Exam 2-abdomen, Cardio Flashcards
When should auscultation of the abdomen be preformed?
Before percussion or palpation, because these can alter the characteristics of bowel sounds
What do bruits suggest when auscultations the abdomen?
Vascular occlusive disease
What are altered bowel sounds common in?
Diarrhea, intestinal obstruction, paralytic ileus, and peritonitis
A bruit in the epigastrum and upper quadrants signifies what?
If it has both systolic and diastolic components, strongly suggest renal artery stenosis (HTN)
Bruits with both systolic and diastolic components suggest what?
Turbulent blood flow form atherosclerotic arterial disease
What are friction rubs heard in?
Present in hepatoma, gonococcal infection around liver, splenic infarction, and pancreatic carcinoma
How many clicks are gurgles are heard in the abdomen per minute?
5-34
What do decreased bowel sounds mean?
A dynamic ileus, peritonitis
What do increased bowel sounds mean?
Diarrhea, early intestinal obstruction
Where do you listen for bruits?
Over aorta, iliac arteries, and femoral arteries
Grating sounds with respiratory variation
Friction rubs
What is a soft humming noise with systolic and diastolic components?
Venous hum
Where do you listen for a venous hum?
Epigastric and umbilical regions
What is a venous hum caused by?
Increased collateral circulation between portal and systemic venous systems; liver cirrhosis
What is heard in liver cirrhosis?
Venous hum
What type of breath sound has inspiratory sounds last longer than expiratory sounds?
Vesicular
Characteristics of vesicular breath sounds
Soft intensity, relatively low pitch, found over most of both lungs
What type of breath sound is inspiratory and expiratory sounds almost equal?
Bronco-vesicular
Characteristics of bronco-vesicular breath sounds
Intermediate intensity, intermediate pitch
Where are bronco-vesicular breath sounds heard?
Often in the 1st and 2nd interspaces anteriorly and between the scapulae
What type of breath sounds is expiratory sounds last longer than inspiratory ones?
Bronchial
Characteristics of bronchial breath sounds
Loud intensity, relatively high pitch
Where are bronchial breath sounds heard?
Over manubrium (larger proximal airways)
Inspiratory and expiratory are almost equal, intensity is very loud, pitch is relatively high
Tracheal breath sounds
What are adventitious or added breath sounds?
Crackles, Wheezes,and Rhonchi
Fine crackles
Soft-high pitched, very brief (5-10 ms)
Coarse crackles
Somewhat louder, lower in pitch (15-30 ms)
Crackles are continuous or discontinuous?
Discontinuous
Crackles (or rales)
Intermittent, nonmusical and brief breath sounds
Wheezes and rhonchi are continuous or discontinuous?
Continuous
Wheezes
Sinusoidal, musical, prolonged, like dashes in time
Wheeze characteristic
Relatively high pitches with hissing or shrill quality
Rhonchi characteristic
Relatively low pitched with snoring quality
What is fremitus?
Palpable vibrations transmitted rough bronchopulmonary tree to chest wall while speaking
Fremitus is decreased or absent if:
High pitched voice, soft voice, thick chest wall, obstructed bronchus, COPD, pleural effusion, fibrosis, air (pneumothorax), infiltrating tumor
Fremitus is typically more prominent in what area?
Interscapular area than the lower lung fields
Asymmetric decreased fremitus raises the likelihood of what?
Unilateral pleural effusion, pneumothorax, or neoplasms c
Grade 1 murmur
Very faint, head only after listener has “tuned in”; may not be heard in all positions
Grade 2 murmur
Quiet, but heard immediately after placing stethoscope on the chest
Grade 3 murmur
Moderately loud
Grade 4 murmur
Loud, with palpable thrill
Grade 5 murmur
Very loud, with thrill. May be heard when stethoscope is partly off the chest
Grade 6 murmur
Very loud, with thrill. May be heard with stethoscope entirely off the chest
How should you examine the pts thorax and lungs when they are sitting?
Have them fold arms across chest with hands resting on opposite shoulders, This swings scapulae laterally and increases access to lung fields
How should you examine the pts thorax and lungs if they are supine?
Allows women’s breasts to be gently displaced.
How should you examine a pts thorax and lungs if they cannot sit up?
Ask for assistant to hold pt up in sitting position, roll pt side to side
What is the trick to remember systolic murmurs?
Mr. AS tried pseudonyms
Mr. AS tried pseudonyms
Mitral regurgitate, aortic stenosis, tricuspid regurgitate, pulmonic stenosis, ASD, VSD, HOCM
A benign sound produced by turbulence of blood in the jugular veins (common in children)
Venous hum
Produced by inflammation of the pericardial sac
Pericardial friction rub
A congenital anomaly that persists after birth causing a left-to-right-shunt form aorta to pulmonary artery
PDA patent ductus arteriosus
What is a continuous murmur without a silent interval, loudest in diastole?
Venous hum
Where is a venous hum heard?
Above the medial third of the clavicles, especially on the right, often when head is turned in opposite direction, best heard if pt is in sitting position
When does the venous hum disappear?
When the patient is supine
Where does the venous hum radiate to?
Right or left 1st and 2nd interspaces
What is the timing of a pericardial friction rub?
Inflammation of the visceral and parietal pericardium from pericarditis produces coarse grating sound with 1, 2, or 3 components
What are the components of a pericardial friction rub?
Ventricular systole, ventricular filling, and atrial contraction during diastole
Rubs can be heard with pericarditis with and without what?
Pericardial effusions
Where is a pericardial friction rub best heard?
Left 3rd interspace next to sternum with patient sitting and leaning forward with breath held after forced expiration
What is the timing of PDA?
Continuous murmur in both systole and diastole, often with a silent interval late id diastole
When is PDA loudest?
In late systole, obscures S2, and fades in diastole
Where is PDA best heard?
Left 2nd interspace and radiates toward left clavicle
What is the Allen’s test for?
Compares the potency of ulnar and radial arteries
How do you do the Allen’s test?
Compress ulnar and radial Artie’s, tell pt to open and close hand a few times to get blood out until hand is white. Release one of arteries
Results of Allen’s test
Hand stays white: positive (indicates occlusion of artery thats no longer compressed)
Hand returns to red/pink: negative, normal
When will we see changes in the hepatojugular reflex?
Right sided HF, passive hepatica congestion
Hepatojugular reflex
JVP observed while pressure firmly applied to RUQ
What is Kussmaul’s sign?
JVP that rises with inspiration
What does Kussmaul’s sign suggest?
Impaired filling or right ventricle (fluid in pericardial space, poorly compliant myocardium/pericardium)
What is primary Raynaud’s phenomenon?
Episodic reversible vasoconstriction in the fingers and toes, usually triggered by cold temperatures (capillaries are normal); no definable cause
What is secondary Raynaud’s phenomenon?
Si/sx related to autoimmune diseases-scleroderma, systemic lupus, mixed connective tissue disease; cryoglobulinemia; also occupational vascular injury, drugs
Where is the location of pain for Raynaud’s?
Distal portions of one or more fingers, pain is usually not prominent unless fingertip ulcers develop
PAD process
Atherosclerotic Disease lading to obstruction of peripheral arteries causing exertional claudication and atypical leg pain
Location of pain for PAD
Calf muscles, but also occurs in butt, hip, thigh, or foot. Depending on levels of obstruction; rest pain may be distal in toes or forefoot
Acute arterial occlusion process
Embolism or thrombosis
Location of pain for acute arterial occlusion
Distal pain, usually involving the foot and leg
What occupies most of the anterior cardiac surface?
Right ventricle
Where odes the inferior border of the RV lie?
Below the unction of the sternum and xiphoid process
Where does the RV join the pulmonary artery?
At the base of the heart at the sternal angle
A PMI >2.5cm suggests what?
LVH from HTN or aortic stenosis
Displacement of PMI lateral to midclavicular line or >10cm lateral to midsternal line occurs when?
LVH and ventricular dilation from MI or HF
To assess the amplitude and contour of the carotid pulse, how should the patient be?
Supine with head of bed elevated to about 30 degrees
Never palpate both carotid arteries at same time, why?
Can decrease blood flow to brain and induce syncope
What it’s he amplitude of the carotid pulse?
This correlates reasonably well with the pulse pressure
The carotid pulse during cardiogenic shock
small, thready, or weak
Carotid pulse is bounding in what
Aortic regurgitation
The carotid upstroke is delayed in what?
Aortic stenosis
What is the contour of the carotid pulse?
The speed of the upstroke, the duration of its summit, and the speed of the downstroke.
The normal contour of the carotid pulse
Upstroke is brisk, smooth, rapid and follows S1 almost immediately.
Summit is smooth, rounded, and roughly midsystolic
Downstroke: less abrupt than upstroke
What is pulses alternans?
Bite I almost pulse that varies beat to beat, a paradoxical pulse varies with respiration
What does pulses alternans almost always indicate?
Severe left ventricular dysfunction
How is pulsus alternans best felt?
By applying light pressure on radial or femoral arteries.
What is paradoxical pulse?
Greater than normal drop is systolic BP during Inspiration, can suspect cardiac tamponade
Where is PMI found?
Apex of heart, midclavicular line in 4th or 5th interspace
What are heaves and lifts?
Sustained impulses that rhythmically lift fingers
What are thrills?
Buzzing or vibratory sensation on the hand
Where is the pulmonic area?
Left 2nd interspace
Where is the aortic area?
Right 2nd interspace
What are S1 and S2 sounds best heard with?
Diaphragm of stethoscope
What is the best position to hear mitral stenosis?
Left lateral decubitus
Where and how should you listen for mitral stenosis?
With bell of stethoscope on apical impulse
How should pt be oriented if checking for aortic regurgitation?
Pt sitting up, lean forward, exhale completely, hold breath
How should aortic regurgitation be heard?
Listen with diaphragm at left sternal border and apex
What is a protuberant abdomen with bulging flanks a suspicion for?
Ascites
Ascites reflects what in cirrhosis?
Increased hydrostatic pressure in cirrhosis, HF, constrictive pericarditis, or IVC or hepatic vein obstruction
What special test is used for ascites?
Check for central tympani
How do you test for central tympany?
Percussion abdomen, anterior abdomen will be tympanic, the flanks will be dull with ascites
How do you test for shifting dullness?
Percuss the border of tympany and dullness with pt supine, then ask to roll onto one side. Percuss and mark borders again
Shifting dullness test for ascites
Without ascites: the border between tympany and dullness usually stays relatively constant
Shifting dullness positive for ascites
Dullness shifts to the more dependent side, whereas tympany shifts to the top
How do you test for a fluid wave?
Ask pt to press edges of both hands firmly down midline of abdomen, while you tap one flank sharply with fingers, feel on opposite flank for an impulse transmitted through fluid
An easily palpable impulse from the fluid wave test suggests what?
Ascites
What is ballottement?
A brief jab over an organ, the quick movement often displaces fluid so that fingers can briefly touch the surface of the organ (with ascites)
Appendicitis is twice as likely in the presence of?
RLQ tenderness, Rovsing sign, psoas sign and McBurney point tenderness
Where is the classic “McBurney point”
Lies 2 inches from the ASIS of ilium
What is Rovsing’s sign?
If you press on the left side of the abdomen, and the pt feels pain in RLQ (appendicitis)
What is the psoas sign?
Extension of the psoas muscle, have the pt lay on left side and extend the hip
What is a positive psoas sign?
Increased abdominal pain on either maneuver, suggests irritation of the psoas muscle by an inflamed appendix
What is the obturator sign?
Flex the right thigh at the hip with the knee at 90 degrees, and rotate the up internally
What is a positive obturator sign?
Right hypogastric pain, form irritation of the obturator muscle by an inflamed appendix. Sign has low sensitivity
What is the heel tap test?
Forcefully stroke bottom of foo twitch hand, strike heels forcibly from standing position
When do you assess Murphy’s sign?
When RUQ pain and tenderness suggest acute cholecystitis
What is a positive Murphy’s sign?
A sharp increase in tenderness with inspiratory effort
How do you preform Murphy’s sign?
Palpate the liver at midclavicular line, tell pt tp inhale deeply, sudden increase in pain is positive
How do you assess ventral hernias?
Ask pt to raise both head and shoulders off table (do a crunch), look for obvious bulge or increase in size of lesion
What is visceral abdominal pain?
With dissension/stretching of hollow organs, difficult to localize and has a varying quality
What is parietal abdominal pain?
More precisely localized over involved structure, aggravated by movement or coughing, steady, aching pain
What is referred abdominal pain?
Follows dermatomes, area of referred pain is usually non-tender to palpation
What is the abdominal exam sequence?
IAPP Inspection Auscultation Percussion Palpation- light touch, deep touch Special Tests
What is the “a” wave for JVP?
Corresponds to atrial contraction
What do absent a waves mean?
AFIB, junctional/ventricular arrhythmias
What are increased a waves?
Increased resistance to RA emptying
What is an “x” descent
Corresponds to atrial relaxation
What is prominent x descent?
Constrictive pericarditis, restrictive CMP, pericardial tamponade
What is decreased/absent x descent mean?
Severe tricuspid regurgitation, AFIB
What is the “c” wave
Represents bulging of tricuspid valve during systole; not present in every pt
What is the “v” wave?
Increased atrial pressure as venous tree turn increases after systole
What is “y” descent?
Reduced pressure observed with tricuspid valve opening and atrial emptying during diastole
How do you measure the JVP?
Identify meniscus fo right internal jugular vein, measure height in relation to sternal angle, add 5cm to number
What is a normal measured JVP?
<9cm, if >9cm: indicates increased right atrial volume
What suggests a normal size spleen?
Lateral tympany on generalized splenic percussion
How do you perform generalized splenic percussion?
Percuss left lower anterior chest wall at Traube’s space
What is Traube’s space?
Start percussion from border of cardiac dullness at 6th rib to anterior axillary line and down to costal margin
What does tympany at full inhalation suggest for spleen?
Normal size spleen
What is a positive splenic percussion sign?
A change in percussion note form tympany to dullness on inspiration
What part of the stethoscope is used to hear gallops?
Bell
What are causes of left sided S4 gallops?
HTN heart disease, aortic stenosis, ischemic and hypertrophic CMP
What are the causes of right sided S4 gallops?
Pulmonary HTN and pulmonic stenosis
What is the pathologic cause of a S3 gallop?
Caused by high LV filling pressures and abrupt deceleration of inflow across mitral valve @ end of diastole
What causes and S3 gallop?
Decreased myocardial contractility, HG, aortic regurgitation; mitral regurgitation, left-to-right shunts
Who can get and S3 gallop?
Physiologic in children, young adults, reign any women in 3rd trimester
Who can get S4 gallop normally?
Sometimes in trained athletes and older people
