Exam 2 (wks 4-7) Flashcards
1
Q
Thorax/Lungs
identify the anatomical landmarks of the anterior, posterior, and lateral thorax
A
- Anterior: Right is mostly upper and middle lobes separated by horizontal fissure at ~ 5th rib in midaxilla to ~4th rib at sternum; Left lower lobe is separated by diagonal fissure from ~5th rib at axilla to ~6th at midclavicular
- Posterior: Primarily the lower lobe T3 -T10 except apices
- Right Lateral: Underlies peak of axilla to 7th/8th rib; upper lobe ~5th rib midaxillary and 6th rib anteriorly
- Left Lateral: Underlies peak of axilla to 7th/8th rib; oblique fissure from 3rd rib medially to 6th rib anteriorly
2
Q
Thorax/Lungs
define nail clubbing and give examples of what can cause clubbing
A
- Enlargement of the terminal phalanges of the fingers and/or toes
- Associated with emphysema, lung cancer, the cyanosis of congenital heart disease, cirrhosis, or cystic fibrosis
3
Q
Thorax/Lungs
examples that indicate respiratory distress
A
- barrel chest
- pursing of the lips
- flaring of the ala nasi
- use of accessory muscles
4
Q
Thorax/Lungs
describe barrel chest
+ 3 examples
A
- AP diameter approaches or equals the lateral diameter
- compromised respiration
- chronic asthma, emphysema, or cystic fibrosis
5
Q
Thorax/Lungs
define tachypnea
A
Persistent respiratory rate > 20 breaths per minute (in adult)
6
Q
Thorax/Lungs
causes of tachypnea
3
A
- examiner watching if not persistent
- symptom of protective splinting from the pain of a broken rib or pleurisy
- Massive liver enlargement or abdominal ascites may prevent descent of the diaphragm and produce a similar pattern
7
Q
Thorax/Lungs
define bradypnea
A
persistent respiratory rate < 12 breaths per minute
8
Q
Thorax/Lungs
causes of bradypnea
3
A
- neurologic or electrolyte disturbance, infection
- a conscious response to protect against the pain of pleurisy or other irritative phenomena
- excellent level of cardiorespiratory fitness.
9
Q
Thorax/Lungs
describe dyspnea
A
difficulty and labored breathing w/ SOB
10
Q
Thorax/Lungs
causes of dyspnea
A
- pulm or cardiac compromise
- sedentary lifestyle/obesity
11
Q
Thorax/Lungs
what is orthopnea
A
SOB that begins or increases when the pt lies down
12
Q
Thorax/Lungs
how to ask about orthopnea in a clear manner?
A
if they sleep with multiple pillows to elevate themselves
13
Q
Thorax/Lungs
describe paroxysmal nocturnal dyspnea
A
a sudden onset of shortness of breath after a period of sleep; sitting upright is helpful
14
Q
Thorax/Lungs
describe hyperpnea
+ 4 causes
A
- Breathing deeply
- exercise, anxiety, CNS dz, metabolic dz, ASA posioning
15
Q
Thorax/Lungs
describe hypopnea
+1 cause
A
- abnormally shallow respirations
- pleuritic pain
16
Q
Thorax/Lungs
describe sighing
A
- An occasional deep, audible sigh that punctuates an otherwise regular respiratory pattern is associated with emotional distress or an incipient episode of more severe hyperventilation.
- Sighs also occur in normal respiration.
17
Q
Thorax/Lungs
describe air trapping
A
- result of a prolonged but inefficient expiratory effort
- increased resistance (i.e. chronic bronchitis), decreased elastic recoil of the lung (i.e., emphysema) or a drop in the critical closing pressure of the airway (i.e., asthma)
- resp rate increases to compensate (more shallow and air trapping increases
- can lead to lung hyperinflation = barrel chest)
18
Q
Thorax/Lungs
describe periodic breathing
A
- regular periodic pattern of breathing w/ intervals of apnea followed by crescendo/decrescendo respiration
- occurs during sleep, when seriously ill, brain damage, drug overdose
19
Q
Thorax/Lungs
describe kussmaul breathing
A
- deep/rapid breathing
- elevation of JVP w/ inspiration
- metabolic acidosis w/ respiratory compensation
20
Q
Thorax/Lungs
describe biot/ataxic
A
- irregular respirations which vary in depth and are interrupted by intervals of apnea
- lacks repitition of periodic respiration
- severe & persistent increased intracranial pressure
- same causes as periodic breathing
21
Q
Thorax/Lungs
AP diameter findings in infants
A
chest of the newborn is generally round, the AP diameter approximating the lateral diameter, and the circumference is roughly equal to that of the head until the child is about 2 years old
22
Q
Thorax/Lungs
AP chest diameter in older adults
A
The barrel chest that is seen in many older adults results from loss of muscle strength in the thorax and diaphragm, coupled with the loss of lung resiliency. In addition, skeletal changes of aging tend to emphasize the dorsal curve of the thoracic spine, resulting in an increased AP chest diameter. There may also be stiffening and decreased expansion of the chest wall.
23
Q
Thorax/Lungs
AP chest diameter in pregnant women
A
Anatomic changes that occur in the chest as the lower ribs flare include an increase in the lateral diameter of about 2 cm and an increase in the circumference of 5 to 7 cm. The costal angle progressively increases from about 68.5 degrees to approximately 103.5 degrees in later pregnancy.
24
Q
Thorax/Lungs
AP chest diameter in healthy adults
A
The AP diameter of the chest is ordinarily less than the lateral diameter – thoracic ratio and is expected to be about 0.70 to 0.75.
25
# Thorax/Lungs
describe the technique to assess thoracic expansion
Technique: To evaluate thoracic expansion during respiration, stand behind the patient and place your thumbs along the spinal processes at the level of the tenth rib, with your palms lightly in contact with the posterolateral surfaces. Watch your thumbs diverge during quiet and deep breathing. A loss of symmetry in the movement of the thumbs suggests a problem on one or both sides.
26
# Thorax/Lungs
describe crepitus
* crackly or crinkly sensation
* can be palpated and heard (gentle, bubbly feeling)
* incdicates that there is air in the subQ tissue from a rupture somewhere in the respriatory system
27
# Thorax/Lungs
where is fremitus best felt
posteriorly and laterally at the level of the bifurcation of the bronchi
28
# Thorax/Lungs
how to test for fremitus
have the pt say 99 while you palpate/auscultate
29
# Thorax/Lungs
what does decreased fremitus mean? from what?
* excess air in the lungs
* emphysema, pleural thickening/effusion, bronchitis
30
# Thorax/Lungs
what does increased fremitus feel like? mean? sign of?
* coarse or rough in feeling
* presence of fluids or a solid mass within the lungs
* may be caused by lung consolidation or heavy, but non-obstructive bronchial secretions
31
# Thorax/Lungs
what would hyper resonance come from?
* abnormal sound
* result of air trapping
* from emphysema, pneumothorax, asthma
32
# Thorax/Lungs
what can cause dullness or flatness to percussion mean?
* pneumonia
* atelectasis
* pleural effusion
* asthma
33
# Thorax/Lungs
expected findings of diaphragmatic excursion
* higher on the R than the L
* ~ 7 cm?
34
# Thorax/Lungs
where are bronchial sounds heard
* only over trachea
* high pitched
* loud and long expirations
35
# Thorax/Lungs
where are bronchovesicular sounds heard?
* main bronchus area and over upper R posterio rlung field
* medium pitch
* expiration equals inspiration
36
# Thorax/Lungs
where are vesicular sounds heard?
* over most lung fields
* low pitch
* soft and short expiration
* louder: thinner people, children
* quiet: obese/muscular pts
37
# Thorax/Lungs
describe crackles/rales
discontinuous, fine crackling, high pitched
38
# Thorax/Lungs
describe rhonchi
* loud, low, coarse sounds (like a snore)
* heard continuously during inspiration/expiration
* usually means mucus accumulation (a cough can clear the sound)
39
# Thorax/Lungs
describe wheezing
* muscial noise
* heard continuously but louder during expiration
40
describe a pleural friction rub
* dry, rubbing, or grating sound
* caused by inflammation of pleural surfaces
* heard during inspiration or expiration
* loudest over lower lateral anterior surface
41
# Thorax/Lungs
describe a mediastinal crunch (hamman sign)
* found w/ mediastinal emphsema
* variety of sounds (loud crackles, clicking, gurgling) over the precordium
* synchronous w/ heartbeat
* easiest to hear when pt leans to the L (L lateral decubitus)
42
# Thorax/Lungs
pathophy of diminution of breath sounds
* fluid or pus accumulating in the pleural space, secretions, or a foreign body obstructs the bronchi
* breathing is shallow from splinting due to pain
* the lungs can overinflate from severe obstruction
43
# Thorax/Lungs
disorders that can cause dimunition of breath sounds
* COPD
* emphysema
* pleurisy
* pneumonia
* bronchiolitis
* hemothorax
* lung abscess
* pleural effusion
* pneumothorax
44
# Thorax/Lungs
describe how to do PE for bronchophony
* have pt speak 1, 2, 3 repeatedly
45
# Thorax/Lungs
what might increased clarity mean for bronchophony?
* consolidated lungs
* carried by liquid
46
# Thorax/Lungs
what is whispered pectoriloquy?
* pt whispers 1, 2, 3
47
# Thorax/Lungs
what is egophony test?
* whisper e
* should hear as e, but could hear as a
* fluid filled, compressed lung
48
# Thorax/Lungs
inspiration to expiration ratio for:
* airway obstruction
* stridor
* airway obstruction: I/E > 2:1
* stridor: I/E > 3:1
49
# Thorax/Lungs
normal lung/thorax findings on inspection
symmetrical movement on expansion, absence of retrations
50
# Thorax/Lungs
normal findings for palpation
* midline trachea, mobile, no tugging
* symmetric, unaccentuated tactile fremitus
51
# Thorax/Lungs
normal findings for percussion
* range of 3 to 5 cm for diaphragmatic excursion
* resonant and symmetric percussion notes
52
# Thorax/Lungs
normal findings on auscultation
* absence of adventitious sounds, vesicular breath sounds
53
# Cardiac/Peripheral Vascular
describe S1
* when systole begins
* ventricular contraction raises the pressure in the ventricles and forces the mitral and tricuspid valves closed which prevents backflow
* LUB
54
# Cardiac/Peripheral Vascular
describe S2
* when the ventricles are almost empty, the pressure falls below that of the aorta and pulmonary arteries causing the pulm and aortic valves to close
* DUB
55
# Cardiac/Peripheral Vascular
describe S3
* as the ventricular pressure falls below atrial pressure, the mitral and tricuspid valves open to allow ventricular refilling
* ventricular diastole
* not always heard
56
# Cardiac/Peripheral Vascular
describe S4
* the atria contract to ensure ejection of remaining blood
* not always heard
57
# Cardiac/Peripheral Vascular
Explain how the relationship between the duration of the systolic and diastolic phases changes at higher heart rates
* As heart rate increases, systole and diastole become more similar in length
* With slower heart rate, diastole is longer than systole
58
# Cardiac/Peripheral Vascular
define pulse pressure
difference between the upper and lower (systolic and diastolic) numbers of your blood pressure. This number can be an indicator of health problems before you develop symptoms
59
# Cardiac/Peripheral Vascular
describe expected CV system changes that occur during pregnancy
* pt's blood volume increases 40-50%
* increased plasma volume
* heart works harded to accomodate increased HR and stroke volume
* CO increases 30-40%
* LV increases in thickness and mass
* heart is shifted toward a horizontal position to make room for baby
60
# Cardiac/Peripheral Vascular
CV changes post partum
* returns to normal levels 3-4 wks after delivery
61
# Cardiac/Peripheral Vascular
describe CV changes in geriatric pts
* heart size may decrease unless HTN or heart disease
* valves may begin to harden
* stroke volume decreases, CO declines
* LV and endocardium thicken
* myocardium becomes more rigid
* tachycardia not tolerated
62
# Cardiac/Peripheral Vascular
describe the "a wave" of jugular pulsation
the upward a wave, the first and most prominent component, is the result of a brief backflow of blood to the vena cava during right atrial contraction. This peaks slightly before the first heart sound (S1).
63
# Cardiac/Peripheral Vascular
describe the "c wave" of jugular pulsation
the upward c wave is a transmitted impulse from the vigorous backward push produced by closure of the tricuspid valve during right ventricular systole.
64
# Cardiac/Peripheral Vascular
describe the "v wave" of jugular pulsation
the upward v wave is caused by the increasing volume and concomitant increasing pressure in the right atrium. It occurs after the c wave, late in ventricular systole.
65
# Cardiac/Peripheral Vascular
describe the "x slope" of jugular pulsation
the downward x slope is caused by passive atrial filling. This ends with the initiation of the v wave.
66
# Cardiac/Peripheral Vascular
describe the "y slope" of jugular pulsation
the y slope following the v wave reflects the open tricuspid valve and the rapid filling of the right ventricle.
67
# Cardiac/Peripheral Vascular
describe where the PMI is located
* In most adults the apical impulse is visible at about the midclavicular line in the fifth left intercostal space, but it is easily obscured by obesity, large breasts, or muscularity.
* It should be seen in only one intercostal space if the heart is healthy
68
# Cardiac/Peripheral Vascular
what might a readily visible and palpable PMI indicate
problem related to intensity
69
# Cardiac/Peripheral Vascular
what might an absent apical impulse + faint heart sounds indicate?
extracardiac problem like pleural or pericardial fluid
70
# Cardiac/Peripheral Vascular
how to characterize an apical pulse that is vigorous or long
heave or lift
71
# Cardiac/Peripheral Vascular
a lift along the LSB could be caused by?
RVH
72
# Cardiac/Peripheral Vascular
an apical pulse that is more forceful and widely distributed, fills systole, or is displaced laterally may indicate?
LVH
73
# Cardiac/Peripheral Vascular
displacement of the PMI to the right may suggest?
* dextrocardia
* diaphragmatic hernia
* distended stomach
* pulm abnormality
74
# Cardiac/Peripheral Vascular
define parasternal heave/life/thrust
* precordial impulse that may be felt (palpated) in pts with cardiac or respiratory disease
* precordial impulses are visible or palpable pulsations which originate on the heart of great vessels
75
# Cardiac/Peripheral Vascular
when is a thrill present?
grade IV murmur or higher
76
# Cardiac/Peripheral Vascular
what is a thrill?
palpable murmur
77
# Cardiac/Peripheral Vascular
where to auscultate the aortic valve area
2nd RICS at the RSB
78
# Cardiac/Peripheral Vascular
where to auscultate the pulmonic valve
2nd LICS at the LSB
79
# Cardiac/Peripheral Vascular
where to auscultate the second pulmonic area
3rd LICS at the LSB
80
# Cardiac/Peripheral Vascular
where to auscultate the tricuspid area
4th LICS at the LLSB
81
# Cardiac/Peripheral Vascular
where to auscultate the mitral area
apex of heart in the 5th LICS at the midclavicular line
82
# Cardiac/Peripheral Vascular
where is S1 best heard
* toward apex
* S1 is louder on the L than the R
* lower in pitch, longer than S2
83
# Cardiac/Peripheral Vascular
where is S2 best heard
* aortic and pulmonic areas
* higher pitched, shorter duration than S1
84
# Cardiac/Peripheral Vascular
define splitting
* when the aortic/pulmonic or the mitral/tricuspid valves do not close simultaneously
85
# Cardiac/Peripheral Vascular
when might S3 be audible
* causes a gallop
* sounds like " ken-TUCK-y "
* best heard in the L lateral decubitus position
86
# Cardiac/Peripheral Vascular
when might S4 be audible
* intense, pre-systolic gallop
* older pts, due to increased resistance to ventricular filling
* sounds like " TEN-nes-ses"
87
# Cardiac/Peripheral Vascular
which sounds are best heard w/ a diaphragm?
S1 and S2
88
# Cardiac/Peripheral Vascular
which sounds are best head via bell
S3 and S4
89
# Cardiac/Peripheral Vascular
what position is S1 best heard in?
any position
90
# Cardiac/Peripheral Vascular
what position is S2 best heard in?
sitting/supine
91
# Cardiac/Peripheral Vascular
what position is S3 best heard in?
supine or left lateral
92
# Cardiac/Peripheral Vascular
what positions are most likely to allow you to hear all sounds?
supine or left lateral
93
# Cardiac/Peripheral Vascular
what position best allows you to hear a summation gallop?
supine or L lateral
94
# Cardiac/Peripheral Vascular
what position best allows you to hear ejection sounds
sitting or supine
95
# Cardiac/Peripheral Vascular
what position best allows you to hear a systolic click?
sitting or supine
96
# Cardiac/Peripheral Vascular
what position best allows you to hear an opening snap
any position
97
# Cardiac/Peripheral Vascular
describe grade I murmur
barely audible even in a quiet room
98
# Cardiac/Peripheral Vascular
describe a grade II murmur
quiet but clearly audible
99
# Cardiac/Peripheral Vascular
describe a grade III murmur
moderately loud
100
# Cardiac/Peripheral Vascular
describe a grade IV murmur
loud, associated w/ a thrill
101
# Cardiac/Peripheral Vascular
describe a grade V murmur
very loud, thrill easily palpable
102
# Cardiac/Peripheral Vascular
describe a grade VI murmur
very loud, audible w/out stethoscope
103
# Cardiac/Peripheral Vascular
describe innocent murmurs
They are usually grade I or II, usually midsystolic, without radiation, medium pitch, blowing, brief, and often accompanied by splitting of S 2 . They are often located in the second left intercostal space near the left sternal border. Such murmurs heard in a recumbent position may disappear when the patient sits or stands because of the tendency of the blood to pool.
104
# Cardiac/Peripheral Vascular
describe S3 and S4 gallops
due to increase blood w/in the ventricles
105
# Cardiac/Peripheral Vascular
describe a summation gallop
combined presence of S3 and S4 due to tachycardia
106
# Cardiac/Peripheral Vascular
describe a quadruple gallop
when S3 and S4 are both heard separately
107
# Cardiac/Peripheral Vascular
describe an aortic/pulmonic early systolic click
* ejection click
* high pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves
* heard just after the first heart sound
108
# Cardiac/Peripheral Vascular
describe mid to late mitral valve systolic clicks
* systolic sounds occuring at AV valves in prolapse of mitral/tricuspid valves
* due to myxomatous degeneration of valve
109
# Cardiac/Peripheral Vascular
describe mitral valve opening snap
* occurs because of increased L atrial pressure
110
# Cardiac/Peripheral Vascular
describe a pericardial friction rub
* grating, to and fro sound
111
# Cardiac/Peripheral Vascular
describe pulse grades
* 0: absent, not palpable
* 1: diminished, barely palpable
* 2: expected
* 3: full, increased
* 4: bounding, aneurysmal
112
# Cardiac/Peripheral Vascular
how to identify varcose veins
Inspect the legs for superficial varicosities when the patient is standing. With varicosities, the veins appear dilated and often tortuous. If varicose veins are suspected, have the patient stand on his or her toes 10 times in succession. Palpate the legs to feel the venous distention. When the venous system is competent, the distention of the veins disappears in a few seconds. If the distention of the veins is sustained for a longer time, suspect venous insufficiency.
113
# Cardiac/Peripheral Vascular
what is Homan's sign
pain in calf w/ dorsiflexion of foot
114
# Cardiac/Peripheral Vascular
describe generalized edema
* massive and generalized (anasarca).
* It is caused by a variety of clinical conditions like heart failure, renal failure, liver failure, or problems with the lymphatic system
115
# Cardiac/Peripheral Vascular
describe localized edema
* Typically, this involves one organ or part of the body.
* Clinically important examples of localized edema are brain edema, lung edema, or accumulation of fluid in the thoracic cavity (hydrothorax) or abdominal cavity (ascites).
116
# Cardiac/Peripheral Vascular
describe pitting edema
* swollen part of your body has a dimple (or pit) after you press it for a few seconds.
* From CHF, liver dz, kidney dz, DVT, preg
117
# Cardiac/Peripheral Vascular
describe non pitting edema
* If you press your finger to a swollen area, it will usually bounce right back.
* From venous insufficiency, angioedema, myxedema
118
# Cardiac/Peripheral Vascular
classify edema
* Trace: does not meet criteria to classify as 1+
* 1+: Slight pitting, no visible distortion, disappears rapidly, 2mm
* 2+: A somewhat deeper pit than in 1+, but again no readily detectable distortion; disappears in 10–15 seconds, 4mm
* 3+: Noticeably deep pit that may last more than a minute; dependent extremity looks fuller and swollen, 6 mm
* 4+: Very deep pit that lasts as long as 2–5 minutes; dependent extremity is grossly distorted, 8 mm"
119
# Cardiac/Peripheral Vascular
where is the carotid artery located
deep to the SCM, superiorly anterior to SCM, medial to IJV, and deep to sternohyoid and sternothyroid muscles.
120
# Cardiac/Peripheral Vascular
where is the IJV located?
just lateral to CA
121
# Cardiac/Peripheral Vascular
where is the EJV located?
superficial to SCM
122
# Abdomen
Discuss the pattern of abdominal organ innervation and correlate to visceral and somatic abdominal pain sensation
The abdominal viscera are innervated, as all viscera are, by the autonomic nervous system. The parasympathetic innervation is delivered by the vagus primarily, with help from the pelvic splanchnic nerves. The sympathetic innervation comes primarily from the thoracic splanchnic nerves, greater, lesser, and least, with help from the upper lumbar splanchnic nerves.
123
# Abdomen
what is within the RLQ
* appendix
* cecum
* inferior ascending colon
124
# Abdomen
what lies within the RUQ
* liver
* gall bladder
* hepatic flexure
* superior ascending colon
* right transverse colon
125
# Abdomen
what lies within LUQ
* L transverse colon
* stomach
* pancreas
* spleen
* superior descending colon
* splenic flexure
126
# Abdomen
what is contained within the LLQ
* inferior descending colon
* sigmoid colon
* rectum
127
# Abdomen
order of PE and why it's important
1. inspection
2. auscultation
3. percussion
4. palpation
Always perform auscultation of the abdomen before percussion and palpation because these maneuvers may alter the frequency and intensity of bowel sound
128
# Abdomen
what is Cullen Sign
* blue-ish periumbilical discoloration (eccymoisis)
* suggests intra-abdominal bleeding
129
# Abdomen
normal striae vs Cushing's striae
* normal: pink, red
* Cushing's: purple
130
# Abdomen
what type of appearance suggests ascites?
glistening/taunt
131
# Abdomen
what is Sister Mary Joseph's sign?
* pearl like, enlarged, painful umbilical nodule
* suggests metastasis
132
# Abdomen
what is Gray-Turner Sign
eccyhmosis on flank
133
# Abdomen
how deep is light palpation? deep palpation?
* 1 cm
* 4-5 cm
134
# Abdomen
what features can commonly be felt as masses?
* kidneys
* aorta
* fecal mass (cecum/sigmoid)
* uterus
* bladder
* sacral promontory
135
# Abdomen
what to use to differentiate enlarged spleen vs enlarged kidney?
* percussion
* spleen: dull
* kidney: resonant
136
# Abdomen
indirect percussion for kidney tenderness
smacking their back
* kidney stones, pyelonephritis
137
# Abdomen
what does lateral pulsation suggest when palpating the aorta?
aortic aneurysm
138
# Abdomen
differentiate flat, rounded, and scaphoid stomachs
* falt: well-muscled, athletic adults (flat)
* round: common in kids, obese adults
* scaphoid: thin adults
139
# Abdomen
what could cause generalized symmetric abd distension
obesity, enlarged organs, bloat
140
# Abdomen
what could cause distention from the umbilicus to the symphysis
* ovarian tumor
* pregnancy
* uterine fibroids
* distended bladder
141
# Abdomen
what could cause distention above the umbilicus?
* tumor
* pancreatic cyst
* gastric dilation
142
# Abdomen
what could cause asymmetric distention or protrustion
* hernia
* tumor
* cyst
* bowel obstruction
* hepato/spleno megaly
143
# Abdomen
what is visible surface motion from peristalsis indicative of?
* maybe they're just skinny
* but also intestinal obstruction
144
# Abdomen
how to properly inspect for abd masses
* take a big, deep breath and hold it
* pushes organs together
145
# Abdomen
where is an epigastric hernia located?
upper abdomen at midline
146
# Abdomen
where is an incisional hernia located
previous incisional site
147
# Abdomen
where is an umbilical hernia located
at the navel
148
# Abdomen
where is a direct inguinal hernia located
near the opening of the inguinal canal (basically on McBurney's point it looks like)
149
# Abdomen
where is an indirect inguinal hernia located?
at the opening of the inguinal canal (close to femoral canal but more medial)
150
# Abdomen
where is a femoral hernia located?
in the femoral canal
151
# Abdomen
what is an abdominal wall hernia
opening or area of weakness which allows abd contents to protrude out of
152
# Abdomen
describe:
* non-reducible hernia
* incarcerated hernia
* strangulated hernia
* cannot be reduced, but has blood flow
* no blood flow
* muscle clamps down on the protrusion of the SI cutting off clood flow
153
# Abdomen
what is diastasis recti?
* enlargement/widening of the linea alba
* occurs in pregnancy
154
# Abdomen
what is borborygmi
stomach growling
155
# Abdomen
norm bowel sound range
5-35 per min
156
# Abdomen
what can cause increased bowl sounds? decreased?
* increased: gastroenteritis, early intestinal obstruction, hunger
* decreases: paralytic ileuss, peritonitis
157
# Abdomen
what would a mechanical bowel obstruction sound like?
* high pitched tinkling sounds
* suggestive of intestional fluid and air under pressure
158
# Abdomen
describe sounds of abdomen when percussing
* most of stomach is tympanic to percussion
* full bladder could be dull
* kidneys are resonant
* spleen/live dull
159
# Abdomen
normal liver span by percussion
6 to 12 cm, on mid clavicular line
160
# Abdomen
how to determine if resistance on abd palpation is voluntary or involuntary
Place a pillow under the patient's knees and ask the patient to breathe slowly through the mouth as you feel for relaxation of the rectus abdominis muscles on expiration. If the tenseness remains, it is probably an involuntary response to localized or generalized rigidity.
161
# Abdomen
overcoming ticklishness
have pt self palpate with your hands over top, slowly bring your hands down onto stomach
162
# Abdomen
where can deep palpation evoke tenderness in healthy persons?
* cecum
* sigmoid colon
* aorta
* midline near xiphoid process
163
# Abdomen
how to determine on PE if abd pass is superficial or intra abdominal
raise head when supine
* superficial: will remain visible, on abd wall
* intra abd: will disappear
164
# Abdomen
what does liver edge feel like to palpation
firm, smooth, even, non-tender
165
# Abdomen
findings associated with palpating gallbladder
* healthy gallbladder is not palpable
* palpable + tender = cholecystitis
* non-tender + palpable = common bile duct obstruction
166
# Abdomen
normal aorta size
1.5 to 3 cm
167
# Abdomen
how does ascites sound to percussion
dull
168
# Abdomen
how does a distended bladder feel/sound
* smooth, round, tense mass
* lower percussion note than air filled intestines
169
# Abdomen
describe "fluid wave" technique
With the patient supine, ask him or her or another person to press the edge of the hand and forearm firmly along the vertical midline of the abdomen. This positioning helps stop the transmission of a wave through adipose tissue. Place your hands on each side of the abdomen and strike one side sharply with your fingertips. Feel for the impulse of a fluid wave with the fingertips of your other hand. An easily detected fluid wave suggests ascites.
170
# Abdomen
describe shifting dullness PE technique
After identifying the borders between tympany and dullness, have the patient lie on one side and again percuss for tympany and dullness and mark the borders. In the patient without ascites, the borders will remain relatively constant. With ascites, the border of dullness shifts to the dependent side (approaches the midline) as the fluid resettles with gravity.
171
# Abdomen
describe puddle sign PE technique
Patient lies prone for 5 minutes, Patient then rises onto elbows and knees, Apply stethoscope diaphragm to most dependent Abdomen, Examiner repeatedly flicks near flank with finger, Continue to flick at same spot on Abdomen, Move stethoscope across Abdomen away from examiner, Sound loudness increases at farther edge of puddle, Sound transmission does not change when patient sits
172
# Abdomen
define:
* Blumberg Sign
* McBurnery Sign
* Rovsing Sign
* B: rebound pain at site of palpation (anywhere)
* M: rebound tenderness in RLQ suggestive of appendicitis
* R: RLQ pain upon palpation of the LLQ
173
# Abdomen
differentiate:
* iliopsoas sign
* obturator sign
* I: R hip flexion against resistance causes RLQ pain
* O: rotation of R hip causes pain in hypogastric area
174
# Abdomen
what is Kehr sign?
abd pain radiating to L shoulder; indicates splenic rupture, renal calculi, ectopic preg
175
# Abdomen
what is murphy's sign
abrupt stop of inspiration upon palpation of gall bladder due to pain
176
# Abdomen
what is courvoisier's sign?
distal CBD obstruction with a palpably enlarged but non-tender GB (carcinoma in head of pancreas)
177
# Breasts/Axilla
anatomical borders of the breast
* Lateral: latissimus dorsi
* Inferior: inframammary ridge
* Superior: second rib
* Medial: sternum
178
# Breasts/Axilla
which muscles form floor of breast?
* pec major/minor
* serratus anterior
* latissimus dorsi
* subscapularis
* external oblique
* rectus abdominis
179
# Breasts/Axilla
what are lactiferous ducts
drain milk from lobe onto surface of nipple
180
# Breasts/Axilla
what are montgomery tubercles
bumps on nipple from sebaceous glands around it
181
# Breasts/Axilla
lymphatic drainage pathways of the axilla
* the anterior axillary (pectoral) nodes are located along the lower border of the pectoralis major, inside the lateral axillary fold.
* The midaxillary (central) nodes are high in the axilla close to the ribs.
* The posterior axillary (subscapular) nodes lie along the lateral border of the scapula and deep in the posterior axillary fold
* The lateral axillary (brachial) nodes can be felt along the upper humerus.
182
# Breast/Axilla
what are supernumery nipples found along?
milk line
183
# Breast/Axilla
changes that occur during pregnancy
* lactiferous ducts proliferate
* alveoli increase in size & number (boobs increase in size)
* breasts become softer & looser
* colostrum is the first milk of pregnancy
* aerola become darker and bigger
184
# Breast/Axilla
what changes to breast are indicative of an underlying malignancy?
* unilateral venous pattern
* recent unilateral inversion of previously everted nipple
* nipple discharge
* painless lump
* palpable mass that is unilateral
* dimpled breast
* peau d'orange, thickened skin appearance
185
# Lymph
describe lymph drainage
lymph capillaries --> afferent lymph vessels --> lymph nodes --> efferent lymph vessels --> lymph trunk --> collecting duct --> L subclavian vein
186
# Lymph
what is Virchow's lymph node?
supraclavicular areas, probing deeply in the angle formed by the clavicle and the sternocleidomastoid muscle
if enlarged, sign of gastric cancer
187
# Lymph
describe matted lymph nodes
group of fused lymph nodes may be a sign of cancer or infection
188
# Lymph
describe shotty lymph nodes
clusters of small lymph nodes < 1 cm in children
189
# Lymph
what are hard, enlarged, non-tender, non-mobile lymph nodes a sign of?
malignancy
190
# Lymph
what are tender, mobile, firm, indurated lymph nodes a sign of?
inflammation
191
# Breast/Axilla
Tanner charts for breast development
* it is unusual for menses to begin before what stage?
* by what stage have most began menses?
* what stage is a breast bud?
* time from breast bud to first period?
* Stage III
* Stage IV
* Stage II
* 2 yrs
192
# Lymph
what is cellulitic streaking indicative of?
infection traveling through lymph
