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82 Cards in this Set

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What are the consequences of using a blood pressure cuff that is too small for the patient’s arm?
A blood pressure cuff that is too small may cause an artificially elevated reading, which can lead to an incorrect diagnosis and/or excess treatment. Too large a cuff introduces the opposite error, an artificially low reading but not nearly the magnitude of the too small cuff error.
What is a “pulse deficit” and what does its presence suggest?
Normally, the heart rate and pulse rate are the same but for patients who are in atrial fibrillation, there is a “pulse deficit” wherein the pulse rate is lower than the heart rate.
excessively rapid respirations
difficult or labored breathing; shortness of breath
difficult or painful breathing except in an erect sitting or standing position.
How do you measure “orthostatic” changes in the blood pressure and heart rate? What do these tell you about the patient?
Measure the patient’s blood pressure and heart rate while seated or recumbent and then while standing. It is abnormal if the blood pressure drops significantly upon standing. Orthostatic changes in blood pressure result from hypovolemia or disturbances in vascular control. If the heart rate is >120 beats/minute or increases by 30 beats/minute with standing and subsides with sitting then the patient may have a dysautonomia. In a standing position blood pools in the legs. Normally, changes in cardiac output and vascular resistant maintain blood pressure so you don’t pass out.
normal blood pressure
normal heart rate
normal respiratory rate
When measuring a blood pressure, what is the “auscultatory gap”
For a given patient the auscultatory gap (AG) may exist at any pressure or not be present at all. Not accounting for the AG can result in inaccurate systolic or diastolic readings. If you inflate the blood pressure cuff to a pressure within the auscultatory gap you will measure an inaccurately low systolic pressure. Assuming you have reached the diastolic pressure when you are in fact in the AG will result in an inaccurately high diastolic pressure. Palpate the radial pulse and inflate the cuff and note the pressure at which the pulse becomes impalpable. Then inflate the cuff 30mmHg beyond the pressure at which the pulse was lost to avoid inaccurate blood pressure measurements.
Epistaxis is defined as acute hemorrhage from the nostril, nasal cavity, or nasopharynx.
Rhinorrhea, or nasal discharge, is any mucus-like material that comes out of the nose.
amaurosis fugax
Amaurosis fugax is a brief, fleeting attack of monocular partial or total blindness that lasts seconds to minutes (although the uptodate source states that it can also be binocular). It is thought to result from plaque in the carotid artery breaking off and traveling to the retinal artery, creating a clot and causing a loss of vision for as long as the artery is blocked
Tinnitus is the perception of sound within the human ear in the absence of corresponding external sound.
Vertigo is a false sensation that the self, surroundings, or both are moving or spinning
Weber Test
It can detect unilateral (one-sided) conductive hearing loss and unilateral sensorineural hearing loss.
-A patient with a unilateral (one-sided) conductive hearing loss would hear the tuning fork loudest in the affected ear. The conduction problem masks the ambient noise of the room, whilst the well-functioning inner ear picks the sound up via the bones of the skull causing it to be perceived as a quieter sound in the unaffected ear.
-unilateral sensorineural hearing loss would hear the sound loudest in the unaffected ear, because the affected ear is less effective at picking up sound even if it is transmitted directly by conduction into the inner ear.
Rinne Test
- compares perception of sounds as transmitted by air or by bone conduction through the mastoid. Thus, one can quickly suspect conductive hearing loss.
-In a normal ear, air conduction is better than bone conduction
-In conductive hearing loss, bone conduction is better than air
-In sensorineural hearing loss, bone conduction and air conduction are both equally depreciated. In sensorineural hearing loss patients there may be a false negative Rinne.
changes in the fundi: Hypertension
Macular star (of cotton-wool patches)
Increased light reflex from arteries just above and below the optic disc
Venous tapering at arterial-venous crossing
Optic disc may have a blurred nasal border
changes in the fundi: Diabetes Mellitus
Microaneurysms and haemorrhages
Retinal thickening or edema in the area around hard exudates results in an enlarged blind
spot and decreased visual acuity
Neovascularization (new vessels); tiny, tortuous retinal vessels
Distortion of the macula
Cotton-wool patches
changes in the fundi: Brain Tumor
Loss of venous pulsations
(also: intracranial compression of CN VI resulting in ophthalmoplegia and diplopia)
Sweating, heat intolerance (warm & smooth skin)
↑systolic, ↓diastolic BP
Tachycardia, atrial fibrillation
Hyperdynamic cardiac pulsations with accentuated S1
Frequent bowel movements
Weight loss (increased appetite)
Proximal muscle weakness & tremor
Stare, lid lag, exophthalmos (Graves disease)
Dry skin, cold intolerance with non-pitting edema and loss of hair
↓systolic, ↑diastolic BP
Bradycardia, hypothermia
Swelling of face, hands, legs
↓intensity of heart sounds
Weight gain (with anorexia)
Weakness, muscle cramps, arthralgias, paresthesias
Periorbital puffiness, lateral sparseness of eyebrows, peripheral neuropathy
Somnolence, impaired memory & hearing, carpal tunnel syndrome,
Rales (Crackles):
short, discrete, non-musical sound caused by previously deflated airway suddenly reinflated during inspiration.
i. Seen in pneumonia, pulmonary edema (CHF), interstitial lung disease
"continuous" sounds lower in pitch than wheezes that have a snoring quality.
i. Usually caused by secretion in the airways.
ii. present when an airway is partially obstructed owing to secretions, mucosal swelling
iii. seen in COPD and bronchitis
continuous musical sound of long duration caused by rapid passage of air through narrowed or obstructed bronchus
i. Seen in asthma, foreign body occlusion, tumor, COPD
ii. May also be associated with prolongation of expiratory phase
inflamed pleural surfaces rubbing against each other. Sounds like rubbing leather strap.
i. See with pleuritis or pulmonary infarction
blood in the sputum
i. true hemoptysis: bronchial or lung source
1. from neoplasm, bronchitiss (bacterial, fungal, TB)
ii. false hemoptysis: nasopharyngeal or oral source
subjective sensation of ventilatory insufficiency (shortness of breath)
What physical exam findings would you expect with the following?: Pneumothorax:
i. Decreased or absent breath sounds over affected area of lung
ii. Hyper-resonant on percussion (over affected area)
iii. Decreased tactile fremitus (over affected area)
iv. Tracheal deviation (collapsed lung)
v. Dyspnea and tachypnea
vi. Tachycardia, cough, cyanosis
What physical exam findings would you expect with the following? Pneumonia
i. Increased tactile fremitus (say ‘99’): consolidation
ii. Dullness to percussion over affected area (consolidation)
iii. Rales (crackles) upon auscultation over affected area
iv. Egophony (bleating like a goat: E to A changes)
v. Whispered Pectoriloquy (whisper ‘1,2,3’ and louder over consolidation)
vi. Bronchophony
What physical exam findings would you expect with the following? Pleural Effusion
i. Decreased tactile fremitus (say ‘99’): effusion muffles sound
ii. Dullness to percussion over affected area
iii. Rales (crackles) upon auscultation over affected area
iv. Diminished breath sounds on affected side; pleural friction rub
v. Above effusion, where lung compressed, may have egophony
abnormal lateral curvature of the spine; asymmetry bilaterally in muscle, bone structure, breathing, etc
abnormal curvature of thoracic spine (humpback). Can cause breathing difficulties
accentuated lumbar spine curvature (the curvature has its convexity anteriorly)
Pectus Excavatum
inward concavity of the chest; sunken chest; may displace the heart
Pectus Carinatum
protrusion of the anterior chest wall. Dyspnea; decreased endurance; decreased lung compliance; progressive emphysema; increased frequency of respiratory tract infections
What conditions would produce a prolongation of the expiratory phase on auscultation of the lungs?
asthma, foreign body occlusion, tumor, and COPD , emphysema
quality of the percussion Normal Lung
Resonant – loud, low, and long
quality of the percussion Emphysematous
Hyperresonant – Very loud, very low, very long
quality of the percussion Stomach
Tympani – Loud, low, long
quality of the percussion Liver
Dull – Medium intensity, pitch, and duration
quality of the percussion Heart
Same as liver – percuss to define
Define Palpitations
Palpitations are extremely common and best defined as an intermittent "thumping," "pounding," or "fluttering" sensation in the chest. This sensation can be either intermittent or sustained, and either regular or irregular.
Define Syncope
a transient loss of consciousness and postural tone due to reduced cerebral blood flow; associated with spontaneous recovery.
What physical findings would be helpful for differentiating cardiac and other forms of chest pain:
Questions to ask about Chest Pain: onset, character, severity, exacerbation/relief
Other questions to consider: dyspnea (in positions, during activity), history/risk of CAD, palpitations, syncope
Ischemia chest pain
• not usually affected by taking a deep breath or pressing on the area of discomfort.
• same regardless of body position
• quality: “discomfort” and not pain…squeezing, tightness, pressure, fullness, band-like, knot, ache, heavy weight on chest, feels like bra is too tight
• Levine sign: patient places a fist in center of chest
• Exacerbated by physical exertion, emotional stress, exposure to cold, eating a meal… remits with rest
Not ischemia chest pain
• pain is felt only on the right or left side, and not in the center of the chest
• able to point with a finger to one area of pain
• If eating a meal / taking antacids relieves the pain, consider esophagus or stomach.
Diagram the cardiac cycle and relate this to the following: heart sounds (S1, S2, S3, S4), electrocardiographic findings (P wave, QRS complex, PR interval, Q wave, QT interval).
- S1- beginning of ventricular systole, closing of mitral/tricuspid valves
- S2- end of ventricular systole, closing of aortic/pulmonary valves
- S3- heard just after S2, “gallop” could be normal in children or active adults, or could be pathological representing ventricular dilatation, decreased systolic function, elevated ventricular diastolic filling. Could be the first indication of CHF
- S4- heard just before S1, “presystolic gallop”, pathological, representing acute MI’s, coronary artery disease, hypertension, aortic/pulmonary stenosis, heard best at apex (L heart origin) or L lateral sternal border (R heart origin)
Relate the pulsations of the jugular vein to mechanical events in the right atrium (a and v waves).
o Contraction of the R atria (the grey a wave) causes the pressure in the atria to increase, increasing the pressure in the venous system which can be visualized as a pulse in the jugular veins (the a wave is smaller than the v wave, which is the one we look for, even tho they look the same size in this diagram)
o When the AV valve opens, and blood flows into the ventricle and causes a rapid fall in atrial pressure and a fall in the jugular pulse, the peak of the jugular pulse is just before the valve opens and is the v-wave
Factors that influence arterial and diastolic pressures
2 things regulate arterial blood pressure
1. Short term regulation involving the baroreceptors, and to a small extent the chemoreceptors. Consequently, anything that stimulates these neurohormonal reflexes – hypovolemia, hypervolemia, hemorrhage, anxiety, exercise, etc. will result in a compensatory increase or decrease in blood pressure.
2. Long term regulation involving the Kidneys : pressure – diuresis mechanism and the renin/ angiotensin/ aldosterone system .
Factors that influence venous pressure
Gravity, Thoracic Pump, Effects of Heartbeat, Muscle Pump, Venous Pressure in the Head, sympathetic nerves
pulmonic stenosis
widely split S2 (P2 occurs later than A2, more than normally)
-aortic stenosis: crescendo-decrescendo systolic ejection murmur following an ejection click (EC is right after S1). radiates to carotids.
aortic regurgitation
high-pitched "blowing" diastolic murmur.
mitral stenosis
"opening snap" right after S2 (forceful opening of mitral valve) followed by a rumbling murmur
mitral regurgitation
high pitched "blowing" murmur throughout systole, ie between S1 - S2.
mitral valve prolapse
mid-systolic click.
idiopathic hypertrophic subaortic stenosis:
S4 (late diastole sound, assoc. w/ increased ventricular filling pressure) is best description. but IHSS is variable, can have may dif sounds
paroxysmal nocturnal dyspnea
sudden and severe dyspnea that wakes you up. (difs from orthopnea - takes longer to relieve and develop. it is not relieved immediately upon sitting up, and it doesn't occur immediately upon lying down)
dyspnea upon laying down, quickly relieved upon sitting upright
frequent need to wake up and pee throughout the night
Bright red blood in the stool, usually from the lower gastrointestinal tract (colon or rectum) or from hemorrhoids (FYI – internal hemorrhoids bleed, external thrombose courtesy of Goljan).
Passage of black, tarry stools composed largely of blood that has been acted on by gastric juices, resulting from a hemorrhage along the upper GI tract.
vomiting of blood, which may be obviously red (fresh) or have an appearance similar to coffee grounds (acted on by gastric juices)
is a yellowish discoloration of the skin, the conjunctival membranes over the sclerae, and other mucous membranes caused by hyperbilirubinemia (>1.5mg/dL). (icterus- jaundice of the sclera)
accumulation of fluid in the peritoneal cavity; most commonly due to cirrhosis and severe liver disease. Special techniques to diagnose: fluid wave, shifting dullness, puddle sign.
Fluid will shift to lowest point of abdomen. When lying on back- circle of tympany around naval area of dullness outside (see below).
What physical findings would be seen with the presence of an abdominal aortic aneurysm (AAA)?
Widened aorta and pulsatile mass by palpating the left of the midline of the abdomen.
the foreskin cannot be retracted from the head of the penis. (can be caused by inflammation of glans, tx: circumcise or steroid creams)
the foreskin becomes trapped behind the glans penis, and cannot be pulled back to its normal flaccid position covering the glans penis
Varicose veins of the spermatic cord (usually found on the left). It feels like a soft “bag of worms” separate from the testes, and slowly collapses as when the scrotum is elevated in the supine patient.
What are the components of the reflex arc?
The reflex arc is the smallest functional unit of the nervous system that consists of two or more neurons (afferent and efferent) and can react to a stimulus. It consists of a sensory neuron that carries a stimulus impulse to the spinal cord, where it connects with a motor neuron that carries the reflex impulse back to an appropriate muscle or gland.
What factors can influence the briskness of the reflex?
Factors that can influence the briskness of a reflex include disease processes, alertness, anxiety, medications, etc…
• Hyperreflexia can be caused by an Upper Motor Neuron lesion, bran tumor, brain trauma, stroke, blood clot or hemorrhage in brain tissue, MS, various infections, and HIV
• Hyporeflexia is usually caused by a lower motor neuron deficit (at the alpha motor neurons from the spinal cord to muscle)
What physical findings would be associated with an Upper Motor Neuron lesion
Spasticity, increase in tone in the extensor muscles (lower limbs) or flexor muscles (upper limbs).
o Clasp-knife response where initial resistance to movement is followed by relaxation.
o Weakness in the flexors (lower limbs) or extensors (upper limbs), but no muscle wasting.
o Brisk tendon jerk reflexes.
o Babinski sign is present, where the big toe is raised (extended) rather than curled downwards (flexed) upon appropriate stimulation of the sole of the foot. The presence of the Babinski sign is an abnormal response in adulthood.
o Increase Deep tendon reflex (DTR)
What physical findings would be associated with a Lower Motor Neuron lesion?
Flaccid paralysis – paralysis accompanied by muscle loss
o Fibrillations
o Fasciculations
o Hypotonia or atonia
o Areflexia or hyporeflexia
o The extensor Babinski reflex may be present. Muscle paresis/paralysis,
loss of consciousness and postural tone caused by diminished cerebral blood flow.
A grand mal seizure is defined as the sudden onset of tonic contraction of the muscles often associated with a cry or moan, and frequently resulting in a fall to the ground.
A spontaneous abnormal usually nonpainful sensation (e.g. burning, pricking); may be due to lesions of both the central and peripheral nervous systems.
What physical findings would be present in a patient with a stroke in the following cerebrovascular accident in the following vessel: MCA
Clinical signs include impaired cognition; aphasia; agraphia; weak and numbness in the face and arms, contralaterally or bilaterally depending on the infarction.
What physical findings would be present in a patient with a stroke in the following cerebrovascular accident in the following vessel: Anterior cerebral artery
paraplegia, incontinence, abulia and aphasic symptoms, and frontal lobe personality changes...
sensorimotor deficit of the opposite foot and leg.
What physical findings would be present in a patient with a stroke in the following cerebrovascular accident in the following vessel: Basilar artery:
Pupillary abnormalities, oculomotor signs, and pseudobulbar manifestations (ie, facial weakness, dysphonia, dysarthria, dysphagia) are seen in more than 40% of patients. Signs of pontine ischemia include limb shaking, ataxia (usually associated with mild hemiparesis), facial weakness, dysarthria, dysphagia, and hearing loss.
What are the segmental levels for all major deep tendon reflexes?
Biceps Reflex: Spinal Level C5 and to a lesser extent Spinal Nerve C6
Brachioradialis Reflex: Spinal Level C6
Triceps Reflex: Spinal Level C7 (Test sensory and motor of C7 and C8)
Patellar Reflex: Tests function of Femoral Nerve and Spinal cord segments L2-L4
Achilles Reflex: Tests function of S1-S2 and could indicate sciatic nerve pathology
Babinski Reflex: Babinski’s sign can indicate upper motor neuron damage to the spinal cord, in the thoracic or lumbar region or brain disease, constituting damage to the corticospinal tract.
What is synovitis and what physical findings would be seen with this condition?
Synovitis is the medical term for inflammation of a synovial membrane.
Joint tenderness is not as reliable or accurate as joint swelling in the assessment of synovitis. Visual inspection alone may be the simplest and most reliable technique for assessing synovitis in rheumatoid arthritis.
Signs and symptoms of carpal tunnel syndrome
• Pain and paresthesia in the thumb, first two fingers, and the radial-half of the ring finger (the distribution of the median nerve).
• Paresthesia and sensory deficits may involve the entire palm area in some cases due to variable nerve innervation. May radiate proximally into the forearm, and occasionally to the shoulder.
• May have pain at night, get awakened by abnormal sensations; shake hand to return normal feeling.
• Persistent/frequent flexion or extension or prolonged use may exacerbate sx
• Longer duration of nerve entrapment  flattening of thenar eminencethumb weakness / motor incoordination  probs with pinch-grasping, writing, holding small utensils.