final pt 2 Flashcards
what is JVP
- reflects RA pressure that equals central venous pressure and RV end diastolic volume
normal JVP
- < 3 cm above sternal angle
- < 8-9 cm in total distance from RA
- should fall with inspiration
increased JVP
- HF
- tricuspid stenosis
- chronic pulm HTN
- pericardial dz
kussmaul’s sign
- JVP rises with inspiration
- suggests impaired filling of RV
hepatojugular reflex
- pressure applied in RUQ causes JVP to increase
what are the systolic murmurs
- mitral regurg
- aortic stenosis
- tricuspid regurg
- pulm stenosis
- ASD
- VSD
- HOCM
aortic stenosis
- systolic murmur
- heard best when leans forward
- can have thrill
- 2-3 interspace
- radiates to carotid, down LSB, apex
HOCM
- systolic murmur
- heard best with squatting and valsalva
- located in L 3 and 4 interspace
- radiates down LSB to apex
pulmonic stenosis
- crescendo decrescendo murur
- systolic
- located at L 2nd and 3rd interspaces
- radiates to L shoulder and neck
mitral regurg
- holosystolic murur
- doesnt change with inspir
- can have S3
- located at apex
- can radiate to L axilla
- if loud assoc with apical thrill
tricuspid regurg
- holosystolic murmur
- increases with inspiration
- lower LSB
- if RB pressure is high and V is enlarged loudest at apex- may be confused for mitral regurg
- radiates to R sternum, xiphoid, L midclavicular
ventricular septal defect
- holosystolic
- located at L 3-5 interspaces
- wide radiation
- smaller= louder murmur
aortic regurg
- decrescendo diastolic murmur
- heard best when leaning foward with exhalation
- L 2-4 interspaces
- if loud radiates to apex
mitral stenosis
- diastolic decrescendo
- opening snap after S2
- use bell
- heard best in LLD with hand grips and exhalation
- usu located in apex without radiation
venous hum
- cont humming murmur
- loudest in diastole
- listen with bell
- located above medial 3rd of clavicles, esp on R
- best heard in sitting
- disappears in supine
- radiates to L 1-2 interspaces
pericardial friction rub
- sounds close to stethoscope
- best with pt leaning fwd with exhalation
- heard best in 3rd interspace next to sternum
- minimal radiation
- scratchy, scraping, grating quality
PDA
- machine like
- L 2nd interspace
- radiates to clavicle
sequence of abdominal exam
- inspect
- auscultate
- percuss
- palpate
tests for ascites
- percuss from central tympany to find dullness
- shifting dullness
- fluid wave
- ballottement
test for shifting dullness
- have pt turn to side
- percuss and mark borders
- with ascites tympany shifts to top
test for fluid wave
- assistant press hands on midline
- top one flank
- feel opposite flank for impulse
ballottement
- straighten and stiffen fingers
- make brief jabbing motion
- will displace fluid
scrotal masses that do not transilluminate
- inguinal hernia
- varicocele
- testicular tumor
- hematoma
femoral hernias
- more common in women
- point of origin below inguinal ligament
indirect hernia
- most common hernial for all ages and sexes
- point of origin above inguinal ligament
- can often enter scrotum
- on exam will touch fingertip
direct hernia
- more common in men > 40
- point of origin above inguinal ligament close to pubic tubercle
- on exam will bulge anteriorly and push side of finger forward
hydrocele
- nontender
- fluid filled mass within tunica vaginalis
- transilluminates
cryptorchidism
- testis is atrophied
- lies outside scrotum in inguinal canal, abdomen, or near pubic tubercle
small testis
- adults: length < 3.5 cm
- small firm testes < 2 cm suggests klinefelter
- small testis often suggests atrophy
causes of testicular atrophy
- cirrhosis
- myotonic dystrophy
- use of estrogen
- hypopituitarism
- can follow orchitis
acute orchitis
- testes is inflamed, tender, painful, swollen
- hard to distinguish from epididymis
- scrotum may be reddened
- seen in mumps or other viral infx
- unilat
testicular tumor
- painless nodule
- as enlarges feels heavier than normal
spermatocele and cyst of epididymis
- painless movable cystic mass
- just above testis
- both transilluminate
- spermatocele has sperm, cyst does not
acute epididymitis
- indurated, swollen, tender epididymis
- hard to distinguish from testis
- scrotum may be reddened and vas deferens inflamed
tuberculosis epidymitis
- chronic inflam of Tb -> firm enlargement of epididymis, +/- tender thickening/ beading of vas deferens
varicocele of spermatic courd
- often on L side
- soft bag of worms
- disappears in supine
torsion of spermatic cord
- acutely painful, tender, swollen testicle
- often retracted up into scrotum
- cremasteric reflex absent
prostate anatomy
- lies against anterior rectal wall
- 2.5 cm long
- normally feel lateral lobes and median sulcus
phimosis
- tight prepuce that cannot be retracted over glans
paraphimosis
- tight prepuce that once retracted cannot be returned
- causes edema
- medical emergency
balanitis
- inflammation of glans penis
breast anatomy
- overlies pec major and serratus anterior
- tail of spence extends into anterior axillary fold
- extends from clavicle/ 2nd rib to 6th rib, sternum across midaxillary line
cystocele
- bulge of upper 2/3 of anterior vaginal wall
- d/t weakened ant supporting tissues
urethral caruncle
- small red benign tumor
- post urethral meatus in females
- postmenopausal women
- usu asymptomatic
bartholin gland infx
- acutely appears tense, hot, very tender abscess
- chronically nontender cyst that may be large or small
- d/t trauma, gonococci, anaerobes
cystourethraocyele
- entire vaginal wall, together with bladder and urethra prod bulge
- +/- groove defines boarder between urethrocele and cystocele
prolapse of urethral mucosa
- forms swollen red ring around urethral meatus
- often occurs in kids before menarche or after menopause
rectocele
- herniation of rectum into post wall of vagina
- d/t weakness or cleft in endopelvic fascia
female breast provocative maneuvers
- arms at side
- arms above head
- hands pressed on hips
- leaning fwd with arms extended
shoulder dislocation
- disarticulation
- usu anterior
- to reduce muscles must be relaxed- can try versed
- best maneuver- fried
shoulder subluxation
- temporary and partial
- can reduce on its own
- joint instability
- may report shoulder rolls out of socket
shoulder dislocationsx
- popping noise
- poor ROM
- A LOT of pain
apprehension sign
- knee placed in 30 degrees of flexion
- lateral pressure applied
- medial instability results in pt apprehension
primary wound closure
- within 6-12 hours of injury
- wound edges are neatly approximated
- rapid return to function
- good cosmetic outcome
delayed primary closure
- used in situations where primary closure is inappropriate- i.e. infx, contamination
- allows for secondary healing to occur before closure- 48-96 hours
phases of wound healing
- hemostasis
- inflammation
- proliferation
- remodeling
hemostasis phase of wound healing
- immed after wound healing
- platelet plug forms and vasoconstriction occurs
- thrombus dev to seal wound
inflammation phase of wound healing
- 2-3 d after injury
- WBC remove necrotic tissue and control infx
proliferation phase of wound healing
- begins on day 2/3 after injury
- lasts 2-4 weeks
- fibroblasts proliferate in wound -> structural proteins
- new capillaries form and epithelial cells migrate across top of wound- granulation tissue
remodeling phase of wound healing
- new capillaries atrophy
- collagen changes from type III to type I
- myofibroblasts cause scar contracture
- forces acting on wound shape remodeling process- best if force is uniaxial
suture removal for scalp
- 6-8 days
suture removal for face
- 4-5 days
suture removal for turnk
- 8-10 days
suture removal for extremities and hands
- 8-10 days
suture removal feet
- 12-14 days
absorbable sutures
- dissolved by enzymes or hydrolysis
- tend to prod more pronounced scar
- often used under the skin
- plain cat gut
- chromic gut
- monocryl
- vicryl
- polydioxanone
- panacryl
nonabsorbable sutures
- remain in place until removed
- less tissue reactive so not as much scarring
- best on skin
- ethilon
- prolene
- nurolon
- permhand silk
- stainless steel
staples
- used for linear lacerations with edges that are well aligned
- avoid in cosmetic areas or if pt needs CT/ MRI
- scalp
dermabond
- skin adhesive
- can be used on face, extremities, torso
- use with SQ sutures if in area of high tension
- dont use over joints, if infx or in mucosal area
steristrips
- used for superficial linear clean edges
- no damage to nerves or vessels
- can be reinforcement for sutures
- dont use over joints or areas that get wet
1% lidocaine
- blocks pain stimuli
- leaves pressure and touch intact
2% lidocaine
- blocks all awareness of stimuli including pressure and touch
what is the max dose of lidocaine
- 4 mg/kg
where should you not use epi
- digits
- nose
- ears
- penis
plaster for splinting
- takes 2-8 min to set
- more time to mold than orthoglass
orthoglass for splinting
- lighter
- longer wear
- more expensive
- less molding time
steps for splinting
- stockinette without folds
- webril- 50% overlap
- extend padding slightly past area of splinting
- measure/ cut plaster or orthoglass
- dip in room temp* water
- apply
- place webril over plaste (prevents sticking to ace)
- ace bandage
- mold
- a lot of webril to bony prominances
how should you wrap for splinting
- distal to proximal
what are some explanations for small head circumference
- abnormal brain dev
- premature fusing of skull- craniosynostosis
history for altered mental status and possible SC injury
- “A MUST”
- A: AMS
- M: mechanism
- U: underlying conditions
- S: sx
- T: timing
significant missed SC injuries
- C1-C2 injuries
- missed on cross table lateral xray
- odontoid or open mouth view recommended
how do you confirm tube placement
- NOT with CXR
- watch tube pass through cords
- look for chest rise symmetrically
- listen over epigastric aea
what hand do you use to intubate
- L hand
straight blade for intubation
- miller
curved blade for intubation
- mcintosh
