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200 Cards in this Set
- Front
- Back
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What does an initial evaluation consist of?
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Look
Listen Feel Percuss |
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What is the alimentary tract and what does it consist of?
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From mouth to anus
27 feet long Includes mouth, esophagus, stomach, duodenum, jejunum, ileum, colon, sigmoid, anus Functions: ingestion and digestion of food, absorption of nutrients, electrolyes and water, and excretion of wastes |
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GI tract/ vascular system contents
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Liver
Stomach Pancreas Spleen Gall bladder large intestine small intestine appendix diaphragm peritoneum mesenteric: lymph and vessels descending aorta IVC |
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Genitourinary tract
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Urinary bladder
Ureters Kidneys Adrenal glands Uterus Fallopian tubes Ovaries Cervix Psoas muscles Prostate Urethra |
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R upper quadrant contents
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Liver
Gall bladder Pylorus Duodenum Head of pancreas R adrenal gland R kidney: upper pole Hepatic flexure Ascending colon: portion Tranverse colon: portion |
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L upper quadrant contents
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Liver, left lobe
Spleen Stomach Pancreas: body L adrenal gland L kidney: upper pole Splenic flexure Transverse colon: portion Descending colon: portion |
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L lower quadrant contents
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Left kidney: lower pole
Sigmoid colon Descending colon: portion L ovary L fallopian tubes L ureter L spermatic cord Uterus (if enlarged) Bladder (if enlarged) |
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R lower quadrant contents
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R kidney: lower pole
Cecum Appendix Ascending colon: portion R ovary R fallopian tube R ureter R spermatic cord Uterus (if enlarged) Bladder (if enlarged) |
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Inspection criteria
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Skin
Shape Distention Symmetry Masses Scars Hernias Venous pattern Aortic pulsations |
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Listening posts for bruits
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Aorta
Renal artery Iliac artery Femoral artery |
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Normal liver span
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4-8 cm in midsternal line
6-12 cm in R midclavicular line |
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Palpation criteria
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Use pads of fingers
Structures Rigidity Pain Organomegaly Guarding Rebound SubQ structures |
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Finger hook technique
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Hepatomegaly measured in cm below costal margin
If hepatomegaly is found, abdominal exam for fluid |
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Ascites
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Free fluid in peritoneal cavity
Usually caused by portal hypertension Symptoms result from abdominal distention Fluid wave If patient is laying on their R side, tympany at top (left side) and dullness at bottom (right side) |
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Rebound tenderness - what does it indicate
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Press down slowly then remove hands quickly
Watch for flinch upon removal of hands Flinch means test is + --> peritoneal inflammation (peritonitis) which indicates acute abdomen/perforation |
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Classical findings in acute appendicitis / cholecystitis
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McBurney's
Rovsing Psoas Obturator Guarding Murphy's |
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McBurney's sign
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R lower quadrant tenderness 1/2 way between umbilicus and ASIS
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Rovsing sign
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Pain in R lower quadrant with palpation of L lower quadrant
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Psoas sign
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Increase in pain from passive extension of R hip joint that stretches iliopsoas
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Obturator sign
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Pain from passive internal rotation of flexed thigh
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Guarding
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involuntary contraction of abdominal muscles that is slightly slower and more sustained than flinch
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Murphy's Sign
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Deep inspiration exacerbates pain during palpation of R upper quadrant and halts inspiration
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Flatus
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Passing gas
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Eructation
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Burping
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Emesis
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Vomiting
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Hematemesis
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Vomiting red blood
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Hematochezia
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Blood in stool (red)
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Melena
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Black, tarry stools (digested by HCl)
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Coffee ground emesis
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Black blood vomited
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Dyspepsia
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Upset stomach
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Obstipation
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Severe constipation but not impacted
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Tenesmus
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Feeling the need to have a bowel movement, but unable to do so
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Intussusception
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Bowel telescopes on itself
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N/V/D/C
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Nausea, vomiting, diarrhea, constipation
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Early satiety
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Unable to finish meal
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Colic
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intermittent cramping and pain
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Icterus
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Yellowing of sclera (jaundice is yellowing of skin)
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Steatorrhea
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Fatty stool (it floats)
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Borborygmus
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Normal bowel sounds
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lithiasis
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Stones
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Dysphagia
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Difficulty swallowing
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Odynophagia
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Pain during chewing and swallowing
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Scaphoid
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Concave curved abdomen (skinny)
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Cachexia
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MASSIVE weight loss
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Volvulus
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bowel is twisted
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Polydipsia
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excessive thirst
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Cardiac surface anatomy
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SVC
R pulmonary artery R atrium R ventricle Aorta Pulmonary trunk L pulmonary artery L ventricle Apical impulse |
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S1 (first heart sound)
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Closure of AV (tricuspid and mitral) valves
At QRS complex |
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S2
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Closure of semilunar (aortic and pulmonic) valves
After T wave |
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EKG
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Measures electrical stimulation of the heart
Depolarization: spread of electrical stimulation through heart Repolarization: return of stimulated heart cells to resting state Synchronized pattern of repolarization and depolarization represented as waves |
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P wave
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Atrial depolarization (contraction)
Diastole |
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QRS complex
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Ventricular depolarization (contraction)
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ST segment and T wave
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ventricular repolarization (recovery)
T wave is systole |
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Systole and diastole
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Systole is between S1 and S2
Diastole is between S2 and S1 |
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Jugular venous pressure
What determines is What does it reflect |
Venous pressure < arterial pressure
Veins have less smooth muscle than arteries Determined by LV contraction Determined by blood volume and RV contractility Venous pressure changes are reflected in internal jugular veins (JVP) |
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Preload
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Volume of blood that stretches the ventricle before contraction (end diastolic volume)
Increased by blood volume expansion |
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Afterload
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Degree of vascular resistance to ventricular contraction
Resistance is reflected by tone of the arterial walls and volume of blood in vascular tree |
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Myocardial contractility
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Ability of cardiac muscle (myocardium) to shorten (contract) when given a load
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Estimating JVP from sternal angle
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?
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JV Pulsations
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R internal jugular empties directly into RA
Oscillations in RIJ reflect changing pressures |
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a wave
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atrial contrAction
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c wave
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Closure of tricuspid valve
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x descent
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atrial relaXation
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v wave
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atrial Venous filling
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y descent
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atrial emptYing (passive)
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Carotid pulse assessment
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?
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Arterial wave forms
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?
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Internal jugular palpation
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Rarely palpable
Soft, undulating, diphasic Pulsations eliminated by light pressure Level of pulsations positional Pulsations descend with inspiration |
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Carotid
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Palpable
Firm, single component Pulsations not eliminated with pressure Pulsations unchanged with position Level unaffected by inspiration |
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Thrills
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Vibratory pulsation associated with murmurs or bruits
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Heaves or lifts
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Associated with hyper dynamic muscle or hypertrophy
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PMI
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Point of maximal impulse
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Apical pulse
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Between 4th and 5th rib, nearer to midclavicular line
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Epigastric
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Subxiphoid
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Aortic area
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R 2nd interspace
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Apex
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L ventricular area
Mitral |
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R ventricular area
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L sternal border
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Pulmonic area
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L 2nd interspace area
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Palpating systolic impulse of R ventricle
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Palpating R ventricle in epigastric area
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Diameter of impulse
What is normal apical impulse |
Measure diameter of impulse
Normal apical impulse is 2.5 cm |
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Amplitude
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Height, or strength of impulse
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Duration - define
How long is duration of apical pulse |
How long does the impulse last during the cardiac cycle
Normal apical impulse lasts 2/3 of systole and does not continue to 2nd heart sound |
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Hyperkinetic amplitude
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Sustained impulse duration
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Hypokinetic apical impulse
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Low amplitude/long duration
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1st heart sound
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Closure of AV valves (mitral and tricuspid)
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2nd heart sound
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Closure of semilunar valves (aortic and pulmonic)
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When is systole
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Between 1st heart sound and 2nd
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When is diastole
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Between 2nd heart sound and 1st
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S3
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Ventricular filling
Volume overload Kentucky |
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S4
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Atrial contraction
Stiff LV Tennessee |
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Summation gallop
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S3 and S4
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Physiologic splitting of S2
Where is it detected What accentuates it |
Detected in 2nd or 3rd L interspace
Accentuated with inspiration because increased return of blood to heart and R ventricle takes a moment longer to fill and beats a split second after aortic |
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Physiologic splitting of S1
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Mitral component is louder than the tricuspid component
Heard best at tricuspid Does not vary with respiration |
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Which valve can be heard across the precordium
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Aortic
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Ejection sound
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Click
Opening sound of aortic or pulmonic valve due to pathology High pitched sound heard best in early systole |
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Systolic click
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Midsystolic click due to mitral valve prolapse
High pitched sound heart at LLSB Frequently followed by ejection murmur |
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Opening snap
What's opening When is it best heard |
Opening sound of mitral valve
High pitched sound heard best in early diastole |
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Midsystolic murmur
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Middle of S1 and S2
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Holosystolic murmur
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Heard throughout S1 to S2, possibly covering S2
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Late systolic murmur
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Right before S2
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Early diastolic murmur
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Right after S2
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Mid diastolic murmur
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Between S2 and S1
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Late diastolic murmur
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Right before S1
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Crescendo murmur
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Grows louder
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Decrescendo murmur
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Grows softer
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Crescendo-decrescendo murmur
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First rises in intensity, then falls
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Plateau murmur
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Same intensity throughout
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Blowing murmur
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Sounds like air rushing out of balloon
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Harsh murmur
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like sandpaper over wood
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Rumble murmur
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Like tires over cut strips on highway
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Where can aortic murmurs radiate to
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Carotids or even apex if loud
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Where can mitral murmurs radiate to
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L axilla
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Where can tricuspid murmurs radiate to
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R lower sternal border
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Where can pulmonic stenosis radiate to
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L neck or shoulder
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Grade 1 systolic murmur
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Very faint, not heard in all positions
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Grade 2 systolic murmur
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Quiet but heard, not necessarily in all positions
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Grade 3 systolic murmur
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Moderately loud
Heard in all positions |
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Grade 4 systolic murmur
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Loud with palpable thrill
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Grade 5 systolic murmru
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Very loud, thrill, heard with stethoscope in partial contact with chest
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Grade 6 systolic murmur
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Very loud, with thrill, can be heard without stethoscope
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Positioning for murmur
How to hear aortic murmurs How to hear mitral murmurs What decreases and increases venous return to heart |
Exhale and lean forward for aortic murmurs
LLD position for mitral murmurs Standing to decrease venous return to heart Squatting to increase venous return to heart |
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Valsalva maneuver
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Get person to exhale against resistance
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Normal pulse
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Pulse pressure is 30-40 mm Hg
Pulse contour is smooth and rounded |
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Small weak pulses
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PP diminished
Pulse feels weak and small Upstroke may be slowed and peak prolonged Causes: Decreased SV (heart failure, hypovolemia, aortic stenosis) Increased TPR (exposure to cold or severe CHF) |
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Large, bounding pulses
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PP is increased
Pulse feels strong and boudning Rise and fall may feel rapid Brief peak Causes: Increased SV Decreased TPR Fever Anemia Hyperthyroidism Aortic regurg AV fistulas PDA Incrreased SV due to bradycardia or heart block Decreased compliance of aortic walls |
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Bisferiens pulse
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Increased arterial pulse with double systolic peak
Causes: Pure aortic regurg Aortic regurg w/ stenosis Hypertrophic cardiomyopathy |
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Pulsus alternans
what does it indicate |
Pulse alternates in amplitude from beat to beat although rhythm is regular
Usually indicates LV failure and is usually accompanied by L sided S3 |
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Bigeminal pulse
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Caused by normal beat alternating with premature contraction
SV of premature beat is diminished, so pulse varies |
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Paradoxical pulse
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Palpable decrease in pulse amplitude during quiet inspiration
Systolic pressure decreases by > 10 during inspiration Found in: pericardial tamponade Constrictive percarditis Obstructive lung disease |
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Pansystolic murmurs
What causes it How long is it Conditions associated |
Arise from blood flow from chamber with high pressure to one of lower pressure through structure that should be closed
Begins immediately with S1 and continues up to S2 Mitral regurg Tricuspid regurg VSD |
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Mitral regurgitation
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Location: apex
May radiate Varying intensity Medium to high pitched Harsh Holosystolic No change with inspiration Decreased S1 Apical S3 - volume overload in LV Apical impulse is increased in amplitude, laterally displaced Due to regurgitation from LV to LA when mitral valve fails toclose fully in systole. |
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Tricuspid regurgitation
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Lower left sternal
May radiate Medium pitch blowing, holosystolic Intensity may increase slightly with inspiration RV impulse is increased in amplitude S3 may be heard along lower L sternal border Elevated jugular venous pressure, with large p waves in jugular veins Due to regurgitation from RV to RA when tricuspid fails to closs fully. Usually due to pulmonary hypertension or LV failure initially |
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VSD
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3rd - 5th L interspaces
Lots of radiation Very loud with thrill High pitched Holosystolic Harsh S2 may be obscured by murmur Congenital. Blood flows from LV into RV through hole |
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Midsystolic ejection murmurs
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Innocent
Physiologic Pathologic Tend to peak near midsystole and usually stop before S2 Gap between murmur and S2 helps distinguish from pansystolic |
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Innocent murmurs
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2nd to 4th L interspaces b/w L sternal border and apex
Grade 1-3 Soft to medium pitch Usually decreases or goes away while sitting Normal splitting No ejection sounds No diastolic murmur No ventricular enlargement Result from turbulent flow, probably by ventricular ejection of blood into aorta and occasioanlly RV |
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Physiologic murmur
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Similar to innocent murmurs
Turbulence due to temporary increase in blood flow in predisposing conditions such as anemia, pregnancy, fever, hyperthyroidism |
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Pathologic murmurs
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Aortic stenosis
Hypertrophic cardiomyopathy Pulmonic stenosis |
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Aortic stenosis
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R 2nd interspace
S2 may be decreased Radiates sometimes soft, but often loud with thrill harsh crescendo-decrescendo may be more musical at apex Best heard with patient sitting and leaning forward A2 may be delayed and merge with P2 into single S2 on expiration or paradoxical split Carotid upstroke may be delayed with slow rise and small amplitude Hypertrophied LV may lead to sustained apical impusles and S4 due to decreased compliance Impaired blood flow across valve, causing turbulence, increasing LV afterload Causes: Congenital Rheumatic Degenerative Conditions that mimic: Aortic sclerosis Bicuspid aortic valve Dilated aorta Increased flow during systole |
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Hypertrophic cardiomyopathy
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3rd and 4th interspaces on L
radiates down L sternal border, possibly to base, but not neck medium pitched harsh Decreases with squatting Increases when standing or with Valsalva S3 maybe present S4 often present at apex Apical impulse may be sustained Carotid pulse rises quickly Associated with rapid ejection of blood from LV |
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Pulmonic stenosis
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2nd and 3rd L interspaces
Crescendo-decrescendo Harsh Early pulmonic ejection Increased RV impulse/afterload Congenital |
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Diastolic murmurs
What do early decrescendo murmurs indicate What do rumbling diastolic murmurs indicate |
Almost always indicate heart disease
Early decrescendo murmurs signifiy regurgitation through incompetent semilunar valve Rumbling diastolic murmurs in mid or late diastolic indicate stenosis of AV valve |
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Aortic regurgitation
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Blowing decrescendo (mistaken for breath)
Best heard w/ pt sitting and leaning forward |
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Mitral stenosis
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No radiation
Decrescendo Low pitched rumble Easiest heard in exhalation |
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Indirect inguinal hernia
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Sac enters internal inguinal ring, passes through inguinal canal and out external inguinal ring and into scrotum
Most common on R side |
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Direct inguinal
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Sac protrudes medial to inguinal canal and through the external inguinal ring
Rarely into scrotum |
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Femoral hernia
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Sac herniates through femoral canal
More common on R due to sigmoid colon on L femoral canal high strangulation rate Dx with CT |
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Obturator hernia
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At obturator ring
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Perineal hernia
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Usually posterior to superficial tranverse perineal muscle
Can happen at: Rectum Superfi transverse perineal m. |
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Sciatic hernia
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Usually through greater sacrosciatic foramen
Or: Piriformis m. Coccygeus m. Lesser sacrosciatic foramen Iliococcygeus m. |
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Ventral hernia
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Lateral, epigastric, or hypogastric
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Lumbar hernia
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At superior lumbar trigone
or Inferior lumbar trigone (Petit's) |
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Diaphragmatic hernia
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Usually through esophageal hiatus
Or phrenopulmonary hiatus |
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Reducible hernia
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Contents can be replaced in surrounding structures
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Nonreducible hernia
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Contents cannot be replaced
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Incarcerated hernia
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Nonreducible with bowel obstruction
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Strangulated hernia
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Nonreducible with obstruction of blood flow and resultant gangrene
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Incidence of hernias
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70% inguinal (2/3 indirect)
15% incisional 10% ventral or umbilical 5% femoral and others |
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Women more likely to have what kinds of hernia
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10x more likely to have femoral
2x more likely to have umbilical and incisional |
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Men are more likely to have what kind of hernia
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25x more likely to have inguinal
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Prevalence of hernias
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Increases with:
Age Obesity More strangulation with age |
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Which hernias are most likely to strangulate
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femoral although most common strangulation are inguinal
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Umbilical hernia
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More common in infants
More common in obesity Usually close spontaneously in infants Sac herniates through defective umbilical ring |
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Epigastric (ventral) hernia
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Sac herniates through defect in linea alba, between xiphoid process and umbilicus
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Incisional (ventral) hernia
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Protrudes through operative scar
More common in obesity, post-op infection Results from tension on one side of scar Smaller defect more dangerous |
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Diastasis recti (ventral hernia)
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Separation of 2 rectus abdominus muscles
Only visible upon increased intraabdominal pressure causing midline ridge Increased with pregnancies, obesity |
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Evaluation of inguinal hernias
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Patient must be evaluated supine and standing or valsalva manuever
Differential dx: Pelvic tumors Lymph nodes Testicular path U/S and CT useful |
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Repair of hernias
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Trusses generally not effective
Surgery indicated if lots of pain or strangulation likely Surgery usually indicated b/c progressive All surgical techniques are tension free repair |
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Sinus review
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Maxillary sinus
Ethmoid sinus Frontal sinus Sphenoid sinus Superior turbinate Middle turbinate Inferior turbinate |
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Blood supply to the nose
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Cartilage of the nose
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?
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Where is the sphenoid sinus in relation to the ethmoid
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It's deep to the ethmoid
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What are the ethmoid sinuses also known as
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Ethmoid air cells
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Evaluation of the nares
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Normal anatomical landmarks
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Type I microtia
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?
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Type II microtia
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Type III microtia
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What does a normal tympanic membrane look like?
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?
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Weber test/lateralization
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Sound is heard in bad ear with conductive hearing loss
Sound is heard in good ear with sensorineural hearing loss Should normally be heard in both ears equally |
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Rinne test
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?
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Expected findings during Weber test
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No lateralization, but will lateralize to ear occluded by patient
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Expected findings in Rinne test
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Air conduction heard longer than bone conduction by 2:1 ratio
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Rinne - conductive hearing loss
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Bone conduction heard longer than air conduction in affected ear (Rinne negative)
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Rinne - sensorineural hearing loss
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Air conduction heard longer than bone conduction in affected ear, but less than 2:1 ratio
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Evaluation of hearing loss
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Osseus landmarks of the hard palate
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Lateral and posterior tongue evaluation
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Grading tonsilar size
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Pharyngitis
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Palatal rugae
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Torus mandibularis
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Torus palatinus
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Indirect laryngoscopy
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Lymph drainage of head/neck
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Posterior auricular and cervical nodes
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Salivary glands
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Epiglottis (thumb sign)
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?
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True vocal cords
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?
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