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PD Year 1 > Final > Flashcards

Final Flashcards

1
Q

•With the arm at _______, center the inflatable bladder over the ____________

A

heart level, brachial artery

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2
Q

•Posterior tibial A palp

A

–Curve your fingers behind and slightly below medial malleolus of the ankle

tom dick an harry

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3
Q

Palpation
Left sternal Border –Right Ventricle

A

Patient supine position at 30 degrees

Place your curved fingers in the 3rd,4th and 5th interspaces at the left sternal border and try to feel the systolic impulse of the right ventricle

You can ask patient to breath out and then briefly stop breathing to improve your exam

Feel for a right sided S3 and S4 in 4th and 5th interspaces

If impulse felt- assess location, amplitude and duration

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4
Q

In order to measure the JVP in a patient who is extremely hypovolemic you may need to:

a) raise the head of the bed to 90 degrees
b) lower the head of the bed to 0 degrees

A

lower the head of the bed to 0 degrees

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5
Q

Venous congestion causes what for bp’s?

A

–falsely low systolic and high diastolic readings

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6
Q

Read both systolic and diastolic levels to

A

•nearest 2 mm Hg

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7
Q

While performing abdominal auscultation on the same patient, you hear a bruit. You proceed to palpate the area and you feel a >3cm pulsatile mass.

You are concerned that you are feeling an:

A

Abdominal Aortic Aneurysm

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8
Q

Diastolic murmurs

A

b/w s2 –> s1

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9
Q

A 39 year old woman presents to your office with fatigue. Which of the following patient responses during the General History would warrant further investigation?

  1. She goes to bed at 1 am and awakens at 4 am each day for work.
  2. She is frequently awakened during the night by her husband’s snoring.
  3. She works 12-15 hour days during the week and brings work home on the weekend.
  4. She has lost 15 lbs unintentionally in the last 6 months and is experiencing night sweats.
A

1.She has lost 15 lbs unintentionally in the last 6 months and is experiencing night sweats.

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10
Q

A patient presents with a chief complaint of shortness of breath. During the interview you ask, “How does the shortness of breath affect your daily activities?”. This information belongs in:

a) Review of systems
b) Physical exam
c) History of present illness
d) Assessment

A

a)History of present illness

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11
Q

•General Survey: Physical Exam (objective)

A

–Part of the “Physical Examination”

–Physician examines elements that relate to the patient’s general state of health- Physical Findings

•The physician’s “assessment/observation” of the patient

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12
Q

•Challenges of pain management

A

–Treatment complex

  • Requires knowledge of multiple types of analgesics
  • Behavioral therapy
  • Physical therapy

–Risk of overdose

–More than 40% of patients report that their pain is poorly controlled

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13
Q

•Electronic thermometer methods

A

–Place the disposable cover over the probe

–Insert under the tongue

–Have the patient close both lips

–Watch for digital readout

–Takes about 10 seconds

–Preferred due to risk of breakage, mercury exposure with glass thermometer

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14
Q

A 68 year old female presents with a productive cough and fever. During pulmonary auscultation you hear the following on inhalation of the right middle lobe. These sounds are consistent with:

a) Rhonchi
b) Crackles
c) Wheezes
d) Stridor
e) Pleural rub

A

Crackles

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15
Q

Which of the following is correct?

A.The appearance of the first “Korotkoff” sound is the diastolic blood pressure

B.The lower border of the blood pressure cuff should be placed about 2.5 cm above the ante-cubital crease/fossa

C.The systolic blood pressure is defined by the “disappearance point”

A

A.The lower border of the blood pressure cuff should be placed about 2.5 cm above the ante-cubital crease/fossa

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16
Q

To determine how high to raise the cuff pressure… stes

A

1.palpation

  • feel radial A –> rapidly inflate cuff until pulse disappears
  • add 30mmHg to it
  • use as target for subsequent inflations

–prevents discomfort from unnecessarily high cuff pressures

–avoids the occasional error caused by an auscultatory gap

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17
Q

ORTHOSTATIC HYPOTENSION

A
  • A fall in systolic BP > 20 mmHg upon standing
  • A fall in diastolic BP > 10 mm Hg upon standing
  • With symptoms and tachycardia

–Lightheaded or dizzy

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18
Q

•Bradycardia

A

–<60 beats per minute

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19
Q

When auscultating, you hear split heart sounds. Which of the following is correct?

•

A.In general, split heart sounds are pathological

B.A2 heart sound is often heard louder than P2 due to the high pressure in the aorta

C.P2 heart sound is often heard louder than A2 reflecting the higher pressure in the pulmonary artery

D.Only S2 is split into A2 and P2, S1 heart sound does not split as it does not vary with respiration

A

A.A2 heart sound is often heard louder than P2 due to the high pressure in the aorta

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20
Q

types of crackles sounds

A

fine:

  • beginning of fluid buildup/atelectasis
  • Often high pitched
  • Very brief

coarse:

greater volume of fluid buildup

  • •Louder
  • •Lower in pitch
  • •Often described as velcro being pulled apart
  • •Louder in inspiration
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21
Q

Evaluation of Swelling or Edema

A
  • Unilateral or bilateral?
  • Grade? (pic)
  • How far up the leg?
  • Location of edema suggests site of occlusion

•Measure the calves 10 cm below the tibial tuberosity

  • Normal difference in calf circumference <3cm
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22
Q

A 24 year old male with no significant past medical history presents with 1 week of severe vomiting and diarrhea. He is unable to keep down any liquids or solids. He appears pale, weak, ill and lethargic. You suspect that he is severely dehydrated. Which of the following would you expect to find on exam?

A.Bradycardia

B.Orthostatic hypotension

C.A normal general survey

D.An increased (widened) pulse pressure

A
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23
Q

stare of hyperthyroidism

A

Sustained and unblinking

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24
Q

Distinguishing Between
S1 and S2

A

palp carotid while listening to heart sounds

S1 will occur just before the carotid upstroke

S2 will follow the carotid upstroke

S1 normally heard louder than S2 at the apex

S2 normally heard louder than S1 at the base

S1 is the “lub” S2 is the “dub”

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25
Q

Glass thermometer method

A

Shake down to <35oC (96oF)

Insert under tongue

Have patient close both lips

Wait 3-5 minutes

Read

Reinsert for 1 minute and read again

If still rising repeat until stable

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26
Q

–Iliofemoral vein occlusion = presentation

A
  • painful, pale swollen leg
  • tenderness in the groin
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27
Q

Displacement of the apical impulse may seen in

A

Êpregnancy, cardiac enlargement

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28
Q

A 68 year old man with a history of hyperlipidemia, diabetes mellitus, and hypertension complains of pain in his right calf whenever he walks one block. He states that the pain resolves with 10 minutes of rest. He has a 40 pack year smoking history.

Which of the following would be most likely found on exam?

  1. Marked peripheral edema
  2. An ulcer over the left lateral malleolus
  3. An ulcer over the left great toe
  4. Homan’s sign

●

A

An ulcer over the left great toe

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29
Q

Physiologic Splitting of S2

A
  • Made up of Aortic closure and Pulmonic Closure (A2 P2)
  • Left sided events in the heart precede right sided events
  • aortic during exhale = slightly earlier than pulm

inhal = increase venous return –> delays pulm closure

= decrease SV –> early closure of aortic

https://www.easyauscultation.com/cases-waveform?coursecaseorder=3&courseid=22

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30
Q

Jugular Venous Pulsations and Waveforms

A

look for pulsations right behind SCM or suprasternal notch

observe R IJ

pt supine @ 30degrees

turn head to opp side –> pen light

  • if volume depleted = lower head
  • if volume overloaded = raise head
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31
Q

Rhonchi: charavteristics

A
  • Low pitch with snoring quality
  • Can be heard throughout inspiration and expiration
  • Louder than crackles due to larger secretions
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32
Q

MEASUREMENT BASED CARE OF CHRONIC PAIN

A
  1. Pain intensity and interference with daily activities
  2. Mood (depression, anxiety)
  3. Effect of pain on sleep
  4. Risk of co-occurring substance abuse
  5. Opioid dose and calculate dose equivalency
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33
Q

The timing of this murmur is:

a) holosystolic
b) late systolic
c) early diastolic
d) systolic ejection
e) presystolic

A

holosystolic

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34
Q

•Tachypnea (adult abnorm)

A

–~>20 breaths per minute in an adult

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35
Q

Regarding the apical impulse:

a) It is normally the size of a dime
b) It is normally located at about the second intercostal space at the mid-clavicular line
c) It normally can be felt through the first two thirds of systole
d) It is normally high, slow and rumbling in amplitude

A

It normally can be felt through the first two thirds of systole

a = nickel

b = 5th IC space, 1/2in medial of mid-clav line

d = small, brisk and tapping in amp

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36
Q

temp methods: axillary

A

–Lower than oral temperatures by 1o C

–Takes 5-10 minutes to register

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37
Q

JNC 7/8 BLOOD PRESSURE CLASSIFICATION FOR ADULTS

A
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38
Q

Ankle-brachial Index (ABI)
Noninvasive Diagnosis of PAD

A
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39
Q

Deep Venous Thrombosis

A

•Palpate for venous tenderness or cords

  • inguinal area, medial to femoral pulse
  • calf: pt’s knee flexed and relaxed - gentle compress M aga tibia with fingerpads

absence of tenderness/cords does NOT rule out DVT

homans!!

  • •Discomfort behind the knee with forced dorsiflexion of the foot
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40
Q

Midsystolic murmur

A

This occurs after S1

slight gap after S1 before the murmur starts

ends before S2

Aortic and Pulmonic Stenosis.

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41
Q

normal RR in adults =

A

12-20

look when pt isn’t looking to not affect it

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42
Q

S4 Gallop

A

end of diastole: contraction of atria “atrial kick”

  • •Atria ejects stream of blood into stiff hypertrophic ventricle causing reverberation
  • Pathologic:
  • Failing, hypertrophic left ventricle
  • Hypertension
  • Severe Aortic Stenosis
  • Hypertrophic Cardiomyopathy

http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=25

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43
Q

Upon palpation of the precordium you notice a prominent pulsation in the left second interspace. Which of the following could explain your finding.

a) Left Ventricular Hypertrophy
b) Aortic Aneurysm
c) Pulmonary Artery dilation
d) Dextrocardia

A

Dextrocardia

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44
Q

if there is irregular ryhtym, listen at the ________

A

cardiac apex

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45
Q

Isometric Hand Grip

A

increase intensity of systolic murmurs Mitral regurgitation, and Ventricular septal defect

increase intensity of diastolic murmurs of pulmonic stenosis, mitral stenosis and Aortic regurgitation

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46
Q

heart P chart

A
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47
Q

S2

A

semilunar: aortic > pulm

splitting = during inspiration

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48
Q

IDIOPATHIC PAIN

A

•Pain without an identifiable etiology

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49
Q

f/u Q about productive cough

A

Quality

Quantity of sputum

Presence of blood ( hemoptysis verses other sources of blood)

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50
Q

A 35 year old female presents for a comprehensive evaluation. Her vital signs are: Temperature: 98.7oF, Heart Rate: 112 bpm, Respiratory Rate: 16 bpm, Blood pressure: 120/65 mm Hg. This patient has which of the following?

A.Hypertension

B.Bradycardia

C.Tachypnea

D.Tachycardia

E.Bradypnea

A

A.Tachycardia

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51
Q

•Normal response to standing

A

–Blood pools in the LE and abd & slight drop in cardiac output

–SBP: No change or slight decrease

–DBP: No change or slight increase

–HR: NL increase of 5-20 bpm

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52
Q

Numeric Grading System for Peripheral Pulses

A
  • Bounding pulses may indicate aortic insufficiency
  • Asymmetric pulses occur in arterial occlusion
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53
Q

•Tachycardia

A

–>100 beats per minute

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54
Q

what is the least accurate temp taking

A

Axillary

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55
Q

Great saphenous

A

dorsum of food

anterior to medial malleolus

up medial aspect of leg

joins femoral vein below inguinal ligament

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56
Q

murmurs by location: erb’s point

A

aortic regurg

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57
Q

what is this sound?

A

Friction Rub

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58
Q

A 35 year old female presents for a comprehensive evaluation. Her vital signs are: Temperature: 98.7oF, Heart Rate: 98 bpm, Respiratory Rate: 30 bpm, Blood pressure: 120/65 mm Hg. This patient has which of the following?

A.Hypertension

B.Bradycardia

C.Tachypnea

D.Hypotension

E.Bradypnea

A

A.Tachypnea

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59
Q

Apical Impulse

A

the 5th intercostal space in the mid clavicular line

VISIBLE! = usually PMI

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60
Q

Physiologic (innocent) Murmurs:

A
  • Caused by increased blood flow across normal valve anatomy
  • Due to conditions that are outside of heart
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61
Q

OTHER THINGS TO LOOK FOR WHEN ASSESSING RESPIRATORY RATE AND RHYTHM

A

•Effort

–Signs of increased work of breathing

  • Accessory muscle use
  • Supraclavicular retraction
  • Distress

–Diaphoresis, anxiety, altered mental status

•General survey and skin findings

–Nail clubbing, cyanosis, pallor

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62
Q

Oral temp can be affect by

not recommended if

higher/lower than core body temp?

A

–Not recommended if: unconscious, restless, can’t close mouth

–Affected by: hot/cold liquids, smoking

–Lower than core body temp

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63
Q

http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=29

A

Patent Ductus Arteriosus

continuous murmur - loudest in systole

–Loud

–Harsh, machinery like

–Medium pitched

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64
Q

palp pop A

A

flex knee with leg relaxed, place fingertips of both hands so that they meet in the midline behind knee

DEEP! and more diffuse –> diff to find

–Alternative: patient is prone, knee is flexed to 90o, lower leg is resting against your shoulder or upper arm, press both thumbs deeply into popliteal fossa

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65
Q

A 12 Yo male presents for a pre-participation sports physical. He has no complaints. His family history includes 2 relatives that died suddenly in their late teens from “heart problems”. On examination you hear a systolic murmur and suspect hypertrophic cardiomyopathy. You would like to distinguish the murmur of hypertrophic cardiomyopathy from the murmur of aortic stenosis. Which of the following will increase the loudness of the murmur of hypertrophic cardiomyopathy :

a. Squatting position
b. Performing Valsalva maneuver
c. Release of the Valsalva
d. Sitting up and leaning forward

●

A

a.Performing Valsalva maneuver

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66
Q

A 64 year old male with a history of tobacco use (60 pack year) presents for an evaluation. On General Survey, you note clubbing of his nails. Upon auscultation, during exhalation, you hear the following diffusely throughout the entire thorax. This sound is consistent with a:

a. Normal finding
b. Wheeze
c. Crackle
d. Friction Rub

A

Wheeze

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67
Q

A 24 year old male with no significant past medical history presents with 1 week of severe vomiting and diarrhea. He is unable to keep down any liquids or solids. He appears pale, weak, ill and lethargic. You suspect that he is severely dehydrated. Which of the following would you expect to find on exam?

A.Bradycardia

B.Orthostatic hypotension

C.A normal general survey

D.An increased (widened) pulse pressure

A

A.Orthostatic hypotension

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68
Q

what is a –Normal response to hard work, sustained stress/grief

A

Fatigue

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69
Q

what is this sound

A

Characteristics:

Creaking, leathery sound

End of inspiration and beginning of expiration

Etiology:

Caused by rubbing of inflamed pleural surfaces against lung tissue

Clinical Causes:

–Pleural effusion

–Pleuritis

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70
Q

technique for Tactile Fremitus

A

unar base of hand

Have them repeat “ninety-nine” or “one-one-one.”

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71
Q

–Popliteal vein occlusion = presentation?

A

swollen lower leg/ankle

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72
Q

Poor sound transmission during auscultation might be due to

A

–Pleural effusion

–Pneumothorax

–COPD

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73
Q

bradycadia (adult abnorm)

A

less than 60 bpm

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74
Q

normal upstroke of carotid pulse

A

brisk, smooth, immediately follows S1

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75
Q

pulse pressure

A

difference between systolic and diastolic pressures

•“Normal” is approximately 30-40 mmHg

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76
Q

Pulsatile mass in the abdomen suggests

A

•abdominal aortic aneurysm

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77
Q

ØDecreased Tactile Fremitus: bilateral

A

copd

chest wall thickening

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78
Q

This patient’s femoral, popliteal, dorsalis pedis and posterior tibial pulses are each 1+ bilaterally. You would describe these pulses as:

a) bounding
b) brisk
c) diminished
d) absent

A

a)diminished

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79
Q

Positioning of the Patient During the Cardiac Exam

A
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80
Q

special maneuvers of auscultation

A

left lateral

lean forward and exhale –> listen at apex

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81
Q

diaphragm: shape and what kind of sounds

A

Diaphragm (flat across)High pitched sounds

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82
Q

•If you find an auscultatory gap

A

–record your findings completely (e.g., 200/98 with an auscultatory gap from 170–150).

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83
Q

Heaves or lifts-

A

§Movement of the thorax and ribs as a result of forceful ventricular contraction, or Hyperdynamic muscle

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84
Q

Gradations of Murmurs

A
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85
Q

Pain and cramping in the legs during exertion that is relieved by rest is termed?

A

Intermittent claudication

pain and/or cramping in the lower leg due to inadequate blood flow to the muscles

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86
Q

Location of edema suggests site of _________

A

occulusion

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87
Q

What is the correct order of the examination of the Thorax and Lungs?

a) Inspection, palpation, percussion, auscultation, special tests
b) Percussion, auscultation, special tests, inspection, palpation
c) Palpation, inspection, percussion, auscultation, special tests
d) Special tests, Inspection, palpation, percussion, auscultation

●

A

a)Inspection, palpation, percussion, auscultation, special tests

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88
Q

how to measure A.Orthostatic hypotension

A
  • Measure BP and HR supine (after pt. has rested for 3-10 minutes) and then within 3 minutes after the pt. stands up
  • Defined as

–Drop in Systolic BP > 20 mm Hg

or

–Drop in Diastolic BP > 10 mm Hg

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89
Q

To enhance the auscultation at the apex, which important maneuver should you perform?

a) Place the patient in the supine position with the head elevated at 30 degrees
b) Have the Patient sit and lean forward
c) Place the patient in the left lateral decubitus position
d) Place the patient in the supine position with the head of the bed at 60 degrees

●

A

a)Place the patient in the left lateral decubitus position

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90
Q

Systolic murmurs

A

b/w s1-s2

•Can be further categorized as early, mid, late or holosytolic

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91
Q

SOMATIC (NOCICEPTIVE) PAIN •Modulated by

A

–Psychological processes

–Neurotransmitters (endorphins, histamines, acetylcholine, serotonin, norepinephrine and dopamine)

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92
Q

Measuring the JVP:

normal?

what’s the point?

A

highest oscillation pt of IJ –> sternal angle in centimeters

Normal is < 3cm above the sternal angle or < 8cm above the right atrium

The JVP provides a rapid estimate of the CVP (central venous pressure) useful in assessing volume status, especially for congestive heart failure

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93
Q

murmurs by location: mitral

A

normal S1, S2, (S3, S4)

MVP

mid systolic clikc

OS

mitral regurg

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94
Q

symptoms of peripheral artery disease being….

A

one level below level of arterial narrowing

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95
Q

THE FOUR CARDINAL VITAL SIGNS

A
  • Blood pressure (BP)
  • Heart rate (HR)
  • Respiratory rate (RR)
  • Temperature (T)
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96
Q

how to tell the difference b/w if you are palp the internal jugular vein or carotid artery?

A

if you press down on it, pulsations should go away with the vein

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97
Q

Pericardial Friction Rub

A

2 layers of inflammed pericaridum rubbing together

“velcro”

high pitched: heard best with diaphragm

http://www.easyauscultation.com/cases-waveform?coursecaseorder=6&courseid=28

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98
Q

A 55yo male presents with a complaint of “shortness of breath”. Upon further expansion of the chief complaint using the OPPQRSST+ AA you find that he has been waking up in the middle of the night, usually about 2 hours after going to bed with sudden shortness of breath. You would record this symptom as:

a) Paroxysmal nocturnal dyspnea
b) Orthopnea
c) Angina
d) Dyspnea

A

a)Paroxysmal nocturnal dyspnea

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99
Q

Lower border of the cuff should be about

A

•2.5 cm above the antecubital crease

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100
Q

Allen test

A
  • Test for occlusive disease of the ulnar and radial arteries
  • Should be done before any procedure that punctures the radial artery
  • Procedure:
  1. Patient makes tight fist with one hand
  2. Compress both radial and ulnar arteries firmly between thumb and fingers
  3. Ask patient to open hand into relaxed, slightly flexed position, the palm is pale
  4. Release pressure over the ulnar artery – if patent, palm flushes within about 3-5 seconds
  5. Test patency of radial artery by releasing pressure over radial artery while ulnar artery still compressed
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101
Q

A 32-year-old male with no past medical history presents for an evaluation. During the cardiac examination, you auscultate at the pulmonic area and hear the following during inspiration :

This is due to:

a) splitting of S1 and increased preload
b) splitting of S1 and decreased preload
c) splitting of S2 and increased preload
d) splitting of S2 and decreased preload

A

a)splitting of S2 and increased preload

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102
Q

Palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking are called:

a) Retractions
b) Tactile fremitus
c) Percussion
d) Transmitted voice sounds

A

a)Tactile fremitus

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103
Q

SOMATIC (NOCICEPTIVE) PAIN

A

•Linked to tissue damage (afferent A-delta, C-fibers)

  • –Skin
  • –Musculoskeletal
  • –Viscera

Sensitized by inflammatory mediators

Sensory nervous system intact

  • –Examples
    • •Arthritis
    • •Spinal stenosis

•Acute or chronic

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104
Q

Bell: shape and what kind of sounds

A

Bell (concave in shape) Low pitched sounds

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105
Q

Heart Murmurs

A

•Sounds that occur when blood flows across valves in the heart

sound created is loud enough to be detected with a stethoscope

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106
Q

STEPS TO ENSURE ACCURATE BP MEASUREMENT

A
  1. avoid exercise, smoking, caffeine for 30 min prior
  2. exam room = quiet, comfortably warm
  3. pt sits quietly in chair with feet on floor for 5min
  4. no clothing, scarring, lymphedema (breast ca)
  5. palp brachial A for pulse
  6. position arm so brachail A @ heart lvl (4th intercostal)
  7. rest arm on table, above pt’s waist, support arm @ mid chest lvl
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107
Q

Broncho-vesicular or Bronchial Breath Sounds Heard in Distant Locations means

A

air-filled lung has been replaced by fluid-filled or solid lung tissue.

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108
Q

A 47 year old female with a BMI of 42 presents for evaluation. You suspect that your standard adult blood pressure cuff will not fit on her arm. Which of the following is the correct way to size her blood pressure cuff?

A.The width of the inflatable bladder should be about 80% of the upper arm circumference

B.The width of the inflatable bladder should be about 40% of the upper arm circumference

C.The length of the inflatable cuff should be about 20% of the upper arm length

D.The length of the inflatable cuff should be about 50% of the upper arm length

E.The length of the inflatable cuff should be about 60% of the upper arm circumference

A

A.The width of the inflatable bladder should be about 40% of the upper arm circumference

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109
Q

Distinguishing
Percussion Notes

A

•In general air filled tissues are “resonant”

–Such as lung tissue

•Fluid filled or solid tissues are dull.

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110
Q

•White Coat Hypertension

A

–the office blood pressure is high but ambulatory pressures are normal

–cardiovascular risk is low

–constituting roughly 15% to 20% of Stage 1 hypertensives

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111
Q

murmurs by location: pulmonic

A

innocent

ASD

PDA

splitting s2

pulmonic regurg/stenosis

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112
Q

•Axillary temperatures

A

─Lower than oral temperatures by approximately 1°

─Generally considered less accurate than other measurements.

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113
Q

cough: Subacute

A

3-8 weeks

causes:

  • post infectious cough
  • Bacterial sinusitis
  • asthma
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114
Q

•Review of Systems (subjective)

A

–Part of the “Health History”

–Physician asks questions that are related to the patient’s general state of health

–Patient reports the their answers to the questions

–Include: Weight changes? Fatigue and weakness? Fever, chills, night sweats? Pain?

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115
Q

A 35 yo female with history of tobacco use (40 pack years) presents with cough for the past 5 weeks.

While performing the physical examination you:

  • press your left 3rd finger distal inter-phalangeal joint firmly on her posterior chest
  • Then, strike that joint with your right third finger with a quick, sharp taps and relaxed wrist motion, at right angles to your left third finger

What physical exam technique is this?

A

Percussion

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116
Q

–Wide Pulse Pressure (increased)

A

(>50mm Hg)

•Pulse will feel strong and bounding on palpation

  • •Increased stroke volume
  • •(Coarctation of the aorta)
  • •(Aortic Regurgitation )
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117
Q

tips for handling bp in Obese patient

A

•use a 16 cm cuff, thigh cuff or very long cuff

use cuff on forearm and palpate radial pulse

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118
Q

Pitch of the Murmur

A

Determined by auscultation

bell = low pitch

Diaphram = medium to high

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119
Q

how to improve palp of apical impulse?

A

left lateral decubitus

ask pt to stop breathing

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120
Q

Palpation of the
Anterior Chest – Expansion

normal =

A

–Normal expansion is about 2”-5“

same circling hand technique as posterior chest wall

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121
Q

Abdominal Aortic Aneurysm (AAA)

A
  • >3 cm suggestive
  • Risk factors
  • –Older age
  • –Male
  • –Smoking
  • –Family history
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122
Q

clinically significant weight loss

A

• >5% of usual over 6 months

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123
Q

In order to measure the JVP in a patient who is extremely hypovolemic you may need to:

a) raise the head of the bed to 90 degrees
b) lower the head of the bed to 0 degrees

•

A

lower the head of the bed to 0 degrees

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124
Q

Hemoptysis

A

•Coughing blood from the lungs

uImportant to distinguish from non pulmonary sources of blood

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125
Q

•Epitrochlear lymph nodes

A

medial surf of arm - approx 3cm aove elbow

–Drain ulnar surface of forearm and hand, 4th and 5th fingers, adjacent middle finger

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126
Q

•“Four A’s”

A

–Analgesia

–Activities of daily living

–Adverse effects

–Aberrant drug-related behavior

•Drug seeking, use despite harm, compulsive use, craving

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127
Q

http://www.easyauscultation.com/cases-waveform?coursecaseorder=2&courseid=30

A

aortic stenosis

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128
Q

You note that Mr. C’s JVP measurement is 5cm above the sternal angle. This finding is:

a) normal
b) below normal
c) above normal

A

above normal

: > 3cm above the sternal angle is considered elevated

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129
Q

clinical causes of rhonchi

A

Pneumonia

Bronchitis

Chronic Obstructive Pulmonary Disease ( COPD)

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130
Q

Early diastolic decrescendo Murmur

A

immediately after s2, fades before s1

Aortic and Pulmonic Regurgitation

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131
Q

Korotkoff sounds are ___ in pitch, and better heard with the ____

A

low, bell

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132
Q

Bruit

A

–turbulent blood flow

–blood flows through an artery that is narrowed

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133
Q

You would like to examine the Jugular Venous Pressure (JVP) in your patient. The usual starting point for the assessing the patient’s JVP is to elevate the head of the bed to:

a) 60 degrees
b) 180 degrees
c) 30 degrees
d) 90 degrees

A

30 degrees

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134
Q

Radiation of murmurs

A
  • Direction that the sound moves away from the area of greatest intensity
  • Rule of thumb: radiation of sound is in the direction of the blood flow away from the point of maximal intensity
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135
Q

•Measure BP and HR in 2 positions….

what is the effect that is normal

A

–Supine – after resting 3-10 minutes

–Standing – within 3 minutes after patient stands up

•Normal

–Systolic pressure drops slightly or remains unchanged

–Diastolic pressure rises slightly

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136
Q

what methods of temp taking use –Infrared thermometry

A

Tympanic, temporal A

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137
Q

•Hyperpyrexia

A
  1. –Extreme elevation >41.1oC (106oF)
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138
Q

S4

A

atrial contraction

patho in adults –> change in ventricular compliance

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139
Q

To further evaluate the clinical suspicion of lower extremity arterial occlusive disease on this same patient, you would perform:

a) measurement of the ankle-brachial index (ABI)
b) bilateral femoral palpation
c) an assessment for pitting edema
d) measurement of the calf size bilaterally

A

a)measurement of the ankle-brachial index (ABI)

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140
Q

ERRORS LEADING TO INACCURATE BP MEASUREMENT

A

•Cuff too small (narrow)

–BP will read high

•Cuff too large (wide)

–BP will read low on a small arm and high on a large arm

•Brachial artery 7-8 cm below heart level

–Pressure 6 mm Hg higher

•Brachial artery 6-7 cm higher

–Pressure 5 mm Hg lower

•Loose cuff or bladder

–Falsely high readings

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141
Q

how to count for HR?

A

normal rhythm, rate = 30s x 2

unusually fast/slow = 60s

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142
Q

Mr. Smith comes to your office for a rash on his chest. He describes the quality of the pain as “burning”, “lance like” and “shock-like” in quality. On examination, you note a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. You suspect that he is suffering from shingles. What is the most likely source of Mr. Smith’s pain?

A.Somatic pain

B.Neuropathic pain

C.Nociceptive pain

D.Psychogenic pain

E.Central sensitization pain

A

A.Neuropathic pain

143
Q

Superficial Inguinal Lymph Nodes

A

•Horizontal group

–High in anterior thigh below inguinal ligament

•Vertical group

–Clusters near upper part of saphenous vein

144
Q

•“True blood pressure”

A

–Average BP measured over days to weeks

–Concern: may not correlate with office readings

  • Observer/measurement error, physiologic fluctuations, anxiety, situation
  • Errors affect clinical decision making
145
Q

•Once you have palpated the systolic pressure, deflate the cuff promptly and completely, wait….

146
Q

Inspection and Palpation of the Epitrochlear Lymph Nodes

A

groove b/w bicep and tricep - 3cm above medial epicondyle

•Difficult or impossible to identify in healthy people

–Enlarged in local or distal infections, associated with generalized lymphadenopathy

147
Q

Signs of Distress: depression

A

–Inexpressive or flat

–Tearful

–Poor eye contact

–Psychomotor slowing

148
Q

auscultatory gap is associated with

A

arterial stiffness and atherosclerotic disease.

149
Q

ISOLATED SYSTOLIC HYPERTENSION

A
  • Systolic BP >140 mm Hg
  • Diastolic BP <90 mm Hg
  • Tx in pt >60 years reduces mortality and complications from cardiovascular disease
150
Q

Delayed carotid upstroke occurs in

A

aortic stenosis

151
Q

An 87 year old male with a history of heart failure who is taking multiple medications presents for evaluation. You observe that he has periods of deep breathing alternating with apnea. What type of breathing is this:

A.Obstructive Breathing

B.Ataxic (Biot’s breathing)

C.Hyperventilation

D.Sighing Respiration

E.Cheyne-Stokes Breathing

A

A.Cheyne-Stokes Breathing

152
Q

Inspect Color : bronchitis v emphysema

153
Q

TYMPANIC MEMBRANE TEMPERATURE: METHODS

A
  • Make sure external auditory canal (EAC) is free of cerumen
  • Place the disposable cover over the probe
  • Position probe in EAC so infrared beam pointed at tympanic membrane
  • Wait 2-3 seconds until digital reading appears
  • More variable than oral or rectal temp
154
Q

Squatting (release of Valsalva):

A

–Increased venous return to the heartà increased left ventricular volume

–Increased arterial blood pressure, increased peripheral vascular resistance àincreased vascular tone

155
Q

Pathologic Murmurs:

A
  • Caused by alterations in valve anatomy
  • Due to leaking or narrowing of blood flow
  • Blood flow through abnormal passages in or near the heart may also cause audible pathologic heart sounds
156
Q

Kentucky: heart sound

A

diastole: lub du bub

s3

–Kids/young adults: rapid deceleration of blood against ventricular wall

–Older adults: pathologic change in ventricular compliance (CHF)

157
Q

where to palpate for carotid A?

A

lower third of neck, medial to SCM

158
Q

palpable S2 @ aorta palp spot =

pulsation?

A

sys htn

dilated/anuerysm

159
Q

An unrecognized auscultatory gap may lead to

A

–an underestimation of systolic pressure or an overestimation of diastolic pressure

160
Q

Adventitious (Added)/ABNORMAL Sounds

A

•Adventitious sounds include:

–Crackles

•formerly called rales

–Wheezes

–Rhonchi

–Stridor

161
Q

Which of the following jugular venous pulsation waveforms represents atrial filling?

a) c
b) y
c) v
d) a
e) x

162
Q

Continuous Murmur

A

Patent Ductus Arteriosus.

163
Q

palp doralis pedis

A

dorsum of foot, distal to navicular, b/w extensor hallucis longus and extensor digitorum

164
Q

Sequence of the Cardiac Physical Exam

A

ÊBlood Pressure and Heart Rate measurement

ÊInspection (Neck and Precordium)

ÊPalpation

ÊPercussion (largely replaced by Palpation)

ÊAuscultation

ÊSpecial Tests/Maneuvers

165
Q

Diameter and duration of the Apical Impulse

A

supine: diameter < 2.5 cm
* may be larger in the left lateral decubitus position

> 3cm indicates left ventricular enlargement

duration: first 2/3rd of systole

166
Q

what IS THE LEADING CAUSE OF DISABILITY AND IMPAIRED PERFORMANCE AT WORK

A

chronic pain

167
Q

•Hypotension (adult abnorm)

A

–Variable. Generally defined as <90/60 mm Hg

168
Q

Palpate the Aorta

A

•Press firmly in the epigastrium, slightly to the left of the midline

•Normal width of the aorta is no more than 3 cm

A widely dilated artery or pulsatile mass may indicate aneurysm!!!!

169
Q

•Masked Hypertension

A

–the office blood pressure is normal but the ambulatory blood pressure is high

–indicating high risk of cardiovascular disease

–Approximately 10% of the general population

170
Q

•When the artery is fully compressed & fully open will soudns be heard?

A

no sounds will be heard

171
Q

Auscultation of the
Posterior Chest

A

same technique as percussion

listen at least 2 full breath @ each location

172
Q

When performing a cardiac exam on a patient, you place the patient in the supine position with the head of the bed at 30 degrees. You place your index and middle finger on the patient’s right carotid artery in the lower third of the neck to feel for the carotid upstroke while you auscultate the patient’s chest. The sound following the carotid upstroke is:

a) S1
b) S2
c) S3
d) S4

173
Q

Inferior mesenteric artery supplies

A

descending and sigmoid colon, proximal rectum

174
Q

A 43 year old Hispanic female presents to the emergency department with the complaint of chest pain of 1 week duration. There is no cognitive or language barrier. Which of the following is correct?

A.The severity of her pain should be assessed using the “Wong-Baker” scale

B.This is most likely somatic pain

C.The physician must be aware that health care disparities exist in pain treatment and delivery of care

D.This is considered chronic pain

A

A.The physician must be aware that health care disparities exist in pain treatment and delivery of care

175
Q

tips to handle White coat HTN

A

•relax patient and re-measure BP later in visit

176
Q

Signs of Distress: chronic/respirtoary

A

•Cardiac or respiratory

–Clutching chest

–Pallor

–Diaphoresis

–Labored breathing

–Coughing

•

177
Q

Palpation of Femoral A

A

deep, below inguinal ligament

midway b/w ASIS and pubic symphysis

may need 2 hands, one on top of the other, in obese patients

178
Q

When performing palpation, percussion and auscultation of the lung, it is essential to progress in which of the following patterns (particularly for palpation, percussion and auscultation).

a) Staircase
b) Vertical
c) Ladder
d) Inner to outer

•

179
Q

pt’s arm should be slightly ________ @ elbow while using a bp cuff

180
Q

A 58 year old male presents for evaluation. His vital signs are: T: 98.6 F, BP: 120/70 mm Hg, HR: 72 bpm, RR: 15 bpm.
Height: 6’ Weight: 199 lbs Waist Circumference: 42 inches
Which of the following is correct?

A.His BMI is normal

B.He is obese

C.He is at high risk for diabetes, hypertension and cardiovascular disease

D.He is underweight

A

A.He is at high risk for diabetes, hypertension and cardiovascular disease

181
Q

Precordium

A

portion of the body over the heart and lower chest.

182
Q

Peripheral Venous Disease

183
Q

Superficial veins are

A

subcutaneous, with poor support

great and small saphenous

184
Q

Deflate bp cuff slowly at a rate

A

•2-3 mm Hg per second

185
Q

when should carotid A ausculation preceded palpation?

A

if plaque concern

bruit = narrowing of carotid A

Prevalence of patients with asymptomatic bruits increases with age

186
Q

patient presents for evaluation. This is your first time seeing the patient. She does not bring any of her medical records. Her BMI is “normal” (her arm is not overly large or small). You obtain her blood pressure. It is 145/95 mm Hg. She states that she takes her BP at home daily and it is never above 120/70 mm hg. Which of the following is correct?

A.The patient may have masked hypertension

B.The BP cuff that the patient is using at home is too small

C.The patient may have white coat hypertension

D.You should diagnose the patient with stage 2 hypertension

E.You may have incorrectly positioned the patient’s arm significantly above heart level

A

A.The patient may have white coat hypertension

187
Q

True or False: Either the bell or the diaphragm of the stethoscope may be used when auscultating a blood pressure

A

True. Use of either part is correct.

188
Q

obesity: heart

A

htn

cad

afib

heart failure

cor pulmonale

varicose veins

189
Q

Normally, there may be a difference in pressure of _______ b/w right and left arms

A

5-10

•Subsequent readings should be made on the arm with the higher pressure

190
Q

Auscultation of Abdominal Arteries for Bruits

A
  • 4-20% of healthy people have abdominal bruits
  • Presence of both systolic and diastolic components = turbulent blood flow

–Stenosis

–Atherosclerotic disease

191
Q

If the cuff is too small (narrow)…

If the cuff is too large (wide)…

A

BP = too high

BP = too low on a small arm and too high on a large arm

192
Q

tips for handling Arrhythmias

A

average several measurements; ambulatory monitoring

193
Q

Wong-Baker

A

•FACES Pain Rating Scale

–children as well as patients with language barriers or cognitive impairment

194
Q

PAIN description

A

•“an unpleasant sensory and emotional experience” associated with tissue damage

sensory, emotional, cog processing

•May lack a specific physical etiology

195
Q
A

Summation Gallop

196
Q

S3

A

blood rushing from atria -> ventricle

heard in children

abnorm in adult heart

197
Q

Fremitis is decreased or absent in which of the following conditions:

A.Thin chest wall

B.Pneumonia

C.Pneumothorax

•

A

Pneumothorax

198
Q

Bruits

A

•turbulence of blood

199
Q

realistic goals for wt loss recomm

A

5-10% = reduces DM and other obesity-assoc health problems

0.5-2lb/wk

deficient 500cal/day: 800-1200 total - healthy eating

200
Q

AORTIC REGURGITATION

A

•A high pitched decrescendo murmur starting immediately after S2 and continuing throughout the first half of diastole.

best heard at Erb’s point

accentuated when the patient sits, leans forward, holds breath after exhalation.

http://www.easyauscultation.com/cases-waveform?coursecaseorder=12&courseid=31

201
Q

percussion of posterior chest wall only penetrates

A

5-7cm : not help with deep-seated lesions

202
Q

once first sound is heard on bp, continue to lower until sounds become ______________

then what?

A
  • sounds become muffled and then disappear
  • confirm disappearance, listen as the pressure falls another 10-20 mm Hg

deflate rapidly to 0

= diastolic P

203
Q

Bradypnea (adult abnorm)

A

–<12 breaths per minute

204
Q

Signs of Distress: anxiety

A

–Facial expression

–Fidgeting

–Cold hands

–Moist palms

205
Q

chronic A v V insufficiency chart

206
Q

You are seeing an 8mo male with no significant past medical history. He has been admitted to the hospital with pneumonia. You are asked to report on his most recent temperature. Upon review of the chart you see that the rectal temperature is reported as 99 degrees F. If the temperature had been taken orally at the same time it would have registered as about:

A.101 degrees F

B.100 degrees F

C.99 degrees F

D.98 degrees F

E.97 degrees F

A

A.98 degrees F

rectal usually 1 degree higher than anywhere else in body

207
Q

–Narrow Pulse Pressure (diminished)

A

–(<30 mmHg)

•Pulse will feel weak and small

  • •Hypovolemia
  • •Decreased stroke volume
  • •(Aortic Stenosis)
208
Q

TEMPERATURE: NORMAL

A
  • Average: 37oC (98.6oF)
  • Varies throughout day by approximately 1oC

–Lowest in early morning

–Highest in late afternoon/evening

209
Q

Chronic pain is defined as…

A

not associated with cancer or other medical conditions that persists for more than 3 to 6 months

lasting more than 1 month beyond the course of an acute illness or injury

recurring at intervals of months or years

210
Q

•Bronco phony

A

–Increased transmitted spoken word when lung tissue has lost air, i.e., pneumonia

–Have patient say, “ninety-nine“

  • normally the transmitted sounds are muffled and indistinct.

–High pitched sounds mean lung tissue has lost air.

211
Q

clinical causes of crackles

A

–Pneumonia

–Fibrosis

–Early congestive heart failure

–Bronchitis

–Bronchiectasis

212
Q

A 35 yo female with history of tobacco use (40 pack years) presents with cough for the past 5 weeks. You would classify her cough as:

a) acute
b) subacute
c) persistent
d) chronic

A

b) subacute

213
Q

High dull sounds of percussion

A
  • Pleural effusion
  • High Diaphragm
  • Atelectasis
  • Diaphragmatic paralysis
214
Q

signs of
Respiratory Disease

215
Q

Dual headed stethoscopes

A

Some come with 2 diaphragms in place (adult size and pediatric size). The pediatric diaphragm must be converted into to a bell by changing the cover.

216
Q

–Patients prefer this to rectal temp measurement

217
Q

config of chest

218
Q

Waist circumference is measured

A

just above the hips (iliac crest)

219
Q

MITRAL REGURGITATION

A

•Mitral area ( R )to the Axilla.

Rectangular pan systolic murmur,

  1. S3 Gallop
  2. Dilated LV and LA
  3. MVP

http://www.easyauscultation.com/cases-waveform?coursecaseorder=13&courseid=31

220
Q

Palpating the Right Ventricle in patients with increased Anteroposterior diameter

A

pts with obstructive pulm disease = hyperinflated lung –> may prevent palp of enlarged RV

  • impulse felt in epigastrium/subxiphoid

hands flattened with index finger just under rib cage and up to L shoulder

221
Q

The “disappearance point” represents

A

diastolic BP

222
Q

Which of the following sounds can be heard during systole?

a) an ejection sound
b) S3
c) S4
d) opening snap

A

a)an ejection sound: aortic/ pulmonic

223
Q

Which of the following is the most appropriate “General Survey” objective assessment for this patient? The patient walked into the office without difficulty.

A.An awake, ill appearing individual who appears to be in emotional distress. She appears to be pale, somewhat unkempt and slender.

B.Patient admits that she is losing weight and feels ill. She denies pain, fever, chills and weakness.

C.Her vital signs are T:98.2, BP: 110/60 mmhg, HR: 92 bpm, RR: 18 bpm.

D.Patient is awake, alert, well appearing and in no distress

A

A.An awake, ill appearing individual who appears to be in emotional distress. She appears to be pale, somewhat unkempt and slender.

224
Q

Buerger test

A
  • Chronic arterial insufficiency
  • Raise both legs to about 90o for up to 2 minutes until there is maximal pallor of feet

–Marked pallor suggests arterial insufficiency

•Ask patient to sit up with legs dangling

–Normal: Skin pinkness returns in <10 seconds, veins of feet and ankles fill in ~15 seconds

–Abnormal: persistent pallor followed by persisting dependent rubor (dusky redness)

225
Q

You note that the murmur was heard with the stethoscope partly off the chest and with a palpable thrill. This murmur as:

a) 1/6
b) 2/6
c) 3/6
d) 4/6
e) 5/6

226
Q

numeric, verbal, visual analogue scale

227
Q

Nocturnal htn

A

•lack of physiologic fall, an excessive fall, or a rise in night time BP

–associated with adverse cardiovascular outcomes

228
Q

In addition to the significant difference in calf circumference you note that this patient’s left calf to be erythematous, warm and tender. Homan’s sign is positive. The most likely diagnosis is a:

A

Deep Vein Thrombosis

229
Q

The difference between the inspiration and expiration levels represents diaphragmatic motion: normal =

230
Q

A 55 Yo female with a past medical history of hypertension presents for an evaluation. You hear the following murmur at the apex:

This is most likely is due to:

a) aortic regurgitation
b) pulmonary regurgitation
c) tricuspid stenosis
d) mitral regurgitation

A

a)mitral regurgitation

231
Q

obesity class

A

I: 30-34.9

II: 35-39.9

III: 40+

232
Q

Late Diastolic crescendo Murmur

A

Mitral stenosis, tricuspid stenosis. And MVP (Mitral valve prolapse)

233
Q

which is correct?

A.The auscultatory gap is the true systolic blood pressure

B.When the artery is fully compressed (occluded), the Korotkoff sounds will be heard

C.Blood pressure difference of up to >25 mm hg between the right and left arms is normal

D.“Estimation of systolic BP” (by palpation of the radial artery) provides a target for how high to inflate the BP cuff when obtaining the actual BP

E.When obtaining the BP, the pressure in the BP cuff should be lowered at a rate of 10 mm hg per second to minimize discomfort to the patient

A

A.“Estimation of systolic BP” (by palpation of the radial artery) provides a target for how high to inflate the BP cuff when obtaining the actual BP

234
Q

murmurs by location: tricuspid

A

tricuspid stenosis/regurg

vsd

235
Q

Celiac trunk arteries supply

A

esophagus, stomach, proximal duodenum, liver,

236
Q

A 50 Yo male is brought to the emergency room after passing out. This is associated with dyspnea and chest pain. Upon auscultation you hear a loud harsh systolic crescendo-decrescendo murmur at the right second interspace which radiates to the carotids. This is most likely due to:

a) mitral regurgitation
b) aortic regurgitation
c) aortic stenosis
d) mitral stenosis

A

aortic stenosis

237
Q

•Calculating the BMI

238
Q

egophany

A

–When spoken word intensity increases through the lungs & has a nasal or bleating quality

say “eee“;

  • “aye” = loss of air in lung tissue and possible lung consolidation.
239
Q

Midsystolic Crescendo-Decrescendo murmur

A

Aortic Stenosis and Innocent flow murmurs

240
Q

•Medication may mask fever

A

–Aspirin, acetaminophen, NSAIDS, steroids

241
Q

•factors influence the patient’s report of pain

A

–Psychiatric

  • Anxiety
  • Depression

–Personality/coping style

–Cultural norms

–Social support systems

242
Q

ØDecreased Tactile Fremitus: unilateral

A

Pneumothorax

Pleural Effusion

Bronchial Obstruction

Atelectasis

243
Q

•Hypothermia

A

–<35oC (95oF) rectally

244
Q

When you palpate the carotid artery you should:

a) Press at the lateral border of the sternocleidomastoid muscle
b) Use your left fingers or thumb to palpate the left carotid
c) Press at the level of the thyroid cartilage
d) Assess the amplitude and the contour of the pulse wave

A

a)Assess the amplitude and the contour of the pulse wave

245
Q

Width of the bladder of the cuff should be about

average adult:

A

40% of upper arm circumference

Average adult: 12-14 cm

246
Q

when does fatigue warrant further investigation?

A

when it is unrelated to life circumstances

247
Q

WEAK/INAUDIBLE KOROTKOFF SOUNDS

A

•Technical problems

–error stethoscope placement

–Failure to make full skin contact

–Venous engorgement of arm from repeated cuff inflations

•Consider

–Shock

–Vascular disease

248
Q

Length of the bladder should be about

A

80% of upper arm circumference

249
Q

A 68 year old patient describes pain in the R knee. It is dull and aching in nature, rated as 5 out of10, has been present for several years and is worsened by walking up or down stairs. The pain does not radiate. There is minimal swelling in the knee but no redness. Anti inflammatory medications improve the pain. X-ray demonstrates osteoarthritis.

What type of pain is this?

A.Somatic (nociceptive)

B.Neuropathic

C.Psychogenic

D.Central sensitization

E.Idiopathic

A

A.Somatic (nociceptive)

250
Q

what is this sound?

characterstics

A

Stridor

high-pitched wheeze produced by turbulent airflow through a partially obstructed upper airway

can be louder in neck than chest wall

251
Q

Warning Signs of Peripheral Arterial Disease

A

•Fatigue, aching, numbness or pain in legs that limits walking or exertion

–Where?

–Associated erectile dysfunction?

  • Poorly healing/nonhealing wounds of the legs or feet
  • Pain in the lower leg or foot present at rest and changes when standing or supine
  • Abdominal pain after meals with associated food avoidance, weight loss
  • Any first degree relatives with abdominal aortic aneurysm (AAA)
252
Q

Grading Pitting Edema

A
  • Depression caused by pressure from the examiner’s thumb
  • Severity graded on 4 point scale
253
Q

S3 Gallop

A

diastolic: rapid ejection atria –> ventricles

  • Physiologic:
  • Young children
  • Trained athletes
  • Pregnant women
  • Pathologic:
  • Congestive Heart Failure
  • Mitral regurgitation

http://www.easyauscultation.com/cases-waveform?coursecaseorder=1&courseid=25

254
Q

Pansystolic (Holosystolic) Plateau murmur

A

s1 –> s2

no gap b/w murmur and heart sound

mitral/tricuspid regurg

256
Q

Palpating for S1 and S2

A

When palpating for S1 and S2 place your right hand on the chest wall and your left index and middle fingers on the right carotid artery in the lower third of the neck

S1 occurs just before the carotid upstroke

S2 occurs after the carotid upstroke

257
Q

Palpation of the Brachial Arteries

A

make sure to flex pt’s elbow slightly

palp medial to biceps tendon in AC, also in groove b/w bicep and tricep

258
Q

If the first 2 readings differ by ….

then….

A

> 5 mm Hg

take additional readings

have to ave 2 bp’s

259
Q

•Trachea deviation could indicate

A

–pneumothorax, mass, etc.

260
Q

To test that it is in the “bell position”:

A

Tap the bell. You should hear the sound very loudly. Tap the diaphragm. You should not hear very much sound. If it sounds louder when you tap the diaphragm, the chest piece is open to the diaphragm and not the bell.

261
Q

is there a commonly used scale for quant dyspnea?

A

no scale from 1-10

determined by pt’s activities

262
Q

Hypertrophic cardiomyopathy (HOCM): Physical Exam Red Flags

A

–Systolic murmur

•Intensity increases with standing (decreased preload) and decreased with squatting

263
Q

•the level at which sounds of two consecutive beats are heard means…

A

systolic P

264
Q

HYPERTENSION (HTN)

A

–>140/90 mm Hg in clinic

–Home automated >135/85

–Ambulatory automated: 24 hr average >130/80, day average >135/85, night average >120/70

–Average of 2 BP readings on 2 or more occasions

265
Q

•Tympanic membrane temperatures

A

─Measures core body temperature and tends to be higher than the oral by ~1.4° F

─Cerumen can impair reading

─More variable than rectal

266
Q

Peripheral Arterial Disease

A
  • Dependent rubor
  • Ulcers on the toes or points of injury
267
Q

temp methods: temporal A

A

–Lower than core temp by 0.5oC

–Like oral temp, correlates with core temp

268
Q

mitral valve prolapse (MVP)

https://www.easyauscultation.com/cases-waveform?coursecaseorder=4&courseid=30

A

mid-sys click followed by crescendo decrescendo murmur

increases with standing

decreases with lifting legs

269
Q

accessory M used in respiratory distress

A

–Sternocleidomastoid

–Scalene muscles

–Supraclavicular retraction?

270
Q

Rectal temperatures

A

─Higher than oral temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F)

─This difference is variable

271
Q

Causes of orthostatic htn

A

drugs, moderate-severe blood loss, prolonged bed rest, dehydration, diseases of autonomic nervous system

272
Q

Opening snap

A
  • Occurs in early diastole: extra heart sound
  • High pitched sound heard best with the diaphragm
  • Most commonly due to opening of stenotic mitral valve indicating pathology
273
Q

ask pt’s to do what while listening for bruits?

A

hold breath

274
Q

A patient presents with a fever and a cough. You suspect pneumonia. During the pulmonary examination you ask a patient to say “ee” while you listen with the stethoscope. You hear this as “aye”. This is an example of:

a) Egophony
b) Adventious breath sounds
c) Fremitus
d) Resonance

275
Q

Which of the following statements reflects the correct way to use the sphygmomanometer to check blood pressure?

A.The cuff should be repeatedly inflated to get an accurate BP

B.The lower border of the cuff should be 2.5 cm above the antecubital crease

C.The cuff should be deflated rapidly once 2 beats are heard

D.Once you have palpated the systolic pressure, rapidly inflate the cuff again

A

A.The lower border of the cuff should be 2.5 cm above the antecubital crease

276
Q

Quality of neuropathic pain

A
  • burning, lancinating, shock like
  • May persist even after healing

–Due to pain signal processing changes (“neuronal plasticity”)

277
Q

Which of the following BMI values falls into the overweight category?

  1. > 30 kg/m2
  2. 25.0-29.9 kg/m2
  3. 18.5-24.9 kg/m2
  4. < 18.5 kg/m2
A

2.25.0-29.9 kg/m2

278
Q

A 12 Yo male presents for a pre-participation sports physical. He has no complaints. His family history includes 2 relatives that died suddenly in their late teens from “heart problems”. On examination you hear a systolic murmur and suspect hypertrophic cardiomyopathy. The following will increase the loudness of a hypertrophic cardiomyopathy murmur:

a. Increase preload
b. Decrease preload

A

a.Decrease preload

279
Q

Clinical Causes of wheezes

A

Asthma

  • Bronchitis
  • Chronic Obstructive Lung Disease( COPD)
280
Q

Which of the following findings are most consistent with chronic arterial disease as compared to chronic venous disease?

A.brown pigmentation on ankles

B.presence of edema

C.non healing ulcers on the toes or points of trauma

D.non healing ulcers on medial side of ankles

A

A.non healing ulcers on the toes or points of trauma

281
Q

During percussion of this same patient you find that her breast tissue is overlying one of the areas that you need to examine. Which of the following is the correct approach to the patient exam?

a) Skip this part of the exam
b) Ask the patient to displace her breast tissue so that you can access the underlying thorax
c) Perform the exam over the breast with the gown covering the breast
d) Perform the exam over the breast with the gown off the breast

A

a)Ask the patient to displace her breast tissue so that you can access the underlying thorax

282
Q

palp carotid A one at a time to avoid…

A

carotid sinus @ level of thyroid cartilage

carotid A = @ level of cricoid cartilage, medial to SCM

283
Q

Deep veins carry

A

•carry 90% of venous return from lower extremities,

well supported by surrounding tissues

284
Q

normal HR

A

60-100 bpm

285
Q

•Abdominal pain after meals…

A

–food fear”, weight loss, dark stools

286
Q

Rectal temps…

A

–More reliable if rapid respiratory rate

287
Q

Superior mesenteric artery supplies

A

–jejunum, ileum, cecum, ascending and transverse colon, splenic flexure

288
Q

tips for handling Very thin patient

A

•pediatric cuff

289
Q

Lymphatics of the Upper Extremity and Breast

A

•Pectoral nodes

  • –Anterior, along lower border of pectoralis major inside anterior axillary fold
  • –Drain anterior chest wall, breast

•Subscapular nodes

  • –Posterior, along lateral border of scapula, deep in posterior axillary fold
  • –Drain posterior chest wall, portion of arm

•Lateral nodes

  • –Along upper humerus
  • –Drain most of arm

Central axillary nodes

  • drain to supraclavicular and infraclavicular nodes
290
Q

Raynaud’s Disease

A
  • Wrist pulses are typically normal
  • Spasm of distal arteries
  • Sharply demarcated pallor of the fingers
291
Q

objective portion of general survey =

A.Includes the physician’s assessment of the patient’s overall appearance

B.Includes the patient’s report of “fatigue, fever, chills and change in weight”

C.Includes the patient’s temperature

D.Includes the patient’s reported alcohol intake

E.Is part of the History of Present Illness

A

A.Includes the physician’s assessment of the patient’s overall appearance

  • Includes the patient’s report of “fatigue, fever, chills and change in weight”
    • –Subjective, “General Survey” review of systems questions
  • A.Includes the temperature
    • –Objective, but a vital sign
  • Includes the patient’s reported alcohol intake
    • –Subjective, part of the social history
  • Is part of the History of Present Illness
    • –Subjective, part of the history
292
Q

Tennessee: heart sound

A

s4 - belub dub

diastole

–immediately precedes S1:

marks atrial contraction

can be pathologic change in ventricular compliance (stiff left ventricle)

293
Q

•Tactile fremitus

A

–Palpable vibrations transmitted via the bronchopulmonary tree to the chest wall as patient speaks

•Provides information about lung tissue and chest cavity density

294
Q

•Mechanismsof neuropathic pain

A

–CNS brain or spinal cord injury

  • Stroke
  • Trauma

–Peripheral NS disorders

  • Entrapment
  • Pressure

–Referred pain syndromes

•Increased/prolonged response to stimuli

295
Q

what would an elevated/low JVP indicate?

A

high = CHF -> R side heart failure RV

low = dehydration

296
Q

Fremitus is usually decreased or absent over

A

precordium

297
Q

innocent murmur

A

early systolic that occurs in non cardiac conditions that increase blood flow over normal cardiac anatomy

. Examples: anemia, hyperthyroidism, pregnancy and exercise

murmurs disappear when conditions are treated

https://www.easyauscultation.com/cases-waveform?coursecaseorder=1&courseid=26

298
Q

Cheyne-Stokes Breathing

mechanism?

A

periods of deep breathing –> periods of apnea

children, aging people –> usu in sleep

•Proposed Mechanism

–apnea–> increased CO2 –> compensatory hyperventilation –> decreased CO2 –>apnea

  • restart the cycle.
299
Q

A 65 Yo male with a history of Coronary Artery Disease presents with a two day history of shortness of breath. You measure his JVP to be 7cm. This finding is:

a) normal
b) abnormal and elevated
c) abnormal and low

A

abnormal and elevated

300
Q

Four Steps to Promote Optimal Weight and Nutrition

A

1.Measure BMI and waist circumference

–Identify risk of overweight and obesity

–Establish risk factors for heart disease, obesity related disease

  1. Assess dietary intake
  2. Assess the patient’s motivation to change
  3. Provide counseling about nutrition and exercise
301
Q

what is this sound?

characteristics?

why?

A

crackles

Characteristics:

  • •Intermittent
  • •Discontinuous
  • •Non-musical
  • •Heard at the end of inspiration

Etiology:

  • From collapsed or narrowed alveoli that could also contain fluid, pus, secretions or edema
302
Q

Wheezing

A
  • Musical audible respiratory sounds
  • Suggests partially obstructed airway
  • Possible Causes

excess secretions

foreign body

asthma

303
Q

what can happen if the breast is not displaced?

A

abnorm percussion note of a right middle lob pna

304
Q

A 4 year old is brought in by his mother due to a respiratory infection. He is irritable, anxious and breathing through his mouth due to severe nasal congestion. Which is the most comfortable and accurate way to measure his temperature?

A.Electronic oral thermometer

B.Glass oral thermometer

C.Electronic tympanic membrane thermometer

D.Electronic rectal thermometer

E.Glass axillary thermometer

A

A.Electronic tympanic membrane thermometer

305
Q

what is this showing?

306
Q

Auscultation- 4 Key Cardiac Areas-
Inching your Stethoscope

A

Start at the base and inch to the apex

  • Aortic- Pulmonic – Tricuspid – Mitral

Start at the apex and inch to the base

  • Mitral- Tricuspid- Pulmonic – Aortic
307
Q

A 65 Yo male with a history of hypertension presents for an evaluation. Upon auscultation of his heart you hear an extra heart sound. Upon listening closely it sounds as if you are hearing the word Tennessee. This sound is most consistent with the presence of an:

a) opening snap
b) S3
c) Ejection sound
d) S4
e) systolic click

308
Q

Palpation of the Posterior Chest to Test for Expansion

A

Technique:

  • Place your thumbs at the 10th ribs, with your fingers loosely grasping and parallel to the lateral rib cage.
  • Have patient inhale deeply.
  • Watch the distance between your thumbs as they move apart during inspiration.
  • As the rib cage expands and contracts, feel for the range and symmetry.

•

309
Q

During the examination you attempt to locate the apical impulse with the patient in the supine position with the head of the bed at 30 degrees but you are not successful. Which of the following would you do next to help you locate the apical impulse:

a) Place the patient in the supine position with the head elevated at 180 degrees
b) Have the patient sit and lean forward
c) Place the patient in the left lateral decubitus position
d) Place the patient in the supine position with the head of the bed at 60 degrees

A

a)Place the patient in the left lateral decubitus position

310
Q

RECTAL TEMPERATURE: METHODS

A
  • Patient lies on one side with hip flexed
  • Lubricate rectal thermometer (stubby tip)

–Or electronic probe cover

  • Insert it 3-4 cm into anal canal, direction pointing toward the umbilicus
  • Remove after 3 minutes

–10 seconds for electronic

•Read

311
Q

murmurs by location: aortic

A

aortic stenosis

fixed splitting of S2

312
Q

•Fever (pyrexia)

A

–Elevated body temperature

–Causes: infection, trauma, malignancy, blood disorders, drug reactions, immune disorders

313
Q

•Night sweats

A

–Normal body temp rises during day and falls at night

–Fever exaggerates this swing and causes night sweats

314
Q

what nodes are accessible on physical exam: cervical, axillary, arms and legs

A

superficial

  • Oval or bean shaped structures
  • Vary in size depending upon location

–Very small and difficult to palpate (ex. preauricular)

–1-2 cm in an adult (ex. Inguinal)

315
Q

Hypertrophic cardiomyopathy (HCM)

A
  • Leading cause of sudden death in pediatrics and young adults
  • Thickening LV –> outflow obstruction
  • decreased blood flow
  • MI
  • arrhythmia
  • death
  • Often first sign is sudden collapse and possible death
  • Detect this during periodic exams and pre-sports screening exams!
316
Q

MITRAL STENOSIS

A

Opening snap followed by a diamond shaped ow pitched murmur in diastole.

Best heard with the bell over the mitral area with the patient laying on left side

http://www.easyauscultation.com/cases-waveform?coursecaseorder=14&courseid=31.

317
Q

ØIncreased Tactile Fremitus =

318
Q

•Intercostal Retractions

A

–Muscles between the ribs pull inward

–Due to reduced air pressure inside your chest

–Seen best at the lower interspaces

–Sign of ↑work of breathing-respiratory distress

319
Q
A

chronic aterial insufficiency, chronic venous insufficiency

320
Q

4 potential uses of palpation of anterior chest

A

–Identifies tender areas

–Assess observed abnormalities

–Further assesses chest expansion

–Assess tactile fremitus

321
Q

•Hypertension (abnormal)

A

–JNC Guidelines ≥140/90 mm Hg

322
Q

Axillary lymph nodes

A

drain most of arm

323
Q

Hypertrophic cardiomyopathy (HOCM): hx red flags

A

–Family Hx of sudden death below the age of 50

•Inherited disease with variable penetrance

324
Q

Posterior Percussion Points: locaton technique

A

pt cross arms –> like a ladder

compare symmetry

325
Q

Standing (Valsalva strain phase)

A

decrease venous return

decreased left ventricular volume.

decreased vascular tone

decreased arterial blood pressure

326
Q

Distinguishing Internal Jugular and Carotid Pulsations

327
Q

Upon observation of the patient’s neck you know that you are observing the carotid artery as opposed to the jugular vein because the

a) height of the carotid pulsation is unchanged by position whereas the height of the jugular pulsation changes with position
b) height of the carotid pulsation changes with position

whereas the height of the jugular pulsation is unchanged with position

c) height of the carotid pulsation rises with inspiration whereas the height of the jugular pulsation falls with inspiration
d) height of the carotid pulsation falls with inspiration whereas the height of the jugular pulsation rises with inspiration

A

a)Height of the carotid pulsation is unchanged by position whereas the height of the jugular pulsation changes with position

328
Q

tips for handling Hypertensive patient with unequal pressure in arms and legs

A

compare BP in arms and legs (5-10 mm Hg higher in arms)

compare volume (force) and timing of radial or brachial and femoral pulses (equal and simultaneous)

329
Q

Measure the calves … where?

normal difference?

A

•10 cm below the tibial tuberosity

–Normal difference in calf circumference <3cm

330
Q

Measuring the Jugular Venous Pressure

A

This distance measured in centimeters above the sternal angle is the JVP.

Normal JVP is 3cm- 4cm above the sternal angle

The JVP provides a rapid estimate of the CVP ( central venous pressure) useful in assessing volume status, especially for congestive heart failure

331
Q

technique for percussion of posterior chest wall

A

Technique:

  • Place the 3rdfinger (pleximeter) of your left hand firmly against the surface to be percussed.
  • Hyperextend your left hand middle finger: the “pleximeter” finger.
  • Press its DIP joint firmly on the surface to be percussed.
  • Note that the thumb and 2nd, 4th, and 5th fingers are not touching the chest

strike DIP with tip of finger with quick, sharp, but relaxed wrist motion @ right angles

  • avoid damping of vib by quickly withdrawing striking finger
  • press HARDER with DIP with fatter pts
332
Q

A 35 year old female presents for examination of new onset swelling of her left leg. Upon observation, you note that the left leg looks larger than the right leg. To confirm that there is actual edema you measure each calf 10 cm below the tibial tuberosity. Which of the following difference in measurements is suggestive of edema?

a) her left calf measures 0.5 cm more than her right calf
b) her left calf measures 3.0 cm more than her right calf
c) her left calf measures 2.0 cm more than her right calf
d) her left calf measures 1.0 cm more than her right calf

A

her left calf measures 3.0 cm more than her right calf

333
Q

Small saphenous

A

lateral side of foot

passes posterior calf

joins deep venous sys in pop fossa

334
Q

•Hypokinetic Apical Impulse can indicate

type of amplitude and duration?

A

dilated cardiomyopathy

low amp, long duration

335
Q

PVD is more visible when…

A

pt stands - veins fill with blood

•Palpate along varicosities to check for thrombophlebitis

336
Q

anterior posterior (AP) diameter of chest may ↑ with

A

–Normal aging

–COPD

–Emphysema

337
Q

Sitting, Leaning forward positioning of pt When
Auscultating the Heart enhances….

A

detection of aortic insufficiency

338
Q

cough: chronic

A

> 8 wks

causes:

  • postnasal drip
  • gastroesophageal reflux
  • chronic bronchitis
339
Q

BMI categories

A

underwt: <18.5

normal 18.5-24.9

overwt: 25-29.9
ovesity: 30 or more

340
Q

Gallop

A

•presence of an S3 or S4 cadence similar to gallop of a horse

Summation gallop: at rapid heart rates S3 and S4 may sound like a single sound

341
Q

appearance of the first two “Korotkoff” sounds represent the

A

–systolic blood pressure

342
Q

A 20 month old male is brought to the ER for cough and fever. On examination, he is drooling and has a whistling sound when he breaths. Upon auscultation you hear the following. This sound is consistent with:

a) Rhonchi
b) Crackles
c) Wheezes
d) Stridor
e) Pleural rub

343
Q

cough: acute

A

<3 weeks

causes:

  • viral URI
  • Asthma
  • Left heart failure
344
Q

A 71 year old male with a history of smoking comes to your primary care office complaining of cramping in his legs during exertion. The pain is relieved by rest within 10 minutes. These symptoms have been slowly increasing for the last few months. There is no swelling, erythema or tenderness on examination of his calves but a there is an unhealed ulcer on his left first toe that he says he has had for several weeks. His femoral, popliteal, dorsalis pedis pulse and posterior tibial pulses are each 1+ bilaterally. You suspect he has:

a) Peripheral Arterial Disease
b) Peripheral Venous Disease

A

Peripheral Arterial Disease

345
Q

higher than average P difference b/w arms =

what is the range above

A

•more than 10–15 mm Hg

subclavian steal syndrome

aortic dissection.

346
Q

taking an oral temp is not recommended when…

A

pt =

unconscious

restless

unable to close mouth

347
Q

•Auscultatory gap

A

–A silent interval that may be present between the systolic and the diastolic pressures

348
Q

Health Care Disparities in Pain Management

A

lower use pain meds for African-American and Hispanic patients

  • ca, post-op, lower back pain

•that clinician stereotypes, language barriers, and unconscious clinician biases in decision making all contribute to these disparities.

349
Q

S1

A

AV: mitral > triscuspid

350
Q

Prevalence of patients with asymptomatic bruits increases with

A

age

8% in pts >75 y/o

3x increase in risk of ischemic heart disease and stroke

351
Q

which part of stethoscope use to hear low pitched sounds?

like what?

A

bell

s3, s4, murmur of mitral stenosis

352
Q

what is this sound

characteristics?

A

wheezes

  • High pitched
  • Continuous

musical,whistling sound

usually more pronounced during expiration

353
Q

what is this sound? what is this test for?

A

Whispered pectoriloquy :

–

–Are louder, clearer whispered sounds and could denote lung consolidation

–Normally whispering “one-two-three or ninety-nine is heard faintly and indistinctly because the lung filters it out.

PD Year 1 (6 decks)

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