Block II Flashcards
How many lobes does the R lung have?
3
How many lobes does the L lung have?
2
How high does the lung apex rise on the anterior chest?
2-4cm above the inner 1/3 of the clavicle
How low does the inferior border of the lung extend?
6th rib at mid-clavicular line & 9th rib at mid-axillary line
What are the borders of the lungs on the posterior?
Lower lungs mostly -T3 to T10 or 12
Where is the right middle lung lobe?
lateral, between 4th and 6th rib. Lies between the horizontal fissure and the oblique fissure.
What is the angle of Louis?
Junction of manubrium and sternum. Attaches the 2nd ribs. Palpable landmark.
What is a VESICULAR breath sound and where is it heard?
Soft, low pitched, breezy. Over healthy lung tissue on periphery.
What is a BRONCIAL breath sound and where is it heard?
High-pitched, harsh, loudest. Heard over the bronchi. Abnormal if heard over peripheral lung tissue.
What is a BRONCHOVESICULAR breath sound and where is it heard?
Medium-pitched & intensity. Heard over major bronchi/mid chest. Abnormal if heard over peripheral lung tissue.
What is a TRACHEAL breath sound and where is it heard?
High-pitched, harsh. Over trachea and neck. Think Darth Vadar.
Discontinuous breath sounds
Fine or course crackles. High (fine) or low (course) pitched discrete crackling sounds during inspiration. Not cleared by cough.
Continuous breath sounds
1) Ronchi: loud, low, course like a snore, inspiration or expiration, coughing may clear (d/t mucus)2) Wheeze: musical or squeaking, continuous during inspiration or expiration
Pleural friction rub
Dry, rubbing, grating during inspiration or expiration. Inflammation of pleural survacles
Chest percussion: where should you hear resonance?
All areas of healthy lung tissue
Chest percussion: why would you hear hyperresonance?
Hyperinflation -emphysema, pneumothoras, asthma
Chest percussion: why would you hear dullness or flatness?
Abnormal findings: Pneumonia, atelecstasis, pleural effusion, pneumothorax, asthmaNormal findings: over heart, diaphragm, or bones of scapula or bigger muscles
Percussion: where would you here tympany?
Abdomen
Define bronchophony
Greater clarity and increased loudness of spoken sounds with auscultation
Define whispered pectoriloquy
Extreme bronchophony where a whisper is amplified.
Define egophony
Nasally distortion of spoken words heard through auscultation.
What do bronchophony, whispered pectriloquy and egophony indicate?
Consolidation in the lungs
What would diminished vocal resonance indicate?
Loss of tissue within respiratory tree
What is a normal diaphragmatic excursion?
3-6cm. **diaphragm normally higher on right d/t liver
What would cause a diminished diaphragmatic excursion?
Pulmonary problems: emphysemaAbdominal problems: ascites, turmorSuperficial: fractured rib
Normal A/P diameter
A/P should be about .7-7.5 of lateral diameter
Increased A/P diameter
Increases with age. Equal to lateral diameter indicates chronic condition.
Where do the bronchi bifurcate?
2nd intercostal space
What would decreased tactile fremitis indicate?
Excess air in lungs, emphysema, pleural thickening, effusion, massive pulmonary edema, bronchial obstruction.
What would increased tactile fremitis indicate?
Fluids or solid mass in lungs d/t consolidation, heavy bronchial secretions, compressed lung, tumor.
Barrel chest
D/t compromised respiration (chronic asthma, emphysema, CF). Ribs become horizontal, spine become kyphotic, prominent sternal angle.
Flail chest
A flapping, unfixed chest wall caused by loss of stability of the thoracic cage after fracture of the sternum and/or ribs. A symptom is paradoxical movement of a portion of the chest wall—that is, the affected area draws in when the patient breathes in and the rest of the chest expands, and the affected area moves outwards as the patient exhales and the rest of the chest contracts.
Scoliosis
Lateral curvature of the spine
Kyphosis
Increased convex curvature of thoracic spine
Gibbus
Similar to kyphosis but with an extreme sharp angular deformity in the mid-thoracic region
Lordosis
Accentuation in lumbar curvature of spine
Pectus carinatum/excavatum
Carinatum: forward protrusion of sternum (pigeon chest)Excavatum: Depression of sternum (funnel chest), may cause fatigue SOB, pain, tachycardia
Cough
Forceful expiration that clears irritants/secretions. Note: dry or moist, rapid or slow onset, frequency, regularity, pitch, postural influences, quality.
Sputum production
Mucus material from lungs brought up by coughing. Any more than a small amount of sputum suggests disease. Acute onset: infection. Chronic problem: indicates anatomic change.
Hemoptysis
Coughing up blood
Dyspnea
Difficulty breathing
Pulsus paradoxus
Abnormally large decrease in systolic BP and pulse amplitude during inspiration (>10mg drop)
Shortness of breath
Dyspnea out of expected for level of physical activity
Tachypnea
Rapid, shallow
Bradypnea
Slow
Eupnea
Normal 12-20/min
Pleural rub
Friction between parietal and visceral pleurae d/t inflammation of pleural surfaces.
Cyanosis
Bluish skin and mucous membranes d/t low O2 blood levels
Chest pain
Symptom of cardiac disease
Stridor
Harsh, high pitched sound during inspiration d/t laryngeal or tracheal obstruction
Orthopnea
Difficulty breathing relieved by positioning
Wheezing
High-pitched, musical hissing. Small/narrowed airways d/t asthma, COPD, bronchitis
Paroxysmal nocturnal dyspnea
Night time respiratory distress, related to posture
What is the order of the abdominal exam?
InspectionAuscultationPalpationPercussion
Gown draping for abdominal exam?
Expose from xyphoid process to pubic symphysis
2 types of abdominal sounds
Bowel sounds & bruits
Normal bowel sounds?
5-35 sounds per minutes. Irregularly occurring clicks or gurgles.
What would cause increased bowel sounds?
Gastroenteritis, intestinal obstruction, hunger.
What would cause high-pitched bowel sounds?
Intestinal fluid or air pressure
What would cause decreased bowel sounds?
Peritonitis or paralytic ileus. Absent sounds along with pain is a sign of emergency.
What would cause a friction rub in the bowel sounds?
Heard (rarely) during respiration. Indicates inflammation of peritoneal surface from tumor, infection, or infarct.
What would cause a bruit in the bowel sounds?
Turbulent flow flow and vascular disease
Referred pain in the R shoulder
acute cholecystitis
Referred pain in the midsternal line
reflux
Referred pain in the right breast
cholecystitis
Referred pain in the epigastric region
angina
Referred pain in the RUQ
pleuritic pain, cholecystitis, perforated gastric ulcer, biliary stones/colic, hepatitis, hepatomegaly, RLL pneumonia
Referred pain in the LUQ
splenic infarct, pancreatitis, splenic rupture, gastric ulcer, aortic aneurysm, perforated colon, LLL pneumonia
Referred pain in the RLQ
appendicitis (starts as periumbilical), R salpingitis, PID, ectopic pregnancy, ruptured ovarian cyst, tubo-ovatian abscess, renal stone, hernia, diverticulitis, perforated cecum
Referred pain in the LLQ
diverticulitis (also down L leg), R salpingitis, PID, ectopic pregnancy, ruptured ovarian cyst, sigmoid diverticulitis, tubo-ovarian abscess, renal stone, hernia, perforated colon, ulcerative colitis
Referred pain in the testes
renal colic
Referred pain in the back
acute pancreatitis
Cullen sign
Bluish periumbilical discoloration at the umbilicus that indicates intraperitoneal hemorrhage (intrabdominal bleeding)
Ballottement
A palpatory technique used to detect or examine a floating object in the body, such as an organ. It is used in examining the abdomen esp. when ascites is present. Pressing at 90 angle into abdomen.
Grey Turner sign
A blue discoloration of the skin around the flanks in a patient with hemorrhagic pancreatitis.
Shifting dullness
A test for ascites. Determine border of tympany and dullness. Reposition patient: dullness will shift if ascites present.
Murphy sign
Test for inflamed gallbladder: Abrupt cessation of inspiration on palpation of gallbladder (below liver margin at lateral border of rectus abdominis)
Fluid wave
Tests for ascites by having patient place their hand in mid abdomen as a barrier. Tap on one side while palpating the other side. If wave transmitted, positive for ascites.
Rovsing sign
RLQ pain intensified by LLQ palpation. Caused by peritoneal irritation or appendicitis.
Psoas sign
Test for peritoneal inflammation (often appendicitis): If flexing or stretching psoas muscle causes RLQ pain.
McBurney sign
Test for peritoneal inflammation (often appendicitis): palpation of Mc Burney point in RLQ. RLQ pain is positive McBurney sign.
Obturator sign
Test for peritoneal inflammation: flex hip and knee with patient supine and passively rotate. RLQ pain is positive obturator sign.
Blumberg sign
Test for peritoneal inflammation by pressing deeeply into abdomen at 90 angle and withdrawing quickly. Rebound tenderness would be a positive Blumberg sign.
Borborygmi
Rumbling, gurgling, tinkling noises heard on auscultation due to hyperactive intestinal peristalsis.
Hematochezia
passage of fresh (bright red) blood within stool
Constipation
difficulty in emptying the bowels, usually associated with hardened feces
Hematemesis
vomiting blood
Dysphagia
difficulty or discomfort with swallowing
Melena
dark tarry stools (indicates bleeding in upper GI)
Globus
persistent or intermittent sensation of a lump or foreign body in throat; between meals; no dysphagia
Nausea
sickness with inclination to vomit
Flatus
gas in or from the stomach or intestines, produced by swallowing air or by bacterial fermentation
Vomiting
eject matter from the stomach through the mouth
Singultus
hiccup (the state of having reflex spasms of the diaphragm accompanied by a rapid closure of the glottis producing an audible sound)
Diarrhea
loose, watery stools that occur more frequently than usual
Reflux
backward flow of the contents of the stomach into the esophagus that causes heartburn
Gastroparesis
delayed gastric emptying= a medical condition consisting of a paresis (partial paralysis) of the stomach, resulting in food remaining in the stomach for an abnormally long time
Eructation
burp
Heel jar test
Test for peritoneal inflammation: Patient stands on tip toes then drops to heels (or patient is supine and strike their heels).
Lymphadenopathy -localized
Enlargement of lymph nodes. Palpable for superficial nodes. Suggest regional infection or disease.
Lymphadenopathy -generalized
Enlarged lymph nodes all over the body suggest systemic inflammatory, infectious, or malignant process. (TB or syphillis)
Lymphedema
Swelling of subcutaneous tissue from obstruction of lymphatic vessels or lymph nodes. Non-pitting.
Lymphadenitis
Inflammation of lymph nodes; stretch skin and may cause breakthrough weeping. (ie buboes in bubonic plague)
Lymphangitis
Inflammation of lymph vessels. Seen as red streaking along the drainage course of the vessel.
a. pericardium
double-walled fibrous sac that holds the heart; contains heart, roots of the great vessels, and pericardial fluid; protects, lubricates, and fixes heart in place
b. right and left ventricles
ventricles receive blood from the atria and then strongly pump it out during systolethick-walled, muscular, provides the “oomph” of the heart, most of the heart’s mass RV receives blood from RA, pumps to lungs via pulmonary artery LV receives blood from LA, pumps to aorta/body
d. aortic valve
semilunar valve between LV and ascending aortaforced open in systoleone-way valve: prevents blood from flowing backward from the aorta into the LVTrileaflet (comprised of three leaves that come together when the valve is closed)
c. right and left atria
atria receive blood from the circulation (body and lungs) and drain into ventricles relatively thin-walled, reservoirs RA receives deoxygenated blood from the body/vena cavae LA receives oxygenated blood from the pulmonary circulation via pulmonary veins
e. pulmonic valve (AKA pulmonary valve)
semilunar valve between RV and pulmonary artery forced open in systoleone-way valve:Trileaflet
f. the great vessels
collectively, the large vessels that route blood to and from the heart:
j. tricuspid valve
AKA right atrioventricular valvebetween RA and RVopen in diastoleone-way valve: prevents blood from flowing backward from the RV into the RATrileaflet (comprised of three leaves that come together when the valve is closed)
k. mitral valve
AKA left atrioventricular valve, AKA bicuspid valvebetween LA and LVopen in diastoleone-way valve: prevents blood from flowing backward from the LV into the LABileaflet (comprised of two leaves that come together when the valve is closed)
A. Preload:
the initial stretching of the cardiac myocytes prior to contraction
B. Afterload:
can be thought of as the “load” that the heart must eject blood against, closely related to aortic pressure
C. Systole:
The part of the cardiac cycle during which the heart contracts, particularly the ventricles, resulting in a forceful flow of blood into both the systemic and pulmonary circulations. (M)
D. Diastole:
That time between two contractions of the heart when the muscles relax, allowing the chambers to fill with blood; diastole of the atria precedes that of the ventricles; diastole alternates, usually in a regular rhythm, with systole. (M)
S1:
produced by the closure of the mitral and tricuspid valves (CE)
S2:
produced by the closure of the aortic and pulmonic valves (CE)
S3 (S3 Gallop):
The first stage of diastole is a period of rapid ventricular filling. At the end of this stage of rapid filling, an S3 may be heard if the volume of blood that has been transferred is abnormally large, as in mitral regurgitation. The S3 gallop is thought to be the sound the ventricle makes when it is forced to dilate beyond its normal range due to volume overload in the atria (ex: heart failure). Conditions of high cardiac output (ex: thyrotoxicosis, severe anemia) can also cause an S3 gallop. (HS)
S4 (S4 gallop):
The late stage of diastole is marked by atrial contraction. If the ventricle is stiff and non-compliant (ex: left ventricular hypertrophy secondary to longstanding severe hypertension, MI, or cardiomyopathies) then the pressure wave gradient generated as the atria contract generates an S4 sound. Ex of right sided S4: pulmonary hypertension, pulmonary stenosis (HS)
Superior Vena Cava
routes deoxygenated blood from the head/neck/upper extremities (upper body) into the RA
Inferior Vena Cava
routes deoxygenated blood from the abdomen/pelvis/lower extremities (lower body) into the RA
Pulmonary Artery
routes deoxygenated blood from the RV to the lungs
Aorta
routes blood from the LV to the body; ascending – arch – descending – thoracic – abdominal
Pulmonary Veins
routes oxygenated blood from the lungs to the LA
a. physiologic splitting
The pressure of the right side of the heart and left side of the heart are not the same. The right atrium, right ventricle, and pulmonary artery have a lower pressure than the left side of the heart. This results in sounds occurring at different times. For example, the aortic valve found on the left side will close before the pulmonic valve on the right side. This creates a split in S2 which can be broken down as sounds A2 and P2.
b. pathologic fixed splitting-
A splitting of sounds A2 (aortic component of 2nd heart sound) and P2 (pulmonic component of 2nd heart sound) that is wide and there is no variation between respirations. This could be heard in atrial septal defect and right ventricular failure.
pathologic splitting ii. paradoxic splitting-
During respiration there is a delay in the closure of the aortic valve (A2) creating an inconsistent movement of A2 and P2. The sounds are separate during expiration and sound closer together during inspiration. This could be heard with a left bundle branch block.
electrical cycle in heart
SA node - contraction of atria, filling of ventricles (diastole)AV node — purkinje fibers — contraction of ventricles (systole)
SA Node
natural pace maker
auscultation position: aortic area
R 2 ICSaortic valve and S2
auscultation position: pulmonic area
L 2 ICSpulmonic valve
auscultation position: Erb’s point
L 3 ICSpulmonary artery - best for S2
auscultation position: Tricuspid (apex)
L 4/5 ICSTricuspid
auscultation position: Mitral
Lateral L 5/6 ICSS1
Cardiac Exam Inspection acute
GA: signs of acute cardiac distress:Cyanosis, diaphoresis, pallor, cool temp, difficulty breathing, anxiety, Levine’s sign (clutching fist over chest)Apical impulse: beating of LV during systole at 4th or 5th LICS at midclavicular line. Not normally seen while supine. May need light.
Cardiac Exam Inspection chronic
GA: signs of chronic heart conditions:Clubbing fingernails, xanthelasma (yellow waxy deposits on extremities & around eyes, d/t increase cholesterol)Obesity or coarction (underdeveloped lower extremities)
Cardiac Exam Palpation
Patient elevated 30 degreesUse carotid pulse to detect timing of systole Palpate for PMI (apical impulse)If elsewhere than apex = abnormalityProvides estimation of size of heartAssess location, diameter (should be one ICS or 1 cm), amplitude (should be gentle), duration
palpable cardiac abnormalities
lift, heave, thrillFor thrills, palpate over areas corresponding to valves
Cardiac Exam: auscultation
Listen to all areas with pt. upright, supine & left lateral recumbentUpright leaning forward best to hear S2 & aortic murmurs LL recumbent best to hear S1, mitral murmurs, & low-pitched diastole filling soundsListen to all areas with bell and diaphragmSkin contact!Listening for: Normal & abnormal heart sounds, rate & rhythm
5 Locations of cardiac exam
Aortic, Pulmonic, Erb’s, Tri, Mitral
S1 heart sound
S1:Produced by closure of mitral and tricuspid valvesIndicates beginning of systoleLoudest over the apex of the heart; best heard with diaphragm of stethoscope
S2 heart sound
S2:Produced by the closure of aortic and pulmonic valvesIndicates beginning of diastoleLoudest at left and right intercostal spaces (left for pulmonic valve, right for aortic valve); best heard with diaphragm of stethoscopeCan sometimes hear physiologic splitting of S2 on deep inspiration
chest pain sx
levine’s sign, fist on chest, uncomfortable look
fatigue sx
can’t maintain normal activitiescan’t keep up with contemporariessleeping moreunusual or persistent
dyspnea sx
aggravated by exertiondifficult breathinglooking uncomfortable
diaphoresis
excessive sweating
syncope sx
associated with palpitationschange in posturehappen with looking up or turning headunusual exertion
cyanosis sx
found in periphery firstblue/pallor colordecreased OX, decrease bloodflow
cough sx
onset/duration?dry/wetincreased when laying down
orthopnea sx
SOB while laying flatLV failurefixed by sitting up
Claudication sx
pain during exercise from decreased blood flowmostly in legs, can be arms
paroxysmal nocturnal dyspnea sx
SOB at nightcoughingawakens pt from sleep
xanthelasma sx
waxy yellow deposits on skinaround eye/extensor surfacesincreased cholesterol in blood
other organ systems evaluated with CV complaint
EKGdiaphragmlungsPVSmusculoskeletal complaints - shoulder pain/jaw pain/xyphoidyniaGI distrubances - heartburn, uclersanxiety
hypotension
low BP
postural/ orthostatic hypotension
abnormal decrease in BP from sitting to standing
hypertension
> 140/90
normotension
<120/80
heart murmur intensity grade 1
Grade 1: faint, intermittent
heart murmur intensity grade 2
Grade 2: quiet but easy to hear
heart murmur intensity grade 3
Grade 3: moderately loud, no palpable thrill
heart murmur intensity grade 4
Grade 4: loud, palpable thrill
heart murmur intensity grade 5
Grade 5: loud, palpable thrill; can hear with stethoscope barely touching chest
heart murmur intensity grade 6
Grade 6: very loud, palpable thrill; can hear with stethoscope off chest
seven dimensions of a heart murmur
timing/durationpitchintensity (grading scale)patternlocationradiationrespiratory phase variations
b. pitch: (murmur)
high, medium, or low? Bell or diaphragm?
a. timing and duration (murmur)
between S1 and S2, or S2 and S1? Short or prolonged?
MURMUR d. pattern: crescendo
: increased blood velocity; decresendo: decreased blood velocity; square/plateau: constant intensity
e. location MURMUR
: where is it auscultated best?
MURMUR f. radiation:
do you hear it only over the specific valve or elsewhere? sound generally transmitted in direction of blood flow
g. respiratory phase variations: MURMUR
impacted by inspiration/expiration? variation of intensity, quality, timing? if venous return issue, increase with insp, decrease with
external cues to peripheral health
Hair pattern on extremities Skin color:o Cyanosis at extremities, lips and noseo Ruboro Palloro mottlingCapillary refill time <2seconds Temperature of skinPulse strength and regularityDependent edema
List the sequence of blood flow through the systemic circulatory system.
LV - aorta - brain/lower body/liver/mesentery - through cap beds - exchange of OX - leaves brain/liver/lower body/mesentery – SVC/IVC – RA — RV —- Lungs — reOX – LA — LV
arterial pulse
pressure wave through system from ventricular contraction
arterial BP
force exerted by blood against wall of artery as ventricles contract and relax
Variable in arterial pulse
blood volumedistensibility of aortaviscosity of bloodperipheral arterial resistance
characteristics of jugular venous pressure (JVP)
Jugular veins reflect activity/competency of the right side of the heart Visibility of jugular venous pulsations/fluttering indicates right atrial pressure
normal range for JVP
The vertical distance from the sternal angle to the straight edge is the JVP valueNormal range is < 3 cm
Normal range for CVP
CVP (central venous pressure) can be approximated:5cm + JVP = CVPNormal CVP is 7 cm, upper limit is 9 cm
carotid -
just below angle of jaw
abdominal aorta -
left lateral and superior to umbilicusAusculate before palpating!Only pulse where both hands needed to apply deep pressurePulsations should be less than 2.5 cm apart
femoral -
crease of groin
brachial -
medial antecubital fossa of elbow
radial -
thumb side of wrist where it creases
ulnar
- pinky side of wrist where it creases
dorsalis pedis
- top of foot, between metatarsals 1 and 2
popliteal
- directly behind (flexed) kneemost difficult pulse to find of peopleIf non-palpable, ensure dosalis pedis and posterior tibialis are symmetrical with good amplitude
posterior tibialis
- posterior to medial malleolus of ankle
Amplitude’s for Pulses 0-4
0=no palpable pulse 1=diminished2=normal / expected 3=full / increased4=bounding
a. pulsus alternans- PE findings:
Pulse has constant rate and rhythm but amplitude (force) alternates between a smaller amplitude and larger amplitude
a. pulsus alternans - Clinical significance:
Can be due to left ventricular dysfunction/failure
b. pulsus bigeminus - Clinical significance:
Can be due to heart disease, digitalis toxicity, or a temporary benign finding.
b. pulsus bigeminus- PE findings:
Normal pulse beat followed by a premature beat (due to premature ventricular contraction) and a pause. Premature beat’s amplitude (force) is less than the amplitude of the normal beat.
c. pulsus bisferiens- PE findings:
Pulse has two peaks during systole-the first is the “normal” pulse that occurs during ventricular contraction, but the second is an early diastole due to a backflow of blood; best noticed with palpation of carotid artery
-c. pulsus bisferiens Clinical significance:
Can be due to severe aortic regurgitation or aortic stenosis (narrowing) coupled with aortic insufficiency.
d. pulsus paradoxus- PE findings:
Atypical decrease in systolic arterial blood pressure (>10 mm Hg) and amplitude (force) during inspiration (breathing in). Normally there is a slight decrease in BP with inspiration, but it’s less than 10 mm Hg. May be detected with palpation, but much easier to detect by taking pt’s BP.
d. pulsus paradoxus - Clinical significance:
Can be due to emphysema, asthma, premature heart contraction, tracheobronchal obstruction, or pericardial effusion (fluid around the heart).
e. pulse deficit- PE findings:
difference between the rates in pulse when auscultating the heart’s apex (assessing the pulse using stethoscope over apex of heart) versus palpating a peripheral artery (e.g. taking someone’s radial pulse)
e. pulse deficit - Clinical significance:
Occurs when ventricular contraction doesn’t eject a sufficient amount of blood to produce a pulse wave in the arteries. Often associated with premature beats, pulsus bigeminus, and atrial fibrillation.
a. venous insufficiency (chronic)Assess:
IPPA of lower extremities, Trendelenberg retrograde filling test, Hx of phlebitis, leg injury
a. venous insufficiency (chronic) Findings:
Brawny ankle edema and induration, stasis pigmentations, varicosities, ankle ulcerations, pitting edema, cyanosis/erythema
b. venous obstructionAssess:
IPPA of lower extremities, pain and swelling in ankle, Homan’s sign; calf measurement
b. venous obstruction Findings:
DVT –> PE, unilateral pitting edema, acute superficial thrombophlebitis
c. arterial insufficiency (chronic)Assess:
IPPA of lower extremities; postural color changes
c. arterial insufficiency (chronic) Findings:
Cool, pale (upon elevation), thin, shiny atrophic skin around ankle/lower leg. Loss of hair over foot and toes; thickened toenails; gangrene; pain that goes away upon resting
d. arterial obstructionAssess:
IPPA of upper and lower extremities; Allen test;
d. arterial obstruction Findings:
Pain, numbness, tingling, weakness, pallor –> Acute Arterial Occlusion;
e. varicositiesAssess:
Inspection of lower limbs, palpate for increased venous pressure.
e. varicosities Findings:
Dilated, tortuous, visibly blue/purple veins. Sometimes painful. Indicative of chronic venous insufficiency.
f. dependent edema / pitting and nonpittingAssess:
Firmly over bony prominence comparing like areas and recording topographic areas. Please refer to lecture slides for picture.
f. dependent edema / pitting and nonpitting Findings:
Bilateral indicates systemic. Unilateral indicates local. “4+ pitting edema from _______ to _______.” CHF —> Edema go higher and higher on Lower Ext.
g. claudicationAssess:
Hx of pain caused by too little blood flow during exercise. Generally affects the blood vessels in the legs, but claudication can affect the arms, too.
g. claudication Findings:
Sx of peripheral vascular disease
h. capillary refillAssess:
Pinch fingernails or toenails and observe for capillary refill < 2 seconds.
h. capillary refill Findings:
Greater than 2 seconds indicative of arterial inefficiency
bruits and where to look
turbulent bloodflow through vessels - may be an obstruction/stenosis/restrictionusing diaphragm listen for bruits overcarotidsfemoraliliacrenalaortic
a. paraphimosis:
foreskin becomes trapped behind the glans penis
o. cryptorchidism:
undescended testicle
n. femoral hernia:
bulging of intestines through the femoral ring
m. direct inguinal hernia:
doesn’t go through internal inguinal ring; through external right; hernia bulges anteriorly, pushes against side of finger
l. indirect inguinal hérnia:
through internal ring; most common type of hernia, pts often young males; pain on straining; touches fingertip on exam
k. epispadias:
urethral deformity; can open on top, side, or be open along length of penis
j. testicular tumor:
câncer that develops in the testicles
b. hypospadias:
urethral opening is on underside of the penis
i. epididymitis:
inflammation of infection of the epididymis; generally caused by chlamydia, gonorrhea, or E. Coli
h. varicocele:
enlargement of the veins within the scrotum
g. spermatocele:
benign, sperm-filled cyst at the head of the epiddidymis
f. hydrocele:
collection of fluid in the scrotum
e. peyronie disease:
connective tissue disorder; chronic inflammation and scar tissue formation in the túnica albugínea
d. condyloma:
presence of warts caused by HPV
c. chancre:
painless ulceration formed during primary stage of syphilis
techniques used to minimize patient anxiety associated with a genital examination
chaperoneanswers all questions before examination positions they will be in equipmentinstruction
Male genital self exam (GSE)Step 1:
Patient should hold penis in handInspect head of penis for lesions or masses (if not circumcised, pull back foreskin)Palpate head of penis feeling for bumps, sores, warts or blisters.
Step 2: Male genital self exam (GSE)
Inspect urethral meatus, squeeze to see if there is any discharge.
Step 3: Male genital self exam (GSE)
Patient should examine entire shaft.Evaluate for any lesions, sores or masses.Use a mirror to visualize the underside.
Step 4: Male genital self exam (GSE)
Patient should then examine the base of the penis by moving pubic hair out of the way.
Step 5: Male genital self exam (GSE)
Scrotum evaluationPatient should hold each testicle gently while inspecting and palpating using lighter then firmer pressure.
sequence and examination techniques for male GU AdultInspection
lesions, chancres, pubic hair patterns, note circumcised or uncircumcised, position, meatus position/stenosis, phimosis and paraphimosis
sequence and examination techniques for male GU Adult Palpation:
tenderness/nodularities/lesions - palpate top to bottomside to sidestrip the urethra looking for any abnormal discharge or blood at urethral meatus. Open meatus to inspect for discharge, lesions.
Scrotum: Inspection
extreme asymmetry - skin (rashes/redness), separate hair to look at skin,
Scrotum: Palpation
P: cremasteric reflex - tongue blade stroked on inside of thigh - testicle on that side should rise voluntarily - tests T12-L1-L2 nerves
Testis:
isolate one testicle at a time - can ask pt to hold penis out of the way, roll testicle around in fingers - smooth - not overly tender - note contours during palpation -
Hernia:
follow spermatacord up to pelvis, toothpick feeling is the vas defrens, find the external inguinal ring - place tip of finger here and have pt cough/bear down. ,
indirect hernia
If bulge felt on tip of finger =
direct hernia
if bulge felt on side of finger =
Adolescent: GU male
allay anxiety, protect privacy, inspect/palpate - Tanner stage
Child GU Male
lesions, malformations, discharge, masses, hernias
Infant GU Male
Mostly looking for congenital abnormalities, urethral placement, retractability of foreskin, descent of testicles (1-2 months) masses (transilluminate)
male erection
two corpora cavernosa become engorged with blood via arterial dilation and decreased venous flowautonomic nervous systemlocal synthesis of nitric oxide
male ejaculation
emission of secretions from vas defrens, epididimides, prostate and seminal vesicles
male orgasm
constriction of vessels supplying blood to corpora cavernosa and gradual subsiding of sexual arousal
