Physical Diagnosis - Fall 09 - Exam 2

Front 1

Thrill

Back 1

A palpable murmur, usually due to vibrations that accompany loud murmurs

Front 2

Lift (Heave)

Back 2

When the cardiac impulse feels more vigorous than normal, and can be felt through the chest wall

Front 3

Claudication

Back 3

Achy leg pain when walking

Front 4

Orthopnea

Back 4

SOB when lying down

Front 5

Paroxysmal Nocturnal Dyspnea (PND)

Back 5

Sudden waking in the middle of the night with SOB

Front 6

Palpation for Apical Impulse

Back 6

Rt Hand on patients chest as shown

Front 7

PMI

Back 7

point of maximal impulse

Front 8

Locations for Cardiac Palpation

Back 8

Apical Impulse
PMI
Left Sternal Border and Base

Front 9

Locations for Cardiac Auscultation

Back 9

Aortic – 2nd ICS, RSB
Pulmonic – 2nd ICS, LSB
Second Pulmonic – 3rd ICS, LSB
Tricuspid – 4th & 5th ICS, LSB
Mitral (apex) – 5th ICS, MCL

Front 10

Locations for Axillary Lymph Node Palpation

Back 10

Anterior axillary line
Midaxillary line
Posterior axillary line
Medial upper arm

Front 11

Identify

Back 11

Bisferiens Pulse

Front 12

Identify

Back 12

Pulsus Alternans

Front 13

Identify

Back 13

Bigeminal Pulse

Front 14

Identify

Back 14

Paradoxical Pulse

Front 15

Specialized Exam: Measurement of JVD

Back 15

Elevate the head of the bed to 30 degrees.
Find internal jugular venous pulsations.
Locate the highest point of pulsation.
Measure from the sternal angle (sternal angle is considered to be 5cm above the right atrium).
JVP higher than 4 cm above the sternal angle (9 cm
above R atrium) indicates elevated right heart
pressure.

Front 16

Specialized Exam: Hepatojugular reflux

Back 16

Another test for fluid overload (heart failure).
Patient is supine, with head at 30 degree angle.
Apply firm and sustained pressure to the abdomen in the RUQ over the liver region.
– Use hand or mildly inflated blood pressure cuff.
Observe the neck for an increase in JVP, followed by a decrease as the hand is released.
JVP will increase in all patients with this maneuver, but it is exaggerated in right heart failure.

Front 17

Abnormal S1

Back 17

First sound produced by closure of mitral and tricuspid valves.
S1 louder than S2 at apex; S2>S1 at base.
Louder S1 due to diseased A-V valve or more forceful closure of A-V valve.
– Eg. Mitral stenosis, tachycardia, fever, HBP.
Softer S1 due to weak contraction of heart or reduced sound transmission from thick chest wall or emphysematous lungs.

Front 18

Where is S1 best heard

Back 18

At the apex

Front 19

Where is S2 best heard

Back 19

At the base

Front 20

Abnormal S2

Back 20

Physiologic splitting during inspiration, heard at 2nd & 3rd left interspace (pulmonic area).
Wide splitting due to delayed closure of pulm. valve (pulm stenosis; RBBB).
“Fixed splitting”--does not vary with respiration (atrial septal defect, RV failure).
Paradoxical splitting present during expiration and gone during inspiration; A2 follows P2
– Occurs when there is a delay in contraction of the left
ventricle due to a left bundle branch block (LBBB).

Front 21

Location where S3 and S4 are best heard

Back 21

Low-Pitched, heard best with bell at apex

Front 22

Pathologic S3

Back 22

Ventricular Gallop
- over age 40, usually pathologic
- Due to heart failure, anemia, volume overload of ventricle, decreased myocardial contractility

Front 23

Pathologic S4

Back 23

Pathologic due to resistance to ventricular filling; stiffness of heart muscle (reduced compliance).
– HBP, CAD, AS, cardiomyopathy
– Right-sided S4 from pulm HBP or pulm. stenosis

Front 24

Aortic or pulmonic ejection click

Back 24

High pitched; indicates valve disease or dilated aorta or pulmonary artery, or pulmonary hypertension.

Heard best with diaphragm of stethoscope

Front 25

Back 25

Left Lateral decubitus position (on left side)

Front 26

Mitral Valve Prolapse

Back 26

Due to ballooning of mitral leaflet(s) into the left atrium during systole.
Mid-late systolic click(s) often present. Variable pitch.
Mitral regurgitation may also occur, with late systolic murmur.
Common condition: over 5% of general population; usually benign.

Front 27

Gradations of Murmurs

Back 27

Grade 1/6: barely audible in quiet room.
Grade 2/6: quiet but clearly audible.
Grade 3/6: Moderately loud.
Grade 4/6: Loud, associated with thrill.
Grade 5/6: Very loud, heard with stethoscope partially off chest; obvious thrill.
Grade 6/6: Very loud, heard with stethoscope entirely off the chest, obvious thrill.

Front 28

Systolic Ejection Murmur

Back 28

Usually crescendo-decrescendo
Usually due to blood flow across semilunar valves
**From high pressure to high pressure** - KNOW THIS

Front 29

Pansystolic (holosystolic) Murmur

Back 29

Usually plateau
Usually regurgitation across A-V valves, or VSD
**From High Pressure to Low Pressure System** - KNOW THIS

Front 30

Late Systolic Murmur

Back 30

Typical of Mitral Prolapse

Front 31

Innocent Systolic Murmur

Back 31

Result from turbulent blood flow, but no valvular narrowing or obstruction
No evidence of cardiac disease
Usually grade 1-2, rarely 3/6
Medium pitch
May disappear with sitting

Front 32

Early Diastolic Murmur

Back 32

Usually decrescendo
usually from regurgitant flow across leaking semilunar valve

Front 33

Mid Diastolic Murmur

Back 33

from turbulent flow across atrioventricular valves

Front 34

Late Diastolic Murmur

Back 34

Usually continues up to S1

Front 35

Opening Snap Diastolic Rumble

Back 35

Mitral Stenosis

Front 36

"To and Fro" Murmurs

Back 36

Systolic/Diastolic murmurs
Severe aortic regurgitation
Aortic stenosis/regurgitation

Front 37

Nine Regions of the Abdomen

Back 37

Epigastric
Umbilical
Hypogastric (suprapubic)
R hypochondriac
L hypochondriac
R lumbar
L lumbar
R inguinal
L inguinal

Front 38

Correct Order for Abdominal Exam

Back 38

Inspect
Auscultate
Percuss
Palpate

Front 39

Normal Span of Liver

Back 39

6-12cm in MCL
Only 4-8cm in midsternal line

Front 40

Liver Palpation

Back 40

Right fingers placed on RUQ a few cm below the costal margin (rib cage)
Left hand placed in R low back
Fingers pointed toward patient’s right shoulder
Fingertips near suspected lower edge of liver
Have pt. take deep breath and feel for liver edge as it moves down with inspiration.
– Exam is inadequate if you do not ask pt to take deep breath while you are palpating liver edge

Front 41

Spleen Examination

Back 41

Stand on the patient’s right side and reach across
Right hand at LUQ, just below costal margin, with fingers pointing toward left lateral chest
Left hand behind ribcage in low back
Have patient take a deep breath; feel for spleen tip

Front 42

Kidney Examination

Back 42

Sitting (check tenderness)
– Use gentle fist percussion at the R & L costovertebral angles
Supine (palpate for size)
– With your right hand on the anterior abdomen, palpate deeply to the right and left of the aorta in the kidney region.
– Reach around the back with your left hand in the small of the back and lift forward so kidney is pulled slightly anteriorly.

Front 43

Pneumonic for Abdominal Pain (OLDCARTS)

Back 43

Onset
Location
Duration
Character
Aggrevators
Relievers
Treatment
Symptoms (ROS)

Front 44

Pneumonic for Abdominal Pain (PQRST)

Back 44

Provocative / Palliative
Quality
Region and Radiation
Severity
Temporal pattern/associated symtoms

Front 45

Abdominal Vessels to Auscultate for Bruits

Back 45

Aorta
Iliac & Femoral Arteries
Renal Arteries

Front 46

Striae

Back 46

Large purple-colored stretch marks (seen in Cushings disease and steroid use)

Large normal-colored stretch marks (seen with pregnancy, weight gain, and rapid growth)

Front 47

Linea Nigra of Pregnancy

Back 47

Dark line of hyperpigmentation down midline of abdomen

Front 48

Diastasis recti

Back 48

Separation of rectus abdominus muscles
Obvious with flexion of neck

Front 49

Ascites

Back 49

Free intraperitoneal fluid

Front 50

Surgical Incisions

Back 50

Subcostal incision
Median or midline
Left paramedian
Gridiron (muscle-splitting)
- McBurney's point
Transverse (abdominal)
Pfannenstiel (suprapubic)

Front 51

Pfannenstiel Surgical Incision

Back 51

Suprapubic
Generally used for C-Sections

Front 52

Hyperactive bowel sounds

Back 52

Gastroenteritis
**Early intestinal obstruction
Peritonitis (early)
**Borborygmi - loud, active sounds

Front 53

High-pitched, tinkling bowel sounds

Back 53

Obstruction
Intestinal fluid under pressure, with rushes of fluid moving through bowel

Front 54

Hypoactive bowel sounds

Back 54

Listen for several minutes
Paralytic "ileus" - little to no bowel activity
Peritonitis - may be hyperactive initially, but eventually becomes hypoactive due to progressively severe inflammation; may progress to an "ileus"

Front 55

Hepatomegaly

Back 55

Hepatic Enlargement
Congestive heart failure
Cirrhosis
Hepatitis
Abscess
Tumor
Cysts

Front 56

Shifting Dullness

Back 56

With patient supine, percuss the border of tympany & dullness.
Have patient roll onto their side, then percuss the border again.
An obvious shift in the location of the border suggests free intraperitoneal fluid.

Front 57

Palpation for Ascites

Back 57

Check for "fluid wave"

Front 58

Succussion splash

Back 58

Testing for Ascites
Shake the abdomen to create a "splash" sound

Front 59

Splenomegaly

Back 59

Enlargement of spleen
Mononucleosis
Hematologic disorders
Cirrhosis with portal hypertension
Cysts
Hypersplenism

Front 60

Palpation for Pain

Back 60

Front 61

Superficial Abdominal Reflexes

Back 61

Upper abdomen
– T-7, 8, 9
Lower abdomen
– T-11, 12
Cremasteric
– T-12, L1, L2

Front 62

Explosive, Excruciating Abdominal Pain

Back 62

Coronary occlusion
Biliary colic
Ruptured viscus
Ruptured aneurysm
Renal colic

Front 63

Severe, Constant Abdominal Pain

Back 63

Acute pancreatitis
Bowel strangulation
Mesenteric thrombosis

Front 64

Gradual-onset Steady Abdominal Pain

Back 64

Acute cholecystitis
Acute appendicitis
Diverticulitis
Pelvic inflammatory disease (PID)

Front 65

Peritoneal Signs

Back 65

Guarding
Abdominal wall rigidity
Rebound / contralateral rebound tenderness

Front 66

Acute Appendicitis

Back 66

Rebound
Psoas sign
Obturator sign
Rovsing's sign
Rectal exam

Front 67

Psoas Sign

Back 67

Two acceptable techniques:
1. Place your hand above patient’s right knee and have patient raise thigh against resistance
2. With pt on left side, gently hyperextend his thigh at the hip

Front 68

Obturator Sign

Back 68

With patient supine and right knee bent, internally rotate the right leg at the hip
This stretches the internal obturator muscle which produces RLQ pain from
obturator muscle irritation due to an inflamed appendix

Front 69

Rovsing's Sign

Back 69

Press deeply and evenly in the LLQ, then quickly withdraw your fingers.
Sudden pain in the RLQ is a positive Rovsing’s sign; suggestive of
appendiceal inflammation

Front 70

Murphy's Sign

Back 70

Used to test for GB or liver inflammation
Position fingers of right hand under right costal margin, and ask patient
to take a deep breath
– OR --
Lay left hand flat against liver; use fist to percuss (Murphy’s punch)

Front 71

Alternate Murphy's Sign

Back 71

Hook left thumb or fingers of right hand under right costal margin, and ask patient to take a deep breath.
– Sudden pain and an abrupt cessation of inspiration suggests cholecystitis or liver inflammation

Front 72

Grading of Pedal Pulses

Back 72

0: Absent, unable to palpate
1+: Diminished, weaker than expected
2+: Brisk, normal
3+: Increased
4+: Bounding

Front 73

Patrick's Test

Back 73

Patient Supine
Flex the leg to 90 degrees at hip and knee
Hold knee with one hand
Grasp ankle with other
Swing ankle medially

Front 74

Straight Leg Raising Test (SLR)

Back 74

Testing for impingement of sciatic nerve
Elevate Leg, dorsiflex foot

Front 75

"Flip Sign"

Back 75

Seated SLR Test
Pt seated with pt's hands on table
Extend leg
Watch for pt to "flip back" when leg extends

Front 76

Bulge Sign

Back 76

With leg straight, "milk" knee joint fluid down one side and up the other and observe for bulge

Front 77

Lachman's Test

Back 77

Flex pt's knee 15 degrees
stabilize thigh with one hand and pull upper tibia forward with other
more sensitive sign of ACL tear than drawyer test

Front 78

McMurray's Test

Back 78

For meniscal tear
Flex knee, place thumb and index finger on joint space
Rotate foot laterally and extend leg
Palpable click indicates medial meniscal tear

Front 79

Ballottement of Patella

Back 79

Test for knee effusion
Apply downward pressure from above the knee to milk fluid down
Push patella into joint space, feeling for fluid

Front 80

Stasis Dermatitis

Back 80

Due to chronic venous insufficiency with incompetent valves and higher pressure in capillary bed
Tissue is damaged and inflamed
"Brawny," non-pitting edema

Front 81

Homan's Sign

Back 81

Test for DVT
Passive forsiflexion of the foot in a patient with calf pain, tenderness, and/or swelling
Calf pain with dorsiflexion suggests DVT