carotid pulse contour
> smooth rapid upstroke close to S1,
- > brief round plateau,
- > less rapid downstroke with dicrotic notch
- > systole - upstroke
- > diastole - plateau and downstroke
pulsus parvus
small amplitude
pulsus tardus
delayed upstroke
aortic stenosis
pulsus parvus
pulsus tardus
low delayed plateau
slow down stroke
aortic regurg
strong and bounding pulse
brisk upstroke
brief short plateau
rapid downstroke
amplitude of pulse
4 - bounding (aortic regurg)
3 - full and inc (hyperdynamic/hyperthyroid)
2 - normal
1 - diminished, barely palpable, thready (heart failure)
0 - absent, non-palpable (obstruction/shock)
pulsus alternans
alternating weak and strong beat with normal rhythm
assoc with left sided S3 - left vent failure
pulsus bisferiens
biphasic pulse
2 main systolic peaks separated by a mid systolic dip
aortic regurg or aortic stenosis + regurg
pulsus bigeminal
2 beats in rapid succession
normal + premature vent contraction
varied amplitude due to reduced SV in 2nd beat
pulsus paradoxus
exaggeration in normal fall in amp during inspiration
best det by change in systolic bp - 12-15 mmHg dip (norm 10)
severe obstructive lung disease, tamponade, constrictive pericarditis
Water Hammer/Corrigan/Collapsing pulse
- > greater amplitude
- > rapid upstroke,
- > normal summit,
- > sudden descent
- ->aortic valve regurg,
- > PDA*
pulse deficit
diff btwn heart rate by ausc at apex and peripheral pulse rate by palpation
rapid irreg rhythm - a fib
radio-femoral delay
increased transmission time of pulse wave to lower ext
norm: radial 75ms, femoral 70ms
Leriche’s syndrome (aorto-iliac dis), post-subclavian coartaction
Measure supine BP in thigh and arm: LE < UE
Quincke’s sign
nailbed capillary pulsation (flush/blanch)
aortic insufficiency
Durozie’s sign
- > femoral bruit/pistol shot
- > hear in both systole and diastole over periph arteries
- > rapid back and forth of flow in aortic insufficiency
De Mussett’s sign
head nodding with carotid pulse
->aortic regurg
pulsus differens
- > asymmetry due to vol differences
- >local compression/stenosis
hypotension
<80 mm systolic
relative - past reading
absolute - signs and sx
orthostatic - fall of 20 systolic and/or 10 diastolic on standing for 3mins after recumbency
hypertension
pre 140
muscles of inspiration
diaphragm intercostals SCM levator scapulae/serratus pos scalenus anterior and medius erector spinae
expiration
usually passive
abdominals
intercostals
respiration control
central (neurogenic)
- > medullary rhythmicity center,
- > apneustic center (depth),
- > pneumotaxic center (rate)
peripheral (stretch)
- > Hering-Breuer reflex,
- > smooth muscles of bronchi and bronchioles (vagus med)
chemoreceptors ->central (outside of BBB, PCO2 and pH), ->peripheral ~carotid/aortic bodies, ~PO2, ~glossopharyngeal/vagus, ~not sig in normal resp
normal resp rates
adult: 12-20
kid: 15-20
infant: 25-50
bradypnea
<10
CNS, diabetic coma, inc ICP
tachypnea
> 24 rapid shallow
restrictive lung dis, pleuritic chest pain, inc intra-abd pressure
hyperpnea
rapid deep
exercise, anxiety, metab acidosis, midbrain/pontine abnorm
Ataxic/Biot’s
unpredictable irregularity - shallow, deep or cease
resp dep/medullary dmg
Cheyne-Stokes
deep-apnea alteration
brain dmg, heart failure, uremia, drug resp dep
prolonged expiration
obstructive lung disease - narrow airway
asthma, COPD
fever/pyrexia
core body temp over 99 in adults/101 in <3mo infants
increase in thermoreg set point
infection, trauma, drug rxn, hyperdynamic state
hyperthermia
inc body temp above thermoreg set point
impaired heat loss/excessive produc - heat stroke, neuroleptic malig syn
NOT FEVER
hypothermia
core body temp <95/35
cold exp, hypothyroidism
hyperpyrexia
above 106/41.1
septicemia
Temp by location
oral - 37/98.6
healthy young adult - 98.2 +/- 0.7
rectal > oral > axillary
continuous temp
persistently above normal for 24hr period, <1F variation
lobar pneumonia
intermittent
diurnal variation
fluctuation between normal and elevation during 24h
malaria
remittent
- > abating and relapsing in cycles,
- > > 1F variation
- > infective endocarditis
relapsing /recurrent (Pel-Ebstein)
recurrent acute episodes of fever and no fever
varied duration, spontaneous
typically 5-7d cycles
lymphoma
manifestations of temp
cold and shivering -> rising temp
hot and sweating -> falling temp
percussion sounds
> resonant
- chest (low pitch, high amp)
- > hyperresonant
- hyperinflation of lungs/air in pleural space
- > dull
- reduction of air/increase in fluid (consolidation)
- > flat
- soft, high pitched, short duration
- > tympanic
- abdomen
- > dull
- fluid in bowel loops/free peritoneal fluid
stethoscope
diaphragm - high pitch
bell - low pitch
manner of speaking
aphonia - loss of voice
dysphonia - alteration in vol, quality and pitch
dysarthria - disease of lips, tongue, pharynx, palate
aphasia - producing/understanding language
cranium
bones of skull minus mandible
calvarium - upper dome, supplied by middle meningeal/pericranial/branch arteries of scalp
base - fossae
facial skeleton
SCALP
Skin
CT - well vasc and innervated
Aponeurosis - frontal/occiptal epicranius muscle
Loose CT - mobile (distends with fluid)
Periosteum
severe bleeds -> failure of arterial retraction into dense CT
Facial innervation
muscles of expression - facial n
muscles of mastication - V3
levator palpebrae superioris - oculomotor
sensory - trigeminal
anterior triangle
- > mandible
- > anteromedian line of neck
- > ant border of SCM
contents:
- >thyroid,
- >parathyroid,
- >submand glands,
- >carotid a,
- >int jug v,
- >CN 9 and 11,
- >deep cervical LNs
posterior triangle
- > post border of SCM
- > ant border of trapezius
- > medial 1/3 clavicle
contents:
- >omohyoid,
- >ext jug v,
- >3rd part of subclavian,
- >CN XI,
- >brachial plexus roots,
- >phrenic n
teeth
2123
2 incisors, 1 canine, 2 premolars, 3 molars
