Ztri 4 - Phys Dx Practical 2

Front 1

what is the general order of assessment for the abdominal exam?

Back 1

Pt position
Inspection
Auscultation
Percussion
Palpation

Front 2

What is the significance of doing the palpation AFTER the auscultation during the abdominal exam?

Back 2

Bowel sounds are more likely to be heard before disrupted by palpation.

Front 3

What is the purpose of the patient position/set up with the abdominal exam?

Back 3

slightly elevated torso, knees bent, and pt arms at side all serve to keep abdomen relaxed.

Upper and lower gown provide privacy.

Exposed abdomen allows for inspection of the surface anatomy.

Front 4

What are 3 things are to be inspected visually on the abdomen?

Back 4

-contour and symmetry (flat/round/scaphoid)

-condition of skin-presence/absence of lesions, rashes, scars, striae)

-visible movement(aortic pulsations, peristalsis)

Front 5

What 2 things are to be auscultated on the abdomen?

Back 5

Bowel sounds
vascular sounds

Front 6

T/F You should not hear bowel sounds when auscultating with the bell in all 4 quadrants.

Back 6

FALSE - you SHOULD hear bowel sounds in all 4 quadrants and the DIAPHRAGM should be used.

Front 7

What are the 7 vascular points auscultated on the abdomen?

Back 7

Aorta
R/L renal arteries
R/L iliac arteries
R/L femoral arteries

Front 8

What sounds are heard in the abdomen with a patient who has vascular issues?

Back 8

vascular bruits
venous hums

Front 9

After auscultating the 7 vascular points of the abdomen with the BELL of the stethoscope in a healthy patient, what are the expected findings?

Back 9

No vascular bruits or venous hums are heard.

Front 10

T/F You should see peristalsis in a healthy patient while visually inspecting the abdomen.

Back 10

FALSE - NO peristalsis should be seen but a slight pulsation of the aorta is normal.

Front 11

T/F Resonances is the predominant tone of the abdomen.

Back 11

FALSE - TYMPANY is the predominant tone in all 4 quadrants.

Front 12

When percussing down to the liver the tone should change from __________ to __________.

Back 12

resonance to dullness

Front 13

When percussing up to the liver the tone should change from __________ to __________.

Back 13

tympany to dullness

Front 14

The span of the normal healthy liver is about ___ cm at the right ______ line.

Back 14

8 cm, right mid-clavicular line

Front 15

3 areas of percussion on the abdomen are...

Back 15

4 quadrants
Liver @ right mid clavicular line
spleen @ left anterior axillary line

Front 16

What are the steps for percussing the liver?

Back 16

Female pt's "guard up" on the right
percuss from lung resonance down to liver dullness
percuss from abdomen tympany up to liver dullness
VERBALIZE: The liver span is 8cm at the right mid-clavicular line.

Front 17

What are the steps for percussing the spleen?

Back 17

Place your plexor at the lowest rib interspace on the left anterior axillary line and percuss for spleenic dullness.
Re-percuss the same location as the patient holds in a deep breath.
VERBALIZE: The spleen does not appear to be enlarged.

Front 18

T/F Superficial palpation is performed using 2 hands placed one on top of the other.

Back 18

FALSE
DEEP is 2 hands one atop the other
SUPERFICIAL is 1 handed

Front 19

What is the purpose of superficial/deep palpation?
What are your findings in a healthy individual?

Back 19

SUPERFICIAL: assessing muscular guarding... normal findings: supple without involuntary rigidity
DEEP: masses and organomegaly... be sure to ask patient to make you aware of any tenderness.

Front 20

What are the 8 assessments of palpation of the abdomen?

Back 20

Superficial
Deep
Free edge of the liver
R/L Kidney
Spleen
Aorta
Inguinal lymph nodes/Femoral pulse
Kidneys

Front 21

What are the steps to palpating the free edge of the liver?

Back 21

Female "guard up" right breast
Ask patient to take a deep breath in/out
In time with expiration doctor rolls the pads of the fingers under the edge of the lowest rib in line with the clavicle

Front 22

T/F The right kidney is easily palpated because of its close approximation to the spleen.

Back 22

FALSE: The LEFT kidney is close to the spleen and NEITHER kidney is normally palpated in a healthy individual.

Front 23

How do you determine the specific location of abdominal masses and what is the name of the test/maneuver?

Back 23

Patient does a partial sit-up. If the mass "goes away" it is intraabdominal. If it stays in your contact it is within the abdominal wall.
The test is called Carnett's maneuver and is not part of the practical exam. However the verbalization script includes it as testable material.

Front 24

T/F Blumberg's sign assesses rebound tenderness in patients with peritonitis.

Back 24

TRUE

Front 25

_________ inspiratory arrest sign is used if cholecystitis is suspected

Back 25

MURPHY'S inspiratory arrest sign

Front 26

T/F The fluid wave test and the shifting dullness test both assess the presence of peristaltic activity in the abdomen.

Back 26

FALSE: for the assessment of ASCITES not peristaltic activity. It is not included in practical performance but rather part of the testable verbalization information.

Front 27

Carnett's Maneuver

Back 27

abdominal masses - verbalized

Front 28

Blumberg's Sign

Back 28

peritonitis/rebound tenderness - verbalized

Front 29

Murphy's inspiratory arrest sign

Back 29

cholecystitis - verbalized

Front 30

Fluid wave/shifting dullness test

Back 30

ascites - verbalized

Front 31

What is the procedure for palpating the groin?

Back 31

Legs down
Over the gown
MALE Patients guard away from palpated area

VERBALIZE: Inguinal lymph nodes are of normal size and consistency. Femoral pulses are strong and symmetrical.

Front 32

Describe Murphy's Kidney Punch.

Back 32

Pt in a seated position facing away with legs over the side of the table.
Dr places hand over the costovetebral angle and strikes own hand in 3 increasing blows.
Be sure to have patient report any pain or tenderness.
VERBALIZE: the classical is flank pain or pain radiating into the groin, which may indicate kidney inflammation, such as polynephritis

Front 33

What is the general order of procedure for the Thoracic and Lung?

Back 33

Inspection
Palpation
Percussion
Auscultation

Front 34

What is included in the visual inspection of the thoracic exam?

Back 34

Symmetry: VERBALIZE: AP<Lateral diameter, Costal angle< 90* (Anterior View)
Respiration: VERBALIZE: Respiration is relaxed and even. (ant/post view)
Appearance: VERBALIZE: No rashes or lesions noted. (post view)

Front 35

What are the 4 procedures of palpation for the thoracic exam?

Back 35

(1) POSTERIOR shoulder/paraspinals, VERBALIZE: no areas of hypersensitivity or tenderness found

(2) POSTERIOR chest expansion - dr's thumb @ T10 bilaterally, pt takes a deep breath, dr observes expansion. VERBALIZE: chest expansion is full.

(3) Begin POSTERIOR: Tactile Fremitus "99" Upper, Middle High (UL), Middle Low (LL), Low/Lateral (LL), Axilla Females guard away (UL) , Mid Lat Thoracic (LL), Mid Clavicle/Apices, Upper Chest Female guard down (UL), Lower Chest Females guard up (RML, LUL) end ANTERIOR

(4) ANTERIOR Dr's Thumbs/Fingers either side of the trachea, VERBALIZE: trachea is midline.

Front 36

T/F Percussion follows palpation in the general order of procedure for the Lung/Thoracic exam.

Back 36

TRUE - palpation ends with you facing the patient ("trachea midline"). Shortcut to percussion (time saver)... proceed/begin ANTERIOR then continue to POSTERIOR then LATERAL. This sets you up to finish percussion at the POSTERIOR where you will then perform the diaphragmatic excursion.

Front 37

How many percussive sites are performed anterior, lateral, and posterior?

Back 37

6 (ant), 4 (lat), 10 (post) total of 20

Front 38

What is verbalized after percussing the lung fields?

Back 38

Lungs are resonant to percussion in all areas. Pneumonia percusses dull, Emphysema percusses hyper-resonant.

Front 39

T/F Percussion of the diaphragmatic excursion is performed bilaterally.

Back 39

TRUE - Diaphramatic excursion is 5cm BILATERALLY.

Front 40

Ending posterior with thoracic percussion, what comes next?

Back 40

Auscultation of lung fields in each of the 20 locations post, lat, and ant.

Have patient breathe with the placement of your diaphragm on their skin. Be sure to have patient make you aware if you are proceeding too quickly.

Front 41

What are the verbalizations for auscultation of the lung fields?

Back 41

Lung sounds are clear and no abnormal breath sounds. Lung sounds are increased with pneumonia, decreased with emphysema. If crackles were heard BRONCOPHONY, EGOPHONY, and WHISPER PECTORILOQUY would be performed. Be sure female patients guard breast tissue away from examination area at appropriate times.

Front 42

T/F Tactile fremitus, percussion and auscultation can be performed through the gown.

Back 42

FALSE - AUSCULTATION must be done directly on the skin.

Front 43

Cardio - What is the general order of procedure?

Back 43

Pt positioning
Inspection
Palpation
Auscultation
Blood Pressure
Peripheral Vascular Exam

Front 44

Cardio - How are patients positioned?

Back 44

Recumbent @ approx 30-40*
Female patients are draped with a gown over the abdomen and pelvis.

Front 45

Cardio - Generally what are you palpating for?

Back 45

Carotid artery pulse
Precordium for cardiac thrills (APETM)
PMI - point of maximum impulse @ the L 5th intercostal space mid-clavicular line.

Front 46

Cardio - What are your verbal findings for the carotid pulse palpation?

Back 46

The carotid artery pulses are strong and symmetrical

Front 47

Cardio - What are the points of palpation when palpating for cardiac thrills?

Back 47

APETM
Aortic
Pulmonic
Erb's
Tricuspid
Mitral

Front 48

Cardio - T/F "No cardiac thrills are palpable" is the only thing to verbalized with the carotid pulse point palpation?

Back 48

FALSE
Each of the points (APETM) must also be verbalized as you palpate ending with your findings statement... "No cardiac thrills are palpable."

Front 49

Cardio - T/F The PMI is palpated at the 5th intercostal space at the midclavicular line on the left.

Back 49

TRUE - this is your verbalized finding for this assessment.

Front 50

Cardio - T/F For female patients you may palpate over the gown with "guarding away" from your palpation.

Back 50

TRUE

Front 51

Cardio - How long must you wait while palpating the carotid artery?

Back 51

3-5 seconds

Front 52

Cardio - Where is the point of palpation for the carotid?

Back 52

Medial to the SCM against the lateral side of the trachea.

Front 53

Cardio - T/F You should use only one finger when palpating the PMI

Back 53

TRUE

Front 54

Cardio - What part of the stethoscope should be used to auscultate the APETM?

Back 54

Diaphragm

Front 55

Cardio - What are the verbalizations for the APETM auscultation?

Back 55

The apical heartbeat was regular and rhythmic.
No clicks, murmurs, or extra heart sounds heard.
S1 is heard loudest at the apex.
S2 is heard loudest at the base.

Front 56

Cardio - How long should you listen during APETM auscultation?

Back 56

3-5 heartbeats

Front 57

Cardio - T/F You should listen to more than just the APETM points?

Back 57

TRUE - "Listen to more than the 5 traditional (APETM) locations."

Front 58

Cardio - What are you listening for when auscultating the carotid artery?

Back 58

Artery bruits

Front 59

Cardio - "With the ______ of your stethoscope, auscultate the carotid artery on each side ________." Have the patient _________ as you listen.

Back 59

bell
3-5 seconds
hold their breath

Front 60

Cardio - What is the setup procedure for taking a blood pressure?

Back 60

Arm supported, approx level with the heart.
Palpate for target systolic pressure
Place stethoscope over the brachial artery.
reinflate 20 mmHg above target systolic pressure.
Deflate cuff slowly (about 2mm/sec)
VERBALIZE: The blood pressure is...____(120/80 in even numbers)

Front 61

Cardio - How many of the 6 inspection sites must you examine and note findings for during the peripheral vascular exam?

Back 61

minimum of 3 bilaterally each for hands and feet which includes...
skin color
temp
turgor (hands)/absence of hair (feet)
edema (hands)/pitting edema (feet)
digital clubbing (hands)/condition of skin & nails (feet)
capillary refill time of the nails

Front 62

Cardio - How long do you hold the brachial/radial and dorsal pedis/post tib pulses before reporting your findings?

Back 62

3-5 seconds bilaterally each location

Front 63

Cardio - What is the angle for normal and abnormal findings when inspecting the fingernail bed?

Back 63

160* normal
180* abnormal