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Physical Diagnosis > PD II > Flashcards

PD II Flashcards

1
Q

cisterna chyli**

A

dilated lymph vessel; beginning of thoracic duct***

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2
Q

what/where are Peyer’s patches?

A

round/oval bundles of lymph cells in ileum

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3
Q

when does thymus reduce in size?

A

after puberty

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4
Q

what are reticular fibers in Lymph?

A

give lymph shape

trap foreign bodies

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5
Q

What is the thymus?

A

site of T cell maturation

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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

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7
Q

how many tonsils are there?

A

5 total
2 palatine
2 lingual
1 adenoid

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8
Q

Where does the epitrochlear nodes drain to?

A

from last three fingers on ulnar surface to axillary nodes

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9
Q

testes lymph drainage***

A

deep drainage to paraaortic lymph nodes

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10
Q

scrotum lymph drainage***

A

superficial drainage to inguinal lymph nodes

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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

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12
Q

How do you palpate popliteal lymph nodes?

A

with patient standing

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13
Q

How do you palpate inguinal lymph nodes?

A

with patient supine

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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

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15
Q

Where do the lower extremities drain to?***

A

both drain to left supraclavicular (thoracic duct)

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16
Q

What is the abdomen drained by?

A

thoracic duct

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17
Q

where do axillary nodes drain to?

A

supraclavicular nodes

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18
Q

What are the superficial nodes?

A 
cervical
axillary
epitrochlear (ulna)
inguinal
popliteal
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19
Q

What does the right lymph duct drain from?

A

upper right side of body

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20
Q

What are you inspecting in the lymph nodes?

A

swelling
erythema
streaking: lymphangitis
associated lesions

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21
Q

what is rubor, calor, dolar, tumor?***

A

rubor: redness
calor: heat
dolar: pain
tumor: swelling
signs of inflammation

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22
Q

what could be implicated when lymph nodes are “fixed”?

A

could be malignancy (cancer)

nodes should roll easily

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23
Q

What size of axilla and inguinal nodes are insignificant?

A

< 3cm

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24
Q

what size of nodes are generally insignificant?

A

< 2cm

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25
Q

What size of supraclavicular fossa nodes are SIGNIFICANT?

A

> 1cm

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26
Q

What are the consistencies of lymph nodes and what do they mean?

A

soft: usually insignificant
rubbery: classic lymphoma
hard: classic malignant and ganulomatous infection

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27
Q

Implications of tender v non-tender nodes

A

tender: classic infection

non-tender: classic malignancy

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28
Q

What do pts 2-12 y.o. commonly present in lymph nodes?

A

insignificant nodes in neck secondary to frequent viral infection

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29
Q

Neck exam sequence

A
  1. preauricular
  2. postauricular
  3. occipital
    4 tonsilar
  4. submandibular (smaller/smoother than gland)
  5. submental
  6. superficial cervical: superficial to SCM
  7. posterior cervical: anterior edge of traps
  8. deep cervical chain: deep to SCM; inaccessible usually
  9. supraclavicular: deep in clavicle SCM angle
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30
Q

How to palpate deep cervical chain nodes?

A

hook thumb and fingers around either side of SCM

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31
Q

What is Virchow’s node?***

A

left supraclavicular node

enlargement: cancer, classic sign of abdominal process

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32
Q

Axillary node significance

A

breast cancer

inflammation

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33
Q

Epitrochlear node significance***

A

Hodgkin’s lymphoma (15-20/55+ y.o.)
cat scratch fever
inflammation

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34
Q

What is typical of inguinal nodes?

A

small, hard –> insignificant

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35
Q

What do you do when you see an inflammatory lesion?

A

look at regional lymph nodes that drain it

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36
Q

What do you do when you see an enlarged/tender node?

A

look for source like infection in area it drains

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37
Q

What do you always evaluate when looking at lymph nodes?

A

SYMMETRY

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38
Q

Left supraclavicular node abnormality is a classic sign of what?

A

intrathoracic process

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39
Q

Who should you not palpate carotid too hard?

A

> 50y.o. bc dislodge clot

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40
Q

What is infraclavicular fossa nodes indicative of?***

A

classic breast cancer or malignant lymphoma

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41
Q

Warm, erythematic tender, swollen lymph nodes with edema?***

A

lymphadenitis

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42
Q

firm, non-tender, fixed lymph nodes***

A

malignancy

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43
Q

What can cortisol do to immune?

A

dampen immune system

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44
Q

What are the categories of abdominal pain?

A

visceral
parietal
referred

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45
Q

visceral pain (abdominal)

A

when hollow organs stretched or distended
hard to localize
varies in quality

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46
Q

parietal pain (abdominal)

A

inflammation of parietal peritoneal
steady pain
localized
aggravated w/mvmt

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47
Q

referred pain (abdominal)

A

felt distant from original site

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48
Q

What do you always document in an abdominal exam of a female?

A

last menstrual cycle of female of child-bearing age

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49
Q

What two systems are pertinent in an abdominal exam?

A

GI

Urinary

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50
Q

What has cannabis abuse recently shown to be associated with?

A

Cannabinoid Hyperemesis Syndrome
abdominal pain
cyclic N/V
Freq hot bath to relieve

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51
Q

Hirschsprung’s disease

A

absence of nerves in a segment of bowel –> difficult peristalsis

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52
Q

Familial Mediterranean Fever

A

recurrent episodes of fever
abdominal, chest, or joint pain
1st ep begin childhood
most often in people of middle eastern or mediterranean descent

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53
Q

Abdominal PE order***

A

Inspection
Auscultation*
Percussion
Palpation

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54
Q

Which side of the patient should be be during abdominal exam?***

A

patient’s right side!

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55
Q

When should you examine painful abdominal spot?

A

LAST!

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56
Q

What should you always keep as differential in abdominal exam?

A

CANCER

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57
Q

Cullen’s sign

A

superficial edema and bruising around umbilicus

sign of retroperitoneal hemorrhage (eg pancreatitis, periumbilical ecchymosis)

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58
Q

Grey Turner’s sign

A

bruising of flank

sign of retroperitoneal hemorrhage

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59
Q

scaphoid abdomen

A

abdomen sucked inward –> malnutrition

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60
Q

What might you see with intestinal obstruction?

A

peristaltic waves

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61
Q

caput medusae

A

Distended + engorged periumbilical veins
Cirrhosis
IVC obstruction

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62
Q

Why should you auscultate before percussion and palpitation?

A

P/P can alter frequency of bowel sounds

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63
Q

borborygami sound

A

“stomach growling”: prolonged peristalsis gurgle

need to listen for 3-5min to document negative for it!

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64
Q

Bruits

A

vascular murmur; turbulent blood flow

partial obstruction or high rate of blood flow

65
Q

friction rubs and what can they mean over liver and spleen?

A

grating sound with respiration

liver: tumor, gonococcal infection
spleen: infarct

66
Q

hepatic bruit +/- hepatic friction rub

A

carcinoma

67
Q

What arteries are you listening for in an abdominal exam?

A 
aorta
renal
iliac
femoral
venous hum
68
Q

pain with percussion of abdomen*

A

peritonitis

69
Q

abdominal percussion: bilateral flank dullness

A

Suspicious of ascites

70
Q

What does percussing bladder do?

A

assess bladder distension

71
Q

What does percussing liver do?

A

estimate size

72
Q

What is the normal size of liver?***

A

6-12 CENTIMETERS: RIGHT MIDCLAVICULAR LINE**

73
Q

What should you do for palpation of the abdomen?

A

light and then deep palpation in all four quadrants

pt’s knee flexed

74
Q

Abdominal palpitations: Rebound tenderness

A

peritoneal inflammation

Press down firmly + slowly then let go quickly – pain induced/increased by quick withdrawal

75
Q

What should you do in all patients with abdominal pain?*

A

rectal exam

76
Q

Rovsing’s sign

A

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
Q

Psoas sign

A

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
Q

Obturator Sign

A

Flex pt’s right thigh at hip w/ knee bent, rotate internally at hip (stretches internal obturator muscle)

79
Q

Murphy’s sign

A

pt exhale –> examiner hand below costal margin right side at midclavicular –> pat inspire
pos: acute cholecystitis

80
Q

Abdominal pain in women

A

do pelvic exam! (pelvic inflammatory disease)

always do pregnancy test

81
Q

aortic valve insufficiency

A

valve leaks; aortic back flow

82
Q

Where can you hear apex of the heart?

A

Left 5th intercostal space, midclavicular

palpable

83
Q

Where is the base of the heart?

A

2nd intercostal space on either side of sternum

84
Q

Where is S2 heard best?

A

base, beginning of diastole (semilunar valve)

85
Q

Where is S1 heard best?

A

apex, beginning of systole (AV valve)

86
Q

what is precordium?

A

portion of chest wall immediately in front of heart; not any specific area

87
Q

PMI (Point of maximal impulse)

A

palpate cardiac pressure the best; usually apical impulse

88
Q

RVH (right ventricular hypertrophy)

A

constant high pressure causing growth; bad

ex: pulmonary HTN, pulmonic valve stenosis

89
Q

LVH (left ventricular hypertrophy)

A

more common than RVH

EX: aortic valve stenosis, HTN

90
Q

Systole

A

ventricles squeezing; between S1 and S2

91
Q

Diastole

A

relaxation of ventricles; between S2 and next S1

92
Q

S1

A

AV valve closure (tricuspid/mitral); beginning of systole

93
Q

S2

A

Aortic/Pulmonic valve closure (semilunar); end of systole

94
Q

S2 splitting

A

during inspiration

95
Q

What heart sounds usually represent pathology?

A

S3 and S4

96
Q

S3

A

rapid ventricular filling; ventricular gallop; “kentucky”
early diastolic sound: just after S2
usually heart failure

97
Q

S4

A

atria squeezing blood into stiff ventricle; atrial gallop

late diastolic sound: “tennessee” (Ten = S4)

98
Q

What position is S3 and S4 best heard?

A

left lateral decubitus

99
Q

Which heart murmur is always bad?***

A

Diastolic (after S2)

100
Q

What is a murmur and what is it caused by?

A

turbulent blood flow

caused by: regurgitation or stenosis (valve not opening fully)

101
Q

What kind of murmur is aortic/pulmonic stenosis?***

A

systolic murmur

102
Q

What kind of murmur is aortic/pulmonic regurgitation?***

A

diastolic murmur

103
Q

What kind of murmur is mitral/tricuspid stenosis?***

A

diastolic murmur

104
Q

What kind of murmur is mitral/tricuspid regurgitation?***

A

systolic murmur

105
Q

normal BP

A

systolic <120 mmHg and diastolic <80 mmHg

106
Q

elevated BP

A

systolic 120 to 129 mmHg and diastolic <80

107
Q

stage 1 HTN

A

systolic 130 to 139 or diastolic 80 to 89 mmHg

108
Q

Stage 2 HTN

A

systolic 140 mmHg or diastolic 90 mmHg

109
Q

What to do with carotid bruits?

A

listen before palpation (prevent dislodging clot)

turbulent blood flow

110
Q

How to inspect jugular veins

A

patient 30 degrees
look at right side
find internal jugular pulsations and measure height above sternal angle

111
Q

What is hepatojugular reflux?

A

when you press on liver to intensify internal jugular pulsations (RUQ)

112
Q

What does internal jugular pulsations tell you?

A

measures jugular venous pressure

113
Q

How to determine an elevated jugular venous pressure?

A

measure pulsation height above sternal angle

pulsations >3cm above sternal angle or >8cm above RA = ELEVATED

114
Q

What are the jugular venous pulsations?

A

A Wave
X Descent
V Wave
Y Descent

115
Q

What does the A wave of jugular pulsation represent?

A

atrial contraction; upward pulsation

before S1

116
Q

What does the X descent of jugular pulsation represent?

A

Atrial relaxation; collapse of internal jugular

between S1 and S2

117
Q

What does the V wave of jugular pulsation represent?

A

atrial filling

118
Q

What does the Y descent of jugular pulsation represent?

A

tricuspid valve opens, atrial emptying

119
Q

Examination of the heart

A

Inspection
Palpation
Auscultation

120
Q

How can aortic insufficiency murmur and S1/S2 be best heard?

A

with Diaphragm (high pitch)

121
Q

How can S3/S4 and mitral stenosis be best heard?

A

with Bell (low pitch)

122
Q

How do you palpate lifts/heaves?

A

with heel of hand

123
Q

What are thrills, what do they tell you, and how do you palpate it?

A

vibratory sensation
indicate intensity of murmur
ball of hand

124
Q

Assessment of murmurs

A 
time: systolic/diastolic
location
shape: crescendo/decrescendo
intensity : 1-6
radiation
125
Q

What do veins have that arteries don’t?

A

valves and thinner walls

126
Q

claudication

A

pain or cramping in arms or legs

127
Q

How does decrease blood flow manifest?

A

pain

128
Q

classic intermittent claudication

A

pain within defined group of muscles induced w/exercise, relieved w/rest

129
Q

subclavian steal syndrome

A

stenosis/occlusion of subclavian artery causes syncope/pre-syncope (patients passing out)

130
Q

How does Peripheral Artery Disease manifest?

A

rest pain; ischemia

131
Q

Buerger’s disease (thromboangitis obliterans)

A

rare; obstruction of vessels of hands/feet –> amputation

132
Q

Raynaud’s phenomena

A

arterial spasm; digital ischemia

blanching of fingers followed by cyanosis with cold temp –> redness with rewarming of hands

133
Q

5 P’s of Peripheral Arterial Disease***

A 
Pain
Pulseless: diminished or absent
Pallor: blanching
Paralysis: sig dec in function
Paresthesia: pins and needles
“Poikilothermia”: temp change
134
Q

Which gender is at greater risk for venous disease?

A

female

135
Q

Virchow’s Triad*** for DVT Risk

A

intimal trauma: injury or surgery
coagulopathy/hypercoagulable state
venous stasis: not moving

136
Q

What can venous insufficiency cause?

A

fluid seeps out of engorged veins –> edema –> tissue breakdown/ulcers

137
Q

What is DVT at risk for (fatal)?

A

pulmonary embolism

138
Q

Allen’s test

A

confirm interconnecting arch blood flow of hands: radiala, ulnar

139
Q

Trendelenburg Test

A

determines valve competency in superficial/deep veins in legs in pts w/varcose veins

140
Q

What does an exaggerated widened pulse suggest?

A

anuerysm

141
Q

Pitting edema

A

pressure on edema leaves indentation

+1 = 2mm

142
Q

ankle brachial index for PAD/PVD

A

ankle pressure/arm pressure
0.4-0.9= moderate PVD
<0.4 = sever PVD

143
Q

McBurney’s point

A

point where appendix is; between ASIS and umbilical

144
Q

Kyphosis

A

hunchback

145
Q

Barrel chest

A

AP to lateral ratio: 1:1 instead of 1:2

146
Q

crepitus

A

grating sensation; pop pop sound

147
Q

How to check for tactile fremitus

A
  1. have patient say 99
  2. feel for vibrations (side of hand)
    can suggest pneuomonia
148
Q

What sound is heard throughout most of lung fields?

A

vesicular breath sounds

149
Q

What sound is heard over trachea?

A

bronchial breath sounds
and also tracheal breath sounds
low pitch, longer expiratory

150
Q

Abnormal breath sounds

A 
rales (crackles): packing material
rhonchi: coarse
wheezes: high pitched
friction rubs
amphoric
151
Q

Hamman’s sign

A

crunching sound of heart beating against air filled tissue

152
Q

Bronchophony

A

“ninety-nine”
should not be able to understand during auscultation
magnification in sound is bad
similar to whispered pectoriloquy

153
Q

egophony

A

“eee”
changes to “aaa”
consolidation

154
Q

increase fremitus

A

denser or inflamed lung tissue like pneumonia

155
Q

decrease fremitus

A

air or fluid in pleural space

156
Q

Atelectasis

A

collapse of lung tissue with loss of volume

157
Q

penumothorax

A

air enters pleural space, compressing lung

shifts mediastinum

158
Q

How to listen for aortic insufficiency

A

pt leaning forward and listen with diaphragm

159
Q

How to listen for S3/S4 and mitral stenosis

A

pt in left lateral decubitus, listen with bell

Physical Diagnosis (3 decks)

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