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330 Cards in this Set
- Front
- Back
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Heart valve problem means you are not getting full
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compression
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The electrical system of the heart is the ___________ system
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conduction
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The ___________ circulation of the heart is akin to gas in the tank!
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coronary
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Cardiac cycle
Conduction of pacing Coronary circulation |
special phenomena of the heart
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The body gives its blood to the heart, "Do you mind holding this a minute?" and the Right side isn't taking it so shoes get tight, ankles swell, because blood has no place to go...
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RSHF
*LIVER swells up and becomes a NUTMEG liver - if you press the liver on a RsHF patient, the jugular will pop out |
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The liver backs up and the body backs up with fluid in Right Sided heart failure...what happens in Left sided heart failure?
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Lungs back up and the person drowns. Pink frothy sputum (serum, aerated blood, mucous)
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fill stage where heart is relaxing - caused by CLOSURE OF SEMILUNAR VALVES
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diaS2ole
S2 AORTIC & PULMONIC valves ('dup") |
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squeeze stage where heart is working
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systole (S for Squeeze/Systole)
*Last 25% of pressure builds because the Aorta and Pulmonic valves fly open while Tricuspid and Mitral slam shut |
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measure of time...How long does it take the SA node to fire?
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ECG
*electrocardiogram |
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SA node and AV node to ?
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AV bundle to Purkinje fibers
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How many boxes long is the PR interval?
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no more than 5
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If the QRS takes more than 3 boxes to complete, where is the problem?
QRS letters are closest to what name for heart chamber? |
Ventricle itself and the bundle branches
(QRS problem = ventricle + bundle) |
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What letter does a Right bundle branch block resemble on the ECG?
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M
Maggie = Write = Right bundle branch block as in M is an upside-down W for write/right |
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If patient is on blood thinner like Coumadin, how should chiro approach?
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NO force techniques due to blood thinner
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Reasons a patient may have suffered prior chest pain
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Gall Bladder
Pancreatic GERD Pleurisy M.S. angina or MI |
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My heart is all AFLUTTER because M.A.E. West just walked into the room!
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My heart is all AFLUTTER because M.A.E.West just walked into the room!
Mitral valve prolapse Anxiety Ectopic pacemaker |
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Shortness of breath, sleeping upright or swollen ankles are signs of?
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Congestive Heart Failure
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If they have diagnosed hypertension, and are on meds, what should you ask?
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Do you actually TAKE the medication? Hypertension meds are the most frequently ignored medication.
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RUQ pain which radiates around to the inferior border to the R scapula, frequently preceeded by a FATTY meal...
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GB pain (choleocystitis, cholelithiasis)
*RUQ pain + FATTY food |
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What are the 6 F's of GB pain?
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Fair
Fat Flatulent Forty Family Fatty MEAL |
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Why would really lean women often have gall bladder problems?
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CCK causes gall bladder to spasm and release bile along with the pancreas. People who never eat fat have coagulated bile in gall bladder -blocked.
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Signs of Cholecystitis (boards) or GB pain?
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RUQ pain radiating around to INFERIOR border of R scapula
Preceded by fatty meal Fair, Fat, Forty, Female (Flatulent, Family) |
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Describe pancreas pain (pancreatitis, pancreatic CA)
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EPIGASTRIC PAIN that shoots STRAIGHT THROUGH TO BACK
The ONLY abdominal RELIEVED BY LEANING FORWARD Not triggered by activity |
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Hiatal Hernia is also called
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GERD
SUBSTERNAL pain with SOB Shortness of breath and ECRETATIONS (burping) Night-time asthma attacks because of RECUMBENT posture of sleep |
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RUQ with FAT
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Gall bladder
Cholelisthiasis Cholecystitis |
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EPIGASTRIC w/ pain shooting STRAIGHT THROUGH TO BACK
Relieved by leaning forward |
Pancreas
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SUBsternal SOB
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GERD/Hiatal Hernia
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LOCALIZED SHARP
SCHEPPLEMAN'S bends away |
Pleurisy
~lean away w/ Scheppleman's ~Cancer, Flu, Trauma |
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Tietze's
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Rib fracture/subluxation/Musculoskeletal pain
WELL LOCALIZED REPRODUCIBLE LEAN INTO W/ SCHEPPLEMAN'S |
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eponymous name for musculoskeletal pain, rib fracture or subluxation that causes a positive Scheppleman's when patient leans towards painful side...
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My MUSCLES are TIETZE!
and I know it's musculoskeletal because I can REPRODUCE THE PAIN. |
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How to distinguish between MI and angina pectoris - cardiac pain?
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MI lasts longer than 20 and pain is NOT RELIEVED BY REST
LEVINE's sign: left shoulder pain (men) Mid thoracic pain w/ indigestion (women) |
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Diffuse retrosternal pressure PRECEDED BY ACTIVITY
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ANGINA PECTORIS
*goes away with rest, radiates to various locations. Is not localized to left shoulder or mid thorax (Levine's) like M.I. |
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Where is the apical impulse
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Above the left 5th intercostal space along the MCL
Easier to see when patient (male) is seated. IF female, defer inspection on a well-female for prechordium. |
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5th ICS left MCL
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APICAL impulse
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When checking prechordium a clearly visible or invisible apical impulse at 5th ICS @ MCL might mean?
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1. muscular, fat, large breasts can't see it (Normal)
2. Lateralization suggests cardiomegaly (Enlarged Heart) 3. Cardiac HEAVES/lifts exaggerated prechordial chest means (Pathology) |
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STONY yellow hard masses,
Bound to EXTENSOR TENDONS |
TENDON Xanthema=
familial HYPERCHOLESTEROEMIA *heart abnormality |
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Brought on by acute onset of high triglycerides (binge drinking) - yellowish papules on erythematous (red) base
ALCOHOLIC RASH |
ERUPTIVE Xanthema=
Alcoholic rash - recedes when triacylglycerides return to normal |
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Indicate SUBACUTE BACTERIAL ENDOCARDITIS (sbe)
Small, REDDISH-brown lines on nails |
SPLINTER HEMORRHAGES
look like blood splinters on nails - mean's your heart is under attack |
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Nail sign of LONGSTANDING HYPOXIA
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CLUBBING
(This CLUB is so f***ing crowded, I can't breathe in here!) |
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an oblique crease, frequently bilateral, seen in patient's over 50+ with SEVERE CORONARY ARTERY disease
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LICHENSTEIN'S SIGN = EARLOBEcrease
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yellowish plaques on eyelids and periorbital region - HYPERLIPOPROTEINEMIA
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XANTHELASMA
(too much yellow protein @ eyelid) |
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whitish RING around CORNEA suggests HYPERLIPOPROTEINEMIA
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ARCUS Senilis - the white ring of lipo
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Central cyanosis suggests?
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a central problem, like heart, lung
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SBE (hemolytic strep disorders) causes _________under nails and palatal _________ in roof of mouth.
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SPLINTER hemorrhaging of nails & palatal PETECHIAE
(subacute bacterial endocarditis from hemolytic strep) |
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Seen in MOUTH with MARFAN's
(along with arachnodactly and aortic knob aneurysm - the cardiac problems of Marfan's including aortic regurgitation or stenosis |
HIGH ARCHED PALATE
MOUTH MARFANS AORTIC ROOT ANEURYSM |
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seen with right sided heart failure - indicates increased JUGULAR VENOUS PRESSURE.
ruler to measure |
JUGULAR VENOUS DISTENTION
(JVD) = RSHF ~boards show ruler used to measure JVP norm 1-2cm/or 3-4cm ~pitting edema ~engorged liver due to body stowing fluids |
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How to measure JVP to determine right sided heart failure associated with JVD?
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Zero of ruler against sternum
Measure to highest point you see throbbing of jugular = JVP ~boards show ruler used to measure JVP norm 1-2cm Mosby or 3-4cm Bates ~pitting edema ~engorged liver due to body |
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Look at sacrum for bedridden and on soles of feet/tibia for ambulatory to find this sign of RSHF
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DEPENDENT (PITTING) edema
*means increased venous pressure in periphery. *Graded 1+ to 4+ with 1+ nothing and 4+ very deep, lasting more than 2 min. |
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If DEPENDENT pitting edema is UNIlateral, think?
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LOCAL BLOCK of a MAJOR vein -unilateral dependent edema is Buerger's Disease/thromboangitis Obliterans
(Anasarca: generalized edema with periorbital and pitting edema due to renal failure is bilateral) |
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If DEPENDENT/PITTING edema is unilateral, think?
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Right Sided Heart Failure (RSHF)
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Describe scoliosis due to heart issues
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Physiologic: spine moved RIGHT to get out of way of enlarged heart
If spine moved left, then may impinge heart |
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Frequently associated with an S1 split, best ascultated at the TRICUSPID (normal)
Don't adjust P-A |
DECREASED kyphosis!
(S1flatback ain't no damn hatchback) Don't adjust P-A |
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S1 FLATback ain't no damn hatchback
Don't adjust P-A |
S1 split listen at tricuspid = decreased kyphosis
Don't adjust P-A |
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Location of tricuspid valve on chest wall
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5th ICS just left of sternal border
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PMI
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Point of Maximum Impulse
MITRAL VALVE 5th intercostal midclavicular line |
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If you see the PMI __________ to the left MCL, you should note possible
LEFT VENTRICULAR HYPERTROPHY |
If PMI is LATERAL TO MCL, then possible left ventricular hypertrophy. PMI should be right over MCL at left 5th intercostal
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Palpatory evidence of the presence of a MURMUR
*when we were in grades 4-6, it was all about cheap thrills because we didn't have any money! |
When we were in grades 4-6, it was all about cheap thrills because we didn't have any money
THRILLS are the actual feeling under your fingers of a heart valve murmur... grades IV - VI (and therefore TURBULENCE through a heart valve = murmur) |
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Feels like the throat of a PURRING CAT...give it a high grade!
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THRILLS!!!
grades IV - VI murmur/turbulence *Thrills feel like the THROAT OF A PURRING CAT |
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How to assess for Right ventricular hypertrophy
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Fingerpads on costal margin just left of epigastric notch
Pulsations on FINGER PADS = NORMAL *due to aortic pulse under Pulsations on finger tips = abnormal b/c you are feeling heart! |
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We know how to palpate for Right ventricular hypertrophy and that feeling the heart on your fingertips is bad. What about LEFT ventricular hypertrophy?
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Observe location of PMI (Mitral)
If lateral to MCL, then suspect left ventricular hypertrophy. |
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Where to listen to the vessels of the head and neck?
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Temporal
Carotid Subclavian |
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How should the temporal/carotid/subclavian pulses feel?
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BILATERALLY EQUAL
clean, crisp carotid most intense |
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ASYMMETRY of pulsations Temporal/Carotid/Subclavian suggests?
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ATHEROSCLEROSIS
asymmetry=atherosclerosis |
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Tenderness of TEMPORAL artery during palpation
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Temporal Arteritis (Giant Cell arteritis)
very bad. POLYMYALGIA RHEUMATICA w/ ipsilateral H/A ...blindness |
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Polymyalgia rheumatica may cause blindness. What is a sign we might encounter?
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temporal arteritis
(tenderness upon palpating temporal arteries before listening to bruits) |
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UNIVERSAL COLDNESS in extremities suggests __________-sided heart failure. Why?
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LEFT (the universe is all we have left)
Left side because this is the side sending blood all over body. If it isn't working, the entire body is cold. |
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If coldness in ONE LIMB only, this suggests a
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local arterial problem
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VENTRICULAR arrhythmia (irregular pulse finding would cause you to test this)
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The ventricle is supposed to collapse after all the blood is gone, not prematurely.
PALPATE ONE RADIAL pulse with fingers, LISTEN TO PMI/MITRAL (apical site) with STETHOSCOPE. Must hear AND feel these two in SYNCHRONY. If not, ventricle fired/collapsed too early before it was empty of blood. |
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If, during testing, you hear the apical rate before you feel the radial pulse under your fingertips, suggests?
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Ventricular origin (ventricular arrhythmia) because ventricle squeezed out blood before it was completely empty.
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If you need to know the size of the heart, you should
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OBTAIN A CHEST X-RAY
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to hear HIGH pitched sounds of the heart, use
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DIAPHRAGM for high-pitched murmur
(diah is high-ya, as in S2, Mid-sys clicks and aortic regurge's) |
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to hear the LOW-pitched heart sounds, use
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BELL for BeLOW
(Bell for BeLow as in S3, Mitrals stenosi) |
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Patient position for ascultation of _________ or __________ valves is leaned forward.
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Aortic or Pulmonic (the two highest) with diaphragm and bell
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Patient position for assessing mitral valve
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LEFT LATERAL DECUBITUS for diaphragm and bell on patient
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How long should you listen to each heart valve site?
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As long as you need to assess what you need to assess
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Describe RATE & RHYTHM as we listen to it with bell and diaphragm:
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RATE & RHYTHM
~Regularly Irregular (sinus arrhythmia affected by breathing) ~Irregularly irregular (beats random) |
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How to identify S1 & S2 as we listen to it with bell and diaphragm:
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S1 = lub (mitral + tricuspid)
S2 = dup (aortic & pulmonic) S2 are the highest heart valves for relaxing/diastole whereas S1 are the lowest for squeeze/systole. |
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How can you tell S1 and S2 apart
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S1 (lub) is heard loudest at apex because it's the lowest two valves (Mitral and Tricuspid)
S1 signals the beginning of Systole |
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-caused by closure of AV valves
-signals the beginning of systole -may note a split (esp. at Tricuspid) but this is a normal variant associated with a flatback that ain't no hatchback but is hypokyphosis. |
S1
lower valves heard loudest Mitral and Tricuspid Systole begins MighTy Squeeze |
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caused by closure of the semilunar valves
signals the beginning of diaS2ole may split 3 ways |
S2 diaS2ole- the Aortic & Pulmonic sounds (the old A&P stores)
Diastole is relax and the top-most valves are 'relax' so think high is relaxed. |
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R ventricle/Pulmonic valve is coming in late during Inspiration
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PHYSIOLOGICAL S2 Split
*due to change in atmosphere so neg pressure drops with diaphragm/inspiration NORMAL! |
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Something wrong on L side of heart because not only is the Pulmonic LATE (normal), now the AORTIC IS PATHOLOGICALLY LATE on inspiration.
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PARAdoxICal S2 split
*P2 closes before pathologically delayed A2 (noted during expiration). Suggests BBB, AORTIC STENOSIS, or patent ductal arteriosis |
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Pulmonic valve is sick all the time, so now closes/splits on every beat.
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FIXED S2 split (fixed means fixed in place here)
*A2 always closes before pathologically delayed P2 (unaffected by respiration) *Suggests Right CHF or ATRIAL SEPTAL DEFECT |
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physiological S2 split
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Right Pulmonic/ventricular comes in late due to normal inspiration
*change in atm pressure |
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paradoxical S2 split
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both Pulmonary (normally late) and Aortic (stenosis!) is late, too
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fixed S2 split
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Pulmonic valve sick all the time - splits on every beat
RCHF or atrial Septal defect |
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Heard in early diastole due to immediate, forceful ventricle filling of first 75% of blood into ventricle
GALLOP RHYTHM (LUB duppa) |
S3
elderly and ATHLETES *extra heart sound |
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heard in late diastole (presystolic) Due to blood volume being too much for ventricular size
SMALL VENTRICLE, LARGE BLOOD VOLUME |
S4
too much blood, not enough ventricle Pregnancy, CAD, Cardiomyopathy, adults over 40 after exercise |
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splits during physiological split because of pushing against pressure
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S2
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Systole (work) Diastole (rest)
S4 S1 S2 S3 What is S3? |
late systole - the GALLOP rhythm
normal in children and the physically fit, plus pregnancy because pumping for two) |
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Gallop S3 LATE SYSTOLE could pathologically suggest
(blood as milk hitting the side of an empty pail as it fills up) |
CHF (edema due to right sided or left sided heart fail from enlargement)
increased thyroid anemia pregnancy great heart health youth |
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When the rap concert oversold and at first everyone is quiet taking their seats but then they others realize the promoters screwed them and suddenly too many people AND NOT ENOUGH SEATS is akin to...
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too much blood showing up in LATE DIASTOLE S4 (or presystole).
Soft, low pitched S4 Seen after exercise in 40-50 yr olds and pregnancy Linked to aortic stenosis and HTN |
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Seen AFTER exercise in 40-50 year olds without heart disease and people who are pregnant
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S4 rap concert overbook
HYPERVOLEMIC due to thickening of heart ventricles = S4 |
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OPENING SNAP
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miso: miTRAL sNAP oPENING
*diastole (supposed to open but doesn't) due to HIGH pressure and Mitral valve not opening. Sharp, high pitched SNAP due to high pressure needed to open a stenotic mitral valve (mitral stenosis) |
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OPENING SNAP
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Sharp, high pitched SNAP due to high pressure needed to open a stenotic mitral valve (mitral stenosis)
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Refusing to open
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stenosis
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Refusing to close
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regurgitation
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MiSO: An opening snap is ________ stenosis.
ACE: A short high pitched click is ________ stenosis. |
MiSO = MItral stenosis Snap Opening
ACE = Aortic stenosis Click Ejection |
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Mitral stenosis makes an ___________!
Mitral valve prolapse makes a weak ___________ |
Opening Snap!
Midsystolic click. |
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due to MVP
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Midsystolic click
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due to aortic stenosis
ACE |
ejection click
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due to mitral stenosis
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opening snap!
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turbulent flow through a heart valve
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murmur
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Murmur grades __________ are palpable.
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4,5,6
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As a general rule, INNOCENT MURMURS tend to be:
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early systolic
Grade I or II soft, musical vibratory quality short duration best heard at pulmonic or Erb's pt low or absent when seated up with exercise or supine |
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turbulent blood flow in an ARTERY
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BRUIT
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___________ murmurs are never innocent.
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diastolic
the heart can't even relax right! |
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abnormal blood flow in artery is a bruit
normal blood flow sound is ______ |
laminar
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Bruit suggests
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atherosclerosis or aneurysm of artery
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Friction rub due to PERICARDITIS is best heard over the _________
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diaphragm
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Bruit at temple
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Temporal artery = TEMPORAL ARTERITIS or autoimmune patient
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Name 4 places to assess bruit
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Temporal, orbital, carotid, subclavian
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Orbital bruit suggests
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CAROTID ARTERY ANEURYSM behind the eye
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the blood pressure measured during the period of ventricular CONTRACTION
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SYSTOLIC pressure
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the blood pressure which is influenced by:
AORTIC DISTENSIBILITY STROKE VOLUME velocity of EJECTION. |
SYSTOLIC pressure
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Stroke volume
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ventricle 70ml in a 70kg man
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the blood pressure measured when the heart is VENTRICULAR FILLING
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diastole (relax)
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blood pressure influenced by total peripheral RESISTANCE and heart RATE
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diastole (relax)
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Pulmonary HTN
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pulmonary ARTERY pressure back to heart is GREATER than
30/15 mmHg |
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Pulmonary HTN (greater than 30/50 mmHg) could indicate:
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LEFT sided heart failure (blood backing up into lungs)
Pulmonary EMBOLUS/THROMBUS Lung parenchyma DISEASE |
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Fen/phen diet pill iatrogenically caused pulmonary HTN.
Severe Sx? |
intense fatigue, precordial pain and occasional drop attacks
due to PULMONARY HYPERTENSION |
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persistent body levels of blood pressure greater than 140/90 mmHg
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SYSTEMIC hypertension
*elderly values: 160/90 mmHg |
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reasons for SYSTEMIC blood pressure hypertension?
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Vascular changes of aging -
PLAQUE (athero & arteriosclerosis) STENOSIS (narrowing) DECREASED FLEXIBILITY (ability to distend) INCREASED SYSTOLIC PRESS. WIDENED PULSE PRESS. |
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If pulse pressure is the difference between the systolic squeeze and the diastolic relax, explain WIDENED pulse pressure...
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bigger difference
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The DIFFERENCE b/w systolic and diastolic pressure readings
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PULSE PRESSURE
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hypertension of UNKNOWN origin
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ESSENTIAL = unknown cause HTN
*primary/essential/unknown |
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hypertension with a SPECIFIC cause/etiology
ie, renal arterial or parenchymal disease, drug side effects, endocrine disorders, tumors, pregnancy |
SECONDARY HTN
*known/secondary to |
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elevation of B/P noted soley during doctor/hospital visits in an otherwise nonhypertensive patient
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wHITe cOAt HTN
due to nervousness |
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drop in SYSTOLIC pressure (less squeeze) greater than 15 mmHg
and/or drop in DIASTOLIC pressure greater than 5-10 mmHg as patient moves from lying down to sitting or standing... |
ORTHOSTATIC (POSTURAL)
hypo tension |
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Orthostatic _________ happens when a patient goes from lying down to sitting or standing.
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HYPOtension
Postural/orthostatic |
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90% of the time, the cause of primary/essential HTN is _________.
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unknown
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Renal disease causes HTN due to
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influence of Renin, then transform into angiotensin
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Adrenal disease causes HTN due to
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Big Al dosterone's influence on water and salt regulation (Cushing's disease, adrenal adenoma)
Norepinephrine and Epinephrine on cardiovascular system (pheochromocytoma) which can lead to sustained or paroxysmal HTN |
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tumor of adrenal gland tissue that could cause HTN
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pheochromocytoma
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THYROID disease and hypertension:
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HYPERthyroid: increase SYSTOLE, normal diastole, WIDENED pulse pressure
HYPOthyroid: increase DIASTOLIC pressure! TOO RELAXED...and narrowed pulse pressure |
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HTN due to influence of
SERUM CALCIUM on excitability of ANS |
HYPER-PARA-THYROIDISM
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HTN due to influence of
GROWTH HORMONE on BMR |
ACROMEGALY
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HTN due to HYPERVOLEMIA and HORMONAL FLUXES
*did you get that last one? HORMONAL FLUX |
PREGNANCY
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HTN can be due to certain DRUGS. Name a few...
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BCP
antihistamines steroids cocaine (ya think?) caffeine and xanthines many scrip drugs |
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____% of population will develop HTN
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20%
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HTN non-modifiable risk factors
*HTN itself has no symptoms |
MALE
FAMILIAL TENDENCY BLACK |
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When do HTN headaches strike?
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ADULT onset
*NO prodrome to let you know |
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Describe HTN HEADACHE
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NO prodrome
STARTS @ AWAKENING then gets better as day progresses (remits) |
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What other conditions all worse in the morning, like HTN headache?
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BRAIN TUMOR
SUBDURAL HEMATOMA BRAIN ABCESS |
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HTN headache
vs. TENSION headache |
TENSION WORSENS DURING DAY
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describe HTN headache
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THROBBING, VASCULAR HEADACHE that is
WORSE IN THE MORNING and happens EVERY DAMN DAY |
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SECONDARY hypertension causes
PERSONAL MEDICAL HISTORY |
BLACK
MALE SMOKER ALCOHOL DIET |
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SECONDARY hypertension causes
FAMILY MEDICAL HISTORY |
CARDIOVASCULAR PARENTS
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SECONDARY hypertension causes
ROS (REVIEW OF SX) IN EYES... |
-AV NICKING/TAPERING
-COPPER WIRE ARTERIOLES -SILVER WIRE ARTERIOLES -FLAME HEMORRHAGES -WOOL/COTTON -PAPILLEDEMA (acute or chronic head trauma) |
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possible THYROID findings if SECONDARY HTN
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ENLARGEMENT
NODULARITY BRUIT OR VENOUS HUM in thyroid |
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possible THORAX findings if SECONDARY LEFT SIDED HEART FAILURE DUE TO HTN
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HEART: loud S2 (A&P valves/dup)
LUNGS: crackles if LSHF |
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possible ABDOMEN findings of HTN
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BRUITS @ A3 and renals if 2* HTN)
CUSHINGS: TRUNCAL OBESITY w/ thin extremities, purple striae, pitting edema |
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EXTREMITIES findings of HTN
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BILATERAL PITTING EDEMA = RIGHT sided heart fail
& changes in pulse quality *remember unilateral pitting edema is renal failure |
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disease due to fibromuscular or endothelial THICKENING of the ARTERIAL WALLS, leading to decrease in lumen size
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ATHROSCLEROTIC OCCLUSIVE ARTERIAL DISEASE
*PERIPHERAL ATHEROSCLEROSIS |
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LOCATION and TARGET ARTERIES of peripheral atherosclerosis
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FEMORAL ARTERY
@ BIFURCATION |
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_______% OCCUSION of atherosclerotic artery before sx appear
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60-80%
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PAIN in the LEGS due to atherosclerosis which is BROUGHT ON BY EXERCISE
and RELIEVED BY REST |
INTERMITTENT CLAUDICATION
*angina of the legs |
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PMH FAMILY: for peripheral atherosclerosis,
now that we found intermittent claudication, smoking, "poor circulation,' and cold feet: |
Hx of CARDIOVASCULAR,
HYPERCHOLESTEROLEMIA HYPERLIPIDEMIA |
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peripheral atherosclerosis triple P's
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POLYDYPSIA (increased thirst)
POLYURIA (increased urination) POLYPHAGIA (increased appetite) |
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Some PHYSICAL FINDINGS of peripheral atherosclerosis
*why does it affect hair and nails first? B/c they are unimportant - body draws their nutrients |
PALLOR of skin on elevation/ruddy
CYANOTIC NAIL CHANGES ULCER LOSE HAIR ON LEGS****** LATE MUSCLE ATROPHY |
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BP presentation for peripheral atherosclerosis
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may be DIFFERENT IN EACH ARM by 10mmHg
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Tests for peripheral atherosclerosis
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SQUAT TEST see if b.p. is lower than normal in legs
BICYCLE TEST lousy circulation after consistent exertion. |
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If pain were ___________, it would be brought on AND relieved by position.
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Neurogenic
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Arteries the Squat and Bicycle tests ...test?
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FEMORALS (most common site of occlusion)
POPLITEALS POSTERIOR TIBIALIS (may need Doppler to see) |
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LOCALIZED DILATION of AORTA
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THORACIC AORTIC ANEURYSM
*40-70 year olds |
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85% of THORACIC AORTIC ANEURYSM (TAA) are due to
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ATHEROSCLEROSIS
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Most common site for DISSECTING ANEURYSM
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THORACIC
*ages 40-70 **60% are ASYMPTOMATIC |
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presentation of patient with thoracic aortic aneurysm
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CONSTANT BORING CHEST PAIN
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Because a thoracic aortic aneurysm is a SPACE OCCUPYING LESION, 75% of them show up on _________.
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X-RAY
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85% of THORACIC aortic aneurysms are due to
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ATHEROSCLEROSIS
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Along with CONSTANT BORING CHEST PAIN, a THORACIC aortic aneurysm presents w/
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DYSPNEA (dff. breathing)
PAROXYSMAL COUGH HOARSENESS DYSPHAGIA |
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A3 is aggravated by _____, but is CAUSED by ____________.
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A3:
aggravated by HTN CAUSED BY ATHEROSCLEROSIS |
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DILATION of AORTA in ABDOMEN (A3) patient characteristics
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4:1 males to females
<60 years old & 60% ASYMPTOMATIC, although if sx, will co-present with ABDOMINAL PAIN (usu. on LEFT) that REFERS TO LOW BACK |
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A3 PAIN
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ABDOMINAL PAIN REFERS TO LOW BACK
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A3 patients have abdominal pain on the left that refers to the low back and can hear
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their heartbeat when they lie down.
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PHYSICAL assessment of A3
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BRUIT ASCULTATED OVER AA
LATERALIZATION of aorta felt PALPATION OF PULSATILE (pulsating) MASS in mid- to upper abdomen |
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INTERMITTENT CLAUDICATION
"HEAR HEARTBEAT" LOW BACK PAIN from left abdomen |
A3
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THROMOANGIITIS OBLITERANS
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BEURGER'S DISEASE
(Prince Albert, King George VI had this) |
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HEAVY SMOKER
MALE ARTERIES AND VEINS |
Buerger's disease
CONSTANT BORING CHEST PAIN that is WORSE LYING DOWN |
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RECURRING INFLAMMATION of the ARTERIES AND VEINS of the UPPER and LOWER extremities
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BUERGER'S DISEASE (Thromoangiitis Obliterans)
****THROMBUS & VESSEL OCCLUSION |
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Presents with UNILATERAL MIOSIS and dilated superficial veins in chest
"M" franchising in the U.S. |
BUERGER'S DISEASE
*constant boring chest pain especially lying down because thrombus and vessel occlusions are bearing down on structures *ages 20-35 male smokers |
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How is Bruerger's disease different from Raynaud's?
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RAYNAUD'S:
WOMEN ARTERIOLES (Buerger's is men and arteries/veins) |
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PAIN
PULSELESSNESS PARESTHESIA PALOR |
STRESS
1. smoking = Breuger's disease 2. cold = Raynaud's phenom/synd |
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abnormally dilated, tortuous superficial veins caused by incompetent valves, INCREASED venous pressure and/or DECREASED tone of veins (Last two freq. seen in pregnancy)
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VARICOSE VEINS
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INCREASE in venous pressure
DECREASE in venous TONE |
VARICOSE VEINS
WOMEN/FAMILIAL/ASYMPTOMATIC if sudden onset, think DEEP VEIN THROMBOSIS!! |
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4 P's of RAYNAUD's DISEASE
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PAIN
PARESTHESIA PULSELESSNESS PALOR |
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describe RAYNAUD'S DISEASE
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4 P's (pain/pallor/pulselessness/paresthesia)
WOMEN AUTOIMMUNE (lupus, scleroderma) BILATERAL (aching, throbbing, burning) ******UNILATERAL =Raynaud's PHENOMENON |
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clot in the wall of a vein
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DEEP VEIN THROMBOSIS
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VEINS at risk of DVT
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ILIOFEMORAL
POPLITEAL small CALF VEINS |
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is local and UNILATERAL in appearance of symptoms associated with scleroderma, SLE, RA or obstructive arterial disease
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Raynaud's PHENOMENON
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VIRCHOW'S TRIAD for DVT
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1. INJURY to endothelium
2. HYPERCOAGULABILITY 3. STASIS of circulation |
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ASYMPTOMATIC until pulmonary embolus ("I can't breathe") because they are ventilating but not respirating...
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DEEP VEIN THROMBOSIS
*AIR HUNGER |
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Cramping or tender CALF on MEDIAL side
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DVT
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In females, there is a ____cm difference between DVT calves.
In males, there is a ____cm difference between DVT calves. |
Females - 1.2 cm
Males - 1.5 cm |
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DVT is red, warm and tender.
Should you do HOMAN'S sign to test for DVT? |
NO! (straightening out leg quickly then dorsiflexion of foot)
You dislodge the clot then great! Now you know but they are dead. |
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Do not mistake DVT for
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gastroc spasm
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Where is the spleen percussed?
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9th intercostal space
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Name the 9 regions of the abdomen
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L/R HYPOGASTRICS
EPIGASTRIC L/R LUMBARS UMBILICAL L/R ILIACS HYPOGASTRIC |
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frequent bloody stools could indicate
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ULCERATIVE COLITIS
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Begins as PERIUMBILICAL PAIN, then REFERS to RLQ
(specifically McBurney's point) |
APPENDICITIS
*due to embryology. Vermiform appendix came from midgut so pain will present around umbilicus |
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usually LLQ (as most frequently affects SIGMOID colon)
"left-sided appendicitis" |
DIVERTICULITIS
LLQ but starts suprapubically because it begins in the embryological hindgut |
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FLANK or INGUINAL PAIN referring to GROIN and scrotum.
FOLLOWS COURSE OF URETER DOWN TO BLADDER USE MURPHY'S PUNCH |
RENAL COLIC/KIDNEY STONE
higher the stone, the lower the pain WRITHING PAIN in search of comfortable position (none) |
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moderately severe LOWER ABDOMINAL PAIN
RADIATING TO BACK |
RUPTURED A3
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PERIUMBILICAL/COLIC PAIN
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SMALL BOWEL obstruction
***does NOT REFER to RLQ like appendicitis |
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LOWER ABDOMINAL COLIC/PAIN
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LARGE BOWEL obstruction
(hindgut) |
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severe lower abdominal pain of sudden onset in a child-bearing age woman
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RUPTURED ECTOPIC PREGNANCY
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circular, periumbilical distribution of VENOUS DILATION suggestive of portal hypertension secondary to hepatic cirrhosis
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CAPUT MEDUSA = portal hypertension
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PERIUMBILICAL BRUISING suggestive of intrabdominal bleeding (ruptured spleen)
May also be seen w/ acute pancreatitis. |
CULLEN'S SIGN = ruptured viscera
Ascites and blood pooling. Most often SPLEEN |
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FLANK BRUISING of pancreatitis
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GREY TURNER'S SIGN = pancreatitis
remember during abdominal exam for fluid, if you 'turn them over and they are bruised,' it is TURNER's sign |
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belly shapes for abdominal inspection
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contour:
FLAT SCAPHOID (hollowed/concave) ROUNDED PROTUBERANT |
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ABDOMINAL FAT
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MOST COMMON CAUSE OF ROUNDNESS
sunken umbilicus, NORMAL percussion, FATTY apron, |
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abdominal GAS
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INCREASED TYMPANY
distention more marked in LARGE BOWEL OBSTRUCTION than small |
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abdominal PREGNANCY
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PERIUMBILICALLY DULL
FLANK TYMPANY FETAL HEART SOUNDS |
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abdominal ASCITES
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PERIUMBILICAL TYMPANY with DULL FLANK (opposite of pregnancy)
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abdominal GROSSLY DISTENDED BLADDER
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SUPRAPUBIC DULLNESS
*post-micturation suprapubic percussive dullness |
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abdomen LARGE SOLID PELVIC TUMOR
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INFERIOR DULLNESS
SUPERIOR TYMPANY *due to air displacement. Ovarian or urterin myomata |
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ASCITES, ADULTS, PREGNANCY, INFANTS
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UMBILICAL HERNIA asymmetrical
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PROTRUSION through a surgical scar
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INCISIONAL HERNIA asymmetrical
How can you tell what is caught up? An artery will have a bruit sound; a bowel will make bowel sounds. |
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LINEA ALBA protrusion
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EPIGASTRIC HERNIA asymmetrical
between xyphoid and umbilicus. ask patient to do a CRUNCH - it's VISIBLE |
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separation of the 2 RECTUS ABDOMINIS mm.
*like the Marfan's pt. you met |
DIASTASIS RECTI asymmetrical
*pt performs a crunch and contents bulge along midline MULTIPARITY OBESITY COPD |
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common BENIGN FATTY TUMOR of abdomen
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LIPOMA asymmetrical
SOFT, LOBULATED, MOBILE dogs get'em! |
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ORDER of abdominal inspection
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ASCULTATION
PERCUSSION PALPATION to minimize deep palpation bowel sounds and "size" the organs before you go pushing on them |
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abdominal ascultation
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start RLQ
listen 1 min 5-34 bowel sounds per min (boryborygmus) move to other quads and listen for sounds |
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INCREASED BOWEL SOUNDS w/ DIARRHEA
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suspect EARLY INTESTINAL OBSTRUCTION
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I will not be explaining the abdominal exam here
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We learned it for lab
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Where to ascultate the SPLEEN for FRICTION RUB
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Left MAL
7th ICS |
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Friction rub over liver suggests
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tumor
hepatitis perihepatitis (Fitzhugh-Curtis syndrome of PID) |
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Friction rub over spleen suggests
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splenic infarct
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What should the examiner keep in mind when percussing the abdomen?
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UNDERLYING ANATOMY
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predominant PERCUSSIVE NOTE FOR ABDOMEN
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TYMPANY
scattered dullness of underlying fluid or feces |
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NORMAL LIVER SPAN
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6-12 cm at right MCL
4-8 cm at MSL |
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condition that would enlarge liver
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HEPATITIS
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skin hypersensitive to touch after surgery so guarding/muscular resistance
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CUTANEOUS HYPERESTHESIA
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where should you start abdominal PALPATION?
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in the quadrant furthest from complaint
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Guarding of abdomen can be overcome but suggests
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PERITONEAL IRRITATION
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enlarged liver w/ firm NON-tender edge
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CIRRHOSIS
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enlarged liver w/ smooth TENDER edge
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HEPATITIS
VENOUS CONGESTION RSHF |
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FIRM,HARD IRREGULAR LIVER
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MALIGNANCY
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murphy's SIGN
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FAIL TO INSPIRE WHILE PALPATING LIVER
suggests CHOLEOCYSTITIS, HEPATITIS, OR MONO |
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If you can feel the spleen
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MONO
splenomegaly due to mono, neoplastic disorders or low diaphragm of COPD |
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Is a normal sized kidney palpable
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no, except in thin, well-relaxed pt
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UNILATERAL ENLARGEMENT OF KIDNEYS
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HYDRONEPHROSIS
cysts, tumors |
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BILATERAL ENLARGEMENT of kidneys
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POLYCYSTIC KIDNEY DISEASE
*would affect BOTH = BILATERAL |
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Aortic pulsations where hands are driven 'towards the ceiling'
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NORMAL
driven towards the walls is A3 |
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Positive finding is for bilateral dullness to become unilateral upon side-lying position
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SHIFTING DULLNESS
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MONO finding
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History: kissing
Inspection: pus pockets (exudative pharyngitis) Ascultation: friction rubs over spleen and liver Percussion: same as ascultation Palpation: pass |
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HEPATITIS finding
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Jersey shore, loose, heroin, untagged shellfish
You look YELLOW Friction rubs over liver and spleen Special finding: MURPHY'S SIGN (liver grab) |
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UROLISTHIASIS (renal stones) finding
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STONE THROWER (two or more bouts w/ kidney stones in past)
Can't sit still No palpatory findings Don't percuss kidneys - + Murphy' punch HYDRONEPHROSIS (bigger and bigger) so do a KIDNEY CATCH |
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pt w/ LBP, negative MRS findings, overweight, 60 yr old male, pulsatile midline mass
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A3
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most common tumor found on MALE SELF EXAM
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EPIDIDYMIS tumor
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In males, black Coca Cola coloured urine
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GLOMERULONEPHRITIS
Beta-hemolytic strep so nephrotic bleeding. Proteins causing froth |
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dull percussion suprapubically even after empties bladder
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SUPRAPUBIC DISTENTION
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swelling of face/around eyes - may be seen w/ NEPHROTIC problems
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PERIORBITAL EDEMA
NEPHRONS- LOSS OF FLUID/PROTEINS |
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end stage RENAL FAILURE powdery deposits on skin
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renal FROST
due to urea buildup Liver and kidneys detox via skin |
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renal failure BREATH smell
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AMMONIA due to lungs detoxing aldehydes
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foreskin ADVANCES AND FIXED TIGHTLY
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PHIMOSIS
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foreskin RETRACTED impedes glans circulation
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PARA-phimosis
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inflammation of GLANS due to BACTERIAL or FUNGAL
diabetes mellitus candida Reiters' |
BALANITIS = B for Bacteria Balanitis
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PROLONGED PAINFUL ERECTION
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PRIAPISM
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suggests STD
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PURULENT DISCHARGE
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NON-TENDER ULCER in uncircumcised men or poor hygiene
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CARCINOMA OF PENIS
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oval or round, dark red, PAINLESS EROSION OR ULCER w indurated base.
ENLARGED LYMPH NODES |
syphilitic chancre
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cluster of small vesicles
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venereal/genital herpes
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condyloma acuminatum
rapidly growing lesions near coronal sulcus of penis |
genital warts
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painless lesion or erosion at coronal sulcus of penis, later lymph involve
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Lymph0granuloma verenum
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VENTRAL urethral deformity
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HYPOSPADIUS
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DORSAL URETHRAL DEFORMITY
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EPISPADUS
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CROOKED PENIS
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PEYRONIE
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VERTICAL CHAIN LYMPH NODE INVOLVEMENT, PAINLESS
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SYPHILLIS
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pearly grey lesions opportunistic penile infection
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molluscum contagiosum
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condylomata LATA
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see you LATA - secondary syphilitic lesion
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tunica vaginalis fluid on scrotum
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hydrocele
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cystic bag of sperm
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spermatocele
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bag of worms
varicose veins of scrotum |
varicocele
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inflammed testes
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orchitis
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acute inflammation of epididymis
assoc w UTI |
epididymitis
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twisting of testicle on spermatic cord
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testicular torsion
adolescents |
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neoplasm on testicle. Non tender, fixed mass that does NOT transilluminate
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testicular tumor
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preceded by abcess, opening from anus or rectum to skin
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anorectal fistula
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painful oval ulceration of anal canal
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anal fissure
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EXTERNAL varicose veins
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hemorrhoids below anorectal line and covered by anal skin
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INTERNAL varicose veins
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above anorectal line and covered by anal mucosa
hmatochezia |
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cyst along midline above coccyx - very painful
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PILONIDAL cyst
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herniation of abdominal contents DIRECTLY THROUGH inguinal ring
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DIRECT inguinal hernia
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herniation of abdominal contents DOWN to inguinal canal
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INDIRECT = DOWN inguinal hernia
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herniation BELOW inguinal ligament
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FEMORAL HERNIA
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direct hernia palpation
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use index finger opposite hernia side
and invaginate loose scrotal skin... DIRECT: feel abdominal contents on PAD of fingers INDIRECT: abdominal contents on TIP of finger FEMORAL: won't feel anything. Palp fem region while pt coughs |
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acute, febrile condition caused by BACTERIAL INFECTION of prostate
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PROSTATITIS
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BPH symmetrical benign enlargement of prostate
males over 50 urinary frequency or hesitancy gland enlarged, firm elastic |
benign prostatic hypertrophy
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prostate feels hard and asymmetrical
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prostate cA
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these scrotal problems WILL TRANSILLUMINATE
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HYDROCELE AND SPERMATOCELE
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will a tumor transilluminate?
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no
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HRT and Birth control pills are female risks for
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THROMBOEMBOLUS
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female gland palpation at vaginal introitus
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Bartholin's and Skene's
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crabs
excoriations of erythematious areas notes on mons pubis w/dark spots also eyebrows and eyelashes |
pediculosus pubis
Pubic lice |
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red swollen vesicles weeping or crusting Reaction from FEMALE HYGIENE PRODUCTS
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contact dermatitis
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clusters of painful ulcers or vesicles assoc wi/ HSV type II
cancer risk |
HERPES HURTS genitalis
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non-tender button like solitary silver papule
nontender inguinal swollen lymph |
syphilitic CHANCRE
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WARTY CAULIFLOWER HPV
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CONDYLOMATA ACCUMINATA
HPV chancre |
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condylomata LATA
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2*syphilis
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MALODOROUS, ASSOCIATED PURITIS discharge yellow green grey
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TRICHOMONAS VAGINALIS = ROTTEN
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white curdy thick NON-malodorous discharge WITH INFECTION
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CANDIDA VAGINITIS = yeast infection
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GREY or white thin discharge MALODOROUS FISHY/MUSTY
NO PRUITUS |
BACTERIAL VAGINOSIS = fishy
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associated pruritus and ESTROGEN AFTER MENOPAUSE
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ATROPHIC (non growing) VAGINITIS
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bulge of the bladder into ANTERIOR WALL OF VAGINA due to weakened pelvic floor
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CYSTOcele
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soft uterus
amenorrhea breast engorgement Chadwick's sign nausea weight gain |
Pregnant uterus
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irregularly enlarged uterus
firm mobile and PAINLESSLY NODULAR PELVIC PRESSURE NOT cancerous |
MYOMA of uterus
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enlarged hard fixed NON tender cervix
abnormal bleeding hypermenorrhea intermenstrual postmenstrual |
ENDOMETRIAL CANCER
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FIXED TENDER UTERUS
SMALL TENDER MASSES PELVIC PAIN LBP HYPERMENORRHEA |
ENDOMETRIOSIS
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cyst that feels like a tomato of the ovary
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ovarian cyst
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ovarian mass that feels like a potato (hard)
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ovarian cancer
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PULSATING FALLOPIAN TUBE MASS
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ECTOPIC pregnancy
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CHANDELIER'S SIGN for abdominal pain female
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PID
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nodular thickened pouch of Douglas (rectovaginal pouch)
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suggest abdominal CA
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bluish discoloration of the cervix suggestive of PREGNANCY
appears @ 6-8 weeks |
CHADWICK'S SIGN
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RIM OF CERVIX red eroded no ulceration
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cervical erosion
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irregular cauliflower like growths on cervix WITH ULCERATION AND INDURATION
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CA of cervix
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bright red soft pedunculated benign growth emerging from os cervix
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cervical polyp
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red granular patches of columnar epithelium covering cervix w/ cock's comb ridge deformity
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FETAL EXPOSURE to DES
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thin watery discharge unilaterally seen wi a BENIGN intraductal papilloma
BCP CA |
SEROUS nipple discharge
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pregnant or menstruating women
MALIGNANT INTRADUCTAL PAPILLOMA |
BLOODY nipple discharge
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seen in breast ABCESS
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PURULENT nipple discharge
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mammary duct ectasia
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MULTICOLORED STICKY nipple discharge
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FIBROADENOMA
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15-30
round, lobular firm, rubbery smooth usually single VERY MOBILE usually no tenderness |
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BENIGN BREAST DISEASE
|
30-55 (decreases post menopause)
round, lobular firm to soft, rubbery smooth usually multiple number mobile TENDER (esp at period) |
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breast CANCER
|
30-80 (increases after 50)
IRREGULAR, STAR SHAPED FIRM, STONE HARD IRREGULAR single FIXED NON tender |
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enlargement of male breasts
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gynecomastia
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hard irregular non tender fixed mass often directly UNDER AREOLA w/ associated nipple retraction
men |
male breast cancer
|
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fibroadenoma and cancer masses in breast are __________.
benign breast disease masses are __________ |
fibroadenoma and cancer are SOLITARY
BBD masses are multiple |
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most commonly missed area for breast cancer
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APICAL
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