Physical Exam Lecture 1 Flashcards
1
Q
9 components of the examination, in order
A
Inspection of the patient Blood pressure determination Assessment of arterial pulse Determination of respiratory rate Assessment of jugular venous pulsation Carotid Pulsation Palpation of heart Auscultation of heart Examination for dependent edema
2
Q
Patient positioning during physical exam
A
Supine
Head of bed may be slightly elevated
3
Q
Physician positioning during physical exam
A
Right side of bed
4
Q
3 questions to ask in terms of general appearance inspection
A
Is the patient in acute distress?
Is the breathing labored?
Are accessory muscles being used?
5
Q
3 things to look out for when inspecting skin
A
Cyanosis
Temperature
Xanthomata
6
Q
3 types of xanthomata
A
Tendinous
Tuberous
Eruptive
7
Q
Describe tendinous xanthomata
A
Stony-hard, slightly yellowish masses in extensor tendons of:
- fingers
- Achilles
- plantar tendons of the soles
8
Q
Describe tuberous xanthomata
A
Palms, soles, knees, elbows, hands
Occur in 15% of patients with primary biliary cirrhosis
9
Q
Describe eruptive xanthomata
A
Small 1 - 3 mm in diameter, yellowish papules on an erythematous base found on buttocks, abdomen, back, face and arms
10
Q
What are Osler’s nodes?
A
Painful lesions in the tufts of fingers and toes
11
Q
What are Janeway lesions?
A
Non-painful, small erythematous macular on the palms and soles
12
Q
What do Osler’s ndoes and Janeway lesions indicate?
A
Infective endocarditis
13
Q
Define splinter hemorrhages upon nail inspection
A
Small, reddish-brown lines in the nail bed
14
Q
What are splinter hemorrhages a sign of?
A
Infective endocarditis
15
Q
What is Lichstein’s sign?
A
Oblique earlobe creases, often bilateral, seen in patients over 50 years of age with significant coronary diseease
16
Q
Two manifestations that can be found upon eye inspection
A
Xanthelasma
Arcus Senilis
17
Q
Define xanthelasma
A
Yellowish plaques on the eyelids (less specific for dyslipidemia than the xanthoma)
18
Q
Define arcus senilis
A
Silver rim around dark of eye, seen in patients younger than 40 years of age
19
Q
What to suspect upon finding arcus senilis
A
Dyslipidemia
20
Q
Define palatal petechiae
A
Red dots on palate of mouth
21
Q
What is palatal petechiae a sign of?
A
Endocarditis
22
Q
2 potential findings upon chest configurations inspection
A
Pectus excavatum (caved in chest) Pectus carinatum (Pigeon breast)
23
Q
What is pectus excavatum a sign of?
A
Marfan’s and mitral valve prolapse
24
Q
What is pectus carinatum a sign of?
A
Marfan’s syndrome
25
What is an extra phalanx, finger or toe a sign of?
Atrioseptal defect (ASD)
26
What are long,slender fingers a sign of?
Marfan's syndrome
27
What is short stature, cubitus valgus and medial deviation of the forearm a sign of?
Turner's syndrome
28
4 essential ingredients for determining BP
The Patient: Preparation and positioning
The Clinician: Positioning
The Instrument: Accuracy
The Procedure: Skill
29
4 ways to ensure patient preparation and positioning
Patient avoids smoking or drinking caffeinated beverages
Patient rests for 5 min in a quiet, comfortably warm room
Arm is free of clothing and should be supported at heart level
Palpate brachial artery
30
Width requirement for a correctly-sized BP cuff
Width of inflatable bladder should be 40% of the upper arm circumference
31
Length requirement for a correctly-sized BP cuff
Length of the inflatable bladder should be 80% of the upper arm circumference
32
Problem with have a cuff that is too small. Too big?
```
Small = May overestimate the BP
Big = may underestimate BP
```
33
Problem with putting on the BP cuff too loosely
May overestimate BP
34
How should the cuff be positioned on the patient's arm?
The lower border of the cuff should be 2.5 cm above the antecubital crease
35
How to avoid error by the auscultatory gap
As you feel the radial artery with the finger of one hand, inflate the cuff until the radial pulse disappears. Add 30 mm Hg
As you deflate the cuff, the pressure on the manometer at which the radial pulse re-appears = systolic BP by palpation
Deflate the cuff promptly and completely --> wait 15 - 30 sec
36
How to determine the BP after complete preparation
Use bell of stethoscope
Deflate cuff at 2 - 3 mm Hg per second
Systolic BP = first sound of at least 2 consecutive heartbeats
Diastolic BP = muffling and disappearance of the heartbeats (only a few mm apart)
Read these 2 values to the nearest 2 mm Hg
Wait 2 or more min and repeat (in both arms)
37
Method for assessing heart rate
Use radial pulse with the pads of your index and middle fingers
Gradually compress the radial artery until the maximal pulsation is detected
Normal or regular = measure over 30 sec
Fast or slow = measure over 60 sec
38
If the rhythm is irregular, how do you measure rhythm?
Use stethoscope at the cardiac apex
39
Most common cause of irregular rhythm
Premature beat
40
5 things to assess for the respiratory rate
Observe the: rate, rhythm, depth and effort of breathing
| Count the number of respirations by visual inspection
41
Normal respiratory rate
20 breaths/min
42
2 reasons why the assessment of jugular venous pressure is important
Provides the astute clinician with an index of RH P and cardiac function
Clinician's window to the assessment of intra-vascular space and/or intra-cardiac P --> provide invaluable info on the presence or absence of heart disease
43
What doe JVP reflect?
Right atrial P = CVP = RV EDP
44
Where is the jugular venous pulsation found?
Deep to the sternomastoid muscle
| Not directly visible
45
4 steps to JVP technique
1 - position patient
2 - distinguish internal jugular with carotid pulsations
3 - estimation of the height of the JVP
4 - evaluation of the various waveforms
46
What does inclination change in determining JVP?
Ability to measure the height of the column of the venous blood
47
What do you consider when inclining the patient for JVP?
Consider/anticipate the patient's volume status
| Usually start at 30 degrees (head elevation)
48
If hypovolemic, how to incline patient for JVP
Lower head of the bed to 0 degrees
49
If hypervolemic, how to incline patient for JVP
Elevate bed to 60 - 90 degrees
50
3 considerations for positioning after successfully inclining the patient for JVP
Tilt patient's head away from the side you are inspecting
Tangential lighting
Tangential inspection (i.e. lean towards bed's midline for examination)
51
What 2 factors make the assessment of the JVP not possible?
A large neck
| Excessive use of accessory muscles (particularly of the sternomastoid)
52
Difference between carotid pulsation vs. JVP palpability
```
Carotid = palpable
JVP = rarely palpable
```
53
Difference between pulsation quality of carotid vs. JVP
```
Carotid = More vigorous thrust with a single outward component
JVP = Soft, biphasic, undulating quality, usually with two elevations and two troughs per heart beat (a and v waves of AP graph)
```
54
DIfference in pulsation elimination between carotid vs. JVP
JVP = pulsations eliminated by light P on the vein(s) jsut above the sternal end of the clavicle
Carotid = pulsations not eliminated by this P
55
Difference in pulsation height due to position between carotid and JVP
JVP = height changes with position, dropping as the patient becomes more upright
Carotid = Height unchanged by position
56
Difference in pulsation height due to inspiration
JVP = usually falls with inspiration
Carotid = usually not affected by inspiration
57
What is an elevated JVP?
> 3 - 4 cm above sternal angle, or by adding a distance of 5 cm, > 8 - 9 cm above the RA
58
Timing of a wave
Precedes the S1/carotid pulse
59
Timing of x descent
Coincides with systole
60
Timing of v wave
Almost coincides with S2
61
Timing of y descent
Almost follows early diastole
62
Why is assessing carotid pulse important?
Provides valuable information on:
- Cardiac function
- Stenosis or regurgitation of the aortic valve
63
Defining characteristics to assess quality of the carotid pulse
Amplitude and contour
| Bruits and thrills
64
Patient positioning for carotid pulsation
Head of bed elevated to 30 degrees
65
Clinician position for carotid pulsation
Stand slightly behind of the patient on right side
66
Location of carotid pulse
Medial to a well-relaxed sternomastoid muscle at the level of the cricoid cartilage
67
Method to take the carotid pulse
Use index and middle finger (or thumb) in the lower third of neck
Slowly increase P until you feel max pulsation
Slowly decrease P until you sense arterial P and contour
68
Define amplitude of carotid pulsation
Pulse pressure
69
Define contour of carotid pulsation
Speed of the upstroke, duration, speed of downstroke
70
Define thrills
Humming vibrations (i.e. like throat of purring cat)
71
4 positions for cardiac examination, in order of sequence
Supine, with head elevated 30 degrees
Left lateral decubitus
Supine, with head elevated 30 degrees
Sitting, leaning forward, after full exhalation
72
Cardiac Examination: how to examine a patient in the first supine position with head elevated 30 degrees
Inspect and palpate the precordium: the 2nd right and left interspaces; the right ventricle; the left ventricle, including apical impulse (diameter, location, amplitude, duration)
73
Cardiac Examination: how to examine patient in left lateral decubitus position
Palpate the apical impulse if not previously detected
| Listen at apex with the bell of the stethoscope
74
Cardiac Examination: how to examine a patient in the second supine position with head elevated 30 degrees
Listen at the 2nd right and left interspaces, along left sternal border, across to apex with diaphragm
Listen at right sternal border for tricuspid murmurs and sounds with the bell
75
Cardiac Examination: how to examine a patient sitting, leadning forward, after full exhalation
Listen along the left sternal border and at the apex with the diaphragm
76
Accentuated findings in the left alteral decubitus position during cardiac examination
Low-pitched extra sounds such as an S3, opening snap, diastolic rumble of mitral stenosis
77
Accentuated findings in sitting position furing cardiac examination
Soft decrescendo diastolic murmur of aortic insufficiency
78
What is the apical impulse?
The breif early pulsation of the LV as it moves anteriorly during contraction and touches the chest wall. PMI (point of maximal impulse) in most cases.
79
What to assess when palpating for the apical impulse
Location (vertical and horizontal)
Diameter
Amplitude
Duration
80
Usual location of apical impulse
Vertical location is usually the 5th or even 4th interspace
81
Normal apical impulse diameter
Supine = 2.5 cm or only 1 interspace
82
What is the significance of a larger diameter of apical impulse?
Enlarged left ventricle
83
Usual apical impulse amplitude
Brisk and tapping
84
Normal duration of apical impulse
Proportion of systole occupied by the apical impulse (usually does not continue to S2)
85
Where to position fingers when palpating the right ventricular area
Place tips of fingers in the left 3rd, 4th and 5th interspaces. Palpate at end-expiration
86
What to assess when palpating right ventricular area
Location, amplitude, duration
87
Significance of high amplitude but not duration in right ventricular area palpation
Chronic RV volume overload
88
Significance of high amplitude and duration in right ventricular area palpation
Chronic RV pressure overload
89
How to "inch your stethoscope" during auscultation
Start at apex, inch toward LLSB, 2nd L. interspace and 2nd R. interspace
90
How to use carotid pulse concurrently with auscultation to accurately identify S1 and S2
S1 occurs prior to the upstroke
| S2 follows the carotid upstroke
91
What kinds of sounds can the diaphragm of the stethoscope hear best?
High pitched sounds (S1, S2, murmurs of AR/MR, mid-systolic clicks, ejection sound, opening snap, pericardial friction rubs)
92
What kind of sounds can the bell of the stethoscope hear best?
Low-pitched sounds (S3, S4, mitral stenosis)
93
2 maneuvers that increase preload
Squatting position
| Release of the Valsalva maneuver (phase 4)
94
2 maneuvers that decrease preload
Standing for the squatting position
| During the strain of the Valsalva maneuver (phase 2)
95
1 maneuver that increases afterload
Handgrip
96
8 categories of information to obtain when assessing murmurs
1) In systole or diastole?
2) Location
3) Radiation
4) Timing
5) Shape
6) Intensity
7) Pitch
8) Alleviating and aggravating factors
