Sign names Flashcards
(158 cards)
1
Q
De Musset’s sign
A
Head bob associated with Aortic regurgitation
AR due to:
- Dilation of aortic root (Marfan’s)
- Rheumatic fever
- Bicuspid aortic valve
- Infective endocarditis
2
Q
Traube’s sign
A
Pistol shot systolic sound over femoral artery due to aortic regurgitation
Other AR physical signs:
- Water hammer pulse; bisferiens pulse
- Wide pulse pressure
- Inferolaterally displaced PMI (indicates volume overload)
3
Q
Quickne Pulse
A
Pulsation in fingertips (alters red and white) due to aortic regurgitation
Symptoms of AR:
- Left-sided heart failure = dyspnea on exertion, orthopnea, PND
- Palpitations, chest pain, pounding in chest
4
Q
Mueller sign
A
Uvula bobbing due to AR–> aortic insufficiency
Auscultation of AR:
- Blowing, diastolic, heard at right 2nd intercostal space or Erb’s point
- Soft S1, tambour S2 (if due to dilation of aortic root)
- May have murmur of functional mitral stenosis (Austin Flint)
- May have systolic ejection sound (indicates severe insufficiency)
5
Q
Duroziez sign
A
Systolic and diastolic murmurs over femoral artery seen in AR
6
Q
Paradoxical splitting
A
Spilling of S2 heart sounds during expiration (vs normal inspiration)
- P2 comes BEFORE A2 (normally A2 before P2)
Due to:
- Delayed A2 closure:
- Left BBB (most common cause)
- Impedence to L ventricular emptying (AS)
- LV dysfunction - Early P2 closure:
- Tricuspid regurgitation
- R atrial myxoma
7
Q
Fixed splitting
A
Timing between A2 and P2 fixed
Due to: Atrial septal defect (ASD)
- Can hear pseudo-fixed splitting in young, healthy pts, but it disappears when lay down & put legs up, decreasing venous return to RV
- Many differential dxs: 1.-Late systolic click OR 2.-Early diastolic extra sounds (pericardial knock, tumor plop, opening snap)
8
Q
Gallavardin Phenomenon
A
Aortic stenosis causing mitral regurgitation sound (systolic) at Apex
9
Q
Austin-Flint murmur
A
Aortic regurgitation causing sound of mitral stenosis (diastolic sound) at apex
10
Q
Valsalva maneuver
A
“Bearing down”- decreases venous return to heart
- Enhancing murmur of mitral valve prolapse, HOCM
11
Q
S3
A
Volume overloaded state
- Ventricular systolic dysfunction (VSD, PDA)
- Increased “preload” (MR)
Right-sided S3= due to tricuspid regurgitation
- Best heard on inspiration
Left-sided S3= due to MR
- Best heard on exhalation
12
Q
S4
A
Pressure overloaded state
- Ventricular diastolic dysfuntion (LVH)
- HTN, AS, CAD
13
Q
Rivero/Carvallo maneuver
A
Murmur intensifies on INSPIRATION= right-sided heart defect
- Inspiration–> negative pressure in lungs–> increased flow thru R side of heart
- Example: pulmonary HTN–> increases with inspiration
vs Louder on expiration= left-sided heart problem
- Blood pushed out of lungs in L side of heart–> increased flow through left side
14
Q
Hand grip maneuver
A
Increases afterload, thus enhancing any defects due to backward flow:
- AR
- MR
- VSD
Decreases intensity of murmurs due to obstructed flow
- AS
- HOCM
15
Q
Pulsus bisferiens
A
Palpable double pulse at radial artery
- Due to AR
16
Q
Pulsus parvus et tardus
A
Slow, weak pulse seen in Aortic Stenosis
- Brachio-radial delay seen
17
Q
Pulsus alternans
A
Alternation of strong and weak beats due to Left ventricular failure
18
Q
Pulsus paradoxus
A
Normal: BP decreases on inspiration by < 10 mm Hg
Paradox: decrease of > 10 mm Hg on inspiration due to:
- Cardiac tamponade
- Pericarditis
- COPD
19
Q
Triple ripple
A
Seen in HOCM: double or triple apical impulse
- Brisk bifid pulse
20
Q
Eisenmegner’s syndrome
A
Pulmonary HTN, reversal of PDA
- Cyanosis + clubbing of fingers
21
Q
Paget’s disease of breast
A
Erythematous, scaly rash under areola
- Sign of ductal carcinoma
22
Q
Troisier’s node
A
= Virchow’s node
- Hard lymphatic node at L supraclavicular fossa
- Think GI cancer (BAD)
23
Q
Sister Mary Joseph’s sign
A
Enlarged, hardened nodules around umbilicus
- Malignancy in abdomen/pelvis
24
Q
Buerger’s test
A
Raise leg, look for pallor before 60 seconds at 30 degrees
- Normally leg should not pale when held up for 60 seconds at 90 degrees
- Sign of Peripheral arterial disease
25
Trendelenburg test
Testing for venous insufficiency
1. Tourniquet superficial incompetent vein (varicose vein) while supine
2. Stand and observe to see if filling from above or below after < 30 sec
- Above= incompetent valves above site
- Below= distal perforating veins (from deep veins) have incompetency
26
Cheyne-Stokes Respiration
Cyclic pattern of progressively deeper (maybe faster) breathing followed by a gradual decrease and an apnea
Causes: heart failure; damage to respiratory center of the brain
27
Trepopnea
"Twisted respiration"
- Have to be on one side to breath better
- Inability to lie supine or prone, preference for lateral decubitus
- Lung is squashed by massive effusion
- Lie down on good lung side to ensure perfusion
- UNLESS effusion "spills", hemoptysis, pneumonia, pneumothorax
28
Abdominal paradox
Abdomen sucking in while patient inhales= sign of respiratory distress
Respiratory alternans= paradoxical breathing alternating with normal breathing
29
Respiratory tirage
Inspiratory retraction of suprasternal and supraclavicular fossa and intercostal spaces
30
Hoover's sign
Diaphragm flattened by hyperinflated lungs--> pulls inward with inspiration
- 90% specific for COPD
- Also seen in Ricket's (flattened rib slope
31
Lung tripod
Leaning up, sitting forward on knees, pursed lips (Emphysematous breathing)
- Can see patch on thighs
32
Laryngeal height
Distance between adam's apple and suprasternal notch
- Should be > 4 cm
- Emphysema/smoking--> decreased laryngeal height
33
Kussmaul's respiration
```
Rapid and deep (hypernea/ hyperventilation- increased rate and tidal volume)
- Differs from hyperventilation of cardiac/respiratory disorders= shallow (less effective)
MAKEUPL
- Methanol
- Aspirin
- Ketones
- Ethylene glycol
- Uremia
- Paraldehyde
- Lactic acidosis
```
34
Hypertrophic osteoarthropathy
Systemic disorder of bones, joints, soft tissue; associated with intrathoracic neoplasm (bronchogenic)
- Also called Hypertrophic pulmonary osteoarthropathy
- Painful, tender periosteal bone proliferation usually associated with clubbing
- Seen in long bones of extremities: pre-tibial aches (shining, thickened warm skin)
Diagnosis: imaging
Treatment: resection
*Can also occur in non-neoplastic pulmonary disorders (CF, bronchiectasia, empyema, lung abscesses)
35
Atelectasis
```
Obstructive:
Excessive secretion due to:
- asthma
- chronic bronchitis
Foreign body aspiration
Blood
Bronchial neoplasms
```
Compressive:
Expansion of the pleural space
- By fluid: effusion (CHF, neoplasms), blood (rupture of aneurysm)
- By air: pneumothorax
Patchy:
Loss of surfactant due to:
- neonatal RDS
- adult respiratory distress syndrome (ARDS)
36
Reduced breath sound intensity
Airflow obstruction
- COPD: reduced transmission of sound (not production)
- + fever and localized sound= pneumonia with effusion
- Confirm obstruction with FETo maneuver
37
Pleural effusion breath sounds
- Vesicular on top
- Bronchial in middle
- Absent on bottom
38
Clubbing
Presentation:
Shunting of blood from finger tips
- does NOT occur in emphysema
- Seen in chronic bronchitis, tetralogy of Fallot, endocarditis
- 4/5 patients with clubbing--> underlying respiratory disorder (inflammatory or neoplastic)
Signs:
Floating nails (ballottability of nail bed)
Abnormal phalangeal depth ratio
Lovibond angle disappears (at cuticle)
- Differentiate from severe nail curvature= illness
* Malignancy can increase periosteum--> tenderness in shins, clubbing (pulmonary hyperperiostrophy)
```
Causes:
SHUNT
Intrathoracic:
- AV malformations (Osler-Weber-Rendu)
- Lung cancers
- Mesothelioma
- Bronchial problems
- Cystic fibrosis
Cardiovascular
- Congenital cyanotic heart disease
- Subacute bacterial endocarditis
- Infected aortic bypass graft
Hepatic/GI:
- Cirrhosis
- IBD
- GI cancer
*10% benign (AAs, idiopathic, pregnancy)
```
39
Loud breath sounds in neck
Inspiratory – stridor
| Expiratory – vocal cord dysfunction
40
Bradypnea
Slow breathing (< 8 bpm) due to:
- hypothyroidism
- CNS depression
- Narcotics/sedatives
41
Toe clubbing
Pulmonary hypertension (due to PDA)
- Fingers normal, pink
- Toes bluer, clubbed
- "Half a smurf"
42
Platypnea
Breathing "flat" due to orthodeoxia when upright
- Left to Right to Left shunt (often ASD with pulmonary hypertension)
- Cirrhotics (Hepato-pulmonary syndrome)
- Bi-basilar processes (embolisms, pneumonia, pleural effusion
43
Hepato-pulmonary syndrome
Cirrhosis--> AV fistulas--> standing feeds fistulas--> hypoxia
Lying down drains AV fistulas--> normoxic
** additionally, liver produces NO--> pulmonary vessel dilation
44
Hypopnea
Shallow respirations due to:
- Impeding respiratory failure
- Obesity- Hypoventilation (Pickwickian syndrome)
vs Apnea= absence of breathing (> 10 seconds)
45
Murphy's sign
Painful right upper quadrant, no nodules= cholecystitis
4Fs= fat, female, forty, female
- The encounter between the examiner’s fingertips and the inflamed edge of the gallbladder causes pain and a reflex arrest in inspiration.
46
Signs of Cholecystitis
Murphy's sign
- Area of hypersensitivity over the right costophrenic angle (Boas’ sign) – sensitivity only 7%.
- At times they may also exhibit an audible rub over the edge of the gallbladder.
- They rarely have a palpable and tender right upper quadrant mass, (see Courvoisier’s law).
* * Courvoisier's law= Jaundice in the setting of a painless, enlarged gallbladder indicates malignancy of the head of the pancreas or the sphincter of Oddi (NOT gallstones)
47
Shifting dullness maneuver
Test used to diagnose Ascites:
- Gravity- dependent shift
- Sensitive test: 500-1000 mL of fluid (can rule out presence of GROSS ascites)
- 50% specificity: confounder= accumulation of fluid in patients with diarrhea
48
Bulging flanks
Weight of intra-abdominal fluid (and effect of gravity on fluid) causing flanks to push outward while supine
- Sensitive but not specific
49
Flank dullness test
Percussing abdomen radiating out from umbilicus: air filled bowels vs dullness from ascites
- Sensitive but not specific
50
Fluid wave maneuver
Place one hand on flanks and tap on opposite flank. Have patient place ulnar hand surface vertically over umbilicus
- Positive test= fluid wave emanating to contralateral side
- Specific, not sensitive
51
Asterixis
"Liver flap"
- Common finding of hepatic encephalopathy
- Hands start flapping while outstretched
52
Spider telangectasias
Small capillary rupture- sign of liver failure
53
Palmar erythema
Sign of liver failure
54
Caput medusa
Portal hypertension causing dilatation of veins around umbilicus
55
Palpable spleen
Hemolytic anemia
| Portal HTN, cirrhosis, obstruction
56
Foeter hepaticus
distinctive breath smell in liver failure (eggs)
57
Guarding
Diffuse or localized tension of abdominal wall
- Involuntary (rigidity)
- Voluntary= elicited by gentle or deep pressure
* Localized rigidity= specific indicator of peritonitis- see absence of respiratory motion in select parts of abdominal wall
58
Carnett's sign
Induced guarding= patient feels less pain when they tense abdominal wall (intrabdominal problem). If they feel more, this is abdominal wall problem
59
Abdominal wall tenderness (AWT)/ modified Carnett's
Patient sits forward- at midway the physician increases pressure on tender spot. If tenderness increases--> positive abdominal wall tenderness. If tenderness decreases--> negative test
* It should not be used in children or elderly patients (because of the risk of misinterpretation).
- It is useless and inhumane in patients with diffuse abdominal pain who already have rigidity.
- It is possibly dangerous in patients with an intra-abdominal abscess (straining and increased intra-abdominal pressure may cause the abscess to burst).
60
Blumberg's sign
Rebound tenderness:
Severe pain of abdominal wall indirectly elicited by sudden release of hand pressure
- Palpate area of tenderness gently, then deeper and release
- OR, light indirect percussion over area of pain
61
Referred rebound tenderness
Rebound testing on side opposite to where pain reported.
| ex: Rovsing's sign
62
Abdominal hyperesthesia
Acute pain in abdomen due to any process in or on abdomen (organs, herpes zoster, etc)
63
Closed eye sign
Closed eyes + beatific smile= nonspecific abdominal pain
64
Stethoscope sign
Palpating abdomen using stethoscope (patient doesn't know they are being palpated)
65
McBurney's sign
Maximum tenderness/rigidity elicited by pressing finger over McBurney's point--> appendicitis
66
Rovsing's
Pain on RIGHT side by pushing on LEFT side (mirror McBurney's point)
67
Rectal tenderness
Should be carried out on any patients on acute abdomen to confirm appendicitis confined to pelvis
- this sign is only helpful in case of perforation, where the rectal exam reveals a right-sided tender mass that represents the pelvic abscess.
68
Obturator test
Patient flexes hip, rotates internally while supine (or physician pulls ankle towards himself, pushes knee away)
- Pain (usually referred to the suprapubic region) indicates inflammation in one of the organs surrounding the obturator internus, and is a specific but poorly sensitive sign of retrocaecal appendicitis.
- Beside appendicitis, the obturator test may also be positive in many obstetric-gynecologic conditions characterized by the presence of pus in the pelvis.
- In such cases the test is usually positive in both legs, whereas in appendicitis is positive only on the right leg.
69
Reverse psoas (iliopsoas) maneuver
Irritation of iliopsoas muscle due to retrocaecal appendicitis or other localized collections of pus/blood
- Have patient roll to left side and hyperextend right hip--> positive when pain elicited
- Low sensitivity, high specificity
70
Symptoms of hypothyroidism
- Feeling cold (hypothermic)
- Constipation, "bloated" feeling
- Mild/modest weight gain
- Skin: myxedema (puffy), capillary fragility (bruising)
- Fatigue, depression
- Alopecia, coarsening of hair
- Queen Anne's sign= lateral eyebrow hair loss
- Bradycardia
- Musculoskeletal: Symmetric decrease in proximal muscle power, *DELAY IN RELAXATION PHASE of ankle reflex*
- Snoring
- Menstrual changes
- Erectile dysfunction, oligospermia
- Nervous system: lethargy, somnolence, confusion, paranoia, severe agitation, sensory deficits, cerebellar ataxia. Mucinous accumulations in cerebellum and nerve fibers.
- Cardiovascular - cardiac output decrease, myxedema heart (dilated
cardiomyopathy) , peripheral vascular resistance increased
- GI: decreased peristalsis with constipation, myxedema megacolon
Rare= Myxedema coma: hypothermia, hypoventilation, hyponatremia, depressed mental status
71
Causes of hypothyroidism
- Endemic goiter (iodide deficiency)
- Defective synthesis of TH with compensatory goiter
- Inadequate function due to decreased gland mass
- - "burned out" Hashimoto's
- - Thyroidectomy (mantle radiation--> xerostomia= kill thyroid gland tissue)
- Inadequate TSH, TRH
72
Symptoms of hyperthyroidism
- Warm/hot (increased sweating)
- Neurologic: Anxiousness, agitation, tremor, emotional lability
- GI: mild/modest weight loss (>10% body mass over 2 months), hyperdefecation/ diarrhea
- CV: palpitations, slight tachycardia at rest (irregularly irregular rhythm= concerning), Afib
- diffuse alopecia with fine, thin hair
- Dermopathy: Plummer's nails= distal onycholysis, acropachy (diagnostic for graves= clubbing of fingers), pretibial myxedema
- Musculoskeletal: Brisk DTR, proximal myopathy
- Lid lag (NOT exopthalmos) due to spasm of eyelid elevator muscles
- GU: oligomenorrhea
73
Causes of hyperthyroidism
Thyroiditis
| Grave's disease
74
Causes of exopthalmos
- Infection (orbital cellulitis)
- trauma
- Tumor
- Grave's disease (unilateral)
- NOT caused by thyroid hormone excess
75
Symptoms of hyperthyroidism due to Grave's
- Diffuse goiter with bruit
- Hyperthyroidism
- Opthalmopathy (non-specific): grittiness, photophobia, lid lag & retration
- Specific opthalmopathy: proptosis (see upper AND lower sclera), exopthalmos, (diagnose with Moebius sign), ophthalmoplegia
- Dermopathy: acropachy (clubbing)
- Elevated T3, T4, increased radioactive iodide uptake
** Can cross placenta and cause fetal hyperthyroidism
76
Moebius sign
test to RULE OUT exopthalmos:
- Patient asked to converge eyes- observe for smooth ocular motion
- Weakness/odd movement seen in early exopthalmos
77
Apathetic hyperthyroidism
Seen in older patients: autonomic degeneration prevents patient from developing classic symptoms of hyperthyroidism
- Can see plummer's nails, hair changes
78
Symptoms of acute hypoglycemia
Glucose < 60 mg/dL
Tachycardia, diaphoresis, tremor, confusion, delirium, intoxicated appearance
** everything but confusion is catecholamine mediate- therefore if on beta-blocker, patient may have no symptoms of hypoglycemia
79
Symptoms of acute hyperglycemia
Not noticeable until glucose > 300 mg/dL
Changes in vision (changes to hydration in lens, polyuria, polydipsia, nocturia, decreased conciousness, hyperventilation in state of acidosis
80
Physical exam for DM
Examine feet, skin, fundus, peripheral/central arterial system:
- Feet: look for tinea infections, acanthosis nigricans; sensory exam
- External genitalia: balanitis (scrotum), vulvovaginitis candida infections
- Skin: Anterior tibial skin breakdown
- Opthalmoscopic: hard/soft exudates, bleeds, neovascularization
- - Exudates- albumen spillage: hard= smaller, soft= larger patches
81
Charcot joint
Neuropathy leading to excess joint damage (can't sense arthritis development)
82
Chvostek's sign
Tap on facial nerve- see spasm in facial muscles (sign of hypocalcemia)
83
Trousseau's sign
Hold BP cuff 20 mm Hg above systolic BP for 3 min--> see spasm of hand muscles (hypocalcemia)
84
Maranon's sign
red, itchy skin over thyroid, usually seen in Graves disease
85
Pemberton's sign
obstruction of the SVC due to substernal goiter upon arm elevation
86
Berry's sign
absent carotid pulses seen in thyroid malignancy
87
Modigliani's syndrome
pseudogoiter caused by a long, curving neckline
88
Digital rectal exam
Detects 60% (or less) of prostate cancers
- 50% of nodules are neoplastic
- High specificity, high negative predictive value
- Moderate sensitivity, low positive predictive value (can't rule IN cancer without PSA and ultrasound)
89
Orthostatic test
1, Patient supine with legs elevated : Take BP & pulse
2. Patient sitting up with legs dangling : Take BP & pulse after ~30 seconds
Normal:
- Pulse slightly increases (< 5% from baseline at standing, returns to baseline by 1 min)
- Systolic BP unchanged
- No symptoms
Volume-depleted:
- Pulse increases > 10% from baseline
- Systolic BP decreases > 10 mmHg or 10% of baseline
- Dizziness, light-headedness
* Avoid test in hypotension, tachycardia, syncope while supine
* * False negative in autonomic neuropathy (DM), false positive in beta-blockers (blunted pulse increase--> systolic BP decrease)
90
Symptoms of hypervolemia
```
Tight clothes
Shortness of breath
Paroxysmal nocturnal dyspnea
Nocturnal puritus of lower extremities
Fatigue
Dyspnea on exertion
Decreased appetite
```
91
Signs of hypervolemia
```
Jugular vein distension
Hepatojuglar reflux
Pitting Edema
Ascites
Increased weight
```
92
Leukonychia totalis
Hypoalbuminemia (renal failure)
| - Causes complete whitening of nail bed
93
Lindsay's nail
"Half and half" nails:
- Whitening of proximal half of nail bed
- Seen in renal dialysis
94
Muehrcke's line
Nephrotic syndrome causing linear discoloration of nail bed (parallel to lunula)
95
Murphy's punch
Assessment for pyelonephritis or renal stone
| - Tenderness over costovertebral angle
96
Physical exam in anemia
- Known bleeding
- Hypoxia
- Hemolysis: jaundice/scleral icterus, pallor, tachycardia, tachypnea
- Splenomegaly, hepatomegaly
97
Symptoms and signs of iron deficiency
Apparent with Hemoglobin < 8
General symptoms of anemia:
- Fatigue, shortness of breath, dyspnea on exertion, dizziness on standing, impaired exercise tolerance
- Pica, geophagia (eat dirt)
- Koilonychia (spoon nails)
- Lemon yellow beefy tongue
- Peripheral neuropathy
Signs:
- tachycardia, tachypnea, orthostasis, pallor
98
Clinical manifestations of B12 deficiency
Hematological:
- Anemia (fatique, dyspnea, SOB, syncope, chest pain)
- Leukopenia (recurrent infections)
- Thrombocytopenia (bleeding)
Epithelial:
- Generally microscopic changes with macrocytosis, increased multinucleate/dying cells
- Abnormal pap smears
- Angular chelitis, glossitis
Neural tube defects, cleft palate
Vascular disease: hyperhomocysteinemia--> arterial/venous thrombotic disease
Neurological:
- Subacute combined degeneration: degenerate dorsal/lateral white matter in spinal cord--> weakness, ataxia, parasthesias, spasticity, incontinence, paraplegia
- Dementia (progressive, irreversible)
- Psychiatric disturbances
99
Grey-turner sign
Bruising of flanks
| Can be sign of severe acute pancreatitis
100
Cullen's sign
Peri-umbilical bruising
| Sign of intraabdominal bleeding (ectopic pregnancy rupture, pancreatitis)
101
Symptoms of Leukemia
Thrombocytopenia, anemia--> Bruising
Gingival hyperplasia
Leukemia cutis (rash)
Beau's lines (lines in nails perpendicular to lunula)
102
Castell's point
Percussion of spleen to detect for splenomegaly
103
SVC Syndrome
Lung cancer--> compression of SVC
| - Red, bloated face
104
Pubic hair distribution tanner stages
Stage 1- Pre adolescent no pubic hair
Stage 2 - Long straight downy hair along the labia
Stage 3 - Darker coarser hair curlier spreading sparsely over the pubic symphysis
Stage 4 - Coarse curly hair as in adults over the entire pubis symphysis
Stage 5 - Hair adult in quality and quantity spread on medial surfaces of thighs
105
Bartholin cyst
Tender nodule
Posterior 2/3 of labia majora
Bartholin glands lie in the labia majora but the orifice is in the cleft between the labia minora and the introitus
Palpate by grasping the posterior portion of the labia between the right index finger in the vagina and the right thumb outside
106
Inclusion cyst
Non-tender nodule
| Anterior 1/3 of labia majora
107
Skene's glands
Paraurethral glands
Lateral to the urethral meatus.
Secrete mucus emptying in to the urethra
Homologous to the prostate
108
Gartner's cyst
Yellowish thin walled nodule anterolateral
wall of the vagina
-Failure of the Wolffian duct to degenerate
109
Tanner's staging for breasts
Stage 1- elevation of nipple
Stage 2 - Breast budding, elevation of breast and nipple as small mound, enlargement of areolar diameter
Stage 3 - Further enlargement of elevation of breast and areola , no separation of their
contours
Stage4 - Projection of the areola and nipple to form a secondary mound above the level of breast
Stage 5- (mature stage) Projection of nipple only
110
Pulmonary Hypertension
Murmur of diastole, increases with inspiration (Rivero/Carvallo maneuver)
Appearance:
- Cyanotic
- Anasarca (edema)
Neck veins:
- Prominent A, giant V wave
- Exercise-induced HYPOtension (hypokinetic pulse)
Precordial:
- RV impulse with S4
- Palpable P2
Auscultation:
- Pulmonic regurgitation (due to pulm HTN)--> loud P2 at apex (splitting should only be audible at base normally)
- Tricuspid regurg (backup)--> pulsatile liver
111
Pericardial tamponade
Appearance:
- Tachycardic, tachypnic
- Sitting up, leaning forward
JVP:
- Elevated
- Prominent X descent, no Y descent (atrium doesn't empty quickly)
- NO Kussmaul's
Pulse:
- Small
- Narrow pulse pressure
- Pulsus paradoxus (systolic BP decrease by > 10 mm Hg on inspiration)
Auscultation:
- 3 part murmur (2 diastolic, 1 systolic)
- Increases on expiration, decreases on inhalation
112
Mitral regurgitation
Systolic murmur (regurgitant blood flow during ventricular contraction) plus S3
- only seen in moderate to severe MR
- Severity of MR in rheumatic disease determined by murmur intensity (not MR due to ischemia/dilation)
- Most common cause in US= dilation of annulus fibrous from heart failure
Appearance: normal
JVP: normal
Arterial pulse:
- brisk upstroke and downstroke (hyperkinetic, normal PP)
- Normal BP
Precordial:
- Downward, laterally displaced PMI
- Palpable S3--> double PMI
- R ventricular impulse
Auscultation:
- Holosystolic plateau apical murmur
- S3 (severe regurgitation)
113
Mitral stenosis
Appearance:
- Acrocyanosis (F. Mitralica), Anasarca
JVP:
- Increased mean pressure
- Giant V wave (final atrial filling) of regurgitation (venous blood and regurgitant blood cause V-wave increase)
Arterial pulse:
- Hypodynamic
- Decreased BP, narrow pulse pressure
Precordial:
- R ventricuar impulse, S3
- Palpable P2
Auscultation
- Loud S1
- Diastolic rumble
- Tricuspid regurgitation (backup!)--> carvallo's
- S3 (pushing L atrial blood into L ventricle against stenotic valve)
- Pulmonaic systolic ejection click/regurgitation
114
Congestive (dilated) cardiomyopathy
Appearance:
- Anasarca
JVP:
- Elevated mean pressure
- Giant A and V wave
Arterial pulse:
- Small, hypodynamic
- Narrow pulse pressure
Precordial exam:
- Inferolateral displacement of PMI (enlarged and sustained)
- Palpable S4, S3, R-sided impulse
Auscultation:
- Loud P2, Possible pulmonic regurgitation
- S3 and Mitral regurg at apex
- possible R-sided S4
115
Muscle power
Definition: Strength of muscles about a joint
- Procedure: Assess strength of movement
- Grading: 0 to 5 (5= normal, 1-4= paresis, 0= plegia)
- FIRST: Perform Passive ROM to assess function of joint
- Compare/contrast with other side
Grading (MRC scale)
5: Against gravity and significant external resistance
4: Against gravity and minimal external resistance (4-, 4, 4+)
3: Against gravity
2: Incomplete, needs assistance against gravity
1: Twitch
0: No movement= plegia
Fasiculations= LMN damage
Atrophy: disuse or LMN damage
Pseudohypertrophy= usually of gastrocnemius; flaccid enlargement, muscular dystrophy
116
Assessment of power
```
Steps:
Passive ROM, inspection, then active ROM for:
- Abduction at shoulder
- Flexion at elbow
- Forward flexion at hip
- Extension at knee
```
117
Abduction at shoulder
Position: Neutral; scapular plane
Joints: Glenohumeral, scapulothoracic, acromioclavicular, sternoclavicular
Muscles: 0 to 100 degrees: Supraspinatus and deltoid
Nerves: C5: axillary and suprascapular nerve
118
Hip forward flexion
Position: standing, sitting or supine
Joints:Femoral-acetabular
Muscles: 0 to 130 degrees:iliopsoas
Nerves: Branches of L1 and 2
119
Knee extension
Position: Knee at 90 degrees of flexion
Joints:Tibiofemoral
Muscles: Quadriceps muscle
Nerves: L3 and L4, femoral nerve
120
Testing for reflexes
Note clonus, look and feel for contraction of muscle
Jendrassik's maneuver:
- Have patient hook hands together and pull to distract from reflex testing
```
Grading:
4+: Clonus and/or cross-over
3+: Brisk; without clonus/cross-over
2+: Normal
1+: hyporeflexia; present only with Jendrassik’s manuever
0: Absent
```
```
3+/4+ = Hypereflexia
1+= Hyporeflexia
0= Areflexia
Clonus= Rhythmic beats
** 1,2,3= normal until proven otherwise
** 0,4= abnormal until proven otherwise
```
121
Biceps reflex
```
Hand and forearm in neutral handshake position
Place thumb over biceps tendon
Strike thumb with plexor
Observe/feel contraction of biceps
Root: C5, C6
```
122
Quadriceps reflex
Stabilize knee in 20 degrees flexion
Tap over the patellar ligament
Observe/feel quadriceps muscle contraction
L4 root
123
Plantar reflex
Gently stretch tendons by passively extending toes and dorsiflexing foot
Tap over mid plantar foot
Observe/feel contraction of posterior compartment muscles-plantar flex/toe flexion
S1 root
124
Cranial nerve exam: eyes
Eyes:
1. Cranial nerve 3: Superior rectus, inferior rectus, Inferior oblique, medial rectus; levator palpebrae
- Damage: multiple deficits and a marked ptosis
2. Cranial nerve 4: Superior oblique
3. Cranial nerve 6: Lateral rectus
125
Cranial nerve exam: face
Cranial nerve 5:
1. Sensory
- V1: Skin of forehead, periorbital skin, conjunctiva, cornea, tip of nose
- V2: Skin of maxilla
- V3: Skin of mandible: Cotton-tipped swab
2. Motor
- Masseter: Gentle bite down on a tongue blade
Cranial Nerve 7:
1. Motor:
- Puff out cheeks-buccinator
- Growl-orbicularis oris
- Protrude lower lip-mentalis
- Close eyes-orbicularis oculis
- Wrinkle forehead-frontalis
* * Central 7 damage:
- Unable to growl, protrude lower lip, smile
- Able to close eyes and wrinkle forehead
- Contralateral UMN lesion
* * Peripheral 7 damage:
- Unable to growl, protrude lower lip, smile, close eye, wrinkle forehead
- Ipsilateral LMN lesion
- Trauma
- Lyme
- Multiple sclerosis
126
Cranial nerve exam: swallowing
Cranial Nerve 9 and 10:
- Swallowing dysfunction
- Abnormal uvular movement with AHHH
- Hoarseness, esp. when stating "AHH"
- NEVER perform gag reflex
Cranial Nerve 12:
- Tongue muscles
- Dysarthria
- Protrusion of the tongue; repeat thrice
1. Normal: Tngue prtruded and midline
2. Paralysis: Unable to protrude
3. Paresis: protrudes but deviates from midline
127
Cranial nerve exam: shoulders
Cranial nerve 11:
- Push hands forward as if one were doing a “push-up” against resistance applied by clinician; look for scapular winging
- Serratus anterior
- Trapezius-Cranial nerve 11
- Shrug shoulders against resistance
128
Normal gait
Normal based: Feet placed beneath the anterior superior iliac spines (ASIS)
Steady
Complementary arm swinging-left arm with right leg; right arm with left leg
129
Spastic hemiparetic gait
Narrow-based
Unsteady
Arm adducted, elbow flexed, forearm supinated
Leg adducted, plantar flexed, increased arch
Concurrent:
- Increased reflexes
- Spastic tone
- Upgoing and flared toes with noxious stimulus applied to foot
130
Ataxic gait
```
Wide-based
Unsteady
Minimal arm swinging
Cerebellar or sensory deficit
Very high falls risk
```
Procedural:
1. Stance
- Patient stands in anatomic position; then is instructed to place feet together
- Note any deviation of body from midline
2. Romberg
- Stance position, then patient instructed to close eyes; then to forward flex arms to horizontal plane; then apply stress to arms
- Note any deviation of body from midline
131
Metria
Procedure: Finger-to-finger-to-finger
- Perform in X, Y and Z axes
- Perform on both sides of midline; on both the left and then the right hand
- Better than old, “Finger to nose”
Outcomes:
- Dysmetria: Unable to judge distances and move to site; past-pointing present. Indicates cerebellar disease
132
Diadochokinesis
Procedure: Ability to perform rapidly alternating actions
- Supinate/pronate forearm…
- Thumb to tip of digit 2 then 3, then 2, then 3…
Outcomes:
- Diadochokinesis: normal
- Dysdiadochokinesis: unable to perform this; indicates cerebellar disease
133
Synergy
Measurement of graceful, gliding smooth actions
Procedure: Swing a bat, heel to shin, write a note using elegant handwriting, state the word “kentucky”
Asynergy: unable to perform; fragmented actions; indicates cerebellar disease
134
Large A wave
A wave= Atrial contraction at end of diastole
- Coincides with any S4 (if present)
Seen in:
- Tricuspid stenosis
- Pulmonic stenosis
- Pulmonary HTN
- 1st degree AV block
- Supraventricular tachycardia
Absent in AFib (no coordination of contraction
135
X-descent
RelaXation of atrium (contraction of ventricle)
- Venous P drops as atrium pulled down by contracting ventricle
- Prominent in cardiac tamponade, constrictive pericarditis
136
V wave
Venous filling of atrium
Large V waves seen in:
- Tricuspid regurgitation (extra blood in atrium already)
- Constrictive pericarditis (atrium filling against restrictive forces
137
Y descent
Atrium emptYing begins
| - Absent in cardiac tamponade, but prominent in constrictive pericarditis
138
Kussmaul's sign
INCREASE in JVP with inspiration (vs normal decrease)
- Due to impaired ventricular filling
Seen with:
- Constrictive pericarditis
- Restrictive cardiomyopathy
- Pericardial effusion
- R heart failure
- Cardiac tumors
- Tricuspid stenosis
139
Lancisi's sign
Tricuspid regurgitation--> flickering earlobes
140
Hepatojugular/abdominojugular reflex
Hepatic pulsatility without Lancisi sign:
- Push on abdomen for 15 sec
- IJV will bulge due to increased volume load from liver
Positive, Asymptomatic: R ventricle failure
Positive, symptomatic: biventricular heart failure (crackles, S3 gallop, lateral PMI displacement)
141
Hyperkinetic pulse
Normal pulse pressure:
- Mitral regurgitation
- VSD
- HOCM
Widened pulse pressure:
- Aortic regurgitation (Corrigan's pulse)
- Anemia
- Pregnancy
- Thyrotoxicosis
142
Pulsus parvus
Small amplitude pulse. Seen in:
- Cardiomyopathy
- Mitral stenosis
- Aortic stenosis (with pulsus tardus)
143
Pulsus tardus
Slow upstroke in pulse
144
PMI
L 5th ICS, MCL
Displacement:
- Down, lateral= MR, AR, L heart failure
- Up, medial= AS, HTN, CAD
Size ~ 1cm
> 2.5 cm= enlarged L ventricle
145
Ludwig's angina
Swelling in submental area (neck)
- Can develop swelling-->
- Airway swelling and stridor
146
Gingival hypertrophy
Side effect of phenytoin, cyclosporine A--> gums grow over teeth
- Can also be seen in leukemia
147
Epulis
Hypertrophic papilla due to overzealous flossing, 3rd trimester pregnancy
148
Aphthous stomatitis
1+ tender erosions on buccal mucosa
149
Quinsy
Smooth nodule/mass next to tonsil due to strep abscess (untreated strep throat)
150
Darymple's sign
Baseline bilateral lid lag (hyperthyroidism)
151
Stellwag's sign
Unilateral lid lag (hyperthyroidism)
152
Von Graef's
Active lid lag (hyperthyroidism)
153
Plummer's nails
Distal onchyolysis (hyperthyroidism)
154
Pectus carinatum
Pigeon chest
Pectus excavatum= funnel chest
155
Flail chest
Part of chest moves in on inspiration
| - Broken rib--> separates from ribcage
156
Finkelstein test
Mischief at anatomic snuff box:
- Fingers flexed around thumb--> push passively to deviate ulnarly at wrist
Scaphoid mischief= pain in palmar wrist
deQuervain's= pain in snuffbox (peeling potatoes, surgeons tying knots)
157
Oliver's sign
Downward tracheal tug due to aortic aneurysm
158
Campbell's sign
Tracheal descent with inspiration due to COPD, chronic airflow obstruction, respiratory distress)
