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