CPD 2 Midterm Flashcards
What is the significance of visible pulsations and/or heaves over the precordium?
o (precordium=portion of body over heart and lower chest)
o Visible pulsations/heaves: Right ventricular enlargement
Know how to palpate for S1, S2, S3, S4 and thrills (palpable murmurs).
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.
Know how to assess the apical pulse for size and understand the significance of that size.
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)
Know how to differentiate S1 from S2 using palpation of the carotid.
• Carotid will give you systole, so more S1 ish (??)
Which valves make S1 and S2 sounds? Where are these sounds best heard?
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)
When (and where) is it normal for S1 to split? What constitutes an abnormally split S1?
o on inspiration
o Normal: Earlier mitral (loud) and later tricuspid sound.
o abn: 60ms apart.
How does one differentiate a split S1 from an S4 gallop?
o S4 is lower frequency than S1
What is the significance of variations in the intensity of the S1 sound?
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)
What is the normal pattern of auscultation? Be able to name regions where each heart valve is best heard.
- Aortic & Pulmonic (2nd interspace)
- Erb’s (3rd interspace, lateral to pulmonic)
- Tricuspid (4th interspace, JUST lateral to sternum)
- Mitral (5th interspace, MCL)
What is a bruit? Where and how does one listen for them during the heart exam?
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
What sounds do the bell and diaphragm bring out?
o Bell: low pitched heart sounds
o Dipahragm: high pitched heart sounds
What positions will help accentuate certain heart sounds, i.e., aortic regurgitation, S3, and S4?
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
What is physiologic splitting of S2? What is paradoxical splitting? What is fixed splitting?
o Physiologic splitting: inhalationincreased 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
How common is physiologic splitting of S2?
o 52.1% of normal adults in a recent study.
How does one differentiate a split S2 from an S3 gallop?
o Split S2 much higher pitch and closer to onset of S2
What are S3 and S4 sounds? What do they signify? What makes them? Where are they best heard? What bedside maneuvers can intensify them?
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.
How does one differentiate a pathologic S3 from a physiologic S3?
- path: ssx: SOB, chest pain, orthopnea, wide or displaced apical pulse, peripheral edema, takes nitroglycerin
- phys: looks fit and asx
How is hypertrophic cardiomyopathy similar to, and different from MVP?
- Both diminish with squat and intensify with valsalva
- MVP—mid systolic click
- Hypertrophic cardiomyopathy—late systolic shwoooshy
What kinds of findings are we looking for on inspection of the abdomen?
- 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
What are the 7 F’s for a distended abdomen?
• Fat, fluid, fetus, feces, flatus, fibroid, fatal growth
Why do we auscultate the abdomen before palpation?
• Palpation and percussion may stimulate peristalsis and alter exam findings
Understand normal and abnormal bowel sounds.
- 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
Be able to perform abdominal percussion using exemplary technique.
• You got it!
What is the expected liver span at the mid clavicular line?
• 8cm (6-12)
What is the splenic percussion sign? Know how to perform it.
- 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
Why and how do we do light palpation? What can you do about ticklish patients?
- Begin away from pain. To help pt relax, to note guarding/tenderness, hyperesthesia, rigidity
- You can use their hand, or make no sudden movements.
What is the significance of guarding and rigidity? What are they?
- 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
Be able to demonstrate deep palpation of the abdomen including the liver, spleen, and kidneys.
___
Which arteries are important to auscultate for bruits over the abdomen?
• Bruits over aorta and renal, iliac, and femoral arteries: obstruction
What is Murphy’s Sign?
- Positive sign—cholecystitis
* With your hands shoved up in there, tell pt to breathe in. Positive sign is abrupt arrest of inspiration!
What is rebound tenderness at McBurney’s Point?
• Possible appendicitis
Referred rebound tenderness (Rovsing)?
• Possible appendicitis
Be able to demonstrate psoas sign, obturator sign, costovertebral angle (CVA) tenderness.
- 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
• Physiological S2 spilts:
o Inspiration → listen for A2 and P2 to split
o bc ↑ venous return overloads RV and delays closure of P valve
• What are 5 things to note when listening to heart sounds?
o Location, timing, intensity, pitch
o Effect of respiration or special maneuvers
What is jugular venous distention? On what side is it measured? How is that done?
- 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
What is kussmauls sign?
- paradoxical increase in JVP during inspiration
* conditions that interfere w RV filling: constrictive pericarditis, constrictive cardiomyopathy, RV infx
what is abdominojugular reflex? When is it useful clinically? Know how to use a BP cuff to exert the correct amount of P
- 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
What should you note when you detect a murmur?
- 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
How are murmurs graded?
- 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
What are the systolic, diastolic, and both sounds?
- 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
What are effects of inspiration on different heart murmurs?
- LCHF: ↓
* PS: ↑
What are the effects of Valsalva on diff heart murmurs?
- MVP: earlier click and murmur
- LCHF: ↑
- PS: ↓
- HOCM: louder
What are effects of squatting on diff murmurs?
- MVP: delays click and murmur
- LCHF: ↓
- PS: ↑
Which maneuvers have similar effects on murmurs?
- Inspiration and squatting
* Valsalva, standing and expiration?
What are the maneuvers for murmurs and their effects on heart/CO?
- 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
What is a HOCM murmur? What are relevant, statistically sig tests?
- May appear like AS, but actually ↑ w any maneuver that ↓ VR and CO
- ↑ w Valsalva
- ↑ from squat to stand
- ↓ w passive leg raise
What is best position to hear S3 and S4 gallops?
- W bell (just enough pressure to get seal)
* In mitral and tricuspid area
What are some findings in CHF that may indicate S3 gallop?
- ↓ ejection fraction
- ↑ L heart filling pressure
- ↑ BNP
What may cause S3?
- L and R diastolic overload (MR, TR)
* ↓ ventricular compliance (CMs, CHF, IHD)
What may cause S4?
- 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
• Paradoxical splitting
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)
• What causes S3 gallops?
- 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
• S4 gallop:
- Presystolic= very late diastole
- Dt atria contracting forcefully to overcome stiff or hypertrophic V →turbulence
- RV: PS, pulm HTN
- LV: LVH, AS, HOCM
• MVP:
- 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
Hypertrophic Cardiomyopathy
- 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
• Aortic Regurgitation
- 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)
Pulmonic stenosis
- Gets louder on inspiration
* Held expiration???
• Mitral Regurgitation timing and shape:
- Timing: holo-systolic
* Shape: rectangular (no tapering)
• Mitral Stenosis
- 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
• Aortic Stenosis: MSM and ejection sound
- 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
• prosthetic valves? Starr?
• Starr-Edwards = world’s first prosthetic valve, made in Portland 1960
• Atrial septal defect?
• LA P initially exceeds R: L → R shunt
Understand normal and abnormal bowel sounds.
- 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
Be able to perform abdominal percussion using exemplary technique.
- Percuss all quadrants
- Listen for dullness or tympany
- Unusual dullness: underlying abdominal mass
- Percuss outline of liver, spleen, stomach
What is the splenic percussion sign? Know how to perform it.
- 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
What are the tests for appendicitis?
- 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)
Keep in mind when beginning abdominal exam?
- 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
In addition to quadrants, what is reference terminology of abdomen locations?
- 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
What is the order of the abdominal exam?
- Inspection
- Auscultation
- Percussion
- Light and deep Palpation
What are the tests for cholecystitis, peritonitis, pyelonephritis?
- 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
What is an exam specific for females?
• Pelvic bimanual exam
How do you distinguish from intra- and extra-peritoneal masses?
- Pt does a crunch, see if mass is still present
- Intra: less palpable
- Extra: more palpable
What are most common dx for acute abdominal pain/tenderness (<7d)?
- Non-specific abdominal pain (43%)
- Acute appendicitis (4-20%)
- Acute cholecystitis (3-9%)
- Small bowel obstruction (4%)
- Urinary caliculi (4%) (not kidney stones)
What exams should you do for RUQ or LUQ pain? Why?
- Heart- mb IHD
* Lungs- mb pneumonia
What exams for lower abdominal pain?
- Woman: pelvic exam (ectopic pregnancy, ovarian cyst, uterine fibroids, PID, endometriosis)
- Rectal exam
What are significant signs in pt appearance?
- Toxic or in acute distress?
- Fever: infx (but absence doesn’t r/o)
- Tachycardia and orthostatic hypotension: hypovolemia
What may cause peritonitis? PE? Pt appearance?
- 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
How do you assess for percussion tenderness?
- Start away from painful area
* (+)= if light percussion causes pain
How to perform Blumberg’s sign, cough test?
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)
How to perform merkel sign, carnett’s sign?
- 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)
What is the risk of appendicitis? Mortality? Location? Complication?
- 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
What are ssx of appendicitis?
- Poorly localized epigastric or periumbilical pain
- Anorexia, N/V
- Lo fever
- McBurney’s pt tenderness (rebound or not?)
What is a positive Rovsing’s sign?
- For appendicitis
- Do this BEFORE McBurney’s pt
- Rebound from LLQ
- Referred pain to RLQ
What are the 3 ssx for hi PLR for appendicitis?
- RLQ pn
- Migration of pain (from epigastric to McBurney’s)
- McBurney’s pt tenderness
How is appendicitis usu dx?
- When ssx suggest, do CT
* Surgical exploration is definitive
What are ssx of cholecystitis?
- Early: biliary colic (ab pain increases, peaks, subsides)
- Acute: continuous epigastric pain, RUQ pn, fever
- PE: RUQ tender, Murphy’s sign, absent Courvoisier sign
How to do Courvoisier and Murphy sign?
- 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
What are ssx of bowel obstruction?
Constipation, acute abdominal pain, visible peristalsis (rare), abdominal distension, ↑BS
What are ssx of pyelonephritis? CVA tenderness test? Elderly?
- 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
What can cause ascites? Amount of fluid?
- Biventricular heart failure
- Lo oncotic pressure (protein loss), nephrotoc syndrome, reduced synth (malnutrion, cirrhosis)
- Peritoneal inflamm (neoplastic, infx)
- PE can detect when 500-1000mL
What are 4 best tests for ascites?
- Inspect for bulging flanks
- Percussion for shifting dullness (supine dull at flanks, LLD tympanic at top) (hi spec)
- Fluid wave (hi sens)
- Anke edema
What is baye’s theorem? Ex?
- Dx accuracy ↑ w combo tests w hi sens and hi spec
* Ascites good ex
