Part 4 Flashcards
Physical exam definition
Process by which the clinician investigates the body of a patient for signs of disease
Always approach patients from the…
right (patient right)
128 Hz tuning fork
Larger fork that tests for vibratory sensation
512 Hz tuning fork
Smaller tuning fork to allow for Weber & Renne’ hearing test
Pan-optic opthalmoscope
Gives a more magnified image of the retina
Diaphragm of stethescope
Large dial on end of stethoscope that listens to high pitched sounds
Bell of stethoscope
Small dial on end of stethoscope that listens to low pitched sounds
The 5 vital signs (sometimes a 6th is included)
1) Temp
2) Blood pressure
3) Respiration rate
4) Heart Rate
5) BMI
6) SOMETIMES Pulse ox
Temperature is regulated by what organ
hypothalamus
Normal oral temp
98.6F/37c
5 ways to measure temp
1) oral
2) Axillary
3) Rectal (patient unconscious, restless, cannot close mouth)
4) Tympanic membrane
5) laser thermometer of the forehead temporal artery
Hypothermic thermometer
Accurate for temperatures a normal thermometer is not, below 94 degrees F
Noninfectious causes of pyrexia
- ovulation
- thyroid storm
- drug effect
- trauma
- cancer
Hyperpyrexia
Fever greater than 104 degrees F, typically resulting from infection
Hypothermia
Temp less than 95 degrees F, exposure to cold, shock, hypothyroidism, hypoglycemia
6 pulse sites
1) radial (easiest)
2) carotid (have to listen for presence of plaque that could be released by pressure)
3) femoral (at about the femoral triangle)
4) apical (on the heart, says nothing about perfusion)
5) Dorsalis pedis
6) Posterior tibial pulse
Carotid baroreceptor mechanism and nerve responsible
Massaging of carotid can cause baroreceptor reflex to stimulate thanks to glossopharangeal nerve that results in a drastic drop in blood pressure and syncope episode
Sinus tachycardia and some common causes
Rapid regular >100 beats, caused by
- heart disease
- fever
- exercise
- anemia
- dehydration
- hyperthyroidism
- drugs
- smoking
-anxiety
Sinus bradycardia and common causes
Slow regular <50 bpm, caused by
- heart disease
- hypothyroidism
- irregular electrolytes
- athlete
Pulsus alternans deinition and cause
Alternating strong and weak pulse, indicates left ventricular heart failure
Pulsus bisferiens and cause
Biphasic pulse, indicates aortic valve problem
Dicrotic pulse and cause
2 distinguishable palpable pulses, indicates low cardiac output
Pulsus parvus et tardus definition and cause
Pulse is weak and has late carotid upstroke, caused by aortic valve stenosis
Pulsus paradoxus definition and cause
Typically SBP falls 3-10mm during inspiration, pulse gets weaker, caused by asthma, COPD, etc…. Note this has NOTHING TO DO WITH PULSE BUT RATHER BP
Regulator of O2 and CO2 in bloodstream
Brainstem - medulla oblongata, pons, midbrain
Kussmaul breathing definition and cause
Fluctuating breathing rates, caused by metabolic acidosis
Cheyne stokes respiration and cause
Breaths with periods of apnea (strict apnea differentiating from kussmaul), seen in head injuries with brain tumors, or strokes
korotkoff sounds
5 phases of taking BP with the start represents systolic and end being silence representing diastolic
Elevated vs narrow pulse pressure and what these could mean
Elevated is >60, predictor of arterial stiffness and CVD, narrow is <40, predictor of shock or cardiac tamponade
Koebner phenomenon (isomorphic response) and what 2 conditions is it seen with?
Skin disease appearance along the region of trauma often seen in skin conditions such as psoriasis and vitiligo
annular vs arciform skin descriptors
annular is a complete ring, arciform is an incomplete
Herpetiform definition
Random grouping
Zosteriform definition
Grouping in dermatomes
Secondary lesions
Changes in skin which are superimposed or the consequence of the primary process
ABCDE for melanoma
1) Asymmetry
2) Border irregular
3) Color variation
4) Diameter larger than 6mm
5) Elevation or Evolving
Autonomy
Patient’s need for self determination and ability to make their own decisions
Beneficence
Provider’s inherent need to do good
Non-maleficence
Provider’s responsibility to first do no harm
Range of motion tests should be ____ first then ___
Active, passive
Apley’s scratch test
common shoulder physical exam technique to test ROM with flexion, extension, abduction, adduction, internal and external rotations where you have the pt scratch the back superioraly with one arm and inferiorally with the other and then switch
Empty can test looks for what?
Supraspinatus rotator cuff instability
Lift off test looks for what?
Subscapularis rotator cuff instability
Rhomboid test
physical exam test performed by having patient place hand on hip and examiner drives the elbow forward while looking at the shoulder, if scapula wings then rhomboid is likely torn
Neer’s impingement test
Passive flexion upward of the patient’s arm with the forearm pronated as to have the thumb pointed downward toward the ground, pain elicited is positive
Hawkin’s Kennedy test
Physical exam test where The examiner places the patient’s arm shoulder in 90 degrees of shoulder flexion with the elbow flexed to 90 degrees and then internally rotates the arm. The test is considered to be positive if the patient experiences pain with internal rotation
Range of motion on wrist
Flexion, extension, ulnar deviation, radial deviation
Adson’s test
Physical exam test for thoracic outlet syndrome involving sitting patient with examiner extending the shoulder maximally and abducting about 30 degrees, patient turns head toward this same side as far as possible and takes a deep breath and holds it, examiner checks the pulse for drop in strength considered positive
Modified adson test
Has the patient look the opposite way of the arm being tested and take a deep breath and hold to check for pulse drop
Range of motion on elbow
Flexion, extension, pronation, supination
sulcus sign
Physical exam test where the humerus is pulled downward and an indentation of skin forms on the top of the shoulder
Lateral epicondylitis test
Pain elicited in the lateral epicondyle with resisted wrist extension
medial epicondylitis test
Patient with arm extended and supine tries to flex and prontate wrist against resistance from examiner, if pain at the medial epicondyle considered positive
Finklestein’s test
Physical exam test involving wrapping the thumb in the 4 other digits then performing ulnar deviation, if painful then positive for dequarvain’s tenosynovitis
Phalen’s test
Pushing dorsum of the wrists against each other and holding if numbness or pain develops after 30-60 seconds considered positive
Tinel’s sign
tapping either on the carpal tunnel or the ulnar tunnel to see if numbness or tingling or pain elicited to test for carpal or ulnar tunnel
Bouchard’s nodes
Swelling and nodule formation at the PIP joint of the hands indicative of osteoarthritis
Heberden’s nodes
Swelling and nodule formation at the DIP joint of the hands indicative of osteoarthritis
ulnar deviation
Hand deformity where the metacarpophylangeal joints cause the fingers to deviate in the ulnar direction indicative of rheumatoid arthiritis
Swan neck deformity
finding of the finger with the DIP bent and the PIP hyperextended
Boutonniere deformity
finding of the finger with the PIP bend and the DIP hyperextended
Patrick’s FABER test
Test for SI joint dysfunction or severe OA of hip, flexion and abduction of the femur, external rotation crossing one leg over the other then putting pressure down onto the knee and the opposing hip
Thomas test
Physical exam test for flexion contracture of hip
How to measure leg length
ASIS to medial malleolus bilateral
Genu varum definition
out bowing knees
Genu valgus definition
Inward bowing knees
Anterior and posterior drawer test
With a slightly flexed knee, pushing and pulling on the lower leg to assess the integrity of the ACL/PCL WHILE examiner is sitting on it, not very accurate
Lachman’s test
Test for ACL laxity or injury involving patient laying flat, knee slightly flexed and supported by examiner’s hands as they draw forward the lower leg
Range of motion on ankle
Flexion, extension, inversion, eversion, medial and lateral rotation
3 tests for meniscal tear and their description
1) Thesalay’s test, have pt stand and twist
2) Mcmurray’s test, pt is lying supine and pick up leg and twist it
3) apley’s grind test, have pt lay prone and push and twist at the knee
Kleiger’s test
Physical exam test for anterior tibiofibular ligament or interosseous membrane of tib fib sprain, involves supporting the tib fib with one hand by examiner and then dorsiflexing and laterally rotating the ankle and if pain occurs up high then needs ortho referral and possible casting to allow healing
Talar tilt test
Physical exam test to look for sprain of the calcaneofibular ligament or the anterior talofibular ligament involving plantar flexing and inverting the ankle, significant laxity is positive
Thompson test
squeezing calf to assess achilles tendon integrity
Bradypnea vs hypopnea
Bradypnea is slow breathing, hypopnea is shallow and infrequent
Tachypnea vs hyperpnea
tachypnea is rapid shallow breathing, hyperpnea is deep and frequent
Hepatic necrotic nail appearance
Half and half coloration of nail
Anemia appearance of nail
White pale color
Hypoxia appearance of nail
Clubbing
Anxiety appearance of nail
Bitten
Nephrotic syndrome appearance of nail
White and pink bands
Hypothyroidism appearance of nail
brittleness
Cranial nerve IV movement
Superior oblique, moves eyes inferiorally and convergently
Cranial nerve VI movement
Lateral rectus, allows movements laterally away from the nose (activated once on each side)
Vertical eye defects are usually caused by…
…vascular problems
Hyperopia
Farsightedness, difficulty focusing on a near object
Myopia
Nearsightedness, inability to focus on distant objects
Nystagmus
Abnormal movement of eye in the vertical, horizontal, or torsional direction
Visual fields by confrontation assessment
Have patient cover one eye, hold up different fingers in each quadrant of visual field
Frontal sinus development period
Do not appear until age 7-8 so no such thing as frontal sinusitis in these children
Optic disc
Entry point into the retina for ganglion cells forming the optic nerve and small vessels entering the posterior eye, lacks any rods or cones and forms the blind spot of the eye, 3-4mm toward the nasal side of the fovea, has an optic cup central depression within
Fovea
Small pit of closely packed cones in the eye at the center of the macula of the retina, forming central vision
A large optic cup to optic disc ratio (close to 1) indicates…
…Glaucoma or other pathology
Tonometry
Testing of intraocular pressure, either via numbing the eye (contact) or via air puff method
Fluorescein eye exam
Applied via drops to most medial area of eye, use cobalt blue light to examine eyes with lights dimmed where abrasions will appear yellow
Weber tuning fork exam
Place tuning fork on top of patient’s head and ask if they hear it equally in both ears or if one is louder, conductive hearing loss sound is heard in impaired ear, sensorineural hearing loss, sound is heard in good ear
Rinne tuning fork exam
Place sound through bone until they lose it, then move to ear, if they can still hear than normal hearing or sensorineural hearing loss, if conductive hearing loss bone is as long or longer than airr
Indirect percussion, plexor versus pleximeter
Plexor is the finger doing the tapping, pleximeter is the finger receiving the tap, important to strike the same location with the same technique
Pyrexia vs hyperpyrexia
Pyrexia is body temp above 98.6 Fand 37C but below hyperpyrexia, hyperpyrexia is temp greataer than 41.1C or 106F,
Hypothermia
Body temp below 35 C or 95 F
Biot’s breathing
Unpredictable irregular breathing, shallow, deep, stopping for periods, sign of respiratory depression or brain damage at medullary level
Auscultory gap
Silent period present between blood pressure reading between systole and diastole, indicative of arterial stiffness
Review of systems order and acronym
General Endo Head Loves Brass, Crass and Gas to Pass Near the Mass General Endocrine HEENT Lungs Breast Cardiovascular Abdominal/GI Genitourinary Psychological Neurological Musculoskeletal
Q angle
Angle formed from the vertical of the inward displacement of the thigh and legs,larger in females than males generally
Patient with nephrotic syndrome facial features
Periorbital edema, puffy pale face
Patient with cushing syndrome facial features
Red cheeks, moon face, hirsutism, buffalo hump on back of neck
Patient with acromegaly facial features
Prominant jaw, soft tissues of nose, ears, and lips enlarged, prominant brow
Presbyopia
Hyperopia (farsightedness) occuring with age
Inferior oblique muscle moves the eye….
….upward and inward
Buccul gingival sulcus
Space where gums lining meet the inside of the cheek lining
The uvula deviates to which side when there is a weakness? What about the tongue?
- Uvula to the opposite side to which the lesion is (vagus nerve)
- Tongue to same side the lesion is (hypoglossal nerve)
RALS system
Determines the orientation of the pulmonary arteries in the hilus of the lung, with the right lung having anterior placed 2 pulmonary arteries to the main bronchus and the left lung having superior 1 placed pulmonary artery to the main bronchus
The left side has ____ bronchial arteries, the right side has ___
2, 1
Which bronchus has a more direct path to the lung?
Right
Where is the carina of the bronchus located?
Directly behind the sternal angle, about the 2nd rib
Pectus excavatum and carinatum
caved in chest vs outward bowing chest wall
Vesicular breath sounds definition and where they can be heard
Normal breath sounds at a higher pitch with a longer inspiratory and shorter expiratory phase, heard throughout most of lung fields and not the sternal borders
Bronchial breath sounds definition and where they can be heard
Normal breath sounds at a lower pitch with a longer expiratory phase and shorter inspiratory phase, heard over large airways, between the scapulae, or on the sternum best
Rales breath sound definition and what it indicates (3 things)
Adventitious breath sound like a cracking pop indicating atelectasis, chronic bronchitis, or COPD
Rhonchi breath sound definition and what it indicates (2 things)
Adventitious breath sound like snoring rough coarse sound indicating bronchitis or COPD
Bronchovesicular breath sounds definition and where they can be heard
Normal breath sound at medium pitch with equal length inspiratory and expiratory phases, heard best between scapula
Diaphragm normal size measured during diaphragmatic excursion
3-5 cm
Wheeze breath sound definition and what it indicates (3 things)
Adventitious breath sound like high pitched squeal with musical quality indicating asthma, bronchitis, or COPD
Bronchophony
Amplification of sound by fluid in a certain space, heard when ascultating by having a patient say 99, it will be louder where there’s consolidation
Egophony
Alteration of sound heard when auscultating by having a patient say eeee and you may hear aaaa if egophony is present, indicative of lung or pleural disease
Whispered Pectriloquy
Loudness due to consolidation tranmission of sound by having a patient whisper 99 while ausculatating, should be barely heard in healthy lungs
Bronchitis findings on lung exam
- Tachypnea
- rhonchi and rales
- clears up with cough
Mitral valve is on the ___ side of the heart and part of the__ circulation, what is the tricuspid?
Left, systemic, right, pulmonary
Apex of heart location
5th intercostal space mdiclavicular line on left side
PMI
Point of maximal impulse, typically same as apical impulse in a healthy individual
S1 heart sound
Closure of mitral and tricuspid valves at the beginning of systole
S2 heart sound
Closure of aortic and pulmonic valves at the end of systole indicating the beginning of diastole
S3 heart sound and associated pathology
Also known as an early diastolic sound heard quickly after S2, indicates heart failure, large ventricle, and ventricular dysfunction most of the time except in young people
S4 heart sound and associated pathology
Also known as a latae diastolic sound heard shortly before S1, indicates atria trying to push blood into a noncompliant ventricle, causes include diastolic dysfunction and LV hypertrophy
Aortic area cardiac exam
Right 2nd intercostal space
Pulmonic area cardiac exam
Left 2nnd intercostal space
Tricuspid area cardiac exam
4th left intercostal space
Mitral or apex area cardiac exam
5th left intercostal space, midclavicular line
Erb’s point cardiac exam
Left 3rd intercostal space, left sternal border
Systolic vs diastolic heart murmurs
Systolic are often benign and present in 60% of people, diastolic is always pathology
Murmur scale heart
1-4 diastolic, 1-6 systolic
1 very faint
2 loud enough to be obvious
3 louder than 2
4 has thrill
5 heard with stethoscope partially off chest with thrill
6 heard with stethoscope completely off chest with thrill
What value for JVP’s measured from sternal angle is considered elevated
> 3cm
Leaning patient forward and listening at the aortic area while they hold their breath exhaled tests for….
….aortic stenosis
Left lateral decibutus and listening to the mitral area tests for….
….mitral stenosis
Virchow’s triad and what it indicates
Intimal trauma
coagulopathy, hypercoagulable state
venous stasis
Indicates DVT
Neurogenic claudication
Indicative of spinal stenosis, improves leaning forward
Subclavian steal syndrome
Stenosis of subclavian artery between the common carotid and vertebral arteries, with exertion causes blood to reverse flow leading to vertebrobasilar insuffiency and sometimes causing syncope
ABI index
Measurement of systolic blood pressure with doppler ultrasound in each arm then in dorsal pedis and posterior tibial, should get higgher ankle pressure than arm by dividing ankle/arm, .9-1.3 is normal, .410.9 is mild pvd, 0-.41 is severe pvd
How to record pulse
4- boudning 3- increased 2- brisk 1- weak 0- abscen
Allen’s test
Shows interconnection between between superfical and deep palmar arch arteries still intact between radial and ulnar part of hand by occluding and then testing
Elevated protein and globulin levels, other than repeating these what should you do if persistently high?
Protein electrophoresis, evaluate for monoclonal gammopathy of undetermined significance (MGUS)
classic pheo triad and what is important to know about it?
Episodic headache, sweating, and tachycardia, most patients do NOT have these 3 classic symptoms
