Physical Diagnosis Flashcards
Blood pressure
- hypertension
- hypotension
- hypertension = over 140/90
- hypotension = under 90/60
- blood pressure values increase in elderly
Dekleyn’s Test
- test for VBI
pt is supine with head extended off table. Pt hyperextends and rotates head, hold for 15-45 sec. Dr. may provide min support. repeat on the other side
Vertebrobasilar artery functional maneuver
- tests for VBI
pt seated. ascultate (bell) and palpate subclavian and carotid arteries. if no bruits, pt rotates and hyperextends the head to each side.
IF PRODUCES: vertigo, blurred vision, nausea, syncope, nystagmus = POSITIVE
Ptosis
- bilateral and unilateral
eye drooping
bilateral = myasthenia gravis
unilateral = horners syndrome (loss of cervical sympathetics, ptosis, miosis, and anydrosis) or CN III lesion
Pancoast tumor indicates what syndrome most often? And shows what clinical signs in the eye?
Horner’s Syndrome (usually has unilateral ptosis)
Iritis indicates what spinal deformity?
AS
Papilledema indicates what?
increased intracranial pressure
arteriosclerosis in the eye is seen with:
AV nicking, silver wire arterioles, widened light reflex
hypertension has what signs in the eye?
flame hemorrhages, cotton wool spots, and narrow light reflex
diabetes mellitus has what signs in the eye?
yellow, hard, waxy exudates, neovascularization (always on test), microaneurysms, absent red light reflex
the external ear consists of what two main parts? What two conditions result from these?
auricle- otitis externa
external auditory meatus- air conduction loss
the middle ear consists of what main part? What three conditions result?
Tympanic membrane ossicles- otitis media, otosclerosis, meniere’s disease
the inner ear consists of what three main parts? What five conditions result from these?
cochlea, semilunar canals, saccule- meniere’s disease, labyrinthitis, vertigo, acoustic neuroma, and ototoxicity
Webers test: how is it performed and what does it indicate (on louder side? on softer side?)
512 Hz tuning fork placed on vertex of patients head. ask patient if they can hear it the same on both sides. IF NOT = lateralization
- either air conduction loss (louder side) or nerve deficit loss (softer side)
- need to perform Rinne test to help determine
Rinne Test: how is it performed and what does it indicate?
to determine air conduction or sensorineural problem
1st test side that was louder to check for air conduction loss- place tuning fork on mastoid process (bone conduction test) and ask the patient to verbalize when they can no longer hear it. After sound stops, place it in front of EAM (air conduction test). check bilaterally.
Normal = hearing near EAM 2x longer than mastoid
IF NOT 2x longer = air conduction loss on that side
IF air conduction is normal than consider sensorineural loss on opposite side.
Herpes zoster follows what dermatomes?
thoracic dermatomes.
- an elevated serous filled cavity 0.5 cm
Palpation of tactile fremitis- explain test. how many locations on front? on back? and location of each.
what does increased tactile fremitis mean?
what does decreased tactile fremitis mean?
palpable symmetrical vibrations
have pt say “99” every time you touch them. Three on front and four on back.
increased fremitis= due to fluid = pneumonia
decreased fremitis = due to air = emphysema
Locate and name the lobes of the lung.
Anterior right side: above clavicle to the 4th rib is the upper lobe, 4th to 6th rib medially is middle lobe, 6th to 8th rib laterally is lower lobe.
Anterior left side: above clavicle to 6th rib is upper lobe, 6th to 8th rib laterally is lower lobe.
Posterior: T3 spinous toward axilla, above is the upper lobe and below to T10 is the lower lobe bilaterally.
PERCUSSIVE chest sounds: Name the three sounds and conditions of each
dullness- pneumonia, atelectasis, pleurisy
resonance- normal, bronchitis
hyperresonance- emphysema, pneumothorax
ASCULTATION breath sounds: what type and where are they located?
tracheal- over trachea
bronchial- over manubrium
bronchovesicular- between 1st-2nd rib anteriorly, btwn scapulae posteriorly
vesicular- remaining lung field
Vital signs:
- oral temperature
- adult pulse
- adult respiratory rate
- adult blood pressure
- oral temperature = 98.6
- adult pulse = 60-100
- adult respiratory rate = 14-18
- adult blood pressure = 90-120/60-80
vocal resonance tests (bronchophony, egophony, and whispered pectoriloquy) are all performed with what?
stethoscope
what does positive bronchophony indicate?
if clear, distinct osunds are heard as the patient says “99” it indicates consolidation
what does egophony indicate?
if you hear “aaaa” as the patient says “eeee” it indicates consolidation
what does whispered pectoriloquy indicate?
if “99” is heard clearly, it indicates consolidation
Name the condition.
Percussion is dull (over fluid), rales (aka crackles), increased tactile fremitus, productive cough @10 days, rusty brown sputum, possible fever
lobar pneumonia
Name the condition.
caused by myobacterium tuberculosis. presents with low grade fever, night sweats, productive cough, yellow/green sputum, starts in apices of the lung, crackles in upper lobe, tine test/Mantoux test, positive purified protein derivative, most definitive test for dx is sputum culture
tuberculosis
Name the condition.
inflammation of the pleura, usually producing an exudative pleural effusion and stabbing chest pain worsened by respiration and cough. dull on percussion, dry/non-productive cough, decreased respiratory excursion, decreased tactile fremitus, dull on percussion, friction rub is present, decreased breath sounds, +schepelmanns test on opp side of bending
pleurisy. (has been on clinical)
Name the condition.
a ruptured lung causing air to become trapped in the pleural space. decreased chest expansion, decreased tactile fremitis, hyper-resonant, decreased breath sounds. can occur in young, previously healthy, tall, thin runners.
unilateral darkening of chest due to collapse of the lung; tracheal shift AWAY from lesion
pneumothorax
Name the condition.
collapse of the lung that is usually the result of bronchial obstruction due to a mucous plug. presents with decreased tactile fremitis, dull on percussion, decreased chest expansion, decreased or absent breath sounds, on xray the collapsed lung will display increased density, and mediastinal shifts to the SAME side.
Atelectasis
Name the condition.
destruction of elastic pulmonary connective tissue results in permanent dilation of the alveoli air sacs. presents with decreased tactile fremitus, hyperresonant percussion, decreased breath sounds, and prolonged expiration with an expiratory wheeze and 20-30 years of smoking likely. fluid will accumulate first in the costophrenic recesses.
bilaterally darkened lung fields; narrowed compressed heart; horizontal ribs; flattening of he diaphragmatic domes
emphysema
Name the condition.
primary malignant tumor that starts in the area of the bronchus. long term history of smoking (20-30 years). coughing (non-productive) more than 30 days, afebrile, dyspnea, weight loss, and clubbing of the fingernails
bronchogenic carcinoma. (clinical case)
Name the condition.
Inflammation of the cartilage connection between the ribs and sternum. it develops as a consequence of physical activity and is worse with exercise. pain increases while taking a deep breath. palpable tenderness at the 3rd, 4th, or 5th costosternal articulation.
costochondritis. been on diagnosis
Name the condition.
inflammation of the costal cartilage at one articulation. this pain can radiate and be chronic in nature.
Tietze syndrome. never been on test
Name the condition.
painful rash following the course of a dermatome usually a single nerve. primarily involves the dorsal root ganglion but when it does involve CN it is most commonly CN V.
starts at spine and goes btwn the ribs.
herpes zoster (aka shingles). been a clinical case
Name the condition.
abnormal collections of inflammatory cells (granulomas) form as nodules. Most often appear in the lungs or lymph nodes. Most commonly seen in ppl of african american decent.
xray: bilateral hilar lymphadenopathy
sarcoidosis. never been on test.
Name the condition.
cancer of the lymphatic system that can spread to the spleen. Most commonly seen in young caucasian males. presents with fever, night sweats, weight loss, intense pruritus (release of IgE), and enlarged spleen. best diagnosed from biopsy of Reed sternberg cells.
xray: unilateral hilar lymphadenopathy.
drinking beer makes it worse.
Hodgkins. (on test many times)
Describe how to percuss the heart.
percuss from the midaxillary line to the right side of the sternum in the 3rd, 4th, and 5th ICS for cardiomegaly.
pt is supine. put left hand under the head. doc stands on right side. Do right side too for the far right border.
during palpation of the heart, what are you assessing for?
abnormal pulsations/find angle of louie (with pads of 2nd and 3rd digits) and thrills (with ball of the hand-mcp).
aortic, pulmonic, tricuspid, and mitral valves
describe heart ascultation
detection of high-pitched sounds (with the diaphragm) or low-pitched murmurs (with the bell).
aortic, pulmonic, tricuspid, and mitral valves
name the valves and their locations for cardiac auscultation and palpation.
Aortic valve- R sternal border at 2nd ICS
pulmonic valve- L sternal border at 2nd ICS
tricuspid valve- L sternal border at 4th or 5th ICS
mitral valve- L midclavicular line at 5th ICS
how do you palpate an apical impulse?
patient supine or seated. use tips of fingers over mitral valve (apex of heart)
Where are all heart murmers best heard?
erbs point
where is aortic regurgitation heard best and in what position?
aortic valve -2nd ICS, heard with diaphragm. patient leaning forward
where is mitral stenosis best heard and in what position?
lying left lateral position, over mitral valve, with the bell
name the condition.
presents with cardiomegaly jugular venous pulsatations/distention, bilateral leg swelling (pitting edema), and difficulty breathing. common causes are L sided heart failure and cor pulmonale.
right sided heart failure
name the condition.
enlargement of R valve of heart, usually caused by primary lung condition (emphysema, bronchogenic carcinoma)
cor pulmonale
name the condition.
difficulty walking stairs- exertion
pulmonary pitting edema, orthopnea (sit up to breathe)
left sided heart failure
name the condition.
comes on with exertion, printzmetal angina comes on with rest (atypical), relieved by vasodilators under tongue (nitroglycerin)
angina pectoris -coronary vasospasm
name the condition.
acute heart failure, comes on with rest, severe substernal chest pain, referral to the left arm, labored breathing, caused by atherosclerosis, CPK is elevated, increased SGOT, increased LDH.
myocardial infarction
What are 2 main heart tests? where to you refer someone with a heart problem?
electrocardiogram, echocardiogram (valves). refer to cardiologist
name the condition
pain referral to the right shoulder or tip of the right scapula (viscerosomatic).
female, fat, forty, eat fatty foods
gallladder
tests: diagnostic US, oral cholecystogram, murphys sign, inspiratory arrest sign.
name the condition.
most commonly seen in overweight females >40 yoa, MC cause is cholelithiasis, severe right upper quadrant pain, nausea, vomiting, precipitated by eating a large fatty meal.
cholecystitis/cholelithiasis/choledocholitiasis
tests: diagnostic US, oral cholecystogram, murphys sign, inspiratory arrest sign.
Name the condition.
epigastric pain going straight through the T10-T12 area like a knife (viscerosomatic)
chronic: seen with alcoholism
acute: 911 emergency (mc cause is cholelithiasis)
pancreatitis
lab tests: increased amylase and lipase.
what is cullens sign?
periumbilical ecchymosis. seen with pancreatitis
name the condition.
a condition in which the pancreas does not produce enough insulin to take the sugar out of the blood and transport it into the tissues. The starved tissue forces the breakdown of fats in order to obtain energy.
Diabetes mellitus.
Name the two types of DM. Who has what type?
Insulin dependent type I- juvenile, under 30, usually thin. not born with enough islet of langerhans
non-dependent type II- adult, over 40, usually obese. have enough beta cells but dont have enough receptor cells to utilize insulin.
refer to endocrinologist.
who do you refer an individual with DM to?
endocrinologist
DM includes what three main overall issues?
elevated blood glucose levels
retinopathy
neuropathy
what are the 4 main signs and symptoms for both type I and II DM?
polydypsia, polyphagia, polyuria, ketoacidosis (breakdown fats)
what are 4 main tests for DM?
glucose tolerance test
fasting plasma glucose
HbA1C (glycosylated hemoglobin) - #1 test
urinalysis (glucose/ketones)
name the condition.
condition of posterior pituitary gland in which there is insufficient ADH. may have polydypsia, polyuria, but not polyphagia.
Diabetes insipidus
name the condition.
protrusion of the stomach above the diaphragm. presents with palpable tenderness in LUQ, reflux esophagitis (acid reflux), dyspepsia (indigestion), made worse after eating large meal or when lying down.
diabetes insipidus
name the condition.
upward reflux of acid contents of the stomach into the esophagus. caused by sliding hiatal hernia.worse when lying down, after big meal, valsalva, or bearing down.
Tests- xray or upper GI series
reflux esophagitis
name the condition.
caused by epstein barr virus and is seen in young adults (18-25).
symptoms similar to the flu such as fever, headache, fatigue, lymphadenopathy in the cervical region, splenomegaly.
atypical lymphocytes in blood (downey cells).
mononucleosis
what tests are done for mono?
monospot AKA heterophile agglutination AKA paul bunnell test
name the condition.
nonspecific inflammatory disorder that affects distal ileum and colon. inflammation is cobblestone in appearance. do not absorb B12 due to location of problem. presents with RLQ pain and chronic diarrhea.
- leads to malabsorption syndromes: non-tropiical sprue/celiac sprue (gluten allergy).
diagnosed with sigmoidoscopy
regionnal ileitis/ AKA Chron’s disease (right side of the intestines)
name the condition.
MC at colon and rectum. bloody diarrhea and fever. can lead to sacroiliitis (enteropathic arthropathy)
test- sigmoidoscopy
ulcerative colitis (left side of the intestines)
name the condition.
variable degrees of constipation and diarrhea in response to stress. more common in females. abdominal pain and gas relieved by bowel movements.
irritable bowel syndrome/ AKA spastic colon
- has never been on part IV
name the condition.
dull periumbilical or epigastric pain that radiates to LRQ. fever, nausea, vomiting, and anorexia. increased WBC (schilling shift to left- bc bacterial).
Appendicitis
what six tests can be done for appendicitis?
McBurney’s point, rebound tenderness (peritonitis), bumbergs rebound tenderness (peritonitis), rovsings sign, psoas sign, obturator sign.
Special test- CT scan
name the condition.
made of calcium: calcium oxalates, calcium urates, calcium phosphates. back pain radiating into groin. writhing pain. Murphys kidney punch is positive. evaluate by increased BUN, uric acid, creatinine clearance. KUB study. UA reveals hematuria (cuts ureters so could have infection).
nephrolithiasis
- staghorn calculi- mc cause is hydronephosis due to kidney stone.
name the condition.
ecoli from UTI, wbc casts
pylonephritis
name the condition.
caused MC by EColi in females and N. Gonorrhea in males.
nitrates in urine
urethritis
name the condition.
noninfectious bladder inflammation that causes burning, painful, and frequent urination with incontinence. suprapubic and low back pain.
cystitis
- usually on part IV
name the condition.
2nd MC cause of cancer death in women. MC >50 yoa, mc location is upper/outer quadrant. presents with nipple retraction, bleeding, orange peel appearance, and dimpling (Pagets disease of the breast). metastasis to axilla via the lymphatic system and will most likely be lytic when seen in bone
breast cancer
name the condition.
posterior lobe is hard, nodular, painless, and enlarged. MC place to metastasize is to the lumbar spine via Batsons plexus
prostatic carcinoma
tests: high uric acid, high PSA, high alk phos
what tests are used to determine prostatic carcinoma?
tests: high uric acid, high PSA, high alk phos
describe the procedure for abdomen percussion
percuss 3x in each quadrant listening for tympany.
describe the process to percuss the inferior border of the liver
begin in mid-clavicular line at the level of umbilicus and percuss upward from tympany to dull. repeat the same procedure in teh mid-sternal line.
the normal span of liver should be 6-12cm mid-clavicular line and 4-8cm mid-sternal line.
*percussion from superior to inferior must be done to obtain an actual measurement.
describe percussion of the spleen.
percuss in the last rib interspace on the left side in the anterior axillary line. repeat while the patient holds a deep inhalation. if the sound changes from tympany to dull this indicates splenomegaly.
describe the process of light abdominal palpation and what you should be looking for.
perform with patients knees flexed to 30 degrees
light: used to determine muscular resistance, abdominal tenderness, superficial masses, involuntary spasm of abdominal muscles may indicate peritoneal inflammation.
describe the process of deep abdominal palpation and what you should be looking for.
perform with patients knees flexed to 30 degrees
deep: shape, size, locations, consistancy, pulsations, mobility of organs and masses.
- if a mass is palpated determine if its superficial vs deep by having the patient do a partial sit up. if the mass becomes more obvious it is superficial, if less obvious its deep.
Rovsingn sign- what is the procedure, + result, and indication of test.
pressure in the LLQ produces pain in RLQ
indicates appendicitis
psoas sign/test- what is the procedure, + result, and indication of test.
pain with flexion of thigh against resistance
indicates = appendicitis
obturator sign- what is the procedure, + result, and indication of test.
flex hip and internally rotate the knee, produces pain in the RLQ
indicates = appendicitis
blumber’s rebound tenderness- what is the procedure, + result, and indication of test.
performed at McBurneys point- press in and release quickly. more pain with release
indicates = appendicitis/peritonitis
rebound tenderness- what is the procedure, + result, and indication of test.
performed anywhere in abdomen BUT mcburney’s point. press in a release quickly. more pain with release
indicates = appendicities/peritonitis
murphy’s sign- what is the procedure, + result, and indication of test.
press on gallbladder during patient inhalation. pt stops breathing due to pain
indicates = cholecystitis
murphy’s test- what is the procedure, + result, and indication of test.
dr gives a blow to each kidney and patient has pain.
indicates = kidney disease or stones.
Name condition.
pain appears while walking and disappears after rest.
intermittent claudication
what are the two types of intermittent claudication?
neurogenic and vascular
neurogenic intermittent claudication-what is the pattern, when is it relieved, and what are the 2 common causes?
pattern- not predictable
relief- position related (seated with flexion)
common cause- DJD, spinal canal stenosis
vascular intermittent claudication-what is the pattern, when is it relieved, and what are the 2 common causes?
pattern- predictably reproducible
relief- always with rest
common cause- arteriosclerosis, Buerger’s
what is the main test used to determine intermittent claudication? what is a positive?
claudication time- patient walks at a rate of 120 steps/min for 1 min.
+ = pain in calves
name the condition.
presents with tenderness, edema, and pain. bedridden ppl usually get this, ppl on drugs, or young and have a baby.
deep vein thrombosis
what main test is used to determine DVT? how is it performed? what is a positive?
Homans test- patient is supine with leg extended while examiner raises the leg off the table to 45 degrees, dorsiflex foot, squeeze calf.
+ = pain the the calf.
also use D-dimer test, and doppler US.
name the condition.
blockage of an artery in the lung by a substance that has travelled from elsewhere in the body through the bloodstream. usually this is due to a thrombus (blood clot) from the deep veins in the legs. symptoms include difficulty breathing, chest pain on inspiration, and palpitations.
risk is increased in various situations like flying and prolonged bed rest
pulmonary embolism.
