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CPD Lab Tests_MH > CPD 2 Midterm > Flashcards

CPD 2 Midterm Flashcards

1
Q

What is the significance of visible pulsations and/or heaves over the precordium?

A

o (precordium=portion of body over heart and lower chest)

o Visible pulsations/heaves: Right ventricular enlargement

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2
Q

Know how to palpate for S1, S2, S3, S4 and thrills (palpable murmurs).

A

o S1 and S2—use firm pressure, place R hand on chest wall. With L index and middle fingers, plpate the carotid artery in lower 1/3rd of neck. Identify S1 just before the carotid upstroke and S2 just after the upstroke
o S2 and S3—apply lighter pressure at cardiac apex to determine if extra movements
o Thrills—press ball of hand on chest to check for buzzing senation from vascular turbulence. Easier to detect if lean forward.

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3
Q

Know how to assess the apical pulse for size and understand the significance of that size.

A

o 5th interspace, mid clavicular
o > 2.5 cm evidence of Left ventricular hypertrophy (LVH) (seen in hypertension and aortic stenosis)
o If pushed laterally—enlarged heart
o If pushed medially—hyper inflated lung (eg COPD)

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4
Q

Know how to differentiate S1 from S2 using palpation of the carotid.

A

• Carotid will give you systole, so more S1 ish (??)

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5
Q

Which valves make S1 and S2 sounds? Where are these sounds best heard?

A

o S1: closure of mitral valve. Best heard over apex (5th intercostal space)
o S2: closure of aortic valve. Best heard over base (2nd intercostal space)

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6
Q

When (and where) is it normal for S1 to split? What constitutes an abnormally split S1?

A

o on inspiration
o Normal: Earlier mitral (loud) and later tricuspid sound.
o abn: 60ms apart.

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7
Q

How does one differentiate a split S1 from an S4 gallop?

A

o S4 is lower frequency than S1

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8
Q

What is the significance of variations in the intensity of the S1 sound?

A

o Feature of atrial fibrillation, premature beats, atrioventricular dissociation (HR can be slow or fast), auscultatory alternans (S1 is soft and loud with alternate beats)

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9
Q

What is the normal pattern of auscultation? Be able to name regions where each heart valve is best heard.

A
  • Aortic & Pulmonic (2nd interspace)
  • Erb’s (3rd interspace, lateral to pulmonic)
  • Tricuspid (4th interspace, JUST lateral to sternum)
  • Mitral (5th interspace, MCL)
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10
Q

What is a bruit? Where and how does one listen for them during the heart exam?

A

o Turbulent blood flow in artery which supplied blood to brain
o just lateral to Adam’s apple
o use either bell or diaphragm , or both

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11
Q

What sounds do the bell and diaphragm bring out?

A

o Bell: low pitched heart sounds

o Dipahragm: high pitched heart sounds

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12
Q

What positions will help accentuate certain heart sounds, i.e., aortic regurgitation, S3, and S4?

A

o S3 and S4—pt lying on L side, partially rolled over
o S3: soft, lo pitch; walking or elevate legs will accentuate
o Aortic murmurs, esp aortic regurgitation—pt sitting up and leaning forward

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13
Q

What is physiologic splitting of S2? What is paradoxical splitting? What is fixed splitting?

A

o Physiologic splitting: inhalationincreased negative pressure, lungs expand, increases venous return
o Paradoxical splitting: exhalation. Pulmomary valve closes before aortic valve seen in aortic stenosis, left bundle branch block
o Fixed splitting: does not vary with inspiration. Usually due to septal defect

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14
Q

How common is physiologic splitting of S2?

A

o 52.1% of normal adults in a recent study.

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15
Q

How does one differentiate a split S2 from an S3 gallop?

A

o Split S2 much higher pitch and closer to onset of S2

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16
Q

What are S3 and S4 sounds? What do they signify? What makes them? Where are they best heard? What bedside maneuvers can intensify them?

A

o S3: right after S2. Associated with heart failure (may be physiologic). Caused by oscillation of blood back and forth between walls of ventricles. Best heard: cardiac apex. Maneuver: lying on left side, partially rolled over.
o S4: right before S1. Associated with failing L ventricle. Atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle. Best heard: over L or R ventricular areas. Maneuver: lying on left side, partially rolled over.

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17
Q

How does one differentiate a pathologic S3 from a physiologic S3?

A
  • path: ssx: SOB, chest pain, orthopnea, wide or displaced apical pulse, peripheral edema, takes nitroglycerin
  • phys: looks fit and asx
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18
Q

How is hypertrophic cardiomyopathy similar to, and different from MVP?

A
  • Both diminish with squat and intensify with valsalva
  • MVP—mid systolic click
  • Hypertrophic cardiomyopathy—late systolic shwoooshy
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19
Q

What kinds of findings are we looking for on inspection of the abdomen?

A
  • Skin markings: scars, striae, dilated vessels
  • Contour: flatness, distensions, 7 Fs
  • Peristalsis: increased w obstruction
  • Pulsations: from vessels, abdominal aortic aneurysm
  • Hernias: most are umbilical
  • Ecchymosis: infiltration of the extraperitoneal tissues w blood
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20
Q

What are the 7 F’s for a distended abdomen?

A

• Fat, fluid, fetus, feces, flatus, fibroid, fatal growth

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21
Q

Why do we auscultate the abdomen before palpation?

A

• Palpation and percussion may stimulate peristalsis and alter exam findings

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22
Q

Understand normal and abnormal bowel sounds.

A
  • High pitched tinkling sounds: early obstruction
  • Absent sounds: late mechanical obstruction or ileus
  • Secussion splash: air and fluid, obstruction, pyloric stenosis
  • Peritoneal friction rub: inflammation
  • Borborygmus: long prolonged gurgles: gastroenteritis
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23
Q

Be able to perform abdominal percussion using exemplary technique.

A

• You got it!

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24
Q

What is the expected liver span at the mid clavicular line?

A

• 8cm (6-12)

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25
Q

What is the splenic percussion sign? Know how to perform it.

A
  • Percuss lowest costal interspace in L anterior axillary line. Normally tympanic
  • Ask pt to take a deep breath and percuss this area again. Dullness here is sign of splenomegaly (.20 false positive with this test)
  • If in doubt, percuss medially to laterally in Traube’s space until dullness is elicited; normally at mid axillary line
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26
Q

Why and how do we do light palpation? What can you do about ticklish patients?

A
  • Begin away from pain. To help pt relax, to note guarding/tenderness, hyperesthesia, rigidity
  • You can use their hand, or make no sudden movements.
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27
Q

What is the significance of guarding and rigidity? What are they?

A
  • Peritonitis or appendidicitis
  • Guard: voluntary contraction on palpation of ab wall mm, dt anxiety or cold hands; can be fully or partially overcome by tact and persuasion
  • Rigid: involuntary contraction of ab mm dt peritoneal inflammation (out of pt’s control); can never be overcome by tact or reassurance
  • To relax pt to distinguish: reassurance, distraction, banter
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28
Q

Be able to demonstrate deep palpation of the abdomen including the liver, spleen, and kidneys.

A

___

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29
Q

Which arteries are important to auscultate for bruits over the abdomen?

A

• Bruits over aorta and renal, iliac, and femoral arteries: obstruction

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30
Q

What is Murphy’s Sign?

A
  • Positive sign—cholecystitis

* With your hands shoved up in there, tell pt to breathe in. Positive sign is abrupt arrest of inspiration!

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31
Q

What is rebound tenderness at McBurney’s Point?

A

• Possible appendicitis

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32
Q

Referred rebound tenderness (Rovsing)?

A

• Possible appendicitis

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33
Q

Be able to demonstrate psoas sign, obturator sign, costovertebral angle (CVA) tenderness.

A
  • PSOAS: Flexion of thigh against resistance. To test for appendicitis
  • OBTURATOR: internal rotation of flexed thigh. To test for appendicitis
  • CVA: to test for pyelonephritis
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34
Q

• Physiological S2 spilts:

A

o Inspiration → listen for A2 and P2 to split

o bc ↑ venous return overloads RV and delays closure of P valve

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35
Q

• What are 5 things to note when listening to heart sounds?

A

o Location, timing, intensity, pitch

o Effect of respiration or special maneuvers

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36
Q

What is jugular venous distention? On what side is it measured? How is that done?

A
  • Significance: hypervolemia, RCHF, SVC obstruction, Tricuspid stenosis or regurg
  • On pt’s righ side
  • 45 deg angle- Position pt so jugular pulse seen on lower neck, tangential light to visualize
  • Identify highest pt pulse is seen
  • Measure vertical distance bw point and sternal angle
  • Abn: >3-4 cm
  • Normal: highest point is below sternal angle
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37
Q

What is kussmauls sign?

A
  • paradoxical increase in JVP during inspiration

* conditions that interfere w RV filling: constrictive pericarditis, constrictive cardiomyopathy, RV infx

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38
Q

what is abdominojugular reflex? When is it useful clinically? Know how to use a BP cuff to exert the correct amount of P

A
  • alt test for JV pulses
  • sig: pos in subclinical RCHF, neg in SVC obstruction
  • position pt so JVP is seen in lower neck (45 deg angle)
  • press firmly on partially inflated BP cuff (25-35 mmHg) around umbilicus for 15-30 sec
  • (+): sustained rise in JV pressure (>4cm)
  • Transient <10 sec rise is normal
39
Q

What should you note when you detect a murmur?

A
  • Timing: systolic or diastolic, early, late, mid, pan/holo
  • Configuration: shape of sound (plateau, crescendo, decrescendo, crescendo-decrescendo)
  • Location: max intensity
  • Radiation
  • Intensity: grade (I-VI)
  • Quality: musical, blowing, harsh, rumbling?
  • Pitch
  • Hemodynamic changes: effects of special maneuvers
40
Q

How are murmurs graded?

A
  • I: very faint
  • II: quiet
  • III: moderately loud, non-palpable
  • IV: loud w palpable thrill
  • V: very loud w thrill
  • VI: very loud w thrill, heard w/o stethoscope
41
Q

What are the systolic, diastolic, and both sounds?

A
  • S: ejection click, click and murmur of MVP, pericardial rub, functional murmur, AS, PS, MR
  • D: S3, S4, MS, TC S, AR, PR, MS
  • B: pericardial rub, mammary soufflé, venous hum
42
Q

What are effects of inspiration on different heart murmurs?

A
  • LCHF: ↓

* PS: ↑

43
Q

What are the effects of Valsalva on diff heart murmurs?

A
  • MVP: earlier click and murmur
  • LCHF: ↑
  • PS: ↓
  • HOCM: louder
44
Q

What are effects of squatting on diff murmurs?

A
  • MVP: delays click and murmur
  • LCHF: ↓
  • PS: ↑
45
Q

Which maneuvers have similar effects on murmurs?

A
  • Inspiration and squatting

* Valsalva, standing and expiration?

46
Q

What are the maneuvers for murmurs and their effects on heart/CO?

A
  • Inspiration: ↑ murmurs in right heart
  • Expiration: ↑ murmurs in left heart
  • Valsalva: ↓ venous return and CO
  • Squatting: ↑ VR and CO
  • Passive elevation of both legs: ↑ VR and CO
47
Q

What is a HOCM murmur? What are relevant, statistically sig tests?

A
  • May appear like AS, but actually ↑ w any maneuver that ↓ VR and CO
  • ↑ w Valsalva
  • ↑ from squat to stand
  • ↓ w passive leg raise
48
Q

What is best position to hear S3 and S4 gallops?

A
  • W bell (just enough pressure to get seal)

* In mitral and tricuspid area

49
Q

What are some findings in CHF that may indicate S3 gallop?

A
  • ↓ ejection fraction
  • ↑ L heart filling pressure
  • ↑ BNP
50
Q

What may cause S3?

A
  • L and R diastolic overload (MR, TR)

* ↓ ventricular compliance (CMs, CHF, IHD)

51
Q

What may cause S4?

A
  • S4= pre-systolic (right before S1)
  • Atrial contractions causing a snap
  • L and R ventricular overload: systemic HTN, pulm HTN, AS, PS
  • ↓ vent compliant: CMs, CHF, IHD
  • During acute ME
  • Mb false + w split S1, or S1 plus ejection sounds
52
Q

• Paradoxical splitting

A

o RV completes systole before LV
• Expiration → A2 and P2 are switched (P2 first)
• Inspiration: retards P2 to coincide with A2
• Cause: Delayed onset (LBBB, RV pacing) or prolongation (AS, HCM)

53
Q

• What causes S3 gallops?

A
  • oscillation of blood back and forth bw walls of ventricles dt hi input from atria.
  • Causes: IHD → global ventricular dysfunction (DCM) → ↓ EF (resists passive filling) → S3
  • Occurs in middle 1/3 of diastole
  • Mb dt tensing chordae tendineae during rapid filling and expansion of ventricle
54
Q

• S4 gallop:

A
  • Presystolic= very late diastole
  • Dt atria contracting forcefully to overcome stiff or hypertrophic V →turbulence
  • RV: PS, pulm HTN
  • LV: LVH, AS, HOCM
55
Q

• MVP:

A
  • Mid-systolic click
  • Valsalva/standing: enhanced; dec vol of LV → murmur occurs sooner (systole), louder, longer
  • Squatting: decreased, inc venous return; moves click to later systole
56
Q

Hypertrophic Cardiomyopathy

A
  • Mid-systolic
  • Valsalva: enhanced (dec LV vol more severely distorts MV)- same as MVP
  • Squat (↑VR) → stand (↓VR): gets louder- same as MVP
  • Passive leg raise: decreases; ↑ VR
57
Q

• Aortic Regurgitation

A
  • can hear 3 murmurs, based on location.
  • Systolic ejection murmur/early diastolic murmur, w diaphragm at Apex.
  • Bell to appreciate the diastolic Austin Flint murmur- over LV
  • bounding carotid (Corrigan’s) pulse (sig in AR pts)
58
Q

Pulmonic stenosis

A
  • Gets louder on inspiration

* Held expiration???

59
Q

• Mitral Regurgitation timing and shape:

A
  • Timing: holo-systolic

* Shape: rectangular (no tapering)

60
Q

• Mitral Stenosis

A
  • Opening Snap (OS): dt forceful opening of mitral valve
  • Hear at base bc where mitral valve is heard
  • Quality of sound changes with bell vs diaphragm
  • Bell: hear lo pitch murmur
  • Diaphragm: higher pitched S1 and OS heard
61
Q

• Aortic Stenosis: MSM and ejection sound

A
  • MSM: best at apex, Split S1 followed by MSM
  • Mid-systolic ejection sound
  • best heard at aortic area, R 2nd ICS, w radiation to R neck
62
Q

• prosthetic valves? Starr?

A

• Starr-Edwards = world’s first prosthetic valve, made in Portland 1960

63
Q

• Atrial septal defect?

A

• LA P initially exceeds R: L → R shunt

64
Q

Understand normal and abnormal bowel sounds.

A
  • High pitched tinkling sounds: early obstruction
  • Absent sounds: late mechanical obstruction or ileus
  • Secussion splash: air and fluid, obstruction, pyloric stenosis
  • Peritoneal friction rub: inflammation
  • Borborygmus: long prolonged gurgles: gastroenteritis
  • Bruits: obstruction
65
Q

Be able to perform abdominal percussion using exemplary technique.

A
  • Percuss all quadrants
  • Listen for dullness or tympany
  • Unusual dullness: underlying abdominal mass
  • Percuss outline of liver, spleen, stomach
66
Q

What is the splenic percussion sign? Know how to perform it.

A
  • Check size of sleep if suspect SM
  • Percuss lowest costal interspace in L anterior axillary line. Normally tympanic
  • Ask pt to take a deep breath and percuss this area again. Dullness here is sign of splenomegaly (.20 false positive with this test)
  • If in doubt, percuss medially to laterally in Traube’s space until dullness is elicited; normally at mid axillary line
67
Q

What are the tests for appendicitis?

A
  • Rovsing’s sign: referred rebound tenderness
  • Rebound tenderness at McBurney’s pt (1/3 from ASIS bw umbilicus): possible appendicitis
  • Obturator sign: internal rotation of flexed thigh (stretches mm), right ab pain = (+)
  • Psoas sign: flex thigh against resistance; OR in LLD, passively extend right leg at hip
  • Rectal exam: for occult blood; R-side tenderness/fullness w appendicitis (pelvic/retrocoecal)
68
Q

Keep in mind when beginning abdominal exam?

A
  • Empty bladder
  • Stand on R side
  • Trim nails, warm shands
  • Pt supine w knees flexed
  • Watch pt’s face
  • Examine chest, too
  • Consider inguinal/rectal in M, pelvic/rectal in F
69
Q

In addition to quadrants, what is reference terminology of abdomen locations?

A
  • Midline
  • Epigastrtic- bw umbilicus, xyphoid, costal margins
  • Periumbilical
  • Hypochondrium: L and R, over lower ribs, below breast
  • Suprapubic/hypogastric: bw umbilicus and pubic bone
  • Inguinal: R and L
70
Q

What is the order of the abdominal exam?

A
  • Inspection
  • Auscultation
  • Percussion
  • Light and deep Palpation
71
Q

What are the tests for cholecystitis, peritonitis, pyelonephritis?

A
  • Cholecystitis: Murphy’s sign= inspiratory arrest on deep inspiration (hooking hands is best) with palpation under right costal margin
  • Peritonitis: Blumberg’s sign= rebound tenderness over a suspected area of abdomen
  • Pyelonephritis: costovertebral tenderness
72
Q

What is an exam specific for females?

A

• Pelvic bimanual exam

73
Q

How do you distinguish from intra- and extra-peritoneal masses?

A
  • Pt does a crunch, see if mass is still present
  • Intra: less palpable
  • Extra: more palpable
74
Q

What are most common dx for acute abdominal pain/tenderness (<7d)?

A
  • Non-specific abdominal pain (43%)
  • Acute appendicitis (4-20%)
  • Acute cholecystitis (3-9%)
  • Small bowel obstruction (4%)
  • Urinary caliculi (4%) (not kidney stones)
75
Q

What exams should you do for RUQ or LUQ pain? Why?

A
  • Heart- mb IHD

* Lungs- mb pneumonia

76
Q

What exams for lower abdominal pain?

A
  • Woman: pelvic exam (ectopic pregnancy, ovarian cyst, uterine fibroids, PID, endometriosis)
  • Rectal exam
77
Q

What are significant signs in pt appearance?

A
  • Toxic or in acute distress?
  • Fever: infx (but absence doesn’t r/o)
  • Tachycardia and orthostatic hypotension: hypovolemia
78
Q

What may cause peritonitis? PE? Pt appearance?

A
  • Inflammation or perforation of a viscus (visceral organ)
  • Perforated peptic ulcers, diverticula, appendicitis, bowel obstruction, cholecystitis
  • PE: guarding, rigidity, rebound tenderness (Blumberg’s sign), TT percussion, positive Cough test, negative Carnett’s sign (+ = pain doesn’t change when tensed muscles), Markel sign (heel jar test), bowel sounds (mb absent, dt paralytic ileum)
  • Pt: prefer to lie very still, observe face
79
Q

How do you assess for percussion tenderness?

A
  • Start away from painful area

* (+)= if light percussion causes pain

80
Q

How to perform Blumberg’s sign, cough test?

A

B: deep pressure for 30-60 sec, sudden rebound. (+) = pain or grimace
C: if pt’s cough causes grimace or brace of abdomen; can r/o (PR 0.1)

81
Q

How to perform merkel sign, carnett’s sign?

A
  • M: stand on toes, drop heel hard, very sensitive. (+) = peritoneal pain
  • C: aka abdominal wall tenderness. Locate painful area, if crunch makes palp more painful = (+). (+) suggest NO peritonitis (but extra-peritoneal)
82
Q

What is the risk of appendicitis? Mortality? Location? Complication?

A
  • 7% risk
  • W tx: mortality <1%, elderly 5-15%
  • 3 cm below ileoceocal valve
  • Prego: 2-3 tri, gravid uterus can displace app to periumbilical or RUQ
83
Q

What are ssx of appendicitis?

A
  • Poorly localized epigastric or periumbilical pain
  • Anorexia, N/V
  • Lo fever
  • McBurney’s pt tenderness (rebound or not?)
84
Q

What is a positive Rovsing’s sign?

A
  • For appendicitis
  • Do this BEFORE McBurney’s pt
  • Rebound from LLQ
  • Referred pain to RLQ
85
Q

What are the 3 ssx for hi PLR for appendicitis?

A
  • RLQ pn
  • Migration of pain (from epigastric to McBurney’s)
  • McBurney’s pt tenderness
86
Q

How is appendicitis usu dx?

A
  • When ssx suggest, do CT

* Surgical exploration is definitive

87
Q

What are ssx of cholecystitis?

A
  • Early: biliary colic (ab pain increases, peaks, subsides)
  • Acute: continuous epigastric pain, RUQ pn, fever
  • PE: RUQ tender, Murphy’s sign, absent Courvoisier sign
88
Q

How to do Courvoisier and Murphy sign?

A
  • C: palpable, non-tender GB (mass) in RUQ, usu jaundice, suspect CA, no chole
  • M: pressure under R costal margin, pt takes deep breath → pain
89
Q

What are ssx of bowel obstruction?

A

Constipation, acute abdominal pain, visible peristalsis (rare), abdominal distension, ↑BS

90
Q

What are ssx of pyelonephritis? CVA tenderness test? Elderly?

A
  • Fever, dysuria, flank pain
  • CVA: start w CVA thumb pressure, progress to percussion of CVA (begin at upper back)
  • Old: mb few sx, do urinalysis to r/o UTI
91
Q

What can cause ascites? Amount of fluid?

A
  • Biventricular heart failure
  • Lo oncotic pressure (protein loss), nephrotoc syndrome, reduced synth (malnutrion, cirrhosis)
  • Peritoneal inflamm (neoplastic, infx)
  • PE can detect when 500-1000mL
92
Q

What are 4 best tests for ascites?

A
  • Inspect for bulging flanks
  • Percussion for shifting dullness (supine dull at flanks, LLD tympanic at top) (hi spec)
  • Fluid wave (hi sens)
  • Anke edema
93
Q

What is baye’s theorem? Ex?

A
  • Dx accuracy ↑ w combo tests w hi sens and hi spec

* Ascites good ex

CPD Lab Tests_MH (3 decks)

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