a there is an unhealed ulcer on his left first toe that he says he has had for several weeks. His femoral, popliteal, dorsalis pedis pulse and posterior tibial pulses are each 1+ bilaterally. You suspect he has:
a) Peripheral Arterial Disease
b) Peripheral Venous Disease
Peripheral Arterial Disease
345
higher than average P difference b/w arms =
what is the range above
•more than 10–15 mm Hg
subclavian steal syndrome
aortic dissection.
346
taking an oral temp is not recommended when...
pt =
unconscious
restless
unable to close mouth
347
•Auscultatory gap
–A silent interval that may be present between the systolic and the diastolic pressures
348
Health Care Disparities in Pain Management
lower use pain meds for African-American and Hispanic patients
* ca, post-op, lower back pain
•that clinician stereotypes, language barriers, and unconscious clinician biases in decision making all contribute to these disparities.
349
S1
AV: mitral \> triscuspid
350
Prevalence of patients with asymptomatic bruits increases with
age
8% in pts \>75 y/o
3x increase in risk of ischemic heart disease and stroke
351
which part of stethoscope use to hear low pitched sounds?
like what?
bell
s3, s4, murmur of mitral stenosis
352
what is this sound
characteristics?
wheezes
## Footnote
* High pitched
* Continuous
musical,whistling sound
usually more pronounced during expiration
353
what is this sound? what is this test for?
Whispered pectoriloquy :
–
–Are louder, clearer whispered sounds and could denote lung consolidation
–Normally whispering "one-two-three or ninety-nine is heard faintly and indistinctly because the lung filters it out.
