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88 Cards in this Set
- Front
- Back
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Inferior tip of scapula at which rib?
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rib 7
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aspices of lungs are where?
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2-4 cm above inner third of clavicle
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inferior borders of lungs are where?
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6th rib in the MCL and 8th rib in the MAL
T10 inspiration; T12 expiration |
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vertebral level at which trachea bifurcates
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T4
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anterior landmark at which trachea bifurcates
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sternal angle
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symptoms associated with PNA
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productive cough
pleuritic CP SOB fatigue anorexia myalgias tachypnea increased tactile fremitus wheeze crackles |
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what pretty much excludes PNS diagnosis
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absence of vital signs abnormalities
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Parts of Great Vessels examination
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Inspection of the Neck
- jugular venous pulsations (JVP) - extimation of central venous pressure Palpation of Carotid Pulses - symmetry, strength Auscultation of Carotid Pulses - bruits (signs of obstruction) |
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What do bruits indicate?
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signs of obstruction
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Compare carotid and jugular venous pulsations
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Carotid pulsations
- uniphasic (one upward motion) - palpable - can't be obliterated by examining finger - medial to SCM Jugular venous pulsations - multiphasic/undulating - not palpable - can be obliterated by examining finger - vary with position of patient |
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Jugular venous pulsations
a-c-v waves |
a wave = atrial contraction
x = descent represents atrial relaxation v = atrial (venous) filling y = descent represents atrial emptying when tricuspid valve opens in diastole |
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pathologies suggested by changes in JVP character
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valvular heart diseases
- tricuspid stenosis - tricuspid regurgitation - ASD - right ventricular hypertrophy - pulmonary HTN - constrictive pericarditis |
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How many cmH2O does it take to get blood from level of RA to level of sternal angle?
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5 cmH2O
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which pressure can be estimated by looking at JVPs?
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central venous pressure
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how to measure central venous pressure (CVP)
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find highest level of jubular venous pulsations on neck
measure verticle distance btw highest visible waves and sternal angle add that number to 5 (distance btw RA and sternal angle) |
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5 things to assess about the carotid pulse
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amplitude (reflects pulse pressure)
contour variation from side to side presence of a "thrill" or palpable vibration auscultate for bruits |
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carotid pulse assessment
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best, most central pulse available
signals conditions involving the vasculature like atherosclerotic ds, aging changes character related to cardiac structure and function changes with lesions like aortic stenosis or aortic regurgitation, various arrthythmias bruits may indicate atherosclerosis, inflammation of the vessels, other processes |
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What are you looking for during inspection of anterior chest
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structural abnormalities
dynamic features like pulsations or heaves where you expect to see them - point of maximal impulse (PMI) or aortic impulse (AI) - abdominal aorta motions where you don't expect to see them |
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precordium
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anterior chest that overlies the heart
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PMI
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normal PMI in 5th ICS at MCL
abnormal location usually signifies decrease in left ventrical (hypertrophy or dilatation) can have Right Ventricular "heave" which signifies RV enlargment |
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normal characteristics of PMI
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located in 5th ICS, MCL
about the size of a quarter (2cm diameter) duration is less than 2/3 of systole |
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Cardiac cycle sounds
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S1 - composed of two sounds
- closure of mitral valve followed by - closure of tricuspid valve S2 - composed of two sounds - closure of aortic valve followed by - closure of pulmonic valve |
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atrioventricular valves
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Mitral valve - btw LA and LV
Tricuspid valve - btw RA and RV |
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semilunar valves
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Aortic valve - btw LV and aorta
Pulmonic valve - btw RV and pulmonary artery |
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quality of heart sounds
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extremely crisp and sharp
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more than two heart sounds means...
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either splitting of normal heart sounds
additional abnormal sound |
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8 things to listen for during cardiac auscultation
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listen to S1
listen to S2 listen to systolic interval listen to diastolic interval listen for extra sounds in systole listen for extra sounds in diastole listen for murmurs in systole listen for murmurs in diastole |
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Events on which side of the heart occur earliest and why?
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Right sided evnts occur later than left sided events
right heart is low pressure system left heart is high pressure system Mitral valve closes before Tricuspid Aortic valve closes before Pulmonic |
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Which heart sound marks beginning of systole
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S1
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Which heart sound marks beginning of diastole?
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S2
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Is the carotid pulse happening during systole or diastole?
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systole!
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Using the carotid pulse to determine S1 and S2
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the sound before the pulse is S1
the sound after the pulse is S2 |
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Where should you hear S1 loudest?
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cardiac apex
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Where should you hear S2 loudest?
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at base of heart
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Where might you hear tricuspid murmur best?
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xiphoid/subxiphoid regions
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Physiologic changes with inspiration
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thoracic volume increases
intrathoracic pressure decreases venous flow to right heart increases increased ventricular volume delays closure of the pulmonic valve increased pulmonary capacitance decreases blood delivery to the left heart decreased left ventricular ejection volume means aortic valve shuts sooner |
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bottom line for cardiac sound changes with inspiration
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components of S2 (A2 and P2) are unusually far apart
S2 "splits" |
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extra sounds in systole
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aortic or pulmonic ejection sound
- high pitched - occurs shortly after S1 mitral valve prolapse - midsystolic click - occurs halfway between S1 and S2 |
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extra sounds in diastole
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mitral or tricuspid stenosis
- occurs shortly after S2 - opening snap non-compliance of the ventricle - presystolic sound of contracting atrium - just before S1 - sometimes called "S4" - can be from RV or LV volume overload of ventricle - immediately after S2 low-pitched, early diastolic sound - called "S3" - from RV or LV |
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describe heart murmurs
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systolic or diastolic noises
timing (systolic, diastolic, midsystolic, holosystolic) shape (diamond-shaped, flat, decrescendo) location of maximal intensity radiation (to carotids, to axillae) pitch (high or low) quality (harsh, blowing, rumbling) |
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Heart murmur intensity grading scale
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scale of 1 to 6
1 - lowest intensity, barely audible 6 - loud, audible with stethoscope off the chest |
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Systolic ejection murmurs
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S1 and S2 are still audible
diamond-shaped, crescendo/decrescendo involve aortic and pulmonic valves |
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Holosystolic murmurs
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obliterate S1 and S2
blowing, constant intensity involve mitral and tricuspid valves |
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mitral stenosis/tricuspid stenosis
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type of diastolic murmur
low-pitched, rumbling opening snap (early diastolic sound) heard at apex, left lateral decubitus |
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aortic regurgitation murmur
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type of diastolic murmur
high-pitched blowing quality decrescendo begins with S2 heard at Erb's Point (L. 3rd ICS) w/ sitting up, learning forward w/ exhaled breath |
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auscultate at apex, left lateral decubitus for what defect?
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mitral/tricuspid stenosis
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auscultate at Erb's Point for what defect?
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aortic regurgitation
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3 systems assessed in the abdomen
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GI system
GU system CV system |
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9 regions/sections of abdomen
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epigastric
umbilical/hypogastric suprapubic R/L hypochondrium R/L lumbar R/L inguinal |
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Things to look for during abdominal inspection
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contours
skin changes - scars - striae - blood vessels pulsations |
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2 categories of abdominal auscultation
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bowel sounds
bruits -renal arteries -aorta in 2 places - iliac arteries |
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percussion of abdomen
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most useful to evalulate liver and spleen
also used to evaluate possible mass or fluid in abdomen |
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normal liver span at MCL
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6-12 cm
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where is spleen located?
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9th ICS, AAL
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goals of palpation of the abdomen
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assess tenderness/muscle tension
size and feel of normal structures locating abnormal structures |
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voluntary guarding
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can be overcome by relaxation, during expiration
may be result of tenderness, worry |
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involuntary muscle spasm/guarding
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remains even with improved relaxation
sign of peritonial inflammation |
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3 signs in assessing for appendicitis
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Rebound tenderness
Rovsing's sign Psoas sign |
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Rebound tenderness
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press slowly but firmly, then let go quickly
in rebound tenderness, letting go hurts more than the pressure indicates irritation of the peritoneum, suggesting inflammation not specific for appendicitis |
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Rovsing's sign
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press slowly but firmly to lower left abdomen, then withdraw quickly
postiive Rovsing's sign is when this causes Right lower quadrant pain Rovsing's sign suggests appendicitis |
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Psoas sign
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How to perform:
- ask pt to reaise Right leg against resistance - extend Right leg at hip w/ pt lying on left side Pain on either is positive Psoas sign suggests inflammation of psoas by inflamed appendix |
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Assessing for cholecystitis
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Murphy's sign
how to perform - hook fingers under right costal margin - ask patient to take a deep breath sharp increase in tenderness/halt in inspiration is a positive Murphy's sign positive Murphy's sign suggests acute cholecystitis |
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Ascites
what is it? how is it confirmed? |
Ascites
free fluid in abdomen confirmed by fluid aspiration by paracentesis confirmed by fluid visualization by U/S or CT scan |
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Significance of Ascites
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free fluid in abdomen may indicated underlying heart failure, liver disease, nephrotic syndrome
ascites has prognostic implications ascites may indicates metastases in pt w/ malignancy |
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Causes of ascites
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elevated hydrostatic pressure
- heart disease - cirrhosis - hepatic vein obstruction Decreased osmotic pressure - liver disease - nephrotic syndrome - malnutrition Fluid production > resorption - infection - malignancy |
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5 historical findings that may suggest ascites
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hepatitis
heart failure increased abdominal girth weight gain ankle swelling |
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physical exam findings suggesting ascites
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bulging flanks
flank dullness shifting dullness prominent fluid wave |
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4 things to look at when inspecting skin
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rashes
lesions hypo- or hyperpigmentation Nevi (moles) |
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things to check regarding arterial circulation in the extremities
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pulses
capillary refill temperature oxygenation lesions |
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things to check regarding venous circulation
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edema
- pitting - non-pitting varicosities thrombosis |
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pulmonary presentation in extremities
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assessing oxygenation
- color - clubbing |
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3 involunatary movements (neurologic assessment)
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tremor
fasciculations writhing movements (chorea, athetosis) |
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neurologic muscle assessment of extremities
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bulk, symmetry
strength - gait, toe, heel - pronator drift |
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neurologic reflex assessment
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deep tendon reflexes (DTRs)
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other systems to assess in extremities
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joints
- swelling, redness, warmth, tenderness - range of motion endocrine/DM - skin lesions - neuropathy nutrition -subcutaneous fat - muscle bulk |
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Horizontal group of superficial inguinal nodes
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underlies inguinal ligament
areas drained: - skin of lower abdomen - external genitalia - anal canal - gluteal area - lower vagina |
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Vertical group of superficial inguinal nodes
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lies along greater saphenous vein
area drained: upper leg |
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4 pulses to check on extremities
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radial pulse (are they symmetric)
femoral pulse posterior tibial pulse dorsalis pedis pulse |
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compare femoral pulses in terms of ...
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bruits?
strength: bounding, normal, diminished, absent |
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what does edema evaluate?
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vascular and lymphatic systems
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edema
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increased interstitial fluid
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places to test PROXIMAL muscle strength and symmetry
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shoulder
hip |
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places to test DISTAL muscle strength and symmetry
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hands
feet |
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Inspection during pt standing
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Station
Gait: normal, toes, heels Back: standing vertebral alignment on flexion |
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DVT
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aka: venous thromboembolism (VTE)
3rd most common DV disease |
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2 patterns of clinical presentations of VTE
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DVT
PE (pulmonary embolism) |
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untreated DVT can lead to...
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PE
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why is DVT diagnosis problematic?
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3/4 patients with suspected DVT have nonthrombotic leg pain
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