PCM 1 - Final Exam Flashcards
Is the diaphragm of the stethoscope best for high- or low-pitched sounds?
High Pitched
e.g.,: S1, S2, AR, MR, Friction Rubs
The diaphragm of the stethoscope is best for high pitched sounds, give some examples.
- S1
- S2
- AR (aortic valve regurgitation)
- MR (mitral valve regurgitation)
- Friction Rubs
Is the bell of the stethoscope best for high- or low-pitched sounds?
Low Pitched
e.g., S3, S4, MS, Carotid Bruit
The bell of the stethoscope is best for low pitched sounds, give some examples.
- S3
- S4
- Carotid Bruit
- MS (mitral valve stenosis)
What are the 4 major steps, in order, to the cardiovascular exam?
- Inspection
- Palpation
- Percussion
- Auscultation
List general appearance items to Inspect for during Step 1 of the cardiovascular exam?
- consciousness
- cyanosis
- flushing
- respiratory patterns
- anxiety/distress
- body habitus
- diaphoresis (sweating)
- neck veins (JVD)
What is the common shape upon inspection of a pt with COPD?
Barrel Chested
What is the shape of a pt’s chest with Pectus Carinatum upon inspection?
Pigeon Chest
What is the shape of a pt’s chest with Pectus Excavatum upon inspection?
Funnel Chest
What are the common landmarks used during Inspection (Step 1) of the cardiovascular exam?
- sternal notch
- sternal angle
- sternal border
- mid-clavicular line
- anterior axillary line
- xiphoid process
- nipples
During Palpation (step 2) of the cardiovascular exam what is the Point of Maximal Impulse (PMI)?
PMI –> used to estimate location of apex/left border of the heart.
> can assess supine or left lateral decubitus position
usually palpated near the 4th-5th intercostal space in the mid-clavicular line
may need to have patient lift her breast
PMI may not e readily felt in healthy heart/patient
What does the Point of Maximal Impulse (PMI) estimate?
Location of Apex/Left Border of the Heart
In what position should the pt be in to determine the Point of Maximal Impulse (PMI) during Step 2 (palpation) of the cardiovascular exam?
Supine or Left Lateral Decubitus
In what location is the Point of Maximal Impulse (PMI) typically palpated?
Normally - near the 4th-5th Intercostal Space in the Midclavicular Line
What is typically palpated near the 4th-5th Intercostal Space in the Mid-clavicular Line?
Point of Maximal Impulse (PMI)
True or False:
The PMI (point of maximal impulse) may not be readily felt in healthy heart/patient.
True
True or False:
Palpation of an impulse should be felt through the second heart sound (S2).
False - should NOT be felt through S2
**Impulse should be a small, brisk beat and measure less than 2.5cm. The impulse should last through the first 2/3 of the systolic period (or less).
What location do you auscultate the Aortic Valve?
Right 2nd Intercostal Space @ Sternal Border
What location do you auscultate the Pulmonic Valve?
Left 2nd Intercostal Space @ Sternal Border
What location do you auscultate the Tricuspid Valve?
Left 4th Intercostal Space @ Sternal Border
What location do you auscultate the Mitral Valve?
Left 5th Intercostal Space @ Mid-Clavicular Line
What location do you auscultate Erb’s Point?
Left 3rd Intercostal Space @ Sternal Border
**Erb’s Point –> point at which S1 and S2 is heard equally.
What is Erb’s Point?
The point at which S1 and S2 are heard equally.
Which sound is heard at the Right 2nd ICS @ the SB?
Aortic Valve
Which sound is heard at the Left 2nd ICS @ the SB?
Pulmonic Valve
Which sound is heard at the Left 4th ICS @ the SB
Tricuspid Valve
Which sound is heard at the Left 5th ICS @ the Mid-Clavicular Line?
Mitral Valve
What causes S1?
Closure of the Tricuspid and Mitral Valves
What causes S2?
Closure of the Aortic and Pulmonic Valves
- may split with inspiration (normal)
What is the S3 sound?
Dull, Low Pitch, Best Heard with Bell
Due to high pressure and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of the cardiac cycle.
Physiologic in children/young adults.
Pathologic > 40 y/o (“Ken-Tuck-Y”)
What is the S4 sound?
Dull, Low Pitch, Best Heard with Bell.
Atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle.
Can be normal in trained athletes.
“Ten-Nes-See”
What is systole?
Ventricular Contraction and Ejection
S1 –> S2
What is diastole?
Ventricular Relaxation and Filling
S2 –> S1
Between which two heart sounds is a systolic murmur heard?
S1 and S2
Give 4 examples of pathologies that cause systolic murmurs.
- aortic stenosis
- pulmonic stenosis
- mitral regurgitation
- tricuspid regurgitation
Diastolic murmurs are heard between which two heart sounds?
S2 and S1
Give 4 examples of pathologies that cause diastolic murmurs.
- aortic regurgitation
- pulmonic regurgitation
- mitral stenosis
- tricuspid stenosis
What are the characteristics of a Grade 1 murmur?
very faint
What are the characteristics of a Grade 2 murmur?
quiet, but heard easily with stethoscope
What are the characteristics of a Grade 3 murmur?
moderately loud, NO THRILL
What are the characteristics of a Grade 4 murmur?
loud, with palpable thrill
What are the characteristics of a Grade 5 murmur?
very loud w/thrill - may be heard with stethoscope partly off chest
What are the characteristics of a Grade 6 murmur?
heard with stethoscope entirely off the chest
Rate the grade of murmur:
Murmur heard with stethoscope entirely off the chest.
Grade 6
Rate the grade of murmur:
Murmur is very loud w/thrill, and can be heard with stethoscope partly off the chest.
Grade 5
Rate the grade of murmur:
Murmur is loud with palpable thrill.
Grade 4
Rate the grade of murmur:
Murmur is moderately loud, with no thrill.
Grade 3
Rate the grade of murmur:
Murmur is quiet, but heard easily with stethoscope.
Grade 2
Rate the grade of murmur:
Murmur is very faint.
Grade 1
Is the carotid pulse palpated medial or lateral to the SCM?
Medial
What is the carotid pulse palpated for?
Assess for thrills and bruits
** pressure on the carotid baroreceptors may cause a hypotensive reflex and possible fainting
What are the 4 grades of the peripheral pulse scale?
0: absent, pulse not palpable 1+: pulse diminished, barely palpable 2+: Normal, average intensity, expected 3+ pulse is strong, full, increased 4+: pulse is bounding
Which grade on the peripheral pulse scale of 4 is considered normal?
2+: normal, average intensity, expected
What is the capillary refill test testing?
Test of Digital Perfusion (e.g., arterial occlusion, hypovolemic shock, hypothermia)
**Normal capillary refill time is 2 seconds or less **
When performing an examination for pitting edema, how long is pressure firmly applied with your finger tip?
Examined by pressing firmly for 5 seconds over the:
- dorsum of the foot - anterior tibia - behind medial malleolus
Where are the 3 locations in which you exam for pitting edema?
1) dorsum of the foot
2) anterior tibia
3) behind medial malleolus
What are the grades used in the four point scale for the examination for pitting edema?
Absent
1+: barely detectable, slight pitting (2mm); disappears rapidly
2+: slight indentation (4mm); remains for 10-15 seconds
3+: deeper indentation (6mm); may be >1 minute
4+: very marked indentation (8mm); 2-5 minutes
From where do the anterior and posterior axillary lines drop vertically from?
Anterior and Posterior Axillary Folds
From where does the Mid-Axillary line drop from?
Apex of the Axilla
From where does the mid-sternal line drop from?
suprasternal notch
From where does the mid-clavicular line drop from?
Vertically from the midpoint of the clavicle.
What is the landmark in which the 2nd rib meets with the manubrium and the body of the sternum?
Sternal Angle
At which landmark is a needle decompression performed for an emergent decompression tension pneumothorax?
2nd ICS just superior to the 3rd rib margin at the mid-clavicular line for emergent decompression tension pneumothorax, followed by chest tube placement.
**recall: neurovascular bundle runs inferior to each rib, so needles and tubes should be placed superior to the rib margins
At what ICS (intercostal space) doe you insert a chest tube?
4th ICS at mid or anterior axillary line in the 4th ICS just superior to the margin of the 5th rib
At which vertebral level would the lower margin of an endotracheal tube appear on a chest x-ray?
T4
Which intercostal space is a landmark for thoracentesis?
7th Intercostal Space
List the 4 major things to evaluate during respiration of the patient.
- rate (normal: 14-20x/minute)
- rhythm
- depth
- effort
In what respiratory problems does intercostal retractions occur?
- severe asthma
- COPD
- upper airway obstruction
What are pursed lips during breathing characteristic of?
Obstructive Lung Disease (COPD)
What is a characteristic posture/position of a pt with obstructive lung disorders?
Tend to sit leaning forward with shoulders elevated.
Contraction of which accessory muscles can occur in pts with difficult breathing?
- sternomastoid
- scalenes
- supraclavicular retraction
Which pathology can cause lateral displacement of the trachea?
Tension Pneumothorax (causes deviation of trahea towards countrlateral side)
What is “clubbing” of the fingernails?
- Bulbous swelling of soft tissue at nail base.
- Loss of normal angel between nail and proximal nail fold (>180 degrees) leading to a spongy or floating feeling.
- Involves vasodilation with increased blood flow to the distal potion of the digits, and changes in connective tissue possible due to hypoxia, changes in innervation, or a platelet derived groth factor from fragments of platelet clumps.
In which pathologies is fingernail clubbing seen in?
- congenital heart disease
- interstitial lung disease
- bronchiectasis
- pulmonary fibrosis
- lung abscess
- inflammatory bowel disease
- malignancies (lung cancer)
- cystic fibrosis
What is Tactile fremitus?
Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks.
- perform on anterior and posterior chest
- pt says “ninety-nine” or “one-one-one”
- often more prominent in the interscapular area than in the lower lung fields, and is more prominent on the right than the left.
- disappears below the diaphragm
What is indicitive of decreased/absent fremitus?
- COPD
- pleural effusions
- fibrosis
- pneumothorax
- thick chest wall
- an infiltrating tumor
What is indicitve of increased fremitus?
- pneumonia
increased transmission through consolidated tissue
What is the purpose of percussion of the chest?
To establish whether underlying tissues are:
- air-filled - fluid-filled - solid
Which finger is used during percussion of the chest?
Hyperextended Middle Finger
- have only hyperextended middle finger firmly contact skin
- strike extended middle finger aiming for the DIP with a quick, sharp, but erlaxed wrist motion
- start superiorly percussing obht sides of the chest working toward the base procedding in a “ladder-like” pattern
- also perform on the anterior chest
- percussion penetrates only 5cm to 7cm into chest, so it can miss deep seated lesions
What is the depth that can be accessed by percussion of the chest?
penetrates only 5cm - to - 7cm
** Thus, percussion can miss deep seated lesions. **
In what position should the pt be in while performing percussion on the posterior side?
- Seated, with both arms crossed in front of chest.
During percussion, what are the 5 percussion notes that you should identify?
- Flat (soft intensity; high pitch)
- Dull (medium intensity; medium pitch)
- Resonant (loud intensity; low pitch)
- Hyperresonant (very loud; lower pitch)
- Tympanitic (loud intensity; high pitch - distinguished mainly by its musical timbre
Of the 5 percussion notes, which is expected to be heard in a healthy lung?
Resonant:
- loud intensity
- low pitch
- long duration
True or False:
Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers.
True
True or False:
Generalized resonance may be heard over hyperinflated lungs.
False - HYPERRESONANCE may be heard over hyperinflated lungs.
Give 2 examples of obstructive disorders that can cause generalized hyperresonance heard over hyperinflated lungs during percussion of the chest.
- COPD/Emphysema
- Asthma
During percussion of the chest you hear unilateral hyperresonance. Name 2 pathologies that this finding could suggest.
- large pneumothorax
- large air-filled bulla in lung
Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers. Name two pathologies that would be suggestive of this.
- lobar pneumonia (alveoli filled with fluid and blood cells)
- pleural accumulations
> effusion (serous fluid)
> hemothorax (blood)
> emphyema
> fibrous tissue or tumor
Pleural accumulation of what substance causes an Effusion?
Serous Fluid
Pleural accumulation of what substance causes a Hemothorax?
Blood - treated with chest tube placement.
Pleural accumulation of what substance causes a Empyema?
Pus
What is Diaphragmatic Excursion?
Used to determine the distance between inhale and exhale of the diaphragm.
1) patient exhale completely and hold it
2) percuss level of diaphragm
3) mark with pen
4) patient breathes normally for a few breaths
5) patient inhales completely and holds it
6. percuss for level of diaphragm
7) mark level with pen
8) distance between the two is diaphragmatic excursion
What can cause asymmetry with one side of the diaphragm than another, noticed during diaphragmatic excursion assessment?
- pleural effusion (will have dullness to percussion)
- high diaphragm secondary to:
> atelectasis
> phrenic nerve paralysis
What is the range of normal diaphragmatic excursion?
Normal Excursion = 3-5.5 cm
What would dullness at a level higher than expected during diaphragmatic excursion suggest?
- pleural effusion
- high diaphragm (as in atelectasis, or phrenic nerve paralysis)
Which side of the stethoscope do you use during auscultation of the lungs?
- Diaphragm of the Stethoscope
While listening to auscultations with the diaphragm of your stethoscope, should the patient breath through an open or closed mouth?
Open Mouth
True or False:
Compare auscultation side to side at each level before going to the next level (“ladder-like pattern”).
True
At minimum, how many spots should auscultation be assessed during a lower respiratory exam?
- Listen at Minimum to each lobe of the lungs:
> upper and lower lobe (left lung)
> upper, middle, and lower lobe (right lung)
What are the 4 normal breath sounds?
- vesicular (sound heard over most of lungs (parenchyma))
- bronchovesicular
- bronchial
- tracheal
What is the intensity and pitch of Vesicular Breath Sounds?
Soft and Low Pitched
During which potions of the respiratory cycle are vesicular breath sounds heard?
Heard through inspiration and about 1/3 of expiration.
What is the intensity and pitch of Bronchovesicular breath sounds?
Intermediate Intensity and Pitch
During which portions of the respiratory cycle are bronchovesicular breaths sounds heard?
Heard equally in Inspiration and Expiration
In which location are bronchovesicular breath sounds best heard?
1st and 2nd Interspaces Aneriorly and Between the Scapulae
What is the intensity and pitch of Bronchial Breath Sounds?
Loud Intensity and High Pitched
During which portion of the respiratory cycle are bronchial breath sounds heard?
Expiratory sounds heard longer than inspiratory.
In which location are bronchial breath sounds best heard?
Over Manubrium (larger proximal airways)
What is the intensity and pitch of Tracheal Breath Sounds?
Very Loud Intensity and High Pitched
During which portion of the respiratory cycle are Tracheal Breath Sounds heard?
Equally in Inspiration and Expiration
In which location are tracheal breath sounds best heard?
over trachea in neck
What is suggestive if bronchovesicular or bronchial breath sounds are heard more distal to expected locations?
- air-filled lung has been replaced by fluid-filled or solid lung tissue
Decreased breath sounds may be due to?
- decreased air flow (COPD, muscular weakness)
- poor transmission of sound (COPD, pleural effusion, pneumothorax)
What are adventitious breath sounds?
Added Breath Sounds that are Superimposed on the Usual Breath Sounds
e.g., crackles (rales), wheezes, rhonchi, stridor, pleural friction rub)
Define Crackles (rales)
- fine crackles: soft, high-pitched, very brief (5-10 msec)
(sometimes likened to sounding like “velcro”) - coarse crackles: louder, lower in pitch, brief (20-30 msec)
Timing in Respiratory Cycle –> Inspiratory, Expiratory, or Mid-Inspiratory/Expiratory
Crackles (rales)
discontinuous; intermittent, nonmusical, and brief adventitious (added) breath sounds
Wheezes
continuous; musical quality and prolonged (not necessarily the entire respiratory cycle)
relatively high pitched, musical, hissing, or shirll quality:
> suggest narrowed airways (asthma, COPD, bronchitis
Rhonchi
relatively low-pitched, snoring quality
suggests secretions in large airways
What is rhonchi suggestive of?
secretions in large airways
What is a stridor?
Wheeze that is entirely or predominantly inspiratory in nature.
Often louder in neck vs. chest wall.
Indicates partial obstruction of larynx or trachea (medical emerency: immediate attention needed)
In which location is a stridor often heard the loudest?
Louder in Neck vs. Chest Wall
What does a stridor indicate?
partial obstruction of larynx or trachea (medical emergency)
What is a Pleural Friction Rub?
inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction
usually confined to a relatively small area of the chest wall
sounds like creaking, usually during expiration but can occur in both phases of respiration
When should transmitted voice sounds be assessed?
If abnormally located bronchovesicular or bronchial breath sounds are heard (pneumonia, consolidations, effusions)
List 3 pathologies that can cause abnormally located bronchovesicular or bronchial breath sounds.
- pneumonia
- consolidations
- effusions
Bronchophony
Spoken words become louder and clearer (indicates consolidation) when while listening to lungs while patient says “ninety-nine” (99).
Normal Lungs –> sounds transmitted through healthy lungs are muffled and indistinct.
Egophony
The “ee” sounds like “A”. The “A: has a nasal bleating quality and should be localized.
Normally –> will hear a muffled long E sound “ee”
** in pts with fever and cough, the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia! **
Whispered Pectoriloquy
Patient Whispers (“ninety-nine” or “one-two-three”) are heard louder and clearer during auscultation.
Normally –> whispered voice is faint and indistinct or not heard at all.
medical term for canker sores
Aphthous Ulcers
what is indicated by Cheilitis?
B12 or Iron Deficiency, red cracks at corners of mouth.
What is gingivitis?
swelling or ulcerations of gums
What is Torus palatinus?
benign lump on hard palate
Which cranial nerves control the soft palate?
CN IX and X
**paralysis -> uvula deviates to opposite side and soft palate does not rise with saying “ah”. **
Which sinus does not open until after 7 years of age?
A) frontal
B) maxillary
C) ethmoid
D) sphenoid
frontal sinus
Where is the best location to palpate the frontal sinuses?
press up under bony brows
Where is the best location to palpate the maxillary sinuses?
press up on location of maxillary sinuses
What is the function of Turbinates?
Cleansing, Humidification, and Temperature control of Inspired Air
** turbinates are covered by highly vascular mucous membrane and protrude into the nasal cavity
What is indicated by a redness and edema of nasal mucosa?
viral rhinitis
Describe the appearance of nasal mucosa in a patient with viral rhinitis?
Red with Edema
Describe the appearance of nasal mucosa in a patient with allergies.
Can be pale, bluish, or red in color.
What is indicated by a pale, bluish, or red nasal mucosa in a patient upon inspection?
Allergic reaction (allergies)
What can cause a septal perforation of the nasal mucosa?
- cocaine
- meth
- trauma
- surgery
what is the medical name for acne rosacea?
rhinophyma
What does the Weber Test assess?
Test for Lateralization
- vibrating tuning fork placed on top of patient’s head or on middle of forehead:
- normal: sound lateralizes to both ears equally
- if sound lateralizes to one ear, it is iether conduction loss in that ear or sensorineural lossin the opposite ear
What are the normal results of the Weber Test?
Sound lateralizes to both ears equally.
** vibrating turing fork placed on top of patient’s head or on middle of forehead.
What does it mean if sound lateralizes to one ear, instead of both, while performing the Weber Test?
It is either:
- conduction loss in that ear, or
- sensorineural loss in the opposite ear
What does the Rinne Test compare?
Compares Air and Bone Conduction of Sound
What is the Rinne Test?
Vibrating tuning fork placed on mastoid bone behind ear and level with the canal.
When patient no longer hears sound, quickly place fork close to ear canal and inquire if can hear the sound and for how long they hear it.
Normal: AC>BC
If AC=BC or BC>AC: there is conductive loss to that ear.
If Weber test was abnormal and Rinne was normal, suspect sensorineural loss in the opposite ear.
What is the whisper test?
Doctor stands behind the patient.
Have patient occlude one ear.
The doctor exhales fully and then whispers a combination of numbers and letters (ex: 2-K-4).
The patient repeats the sequence.
Repeat with a different sequence if responds incorrectly.
What is a normal result for the Whisper Test?
Patient correctly repeats the sequence or after 2 sequences, can identify 3 of the 6.
Abnormal: patient incorrectly identifies 4 of the 6.
What is an abnormal result for the Whisper Test?
pt incorrectly identifies 4 of the 6 after 2 sequences (3 items per sequence [ex: 2-K-4]) that the doctor whispered when fully exhaled
What causes conductive hearing loss?
external or middle ear problem (conductive phase)
What causes sensorineural loss?
inner ear, cochlear nerve or central brain connections problem (sensorineural phase)
Describe the normal appearance of the Tympanic Membrane upon inspection?
Translucent and Pearly
In what direction do you pull to straighten the ear canal for inspection in adults?
pull up, out, and away
In what direction do you pull to straighten the ear canal for inspection in children?
pull down, out, and away
What is presbycusis?
Loss of higher frequency hearing; common in older adults.
Determined by Whisper Test.
Whisper Test –> 90% - 100% sensitive and 70-87% specific to detect hearing loss of > 30 decibels
Note: Consonants use higher frequencies than vowels!
What is the normal range of the Carrying Angle?
5-15 degrees
What Carrying Angle is required for cubitus varus?
< 5 degrees
What Carrying Angle is required for cubitus valgus?
> 15 degrees
What nerve root is tested during the biceps reflex?
C5
What nerve root is tested during the brachioradialis reflex?
C6
What nerve root is tested during the triceps reflex?
C7
What is a positive valgus stress test?
Pain/Tenderness with palpation and valgus stress; increased laxity (degree of laxity correlates to degree of injury to UCL)
What does a positive valgus stress test indicate?
- sprained medial (ulnar) collateral ligament
What does a positive varus stress test indicate?
sprained lateral (radial) collateral ligament
What is a positive varus stress test?
Pain or Increased Laxity in LCL (lateral collateral ligament)
What is indicated by a positive Tinel Test of the Elbow?
Ulnar Nerve Entrapment/Cubital Tunnel Syndrome
+ Test = eliciting tingling sensation down forearm within ulnar nerve distribution
What is indicated by a positive Golfer’s Elbow Test?
Medial Epicondylitis
- pain/tenderness around the medial epicondyle
What pathology typically causes Little League Elbow in children?
medial apophysitis
What pathology typically causes Little League Elbow in adolescence?
medial epicondyle avulsion fracture
What pathology typically causes Little League Elbow in adults?
Medial Collateral Ligament Tear
What is Nursemaid’s Elbow (radial head instability) caused by?
annular ligament tear and/or radial head subluxation from annular ligament
pain with palpation of radial head with anterior displacement of radial head and restriction to posterior glide
What are the coupled motions at the elbow joint?
- ulnar adduction with supination
- ulnar abduction with pronation
- radial head anterior glide with supination
- radial head posterior glide with pronation
What is the coupled motion with ulnar adduction?
supination
What is the coupled motion with ulnar abduction?
pronation
What is the coupled motion with radial head anterior glide?
supination
What is the coupled motion with radial head posterior glide?
pronation
What muscle is the medial border of the anatomic snuffbox?
extensor pollicus longus m.
What muscle is the lateral border of the anatomic snuffbox?
extensor pollicus brevis, abductor pollicus longus muscles
What is the proximal border of the anatomic snuffbox?
radial styloid process
What nerve is tested with the “OK” Sign test?
anterior interosseous nerve
motor branch of median nerve innervating:
- flexor pollicis longus
- deep flexors of digits 2 and 3
- pronator quadratus
What does the Allen Test assess?
evaluates functioning of radial and ulnar arteries
What pathology does the Phalen’s sign test for?
Carpal Tunnel Syndrome
What does a positive Finkelstein Test indicate?
DeQuervain’s tenosynovitis
What is the most common carpal bone to fracture when falling on outstretched hand (FOOSH)?
scaphoid fracture
What is a Colle’s Fracture?
fracture of the distal radius in the forearm with dorsal (posterior) and radial displacement of the wrist and hand.
What is a Monteggia Fracture?
- fracture of the proximal ulna
- dislocation of the radial head
What is a Galeazzi Fracture?
- fracture of the distal radius
- dislocation of the ulna
What is a nightstick fracture?
isolated fracture of the mid-shaft of the ulna from a direct blow
What ligament is the primary stabilizer of the medial ankle?
Deltoid Ligament
What bones make up the medial longitudinal arch?
- navicular
- cuneiforms (1-3)
- talus
- metatarsals (1-3)
Which longitudinal arch of the foot is our weight-bearing arch?
Medial Longitudinal Arch
What are the components of the lateral longitudinal arch?
- calcaneus
- cuboid
- metatarsals (4-5)
What bone is a component of both the medial- and lateral-longitudinal arch of the foot?
calcaneus
Which 3 tendons pass through the Tarsal Tunnel?
- flexor digitorum longus tendon
- flexor hallucis longus tendon
- posterior tibialis tendon
What does the Anterior Drawer Test of the ankle test for?
ATF ligament pathology/tear (lateral ankle sprain)
What does the Talar Tilt Test assess?
Calcaneofibular ligament pathology/tear and some ATF (lateral ankle sprain)
What does the Eversion Test assess?
Deltoid ligament pathology (medial ankle sprain)
What does the squeeze test assess?
syndesmosis pathology (high ankle sprain)
What does the cross leg test assess?
syndesmosis pathology (high ankle sprain)
What does the Thompson test of the ankle assess?
achilles tendon rupture
What does a positive Homan’s sign indicate?
thrombophlebitis or acute deep venous thrombosis (DVT)
**not always performed clinically due to potential risk of embolus
What does a positive Moses sign indicate?
deep vein thrombosis of the posterior tibial veins
**not always performed clinically due to potential risk of embolus
Which ligament always tears first in an inversion (lateral) ankle sprain?
anterior talofibular ligament (ATF)
What type of sprain accounts for 10% of all ankle sprains?
high ankle sprain
What is a Morton’s Neuroma?
inflammation and thickening of tissue that surrounds the nerve between toes.
Most commonly between 3rd and 4th toes.
Patient reports that it feels as if they are walking on a marble.
What is a Turf Toe?
inflammation and pain at base of 1st MTP
caused by hyperextension of great toe causing damage to the joint capsule
What does a positive Apprehension Test indicate?
glenohumeral instability
What does a positive Sulcus Sign indicate?
glenohumeral instability
What are the 2 special tests for assessing glenohumeral instability?
- apprehension test
- sulcus sign
What does a positive Yergason’s Test indicate?
unstable bicipital tendon/subluxation bicipital tendonitis
What does a positive Speed’s test indicate?
bicipital tendonitis of longhead biceps
What does a positive empty or full can test indicate?
rotator cuff pathology (specifically supraspinatus)
What does a positive drop-arm test indicate?
full thickness tear of supraspinatus
What does a positive neer impingement test indicate?
subacromial bursa or rotator cuff impingement
What does a positive Hawkins test indicate?
rotator cuff or subacromial bursa impingement
What does a positive Lift Off Test indicate?
subscapularis weakness
What does a positive Cross Arm Test indicate?
AC joint pathology
What does an Upper Apley Scratch Test assess?
test ROM and is coupled external rotation and abduction of the shoulder
What does an Lower Apley Scratch Test assess?
test ROM and is coupled internal rotation and adduction
What is the posture of a patient with Genu valgum?
knees close together and feet farther apart (knock-kneed)
What is the posture of a patient with Genu varus?
where the legs appear bowed with feet together (bow-legged)
What is the posture of a patient with Genu recurvatum?
posture seen from a lateral view, where the knee has a backward curvature (hyperextension)
What is the normal Q-angle in degrees?
15 degrees
How is the Q-angle measured?
Measured by creating a straight line from the ASIS to the center of patella and another line through the tibial tuberosity and the same point on the patella.
This difference between these two lines forms the “Q-angle”.
Females typically have an increased Q-angle.
Do males or females generally have an increased Q-angle.
females
What does a positive valgus stress test indicate?
medial collateral ligament (MCL) disruption
What does a positive varus stress test indicate?
lateral collateral ligament (LCL) disruption
What does a positive anterior drawer test indicate?
ACL insufficiency
What does a positive Lachman’s test indicate?
ACL insufficiency
What does a positive posterior drawer test indicate?
PCL deficiency
posterior capsular injury
disruption
What does a positive reverse Lachman’s test indicate?
PCL deficiency/posterior capsule deficiency
What does a positive McMurray’s test indicate?
possible medial or lateral meniscus tear
What does a positive Apley’s Grind Test-Compression test indicate?
possible meniscal injury
possible collateral ligament injury
or both
What does a positive Apley’s Grind Test-Distraction test indicate?
possible collateral ligament damage
What does a positive Patellar Laxity and Apprehension test indicate?
possible previous patellar dislocation or severe instability
What does a positive Patellar Compression (grind) test indicate?
possible inflammation, chondromalacia, or injury to the patellofemoral articular surfaces
What does a positive Patella-Femoral Grinding test indicate?
roughness of articulating surfaces (e.g., chondromalacia)
What does a positive Patellar Glide Test indicate?
possible damage to the articular surface
What is the superior border of the femoral triangle?
inguinal ligament
What is the medial border of the femoral triangle?
medial border of adductor longus muscle
What is the lateral border of the femoral triangle?
medial border of sartorius muscle
What is the major flexor of the hip?
Iliopsoas muscle
- femoral nerve (L2-4)
- ventral rami of lumbars (L1-2)
What is the main extensors of the hip?
Gluteus maximus muscle
- inferior gluteal nerve (L5, S1-S2)
What is the main abductor of the hip?
Gluteus Medius and Minimus Muscles
- superior gluteal nerve (L5, S1)
What is the main adductor of the hip?
Adductor longus muscle
- obturator nerve (L2-4)
What are the main central compartmental structures of the hip?
- labrum
- ligamentum teres
- articular surfaces
What are the main peripheral compartmental structures of the hip?
- femoral neck
- synovial lining
What are the main lateral compartmental structures of the hip?
- gluteus medius
- gluteus minimus
- piriformis
- IT band
- trochanteric bursae
What are the main anterior/iliopsoas compartmental structures of the hip?
- iliopsoas insertion
- iliopsoas bursae
What is hypopnea?
decreased depth (shallow) and rate (slow) of respiration
What is bradypnea?
regular rhythm but slower than normal rate (RR < 14/min)
What is hyperpnea?
increased depth (deep) of breathing and rate (fast) of respiration (normal in exercise)
What is tachypnea?
rapid breathing (RR> 20/min)
What is dyspnea?
feeling short of breath
What is hypoxemia?
oxygen deficiency in arterial blood
what is apnea?
no breathing
what is atelectasis?
collapse of lung tissue that affects the alveoli from normal oxygen absorption
what is pleximeter finger?
hyperextended middle finger of non-dominant hand in percussion
what is plexor finger?
“tapping” finger, dominant hand, for percussion
the chief complaint is always stated in who’s words?
the patient’s words, not the nurse or physician
List the 13 steps of the physical examination for an extensive lower respiratory workup.
- sitting position and breathing pattern
- use of accessory muscles for breathing
- color of fingers and lips. shape of nails
- breathing thru pursed lips
- ability to speak (e.g., 2 word conversational dyspnea)
- chest deformities
- spinal deformities
- is the trachea in the mid-line?
- chest excursion
- tactile fremitus
- percussion
- lung sounds
- lymphadenopathy (think axillary LNs in respiratory patient workup)
** vital exams - pulse oximetry reading (important tool to get heart rate and oxygen saturation of patient quickly)
Which 2 tests make up the pulmonary function test (PFT)?
- plethysmography
- spirometry
What are the things you’re looking for during the Inspection portion of the lower respiratory exam?
- rate, rhythm, depth, and effort
- color
- inspect the neck (accessory muscle use)
- inspect the hands (e.g., capillary refill time, clubbing)
- shape of the chest (e.g., barrell chest = COPD)
- how the chest moves
What is a common posture of a patient presenting sitting in a “Tripod Position”?
Emphysema (COPD is a subtype)
What are the expiratory accessory muscles of respiration?
- abdominals
- expiratory intercostals
What are the inspiratory accessory muscles of respiration?
- inspiratory intercostals
- sternomastoids
- scalenes
- external obliques
what can cause racheal deviation in a pt?
- pneumothorax (tension and non-tension)
- pleural effusion
- atelectasis
- mass
List as many pathologies as you can that can cause clubbing of the fingernails (8).
- congenital heart disease
- interstitial lung disease
- bronchiectasis
- pulmonary fibrosis
- cystic fibrosis
- lung abscess
- malignancy
- inflammatory bowel disease
** clubbing not caused by COPD!!! **
clinical name for “funnel chest”?
pectus excavatum
clinical name for “pigeon chest”?
pectus carinatum
“pick puffer” is a typical appearance in patients with what pathology?
emphysema
“blue bloater” is a typical appearance in patients with what pathology?
chronic bronchitis
what does the presenation of traumatic flail chest look like?
- on inspiration the injured area caves inward
- on expiration the injured area moves outward
** multiple rib fractures may result in PARADOXICAL MOVEMENTS of the THORAX **
is thoracic kyphoscoliosis only a musculoskeletal condition?
No, thoracic kyphoscoliosis is caused by a musculoskeletal disorder, but can affect breathing greatly because it compresses against the lungs, and other organs.
