PD Crammin for Exam 2 lol Flashcards
lord help me
Superior lobes of the lung are easier to ascultate on the ___, inferior lobes are easier to auscultate on the _____
anterior, posterior
Horizontal fissure of lung is marked by what palpable structure?
Right 4th-5th rib moving medial to lateral
Right oblique fissure of lung is marked by what palpable structure?
5th to 6th rib moving lateral to medial
Directly behind the body of sternum sits the….
…right ventricle of the heart
Left oblique fissure of lung is marked by what palpable structure?
6th rib
RALS system
Determines the orientation of the pulmonary arteries in the hilus of the lung, with the right lung having anterior placed pulmonary artery to the main bronchus and the left lung having superior 2 placed pulmonary artery to the main bronchus
Objects entering the hilus of the lung
Left and right main bronchus, 1 pulmonary artery on each side, 2 pulmonary veins exiting on each side, tiny bronchial arteries entering, 2 on the left and one on the right
Inspection of the thorax
shape and symmetry, accesory breathing muscles, A/P to lateral ratio (pectus excavatum and carinatum or barrel chest), scoliosis, kyphosis, skin for cynaosis, breath odor, respiratory rate pattern
Palpation of the thorax
Feel around for pulsations, bulges, depression or crepitus on both anterior and posterior side, demonstrate tactile fremitus and respiratory excusrion
Tactile fremitus
Have patient cross arms, pallpate with ulnar side of hands the posterior wall starting high and going down and medial around the shoulder blade asking them to say 99 at each point, do same thing atneriorally between pecs and sides
Decreased bilateral tactile fremitus indicates…
….obstruction, copd, pleural effusion, fibrosis, or pneumothroax
Assymetric decreased fremitus indicates…
…unilateral pleural effusion
Asymmetric increased tactile fremitus indicates….
…consolidated tissue thru unilateral pneumonia
Ventilary excursion
Have patients cross arms, place hands on mid lower back and have take deep breath, watch for thumbs to grow in distance between them, anteriorally place thumbs near xyphoid process and do same thing
Percussion of thorax
Tap back going left to right across the back below the scapula listening for dullness, resoonance, or hyperresonance in a ladder pattern, do same on front, then move to diaphragmatic excursion
Hyperresonance during thorax percussion indicates….
…copd and asthma
Diaphragmatic excursion
Have patient roll shoulders forward, tap to find level of diaphragm during quiet respiration (where downward is dull and above is resonant, mark that point), then have patient inspire and hold, percuss down until dull, mark that point, have patient fully expire and hold percuss up until resonance, mark that point, should be 3-5cm diff between inspiration and expiration
Auscultation of thorax
Have patient cough a few times, bend head forward and fold arms over anterior chest, follow same pattern as percussion with stethoscope having them take an open mouth deep breath each time you move, same for front, listen for bronchophony, egophony, and whispered pectriloquiy
Vesicular breath sound
Long inspiratory and short expiratory, low pitch, heard over most of lungs
Bronchial breath sound
Short inspiratory and long expiratory, high pitch, heard over manubrium best
Bronchovesicular breath sound
Equal length inspiratory and expiratory medium pitch, heard best between scapula
Rales
Adventitious breath sound involving packing paper pop, indicative of pneumonia, pulmonary fibrosis, ateclasis
Wheezes
Adventitious breath sound involving higher pitched hissing, increased in asthma, copd, bronchitis
Ronchi
Adventitious breath sound rough coarse snoring on exhalation, increased in asthma, copd, bronchitis
Friction rub
Adventitious breath sound, pleura rubbing together in a mechanical grating
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 pectoriloquy
Loudness due to consolidation tranmission of sound by having a patient whisper 99 while ausculatating, should be barely heard in healthy lungs
Lymphadenitis
Swollen, tender, and erythematous lymph nodes
Thoracic duct
Receives overwhelming majority of lymphatic drainage from the entire left side and bottom right side of body, travels up the left side of the abdomen and thorax to empty where the left internal jugular and left subclavian vein meet
Right lymphatic duct
Responsible for minimal lymphatic drainage from the body, just the right upper extremity and right side of the head, travels to empty into the junction where the right internal jugular and right subclavian vein meet
Cisterna chyli
Dilated lymph vessels in the lumbar spine marking the beginning of the thoracic duct
What are the indications for performing a lyphatic exam?
Every patient, easy and important, palpating provides info about possible presence of malignant or inflammatory process
What lymphatic regions can be clinically examined?
Cervical head and neck, axillary, epitrochlear, inguinal, popliteal
Horizontal inguinal lymph nodes
Travel along th einguinal canal and drain the lower abdomen and buttocks, external genitalia (minus testes) scrotum, anal, and lower vagina
Vertical inguinal lymph nodes
Travel along the line of the great saphenous vein and drain portions of the leg corresponding
Testes lymphatic drainage
Separate pattern from horizontal and vertical inguinal lymph nodes going to paraoritc lymph nodes following testicular arteries deep into abdomen
Inspection lymphatic exam
Lopoking for swelling, erythema, streaking, lesions, rubor, calor, dolar, tumor
General palpation lymphatic exam
Gentle circular motion making note of shape, delimination (boundaries), mobility, consistency, tenderness, or pulsation (meaning its not a lymph node)
Neck palpation lyphatic exam
Pre and post auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical along anterior edge of traps, deep cervical chain down scm, supraclavicular deep to clavicle
Axillary palpation lymphatic exam
Have patient grasp your upper arm, palpate with patient seated supine wearing gloves, apical, lateral medial, anteior and posterior lymph nodes
Epitrochlear palpation lymphatic exam
Hold patients wrist and palpate above olecranon for nodes
Popliteal palpation lymphatic exam
Flex knee and palpate in popliteal fossa
Palpating infraclavicular nodes or supraclavicular nodes are indicative of…
…breast cancers or other axillary cancers
When it comes to palpating a lymph node, what things are bad signs?
Stiff, hard, or nontender nodes.
Virchow’s node
Left supraclavicular node indicative of stomach, intestineal, breast, or lung cancers
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 area or apex area (cardiac exam)
5th left intercostal space, midclavicular line
Erb’s point (cardiac exam)
Left 3rd intercostal space, left sternal border
Point of maximal impulse is typically located where?
Apical pulse, can shift indicative of pathology
Precordium
Chest wall that sits directly anterior to the heart
S1 heart sound
Closure of mitral and tricuspid valves beginning of systole, the lub sound
S2 heart sound
Closure of aortic and pulmonic valvees, end of systole start of diastole, the dub sound
S2 splitting
Occurs upon inspiration and delays closure of pulmonic valve creating a2 and p2
S3 heart sound
Early diastolic sound heard after S2 sounding like an extra little slap “kentucky”
S3 associated pathology
While normal in some young, typically ventricular dysfunction, heart failure, a large ventricle undergoing rapid ventricular filling
S4 heart sound
A late diastolic sound heard right before S1
S4 associated pathology
Due to atrium pushing blood into stiff ventricle creating atrial gallop, often due to diastolic dysfunction or LV hypertrophy
Systolic vs diastolic heart murmurs
Systolic are often benign and present in 60% of people, diastolic is always pathology
Aortic regurgitation is a ….
diastolic murmur
Aortic stenosis is a….
systolic murmur
Pulmonic regurgitation is a…
diastolic murmur
Pulmonic stenosis is a…
systolic murmur
Mitral regurgiation is a…
systolic murmur
Mitral stenosis is a…
diastolic murmur
Tricuspid regurgitation is a…
systolic murmur
Tricuspid stenosis is a…
diastolic murmur
Inspection of the heart
First assess jugular venous pulsations, if not seen put pressure on liver via hepatojugular reflex, measure jugular venous pressure using 2 ruler technique, above 3 cm is considered elevated
Palpation of the heart
FIRST listen to the carotids before palpating in case of bruits, then take carotid pulse, then move patient to sitting position, inspect precordium, palpate pmi with haeel of hand for lifts, use ball of hand to test for thrills
Auscultation of the heart
Auscultate aortic, pulmonic, erbs, tricuspid, and mitral points using diaphragm, have patient lean forward and listen with diaphragm for murmur of aortic insufficiency, place patient supine flat, inspecte, palpate, auscultate with diaphragm and bell along diff heart positions, move into left lateral decubitus position and auscultate mitral area with bell
Erbs point
An auscultory point at the left sternal border of the 3rd intercostal space that allows to hear a 2nd pulmonary area
A Wave (jugular venous pulsations)
Atrial contraction prior to S1, appears as an upward pulsation
X descent (jugular venous pulations)
Atrial relaxation, collapse between s1 and s2
V wave (jugular venous pulsations)
Atrial filling
Y descent
Tricuspid valve opening, atrium emptying
Murmur scale
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
Most important factor for risk of breast cancer
Age
Inspection of breasts
Full exposure of breast initially, sitting position, looking for symmetry, contours, and retraction in 4 views (hands on hips, arms overhead, arms at sides, and leaning forward)
Palpation of the breasts
Lay patient on back, expose just one breast, use pads of 2nd-4th fingers keeping them slightly flexed and follow striped pattern, ask patient to roll onto opposite hip and place hand on forehead keeping shoulder flat and palpate in the axilla, palpate nipple lightly and express with index finger, have patient sit up and palpate the axilla with their arm down, pres fingers in and down
The most important risk factor for cervical cancer
Persistent infection with high risk HPV subtypes, HPV 16 or 18
Inspection of female pelvis
Examine the female genitalia, will need to touch and separate and inspect the labia minora, clitorus, urethral meatus, insert speculum and perform papsmear, inspect vagina on way out, continue on to perform bimanual examniation and rectovaginal examination if indicated
Bimanual examination
Standing insertion of two lubricated fingers into vagina while the other hand palpates structures on the abdominal surface to try to capture different organs, must palpate cervix, uterus, and ovaries
Rectovaginal examination
The introduction of index finger into vagina and middle finger into rectum, have patient strain down to relax anal sphincter, press the fingers together while putting downward pressure with hand on abdomen
Inspection of the abdomen
Inspect for scars, bulging, peristalsis, pulsations, cullen/grey turn’er sign
Cullen or grey turner’s sign
Purplish coloration indicative of retroperitoneal hemorrhage or acute pancreatitis
Ausculatation of the abdomen
Listen for bowel sounds in all 4 quadrants, listen over aorta for bruits
Percussion of the abdomen
Percuss for areas of tympany, percuss liver, bladder, and spleen
Palpation of the abdomen
Palpate all around superficially then do it again with knees flexed for deep palpation, capture liver, spleen, and kidneys
Order of exam on abdomen
Inspect and auscultate before percussing and palpating In that order
CVAT test
costal vertebral angle test, place ball of hand on costovertebral angle and strike with ulna to detect pain
Abdominal wall mass test
Ask patient to raise head/shoulders to see if mass remains palpable to see if abdominal wall or cavity based
Roysing’s sign
Press deeply in LLQ, pain in RLQ with pressure in LLQ or with RLQ rebound tenderness is positive for appendicitis
Psoas sign
Flex right hip to test for appendicities
Obturator sign
Flex right thigh at hip with knee bend, internally rotate hip, positive if pain for appendicitis
Murphy’s sign
Ask patient to exhale, place hand below costal margin on right side of midclavicular line, have patient inspire, if sharp pain then positive test for acute cholecystitis
Patient’s hands need to be where during abdominal exam?
At their sides
List all the definable pulses
carotid radial brachial aorta femora popliteal dorsal pedis posterior tibial
5 p’s of PAD
Pain, pulselessness, pallor, paralysis, parasthesia, poikilothermia
Virchow’s triad
Intimal trauma
coagulopathy, hypercoagulable state
venous stasis
Arterial claudication
Indicative of atherosclerotic disease, pain in defined group of muscles relieved with rest
Neurogenic claudication
Indicative of spinal stenosis, improves leaning forward
Subclavian steal syndrome
Stenosis of subclavian artery causing syncope
Rest pain
Waking up with pain, laying legs over side of bed and pain goes away, indicative of PAD
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- abscent
