Midterm Flashcards
What are the steps of the enhanced Calgary Cambridge guide for effective clinical interviewing
Initiating - gathering information - physical exam - explain and plan - close session
What does FIFE stand for and where is it in the clinical interview
Feelings, Ideas, Functions and expectations. Part of gathering information
What are the 5 R’s of cultural humility
Reflection, respect, regard, relevance, resiliency
What does VINDICATE stand for and what is its use
used for ruling out DDx. Vascular, Infectious, Neoplastic, Drug related. Inflammatory/idopathic/iatrogenic, Congenital, Autoimmune/allergic, Trauma/toxic, Endocrine/metabolic
What is the difference between a diagnostic and therapeutic plan
diagnostic plan is rationale for evaluating each DDx whereas therapeutic plan is rationale for managing a chronic or known condition
What are the two components of the dual process theory for clinical reasoning
The non analytical and the analytical model
in the dual process theory for clinic reasoning, which model is the fast system and which is the slow system
non analytical is fast and analytical is slow
What are heuristics
mental shortcuts or cognitive strategies that are automatic and unconsciously applied
What is validity
does the test accurately identify whether a patient has a disease, measured with the 2X2 table
what is sensitivity
true positive. the probability that a person with disease has a positive test
what is specificity
true negative. the probability that a non diseases persion and a negative test
A negative result from a test with high sensitivity usually: includes or excludes disease
excludes
What does SNOUT stand for for measuring sensitivity and specificity
a Sensitive test with a Negative result rules OUT disease
What does SpPIN stand for for measuring sensitivity and specificity
a Specific test with a Positive results rules IN disease
what are predictive values
how useful is the test in telling us whether the disease is absent or present
what is a positive predictive value
true positive. Probability that a person with a positive test has the disease
what is a negative predictive vaule
true negative. Probability that a person with a negative test doesnt have the disease
if prevalence is low in a population, will there be more and less false positives of a test
more false positives
what are liklehood ratios
the probability of obtaining a given test result in a diseased pt divided by the probability of obtaining a given test result in a non diseased pt
pre and post test probability are based on ___
likelihood ratios
LR values >1 are associated with positive or negative LR’s
positive
LR values <1 are associated with positive or negative LRs
negative
what is the coefficient of variation and when is it used
statistics used to characterize precision and often used in lab tests
what is the most abundant extracellular electrolyte
sodium
what is the most abundant intracellular electrolyte
potassium
where is the best location to list for S3 and mitral stenosis
Apex
is the PMI felt at the apex or base of the heart
Apex
Where, anatomically, can the PMI usually be felt
5th intercostal just medial to left midclavicular line
What would cause the PMI to be on the right side
dextrocardia
what length is considered an abnormally large PMI and what can cause it
> 2.5 cm caused by LVH from HTN or dilated cardiomyopathy
Why might a COPD patient have a displaced PMI
RV hypertrophy
What would a PMI displaced more than 10cm from the midclavicular line indicated
LVH or ventricular dilation from MI or HF
what are the AV valves
mitral and tricuspid
what are the semilunar valves
aortic and pulmonic
in Adults, S3 correlated to (systolic or diastolic) HF and S4 correlates to (systolic or diastolic)
S3 correlates to systolic and S4 correlated to diastolic HF
What is an Ej sound and when is it heard
early systolic ejection sound accompanying opening or aortic valves heard in some pathologic conditions
the mitral and tricuspid valves close during (s1 or s2)
S1
the aortic and pulmonic valves close during (S1 or S2)
S2
What is an opening snap and what causes is
audible opening of the mitral valve from restricted motion caused by mitral stenosis
What does S4 indicate if heard in adults
marks atrial contraction and usually from ventricular stiffness cause by HTN or acute MI
Does S1 or S2 splitting vary with respirations and how so
S2 splitting is heard during inspiration only, S1 does not vary with respiration
Where is the best anatomical location to hear S2 splitting
2nd and 3rd intercostal space close to sternum
Where is the best place to hear S1 splitting
lower left sternal border
what causes heart murmurs
turbulent blood flow from valvular disease
what is a normal ejection fraction
60%
what are some causes of decreased RV preload
exhalation, dehydration, pooling of blood in capillary beds or venous system
how can volume overload cause clinical HF
pathologic increase in preload and afterload changes ventricular functioning making the heart inneffective as a pump
what is pulse pressure
difference between systolic and diastolic pressure
on a JVP graph, what does the A wave and x descent represent
A wave = atrial contraction (forcefull push of blood into ventricles) and X descent = atrial relaxation and filling
What can cause prominent A waves in JVP
anything that causes increased resitance to atrial contraction like triscupid stenosis, heart blocks, SVT, junctional tachycardia, pulmonary HTN and pulmonic stenosis
what would cause absent A waves in JVP
A-fib
What is the V wave in JVP graphe
venous filling and atrium tensing
what would cause increased V waves in JVP graph
tricuspid regurg, atrial septa defects and constrictive pericarditis
what are cardiac causes of chest pain in a patient with a normal angiogram
microvascular coronary dysfunction and abnormal cardiac nocioception
Unstable angina, NSTEMI and STEMI are all branched under what term
ACS
what are the life threatening cardiac causes of chest pain
MI, PE, dissecting AAA, angina pectoris
what are causes of acute sudden onset dyspnea
PE, spontaneous pneumothorax, anxiety
what conditions cause orthopnea and paroxysmal nocturnal dyspnea
LV HF, mitral stenosis, obstructive lung disease
what condition can mimick paroxysmal nocturnal dyspnea
nocturnal asthma attacks
what is anasarca
severe generalized edema extending to the sacrum and abdomen
periorbital puffiness and tight rings indicate what condition
nephrotic syndrome
a pathologic enlarged waist line may be caused by what conditions
ascites and liver failure
what are some concerning cardiac causes of syncope
end stage HF and arrhythmias
what role does JVP findings play in terms of patients with HF
predicts elevations in fluid volume
what is the difference between venous and carotid pulsations
venous are inward and carotid are outward
what causes a decreased JVP
blood loss or decreased venous vascular tone
what causes increased JVP
HF (most likely), pulmonary HTN, tricuspid stenosis, AV dissociation, increased venous vascular tone, pericardial compression
what is the angle of Louis
vertical distance above sternal angle where JVP is measured
how many CM do you add to the measured height of a JVP
5cm
What is an elevated JVP measurement
more than 3cm above sternal ankle or more than 8cm total finding (with 5cm add on)
When might you see an elevated JVP on expiration but collapsed veins on inspiration
obstructive lung disease, this finding is not indicative of HF
why should you not palpate if you auscultate a possible carotid bruit
it is indicative of an atherosclerotic plaque and could be dislodged with palpation
high grade stenosis have higher or lower frequencies
lower
lower frequencies are better heard with the bell or diaphragm
bell
what are causes of bruits
atherosclerotic stenosis, tortorous carotid artery, aortic stenosis
Are bruits indicative of clinically significant underlying disease
no
What may be seen when assessing carotid arteries if the artery is tortorous or kinked
A unilateral pulsatile bulge
what are causes of decreased carotid pulsation
decreased stroke volume form shock or MI, local atherosclerotic narrowing, occlusion
what is one possible negative side effect of applying pressure to the carotid sinus
reflex bradycardia and hypotension
a normal carotid upstroke follows S1 or S2
S1
what causes a thready or weak carotid pulse
cardiogenic shock
what causes a bounding carotid pulse
regurg
what causes a delayed carotid upstroke
aortic stenosis
what condition causes thrills
aortic stenosis
what is pulsus alternans and what does it indicate
rhythm is regular but alternating force of arterial pulse, usually indicates severe left ventricular dysfunction
How can you determine pulsus alternans with blood pressure
loud and soft korotkoff sounds or a sudden doubling of the apparent heart rate as the cuff pressure declines. Especially seen when patient is upright
what is a paradoxical pulse
greater than normal drop in systolic blood pressure during inspiration
what would you expect for a patient with pulsus paradoxis with increased JVP, dyspnea, tachycardia, HoTN, and muffled heart sounds
cardiac tamponade
what is the difference between blood pressure amounts throughout the respiratory cycle that constitutes pulsus paradoxus
10-12
what are causes of pulsus paradoxus
pericardial tamponade, acute asthma, obstructive pulmonary disease, constrictive pericarditis, PE
which condition varies with respirations: pulsus paradoxus or pulsus alternans
pulsus paradoxus
What causes a diminished S1
first degree heart block
what causes a diminished S2
aortic stenosis
what causes lateral displacement of the PMI
ventricular dilation from HF, cardiomyopathy, ischemic heart disease, and mediastinal shift
midsystolic murmurs typically arise from blood flow acros the semilunar or AV valves
semilunar
murmurs that coincide with a carotid upstroke are systolic or diastolic
systolic
a Crescendo, decrescendo, cresceno-decrescedno or plateau of a murmur is describing what quality
shape of the murmur
when grading a systolic murmur, what levels require a palpable thrill
4-6
a medium pitches, grade 2/4, blowing decrescendo diastolic murmur best heart in the fourth left intercostal space with radiation to the apex is describing what type of murmur
aortic regurgitation
right sided heart murmurs generally increase with inspiration or expiration
inspiration
left sided heart murmurs generally increase with inspiration or expiration
expiration
what is the only murmur that increases during the strain phase of the valsalva and during squatting to standing
hypertophic cardiomyopathy
the square wave response, where blood pressure remains elevated during phase 2 of valsalva but during during phase 4, is highly correlated with what
volume overload and elevated left ventricular end diastolic pressure
what murmur is heard at the apex and radiates to the axilla
mitral regurg
what classic feature of PAD do only 10% of patients present with
pain in legs with exertion relieved with rest
What does the ankle brachial index test for
PAD
edema with low protein content is more likely to be non pitting or pitting
pitting
what kind of edema is hard an non pitting with skin thickening
lymphedema
what causes bounding carotid, radial and femoral pulses
aortic regurg
what is pulsus tardus and what causes it
a sluggish pulse caused by aortic stenosis or low cardiac output
what is pulsus parvus and what causes is
a weak pulse, caused by ahterosclerotic PVD
What is ABI and what is it used for
raiot of blood pressure in foot and arm, used to assess PAD
what patients may have an artificially high BP reading on an ABI
elderly or diabetic due to fibrotic or calcified vessels
what is a normal ABI
0.9-1.4
what ABI value is diagnostic for PAD
less than 0.9
what is the triangle of safety
formed by lateral border of pectoralis major anteriorly, lateral border of the latissumus dorsi posteriorly and the nipple like where it is safe to insert a chest tube
What would cause foul smelling sputum
anaerobic lung abscess
What is levine sign
a clenched fist over the sternum
What causes delayed expiration
COPD
What is diaphragmatic excursion
descent of the diaphragm measured by percussion
what does a high level of diaphragmatic excursion indicate
pleural effusion, atelectasis or phrenic nerve paralysis
what does a gap between inspiratory and expiratory breath sound ssuggest
bronchial breath sounds
how are vesicular breath sounds described
soft and low pitched through inpiration and expiration
how are bronchial breath sounds described
louder, harsher, higher pitch, short silence between inspiratory and expiratory
what conditions cause wheezing
asthma, COPD, bronchitis
what sounds are described with the term rhonchi
sounds from secretion in large airways that change with coughing
what kind of lung sounds would you expect to hear in pneumonia
bronchial or bronchovesicular
what is egophony and what causes is
A to E lung sounds from pneumonia
What would you expect to see with lower motor neuron disease
decreased muscle tone, fasciculations, atrophy, hyporeflexia
what would you expect to see with upper motor neuron disease
increased muscle tone, hyperreflexia
what parts of the nervouse system are included in lower motor neuron
cranial nerves, spinal nerve roots, peripheral nerves
the corticospinal tract is part of the upper or lower motor neurons
upper
if damage occurs to upper motor neuron before the medulla, would symptoms be on the same side or opposite side
opposite side because it is before the crossover in the medulla
what are the differences in symptoms for diabetics with small fibre neuropathy versus large fiber neuropathy
small fiber reports sharp, burning or shoot foot pain and large fiber reports numbness or tingling
which reflexes connect to the cervical spinal segment
tricep, brachioradialis and bicep
which reflex connects to the lumbar spinal segment
knee
which reflex connects to the sacral spinal segment
ankle
what causes a dull headache with increase by coughing and sneezing
brain tumor or abscess
when is a migraine suspicious for stroke
atypical presentation of a patients usual migraine symptoms especially in women taking birth control
what does the acronym POUND stand for and when is it used
used to assess likelyhood of migraine and migrain is likely is at least 3 are present. Stands for Pulsatile, one day duration, unilateral, nausea, disabiling
what are spark photopsias, fortifications, and scotomas
auras before a migrain: flashes of light, zig zag arcs of light and areas of visual loss
what headaches are usually unilateral
migraines and cluster
what headache usually arises in the temporal areas
tension
what headache may be retro orbital
cluster
what is a concerning cause of ataxia, dipolpia and dysarthria
TIA or stroke
chronic and gradual progression of weakness may be caused by what
tumor or ALS
what symptoms would you expect to see in a myopathy from drugs or alcohol
proximal weakness like difficulty reaching up a shelf or climbing stairs
what condition causes fatigable proximal weakness
myasthenia gravis
what are some examples of distal weakness
hand strength opening har, using sciossrs, tripping when walking
what condition would you expect to have bilateraly predominatley distal weakness with sensory loss
polyneuropathy from diabetes
what is the difference between paresthesia and dysesthesia
para is pins and needls and dys is distorted sensation
a light pin prick causes a burning sensation is an example of what
dysesthesia
what condition causes stocking glove pattern
diabetes
what conditions cause multple pathcy areas of sensory loss in different limbs
vasculitis or RA
low frequency unilateral resting tremor, rigidity, bradykinesia and postural instability typify what disorder
parkinsons
what is an essential tremor
high frewuency, bilateral upper extremity tremor that occurs with movement and at sustained posture and susbsides when limb is at rest
what is anisocoria
differnent sized pupils
pronator drift indicates a lesion in what area
corticospinal tract in the opposite side
what is ataxia
loss of control of coordinated movements
what would cause nustagmus, dysarthria, hypotonia and ataxia
cerebellar disease
what is dysdiadochokinesis and when is it seen
slow, irregular and clumsy rapid alternating movements seen in cerebellar disease
what is an intention tremor
rhythmic oscillitory tremor during an intentional movement like trying heel to shin movement
how would you describe an ataxic gait
wide base, uncoordinated with reeling and instability
what would you see in cerebellar ataxia
difficulty standing with feet together whether eyes open or closed
what is a positive romberg sign
patient stands well with eyes open but loses balance with eyes closed
wat is stereognosis
ability ot percieve an object by touch
what is a positive brudzinski sign and what does it indicate
flexion of both hips and knees when neck is flexed, meningities
kernig sign, and what does it indicate
pain and increased resistant to knee extension when flexing leg at hip and knee and then trying to extend leg, meningitis
what is a jolt accentuation of headache and what does a positive indicate
rotating head side to side quickly worsens headache, indicates meningitis
what is asterixis
flapping tremorf
what is dysarthia
defective articulation
what is dysphonia
impaired volume, quality or pitch of voice
what are the two common kinds of aphasia
expressive (broca) and receptive (wenicke)
what is seen in expressive (broca) aphasia
preserved comprehencion but slow non fluent speech
what is seen in Receptive or wericke aphasia
impaired comprehension with fluent speech
are fine crackles heard in inspiration or expiratoion
inspiration
fine or coarse crackles start in early inspiration and last throughout expiration
coarse
