FINAL Flashcards
1
Q
Inspection of arms
A
Inspect both arms and hands for symmetry and size, color and texture of the skin and nail beds, venous pattern, and edema. Compare both sides.
2
Q
Pulses of arms
A
Palpate the radial, ulnar and brachial pulses on both arms
Describe the pulse as increased (bounding), normal, diminished, or absent
3
Q
Allen’s Test
A
have pt raise arm, occlude both radial and ulnar arteries, have patient pump fist, bring hand down and un-occlude. Should see profusion in 3-5 seconds
Persisting pallor indicates occlusion of the ulnar or radial artery
4
Q
Purpose of Allen’s Test
A
assess the patency of the ulnar and radial arteries and the arteries of the hand
5
Q
Capillary Refill
A
hold patient’s hand at heart level and compress the nail for 5 seconds. The amount of time required for the nail to regains its normal color is capillary refill time.
6
Q
Purpose of Capillary Refill
A
test for assessing volume status.
7
Q
What are the upper limits of normal capillary refill (at room temp)?
A
children & adult men: 2 sec
adult women: 3 sec
elderly: 4 sec
8
Q
Where to palpate for the epitrochlear nodes?
A
palpate btwn the grooves of the biceps and triceps muscles, about 3 cm proximal to the medial epicondyle
9
Q
Which aspect of the hands do the epitrochlear nodes drain?
A
Ulnar aspect
10
Q
Inspection of legs
A
Inspect both legs and feet for their size and symmetry, color and texture of the skin and nails, hair distribution, ulceration, venous pattern or enlargement, and edema.
Inspect the great and small saphenous veins for varicosities (lying and standing).
11
Q
Locate pulsations of the femoral artery
A
just below the inguinal ligament, midway between the anterior superior iliac spine and the symphysis pubis
12
Q
Locate pulsations of the popliteal artery
A
the extension of the femoral artery that passes medially behind the femur, palpable just behind the knee
the patient’s knee should be flexed, with the leg relaxed. Place the fingertips of both hands so that they just meet in the midline behind the knee and press them deeply into the popliteal fossa. This is a difficult pulse to find.
13
Q
Locate pulsations of the dorsalis pedis artery
A
just lateral to the extensor tendon of the large toe. Place three fingers across dorsum of foot to increase odds of finding
14
Q
Locate pulsations of the posterior tibial artery
A
right behind the medial malleolus of the ankle (just up against bone)
15
Q
Homan’s sign
A
take hands around calf and gentle squeeze
also passive dorsal flexion (take foot and bend towards calf)
if either elicit pain —> + or Homan’s sign
16
Q
What does Homan’s sign test?
A
test for deep phlebitis
17
Q
How to assess for edema
A
press firmly with your thumb for at least 5 seconds to check for pitting. Note the degree of pitting in millimeters
18
Q
Pitting edema scale
A
trace (1+) = slight and rapid response
mild (2+) = 0-.6cm and 10-15 sec response
moderate (3+) = .6-1.3cm and 1-2 min response
severe (4+) = 1.3-2.5cm and 2-5 min response
19
Q
Palpate the superficial inguinal nodes
A
includes two groups, the horizontal group lies in a chain high in the anterior thigh below the inguinal ligament
the vertical group clusters near the saphenous vein
20
Q
Trendelenburg Test- how to perform
retrograde filling test
A
Start by examining for varicosities in legs by using tangential lighting,
Then with patient supine, elevate one leg to 90 degrees to empty it of venous blood
Occlude the superficial veins of the leg by applying a tourniquet and then have patient stand up.
looking to see if vein fills and if it does means that incompetence is deeper within thigh because superficial vein is occluded
then remove tourniquet and superficial will re-profuse
21
Q
Why perform the Trendelenburg test?
A
to asses the competency of the superficial and deep veins of the legs
22
Q
Beurger’s Test
A
If you note pallor, ulcers, loss of normal hair distribution, and diminished pulses, have the patient raise his or her leg to 60 degrees until maximal pallor develops (usually ~60 seconds).
23
Q
What findings of Beurger’s test suggest arterial insufficiency?
A
Marked pallor on elevation or increased time for color to return after the legs are set down (> 10 seconds) suggests arterial insufficiency
24
Q
Why perform Beurger’s test?
A
to assess for arterial insufficiency
25
Test for Coarctation of the Aorta
congenital narrowing in arotic arch that changes upper and lower circulation
feel femoral and radial pulse at the same time and feel delay in femoral pulse
26
Key physical exam finding for deep venous thrombosis are
pain and tenderness along the course of the major veins
unilateral pitting edema
swelling of the entire leg
calf swelling greater than 3 cm compared to the uninvolved leg
27
Wells criteria
assembles the more reliable signs, symptoms and risk factors into a decision rule that stratifies patients into high, medium or low probability of having a DVT. Patients with a low pretest probability can have DVT ruled out with a negative serum D-dimer. If they have a positive D-dimer they will need a compression ultrasound. Moderate and high probability Wells score should have compression ultrasound performed first.
28
Ankle Brachial Index (ABI) - how to perform test
1. Patient should rest supine in a warm room for at least 10 minutes before testing
2. Place blood pressure cuffs on both arms and ankle, then apply US gel over brachial, dorsalis pedis, and posterior tibial arteries
3. Measure systolic pressures in the arms (use vascular Doppler to locate brachial pulse, inflate cuff 20 mm Hg above last audible pulse, deflate cuff slowly and record pressure at which pulse become audible, obtain 2 measures in each arm and record the avg)
4. Measure systolic pressures in ankles (same technique as above)
5. Calculate ABI:
Right ABI = highest right avg ankle pressure/ highest avg arm pressure ( right or left)
Left ABI = highest left avg angle pressure/highest avg arm pressure ( right or left)
29
What constitutes a normal versus abnormal ABI
>.9 (with a range of .9-1.3) = normal lower extremity blood flow
< .89 to > .6 = mild PAD
< .59 to > .4 = moderate PAD
< .39 = severe PAD
30
Who is at risk of developing PAD?
smokers over 50
diabetics over 50
patients over 70
31
What are preliminary things to do before beginning gyn exam?
Have patient empty her bladder completely
Wash hands
Make eye contact with pt
32
Inspect breasts
this step not routinely done unless patient has noticed some changes in her breast
Ask patient to pull arms back so that she tightens skin over the breast. Then ask her to move hands over hips and tighten the muscles of her chest. Have her lean forward and raise her arms above her head to observe movement of both breasts.
Inspect for changes in shape (flattening, dimpling or bumps), color (redness or vein patterns), texture (thickening, like an orange peel) or in the appearance of the nipple.
*these maneuvers may reveal dimpling not seen before
33
Examine supraclavicular area and axilla (wear gloves)
While patient is still seated, feel above the clavicle bilaterally for supraclavicular nodes.
Examine the axilla while the patient is still seated. Support her (L) forearm with your (L) hand. Cup the finger of your (R) hand and reach into the apex of the axilla. Bringing the fingers down over the surface of the ribs, feel for the central nodes, then anteriorly and posteriorly for the pectoral, subscapular and lateral axillary nodes.
34
Positioning of patient for breast exam
Ask the patient to lie down pulling out the shelf to support her legs. Have her move her (R) arm under her head. Ask her to move her (R) bent knee towards left side to center her breast on her chest.
35
Palpation of breasts
Use the pads of your middle three fingers in a rotary motion at 3 progressive depths to compress the tissue. Begin at the periphery of the upper outer quadrant. Move across the breast from top to bottom. There will be less and less glandular tissue and more fatty tissue toward the bottom. If the patient has presented with a complaint of nipple discharge, squeeze the nipple with thumb and forefinger to express any discharge.
Repeat process on Left breast
36
signal beginning of pelvic exam
Tell patient that you are going to examine the external genitalia. Let her know that you’ll be placing the back of the non-dominant hand on her thigh to signal that the exam is about to begin.
37
examine external genitalia
Using the index and middle finger of the non-dominant hand, separate the labia majora from the labia minora on each side, and briefly inspect the area for obvious skin lesions. Evaluate any lesions by palpation, but avoid unnecessary manipulation of the vulva, particularly the clitoris. Conclude by separating the labia minora to inspect the urethral meatus and vaginal introitus. You may point out the hymenal tag if it is visible. Drawing the fingers upward slightly will reveal the glands of the clitoris.
38
palpate bartholin's glands
Explain to patient that you will now be inserting a finger very slightly into her vagina to check her Bartholin’s glands. Insert the index finger of the examining hand slightly into the vaginal introitus and briefly palpate at 5-7 o’clock between thumb and index finger.
39
findings for palpation of bartholin's glands
Ordinarily, you will not feel the Bartholin’s glands unless they are inflamed and swollen, in which case they would also be tender.
DDX of swelling of Bartholin’s glands:
Bartholin’s gland cyst, abscess, adenocarcinoma
40
Assess for pelvic support
Ask the patient to squeeze her muscles around your inserted finger to assess muscle tone. Then withdraw your finger, separate the labia using that hand Ask the patient to “bear down.” Observe for anterior wall bulging which may indicate a cystocele and posterior wall the presence of a rectocele.
41
Preparing to insert the speculum
Instruct the patient you will now be inserting the speculum. Touch the patient’s thigh with the speculum first, alerting her to its temperature. Separate labia with thumb and index finger to form an entrance. You may need to modify your technique based on the anatomy of your patient’s labia, and degree on relaxation.
42
A few considerations before inserting the speculum
warm speculum beforehand and check degree of warmth before insertion
a small amnt of KY jelly should be used
43
Speculum insertion
Hold the speculum in the dominant hand, keeping it closed between your index and middle fingers. Separate the labia with your non-dominant hand. Hold the speculum at the introitus and slowly insert it into the vagina with posterior pressure at a 45 degree or less angle downward, and continue to complete insertion. Have your assistant adjust the light. Gently open speculum until the cervix is visualized. Then tighten the thumbscrew and release the handle.
44
What if you can't visualize the cervix?
If the cervix is not visible when you begin opening the speculum, slightly sweep it upward and look for the cervix to come into view. If it is still not visible, withdraw the speculum and re-insert on another plane.
45
Observe cervix
Note any discharge. Observe the size, position, color and consistency of the cervix. See if the location of the squamocolumnar junction (margin between pink squamous epithelium of the cervix and red columnar epithelium near the os) is visible on the ectocervix. Assess the character of the transformation zone.
46
Normal and abnormal appearance of the cervix
Normal vaginal discharge may be thin, thick, clear or creamy. It is often heaviest and somewhat stringy during ovulation. An abnormal discharge is more likely to vary in color. The cervix should be pink and smooth and should not bleed easily when obtaining the pap smear. The squamocolumnar junction may be visible as a darker pink circle around the os (termed ectropion). Note any nodules or ulcerations of the cervix. The os will usually be small and round (in a nulliparous woman) or will appear as a horizontal or irregular slit (multiparous)
47
Wet prep
For a wet prep, insert a cotton-tipped applicator into the posterior fornix and obtain a sample of the vaginal discharge. Place swab in saline to preserve cells.
* Swabs should be done prior to the pap smear for best results
* It can be examined under the microscope for Candida albican, Trichomonas and Bacterial Vaginosis. Keep the sample warm
* can do Culture at same time, to be able to determine the type of bacteria present
48
Cervical culture and DNA probe
Culture: Insert a dry sterile swab into the os to the level of the cotton. Gently rotate once, holding the swab in the os for 30 seconds. Place swab in transport medium immediately.
This will help detect Streptoccocus and other bacteria
DNA Probe: The same procedure is used to assess for gonorrhea, and chlamydia. The swab in placed in a specialized collection tube and is sent out to assess via Polymerase Chain Reaction (PCR) for DNA for GC and chlamydia.
49
Pap smear
(a) Using the v shaped brush, insert the longer pole into the os and rotate 360 o with moderate pressure, making sure to obtain a sample from the squamocolumnar junction if it is visible. Drop the tip of the brush into the container.
(b) Insert the cytobrush in the os to the depth of the brush and rotate it once gently to obtain cells from the endocervix. Drop the cytobrush head into the liquid container.
50
Removing the speculum
Inform patient you will be removing the speculum. Place a hand on the speculum handle, maintaining pressure on the lever while completely loosening the thumbscrew. Withdraw the speculum past the cervix and then release the pressure on the lever. Observe the vaginal walls during speculum withdrawal
51
Palpate the cervix
Move the fingers to a palm up position to examine the cervix. Position the thumb to avoid the clitoris. Locate the cervix with the fingertips. Note the consistency of the surface. Move the cervix from side to side. Note any tenderness. (CMT)
52
Palpate the uterus
Place the palmar surfaces of the internal fingers at and under the os. Exert pressure upwards toward the pubis. At the same time, place the abdominal hand about midway between the umbilicus and the symphysis pubis. Press downward toward the internal hand to appreciate the size and shape of the uterus.
53
Assess adnexa
To assess the left adnexal region place the internal fingers in the left lateral fornix, palmer surface upward. Place the fingertips of the abdominal hand just medial to the iliac crest. Slightly cup the abdominal hand and then palpate toward the pubis in a dipping sweeping motion to permit the abdominal contents to move over the internal fingers trapping the ovary.
54
What percent of breast cancer is found in upper outer quadrant (tail)?
50%
55
What percent of breast cancer is found in areola-nipple complex?
18% (second most common site for breast cancer)
56
The risk of developing breast cancer increases with______?
age.
Eighteen percent (18%) of breast cancer diagnoses are among women in their 40s. Seventy-seven percent (77%) of women with breast cancer are older than 50.
also:
Inherited mutation in BRCA1 or BRCA2 leads to 80% chance of developing breast cancer
57
What are protective factors against the development of breast cancer?
late menarche and early menopause
pregnancy before age 30
physical activity
breast feeding
58
Note the following while doing a CBE
Color. Redness in mastitis and some inflammatory cancer.
Thickening of the skin with prominent pores (Peau d’orange). An indicator of malignancy.
Size and Symmetry. Note Tanner’s sexual maturity scale in young women.
Contour of the breast. Look for masses, dimpling or flattening of the normal contour.
Nipples. Note inversion, retraction, dermatitis around the areola. Consider Paget’s disease of the breast (usually associated with a mass). Nipples should point in symmetrical directions. Note any discharge.
59
What is the best practice for CBE?
Vertical Strip search pattern
Palpating with the finger pads of the 3 middle fingers and moving in dime-sized circular motions, applying 3 levels of pressure at each point.
60
If you note nodules or masses while palpating the breasts, be sure to chart which of the following?
location, size (in cm), shape, consistency, delimitation, and mobility (into skin, fascia, and chest wall)
61
The breast is delineated by which perimeters?
```
Clavicle superiorly
Lateral edge of sternum medially
Inframammary fold inferiorly
Latissimus dorsi muscle laterally
Line from lateral edge of clavicle to edge of latissimus dorsi at lower axillae
```
62
Which common errors should you avoid while doing a CBE?
Missing the axillary tail
Not palpating the nipple/areola complex
Inconsistent pressure
Pattern of search doesn’t extend to entire breast perimeter
63
Which signs of a mass should be concerning?
non-mobile because could indicate the cancer has adhered to the skin
64
the abdominal exam needs to be performed in which order?
inspection, auscultation, percussion, and light and deep palpation
65
What are you looking for upon inspection of the abdomen?
Skin markings: Scars, striae, dilated vessels.
Contour: Flatness. Distension, noting any of the “7 Fs”: fat, fluid, fetus, feces, flatus, fibroid, fatal growth.
Peristalsis: Increased with obstruction.
Pulsations: From vessels, abdominal aortic aneurysm..
Hernias: Most are umbilical.
Ecchymosis: Infiltration of the extraperitoneal tissues with blood
66
During auscultation high pitched tinkling sounds could indicate what?
Early obstruction
67
During auscultation absent sounds could indicate what?
Late mechanical obstruction or ileus (adynamic bowel)
68
During auscultation a secussion splash could indicate what?
Air and fluid, obstruction, pyloric stenosis
69
During auscultation a peritoneal friction rub could indicate what?
Inflammation
70
During auscultation borborygmus could indicate what?
Gastroenteritis
71
During auscultation you should listen over which arteries for bruits?
Aorta and renal, iliac, and femoral arteries:
72
During auscultation bruits over aorta and renal, iliac, and femoral arteries could indicate what?
Obstruction
73
Percussion: measure the liver span
Measure the liver span at the mid-clavicular line (MCL).
1. Percuss downward from the chest in the right MCL until you detect the top edge of liver dullness.
2. Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness.
3. Measure the liver span between these two points; this measurement should be 6-12 cm in a normal adult.
74
Percussion: Splenic Percussion Sign
1. Percuss the lowest costal interspace in the left anterior axillary line. This area is normally tympanic.
2. Ask the patient to take a deep breath and percuss this area again. Dullness in this area is a sign of splenic enlargement.
✏ There is approximately .20 false positive rate with this test.
3. If in doubt, percuss medially to laterally in Traube’s space until dullness is elicited; this normally occurs at about the mid-axillary line.
75
Light palpation accomplishes what?
Help the patient to relax. Note any guarding or tenderness, hyperesthesia, rigidity
76
What should you have patient do before beginning deep palpation?
BEND KNEES
77
Deep palpation of the abdomen:
1. Palpate all quadrants, outlining and identifying any masses and noting any tenderness or guarding.
2. Palpate liver, noting any tenderness. The edge should be smooth and non-tender.
3. Palpate the kidneys. Feel for the right kidney between iliac crest and costal margin; you may be able to palpate the lower pole on inspiration. The left kidney is seldom palpable.
4. Be careful with palpation of the spleen after trauma.
5. Measure the width of the aorta; the normal size is ~3 cm. A large pulsatile mass is suggestive of aortic aneurism.
Palpate any areas protrusion of abdomen (bulging flanks)
78
What tests should you perform for appendicitis and in what order?
1. Rovsing's sign - referred rebound tenderness at McBurney's point
2. Obturator sign - internal rotation of flexed thigh
3. Psoas sign - flexion of thigh against resistance
4. McBurney's point- midway between ASIS and umbilicus on the right side
5. Rectal exam - for occult blood; right-sided tenderness with appendicitis
79
What tests should you perform for Ascites?
Percuss for shifting dullness
Fluid wave
Ankle edema
Inspect for bulging flanks
80
What test should you perform for peritonitis?
Blumberg’s sign
pain felt upon sudden release of steadily applied pressure on a suspected area of the abdomen
Guarding (voluntary) and rigidity (involuntary)
Percussion tenderness
Cough test
Carnett's sign - crunch elicits pain argues AGAINST peritonitis
Markle sign (Heel Jar Test)
Absent bowel sounds
81
What tests should you perform for cholecystitis?
Murphy’s sign
indicated by inspiratory arrest on deep inspiration (hooking hands is best) with palpation under the right costal margin
Courvoisier sign
A palpable, non-tender gallbladder (mass) in the right upper quadrant. The patient often has jaundice. You should suspect cancer, not cholecystitis
82
Which three signs and symptoms indicate a high positive likelihood ratio for appendicitis?
Right lower quadrant pain
Migration of pain
McBurney’s point tenderness
83
What are the findings for bowel obstruction?
visible peristalsis (rare finding), abdominal distention, and hyperactive bowel sounds wall suggest bowel obstruction
84
What exam should you perform with suspected pyelonephritis?
Costovertebral angle tenderness
start with thumb pressure and progress to percussion of the costophrenic angle. Pain indicates distension of renal capsule.
85
What three problems can cause ascites?
Biventricular heart failure
Low oncotic pressure from protein loss (i.e. nephrotic syndrome) or reduced synthesis (malnutrition and cirrhosis)
Peritoneal inflammation (neoplastic, infectious)
86
What might account for a laterally displaced apical impulse?
enlargement of the heart or mediastinal abnormalities
87
What does an apical impulse greater than 2.5 cm indicate?
suggest left ventricle hypertrophy
88
Note the following when assessing the API
location
duration
amplitude
diameter
89
Order for auscultation of the heart
listen over carotids (with bell)
| listen over aortic, pulmonic, erb's, tricuspid and mitral areas with both bell and diaphragm
90
Listen for S1
at apex (5th IS at MCL)
91
Listen for S2
at base (2nd IS)
92
The bell is better for picking up which sounds?
Low pitched sounds
93
The diaphragm is better for picking up which sounds?
High pitched sounds
94
The patient lying on the left side, partially rolled over in left lateral decubitus position is best for listening to which heart sounds?
This position is particularly helpful for hearing S3 and S4 sounds and palpating faint apical impulses
95
Patient sitting up and leaning forward. Ask the patient to fully exhale and hold it
Listening in the tricuspid area will help you appreciate aortic murmurs, particularly the murmur of aortic regurgitation.
96
Physiologic splitting of S2 occurs when?
During inhalation, heard especially at the base of the heart
should disappear with exhalation
97
JVD measurements greater than 3-4cm above the sternal angle are seen in patients with which conditions?
Hypervolemia, RCHF, SVC obstruction, tricuspid stenosis of regurgitation
98
Abdominojugular reflex is an alternate test to assess for
jugular venous pulses
99
Performing the Abdominojugular reflex test
1. Position the patient so the jugular pulse is seen in the lower half of the neck.
2. Press firmly on a partially inflated BP cuff (20-35 mmHg) in the periumbilical area for 15-30 seconds.
3. Watch for a sustained rise in jugular venous pressure (> 4 cm).
+ a transient rise in the position of the jugular venous pulse of 10 sec or less is normal
100
Significance of abdominojugular relfex test
Positive in subclinical RCHF and negative in SVC obstruction
101
Aspects of a murmur that you should note
Timing: Systolic or diastolic?
Configuration: What’s the shape of the sound?
Location: Where is the maximum intensity?
Radiation: Does the murmur radiate?
Intensity: What is the grade (I-VI)?
Quality: Does the murmur sound musical, blowing, harsh, or rumbling?
Pitch: Is the murmur high-pitched or low-pitched?
Hemodynamic changes: What effects do inspiration, Valsalva, and squatting have?
102
Diastolic murmurs usu indicate
disease
103
Systolic murmurs may indicate
disease or may be present in healthy hearts
104
If you hear a murmur with a palpable thrill, what grade might it be?
Grades 4-6
105
hemodynamic maneuvers:
| MVP
Inspiration- none
Valsalva- click & murmur occur closer to S1 (earlier)
Squatting- click & murmur occur closer to S2 (delayed)
106
hemodynamic maneuvers:
| LCHF
Inspiration- decrease
Valsalva- increase
Squatting- decrease
107
hemodynamic maneuvers:
| Pulmonic stenosis
Inspiration- increase
Valsalva- decrease
Squatting- increase
108
hemodynamic maneuvers:
| Hypertrophic cardiomyopathy
Inspiration- none
Valsalva- louder
Squatting- quieter
109
An S3 gallop is produced by
rapid diastolic filling of the left ventricle in “stiff” ventricles. caused by cardiomyopathies, CHF, or ischemic heart disease
110
An S4 gallops is produced by
atrial contractions causing a snap
caused by conditions that lead to left and right ventricular overload: systemic hypertension, pulmonary hypertension, aortic and pulmonic stenosis
