PD II Flashcards
1
Q
cisterna chyli**
A
dilated lymph vessel; beginning of thoracic duct***
2
Q
what/where are Peyer’s patches?
A
round/oval bundles of lymph cells in ileum
3
Q
when does thymus reduce in size?
A
after puberty
4
Q
what are reticular fibers in Lymph?
A
give lymph shape
trap foreign bodies
5
Q
What is the thymus?
A
site of T cell maturation
6
Q
largest mass of lymph tissue and what does it do?
A
spleen
site of B cell –> AB producing plasma cells
sequester damaged RBC
7
Q
how many tonsils are there?
A
5 total
2 palatine
2 lingual
1 adenoid
8
Q
Where does the epitrochlear nodes drain to?
A
from last three fingers on ulnar surface to axillary nodes
9
Q
testes lymph drainage***
A
deep drainage to paraaortic lymph nodes
10
Q
scrotum lymph drainage***
A
superficial drainage to inguinal lymph nodes
11
Q
What are the divisions of the inguinal lymph nodes and what do they drain?
A
horizontal group: lower ab, butt, external genitalia, anal, lower vaginal
vertical group: great saphenous territory of leg
*testes not in these, only scrotum
12
Q
How do you palpate popliteal lymph nodes?
A
with patient standing
13
Q
How do you palpate inguinal lymph nodes?
A
with patient supine
14
Q
Where do popliteal lymph nodes receive drainage from?
A
superficial: lateral leg/food (small saphenous)
deep: ant/post tib a.
a bit superior to knee crevice
15
Q
Where do the lower extremities drain to?***
A
both drain to left supraclavicular (thoracic duct)
16
Q
What is the abdomen drained by?
A
thoracic duct
17
Q
where do axillary nodes drain to?
A
supraclavicular nodes
18
Q
What are the superficial nodes?
A
cervical axillary epitrochlear (ulna) inguinal popliteal
19
Q
What does the right lymph duct drain from?
A
upper right side of body
20
Q
What are you inspecting in the lymph nodes?
A
swelling
erythema
streaking: lymphangitis
associated lesions
21
Q
what is rubor, calor, dolar, tumor?***
A
rubor: redness
calor: heat
dolar: pain
tumor: swelling
signs of inflammation
22
Q
what could be implicated when lymph nodes are “fixed”?
A
could be malignancy (cancer)
nodes should roll easily
23
Q
What size of axilla and inguinal nodes are insignificant?
A
< 3cm
24
Q
what size of nodes are generally insignificant?
A
< 2cm
25
What size of supraclavicular fossa nodes are SIGNIFICANT?
> 1cm
26
What are the consistencies of lymph nodes and what do they mean?
soft: usually insignificant
rubbery: classic lymphoma
hard: classic malignant and ganulomatous infection
27
Implications of tender v non-tender nodes
tender: classic infection
| non-tender: classic malignancy
28
What do pts 2-12 y.o. commonly present in lymph nodes?
insignificant nodes in neck secondary to frequent viral infection
29
Neck exam sequence
1. preauricular
2. postauricular
3. occipital
4 tonsilar
5. submandibular (smaller/smoother than gland)
6. submental
7. superficial cervical: superficial to SCM
8. posterior cervical: anterior edge of traps
9. deep cervical chain: deep to SCM; inaccessible usually
10. supraclavicular: deep in clavicle SCM angle
30
How to palpate deep cervical chain nodes?
hook thumb and fingers around either side of SCM
31
What is Virchow's node?***
left supraclavicular node
| enlargement: cancer, classic sign of abdominal process
32
Axillary node significance
breast cancer
| inflammation
33
Epitrochlear node significance***
Hodgkin's lymphoma (15-20/55+ y.o.)
cat scratch fever
inflammation
34
What is typical of inguinal nodes?
small, hard --> insignificant
35
What do you do when you see an inflammatory lesion?
look at regional lymph nodes that drain it
36
What do you do when you see an enlarged/tender node?
look for source like infection in area it drains
37
What do you always evaluate when looking at lymph nodes?
SYMMETRY
38
Left supraclavicular node abnormality is a classic sign of what?
intrathoracic process
39
Who should you not palpate carotid too hard?
>50y.o. bc dislodge clot
40
What is infraclavicular fossa nodes indicative of?***
classic breast cancer or malignant lymphoma
41
Warm, erythematic tender, swollen lymph nodes with edema?***
lymphadenitis
42
firm, non-tender, fixed lymph nodes***
malignancy
43
What can cortisol do to immune?
dampen immune system
44
What are the categories of abdominal pain?
visceral
parietal
referred
45
visceral pain (abdominal)
when hollow organs stretched or distended
hard to localize
varies in quality
46
parietal pain (abdominal)
inflammation of parietal peritoneal
steady pain
localized
aggravated w/mvmt
47
referred pain (abdominal)
felt distant from original site
48
What do you always document in an abdominal exam of a female?
last menstrual cycle of female of child-bearing age
49
What two systems are pertinent in an abdominal exam?
GI
| Urinary
50
What has cannabis abuse recently shown to be associated with?
Cannabinoid Hyperemesis Syndrome
abdominal pain
cyclic N/V
Freq hot bath to relieve
51
Hirschsprung's disease
absence of nerves in a segment of bowel --> difficult peristalsis
52
Familial Mediterranean Fever
recurrent episodes of fever
abdominal, chest, or joint pain
1st ep begin childhood
most often in people of middle eastern or mediterranean descent
53
Abdominal PE order***
Inspection
Auscultation*
Percussion
Palpation
54
Which side of the patient should be be during abdominal exam?***
patient's right side!
55
When should you examine painful abdominal spot?
LAST!
56
What should you always keep as differential in abdominal exam?
CANCER
57
Cullen's sign
superficial edema and bruising around umbilicus
| sign of retroperitoneal hemorrhage (eg pancreatitis, periumbilical ecchymosis)
58
Grey Turner's sign
bruising of flank
| sign of retroperitoneal hemorrhage
59
scaphoid abdomen
abdomen sucked inward --> malnutrition
60
What might you see with intestinal obstruction?
peristaltic waves
61
caput medusae
Distended + engorged periumbilical veins
Cirrhosis
IVC obstruction
62
Why should you auscultate before percussion and palpitation?
P/P can alter frequency of bowel sounds
63
borborygami sound
"stomach growling": prolonged peristalsis gurgle
| need to listen for 3-5min to document negative for it!
64
Bruits
vascular murmur; turbulent blood flow
| partial obstruction or high rate of blood flow
65
friction rubs and what can they mean over liver and spleen?
grating sound with respiration
liver: tumor, gonococcal infection
spleen: infarct
66
hepatic bruit +/- hepatic friction rub
carcinoma
67
What arteries are you listening for in an abdominal exam?
```
aorta
renal
iliac
femoral
venous hum
```
68
pain with percussion of abdomen*
peritonitis
69
abdominal percussion: bilateral flank dullness
Suspicious of ascites
70
What does percussing bladder do?
assess bladder distension
71
What does percussing liver do?
estimate size
72
What is the normal size of liver?***
6-12 CENTIMETERS: RIGHT MIDCLAVICULAR LINE**
73
What should you do for palpation of the abdomen?
light and then deep palpation in all four quadrants
| pt's knee flexed
74
Abdominal palpitations: Rebound tenderness
peritoneal inflammation
| Press down firmly + slowly then let go quickly – pain induced/increased by quick withdrawal
75
What should you do in all patients with abdominal pain?*
rectal exam
76
Rovsing's sign
press deeply in LLQ. Pain in RLQ w/ pressure in LLQ is positive
Also positive if RLQ pain on quick withdrawal (referred rebound tenderness)
77
Psoas sign
Place hand above right knee, ask pt to raise that thigh against hand or to turn onto left side. Then extend pt’s rt leg at hip (stretches muscle)
78
Obturator Sign
Flex pt’s right thigh at hip w/ knee bent, rotate internally at hip (stretches internal obturator muscle)
79
Murphy's sign
pt exhale --> examiner hand below costal margin right side at midclavicular --> pat inspire
pos: acute cholecystitis
80
Abdominal pain in women
do pelvic exam! (pelvic inflammatory disease)
| always do pregnancy test
81
aortic valve insufficiency
valve leaks; aortic back flow
82
Where can you hear apex of the heart?
Left 5th intercostal space, midclavicular
| palpable
83
Where is the base of the heart?
2nd intercostal space on either side of sternum
84
Where is S2 heard best?
base, beginning of diastole (semilunar valve)
85
Where is S1 heard best?
apex, beginning of systole (AV valve)
86
what is precordium?
portion of chest wall immediately in front of heart; not any specific area
87
PMI (Point of maximal impulse)
palpate cardiac pressure the best; usually apical impulse
88
RVH (right ventricular hypertrophy)
constant high pressure causing growth; bad
| ex: pulmonary HTN, pulmonic valve stenosis
89
LVH (left ventricular hypertrophy)
more common than RVH
| EX: aortic valve stenosis, HTN
90
Systole
ventricles squeezing; between S1 and S2
91
Diastole
relaxation of ventricles; between S2 and next S1
92
S1
AV valve closure (tricuspid/mitral); beginning of systole
93
S2
Aortic/Pulmonic valve closure (semilunar); end of systole
94
S2 splitting
during inspiration
95
What heart sounds usually represent pathology?
S3 and S4
96
S3
rapid ventricular filling; ventricular gallop; "kentucky"
early diastolic sound: just after S2
usually heart failure
97
S4
atria squeezing blood into stiff ventricle; atrial gallop
| late diastolic sound: "tennessee" (Ten = S4)
98
What position is S3 and S4 best heard?
left lateral decubitus
99
Which heart murmur is always bad?***
Diastolic (after S2)
100
What is a murmur and what is it caused by?
turbulent blood flow
| caused by: regurgitation or stenosis (valve not opening fully)
101
What kind of murmur is aortic/pulmonic stenosis?***
systolic murmur
102
What kind of murmur is aortic/pulmonic regurgitation?***
diastolic murmur
103
What kind of murmur is mitral/tricuspid stenosis?***
diastolic murmur
104
What kind of murmur is mitral/tricuspid regurgitation?***
systolic murmur
105
normal BP
systolic <120 mmHg and diastolic <80 mmHg
106
elevated BP
systolic 120 to 129 mmHg and diastolic <80
107
stage 1 HTN
systolic 130 to 139 or diastolic 80 to 89 mmHg
108
Stage 2 HTN
systolic 140 mmHg or diastolic 90 mmHg
109
What to do with carotid bruits?
listen before palpation (prevent dislodging clot)
| turbulent blood flow
110
How to inspect jugular veins
patient 30 degrees
look at right side
find internal jugular pulsations and measure height above sternal angle
111
What is hepatojugular reflux?
when you press on liver to intensify internal jugular pulsations (RUQ)
112
What does internal jugular pulsations tell you?
measures jugular venous pressure
113
How to determine an elevated jugular venous pressure?
measure pulsation height above sternal angle
| pulsations >3cm above sternal angle or >8cm above RA = ELEVATED
114
What are the jugular venous pulsations?
A Wave
X Descent
V Wave
Y Descent
115
What does the A wave of jugular pulsation represent?
atrial contraction; upward pulsation
| before S1
116
What does the X descent of jugular pulsation represent?
Atrial relaxation; collapse of internal jugular
| between S1 and S2
117
What does the V wave of jugular pulsation represent?
atrial filling
118
What does the Y descent of jugular pulsation represent?
tricuspid valve opens, atrial emptying
119
Examination of the heart
Inspection
Palpation
Auscultation
120
How can aortic insufficiency murmur and S1/S2 be best heard?
with Diaphragm (high pitch)
121
How can S3/S4 and mitral stenosis be best heard?
with Bell (low pitch)
122
How do you palpate lifts/heaves?
with heel of hand
123
What are thrills, what do they tell you, and how do you palpate it?
vibratory sensation
indicate intensity of murmur
ball of hand
124
Assessment of murmurs
```
time: systolic/diastolic
location
shape: crescendo/decrescendo
intensity : 1-6
radiation
```
125
What do veins have that arteries don't?
valves and thinner walls
126
claudication
pain or cramping in arms or legs
127
How does decrease blood flow manifest?
pain
128
classic intermittent claudication
pain within defined group of muscles induced w/exercise, relieved w/rest
129
subclavian steal syndrome
stenosis/occlusion of subclavian artery causes syncope/pre-syncope (patients passing out)
130
How does Peripheral Artery Disease manifest?
rest pain; ischemia
131
Buerger's disease (thromboangitis obliterans)
rare; obstruction of vessels of hands/feet --> amputation
132
Raynaud's phenomena
arterial spasm; digital ischemia
| blanching of fingers followed by cyanosis with cold temp --> redness with rewarming of hands
133
5 P's of Peripheral Arterial Disease***
```
Pain
Pulseless: diminished or absent
Pallor: blanching
Paralysis: sig dec in function
Paresthesia: pins and needles
“Poikilothermia”: temp change
```
134
Which gender is at greater risk for venous disease?
female
135
Virchow's Triad*** for DVT Risk
intimal trauma: injury or surgery
coagulopathy/hypercoagulable state
venous stasis: not moving
136
What can venous insufficiency cause?
fluid seeps out of engorged veins --> edema --> tissue breakdown/ulcers
137
What is DVT at risk for (fatal)?
pulmonary embolism
138
Allen's test
confirm interconnecting arch blood flow of hands: radiala, ulnar
139
Trendelenburg Test
determines valve competency in superficial/deep veins in legs in pts w/varcose veins
140
What does an exaggerated widened pulse suggest?
anuerysm
141
Pitting edema
pressure on edema leaves indentation
| +1 = 2mm
142
ankle brachial index for PAD/PVD
ankle pressure/arm pressure
0.4-0.9= moderate PVD
<0.4 = sever PVD
143
McBurney's point
point where appendix is; between ASIS and umbilical
144
Kyphosis
hunchback
145
Barrel chest
AP to lateral ratio: 1:1 instead of 1:2
146
crepitus
grating sensation; pop pop sound
147
How to check for tactile fremitus
1. have patient say 99
2. feel for vibrations (side of hand)
can suggest pneuomonia
148
What sound is heard throughout most of lung fields?
vesicular breath sounds
149
What sound is heard over trachea?
bronchial breath sounds
and also tracheal breath sounds
low pitch, longer expiratory
150
Abnormal breath sounds
```
rales (crackles): packing material
rhonchi: coarse
wheezes: high pitched
friction rubs
amphoric
```
151
Hamman's sign
crunching sound of heart beating against air filled tissue
152
Bronchophony
"ninety-nine"
should not be able to understand during auscultation
magnification in sound is bad
similar to whispered pectoriloquy
153
egophony
"eee"
changes to "aaa"
consolidation
154
increase fremitus
denser or inflamed lung tissue like pneumonia
155
decrease fremitus
air or fluid in pleural space
156
Atelectasis
collapse of lung tissue with loss of volume
157
penumothorax
air enters pleural space, compressing lung
| shifts mediastinum
158
How to listen for aortic insufficiency
pt leaning forward and listen with diaphragm
159
How to listen for S3/S4 and mitral stenosis
pt in left lateral decubitus, listen with bell
