Physical Diagnosis Exam 2 Flashcards
Cough
response to irritant
Prostate gland location
Lies against the anterior rectal wall
Rounded, heart sharped
about 2.5cm long
lateral lobes nad median sulcus are palpable
5 tanner stage descriptions in boys
Stage 2
- Public hair: Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly at the base of the penis
- Penis: Slight or no enlargement
- Testes larger; scrotum larger, somewhat reddened, and altered in texture
Scalene muscle use
Used continuosly in COPD
Unable to see
Use fingers to palpate
Lower margin for et tube on x ray
T4, 2-3 cm above carina
Strawberry cervix
Vaginitis
Pneumothorax
acute onset of unilateral chest pain and dyspnea
unilateral expansion
decreased tactile fremitus
hyperresonance
diminshed breath sounds
mediastinal shift
cyanosis
hypotension in tension pneumothorax
Heavies or lifts
abnormal ventricular movements
Carotid pulse quality
Upstroke may be
Brisk = normal
delayed = aortic stenosis
bounding = suggests aortic insufficiency
5 tanner stage descriptions in boys
Stage 4
- Pubic hair: Coarse and curly hair, as in the adult; area covered greater than in stage 3, but not as great as in the adult and not yet including the thighs
- Penis: Further enlarged in length and breadth, with development of the glans
- Testes and Scrotum: Further enlarged; scrotal skin darkened
5 tanner stage descriptions in girls
Stage 1
Stage 1: No hair. No glandular breast tissue palpable
Pediatric SVT
Most common rhythm disturbance in children
0.1 - 0.4% of population, 7% in patients with congenital defects
majority of patients are structurally normal
HR is age dependant, infants = 220-280, children/teens = 180-240
usually 10-15 minutes, can be hours
in early infancy often resolves by year 1
if presetn after 5 y/o, tends to persist
Grey turners sign
Necrotizing pancreatitis
Breathing Pattern Wave forms
cremasteric reflex
Testicular torsion
tickle thigh
watch for testicular retraction
no movement means a positive test
Rectum vs anus
- A serrated line demarcates the anal canal from the rectum
- The anorectal junction (often called the pectinate or dentate line) is the boundary between somatic and visceral nerve supplies
Site for decompression
2nd intercostal space, mid clavicular
ChronIc Bronchitis
Blue Bloater
Chronic bronchitis
Type of COPD
Obese, long expiration,
crackles, wheezes
edema, cyanosis
hemoptysis
productive cough
Membrane of scrotum
Tunica vaginalis
Vas deferens
Cordlike structure begins at tail of epididymis
What is the best anatomical place for a needle insertion with suspected tension pneumothorax?
A.1st ICS space
B.2nd ICS space
C.3rd ICS space
D.4th ICS Space
A.2nd ICS space
Irregular breathing patterns
Biots breathing (CNS injury)
Harsh, high-pitched sound during inspiration caused by laryngeal, tracheal or large upper obstruction airway disease/obstruction is this?
A.Stridor
B.Wheeze
C.Rale
D.Crackle
A.Stridor
Arrhythmias
in a symptomatic child
common symptoms
- Weakness
- Tiredness
- Palpitations
- Feeling lightheaded or dizzy
- Fainting or near fainting
- Paleness
- Chest pain
- A slow heartbeat
- A fast heartbeat
- Feeling pauses between heartbeats
- Sweating
- Shortness of breath
- Irritability in infants
- Difficulty feeding (infants)
Decreased bronchophony are related to all of the following conditions except for..
A.Asthma
B.COPD
C.Pleural effusion
D.Pneumonia
D.Pneumonia
Afterload
Factor in pressure overload
Breast exam techniques
- Males - Palpate areola and breast tissue for nodules
- Typically done without gloves to improve detection of abnormality•
Patient is supine with ipsilateral hand behind head or next to head
•Be sure to capture the tail of Spence in your exam
Axilla and chest wall
infraclavicular and supraclavicular nodes
3 method = vertical, radial (star), spiral
Normal S2 splitting
able to hear two distinct sounds
1st aortic, then pulmonic
Emphysema
Pink Puffer
Emphysema
Type of COPD
Dyspnea, minimal cough
increased minute ventilation
pink skin
pursed lips, accessory muscle use
hyperinflation, barrel chest
Tachypnea
decreased breath sounds
5 tanner stage descriptions in girls
Stage 2
Stage 2: Downy hair. Breast bud palpable under the areola (1st pubertal sign in females)
Sexual history 5 P’s
Partners
Practices
Protection (STD’s)
Past history
Prevention of pregnancy
Tieze syndrome
Slipping rib syndrome
A sign which confirms the presence of peritonitis is:
a. Borborygmus
b. Friction rub
c. Voluntary guarding
d. Rebound tenderness
d.Rebound tenderness
Whisper pectorilquy
Whisper 99
should only hear faint sounds or no sounds
if you hear sounds well, consolidation
S1 heart sound
Caused by closure of AV valves
best heard at apex
slightly longer than S2
Preload
factor in volume overload
Splenic Percussion
- To detect an enlarged spleen, percuss the lowest interspace in the left anterior axillary line.
- Shifting from tympany to dullness with inspiration suggests an enlarged spleen. This is a positive splenic percussion sign.
Central cyanosis Peds
Congenital heart disease
Cyanotic cardiac lesions account for approximately 15 % of all congenital heart disease (CHD) cases and 1/3 of potentially fatal forms of CHD
Bowel Sounds
borborygmi
•The normal frequency of sound is 5-34 sounds per minute.
PMI indications
Tapping = normal
Sustained = suggests LVH due to hypertension, or aortic stenosis
Diffuse = dilated ventricle due to congenital heart failure and cardiomyopathy
Translumination
Scrotal assessment
masses
hernias
enlargment
Ill vs well breath sounds
Kehrs sign
Pain in left shoulder
Splenic rupture
Ectopic prenancy
Diastolic BP
Pressure generated by blood remaining in the arterial tree during diastole when ventricles are relaxed
Increased AP diameter
COPD
Barrel CHest
When examining a patient for the apical impulse (PMI), which of the following is LEAST important to assess?
a. Location
b. Amplitude
c. Rhythm
d. Diameter
c.Rhythm
•Assess location, amplitude, duration, and diameter
Dysmenorrhea
Pain with menstuation
inguinal hernia types
indirect (most common)
all ages, children as well
direct
men over 40
femoral hernias (least common)
more in women
Listening for S3 in LL deQ position, what part of the stethoscope should be used?
A.Bell
B.Diaphragm
A.Bell
Broncophony
99
Increased =
Consolidation, segmental atelectasis
Decreased =
Hyperinflation, pneumothorax, COPD, asthma, pleural effusion
Testicular torsion
Sudden severe pain
surgical emergency
swelling
spermatic cord is wrapped around
Which Tanner Stage of Male correlates with darker, coarser, curlier hair spreading sparsely over the pubic symphysis?
A.Stage 1
B.Stage 2
C.Stage 3
D.Stage 4
E.Stage 5
A.Stage 3
Percussion sounds
Flatness
dullness
resonance
hyperresonance
tympany
Wheeze description
Musical respiratory sounds
Whistling sound
louder on expiration
caused by small airway obstruction
Distal airway obstruction
- TB
- Bronchitits, bronchiolitis
- ASthma, COPD, Emphysema
Stridor
- Harsh high pitched sound during inspiration caused by laryngeal, tracheal or large upper obstruction airway disease / obstruction
- Etiologies: Epiglotitis, Laryngitis, Retropharyngeal abscess
- Inspiratory and expiratory
- Barking cough
- Retractions involve subcostal and intercostal spaces
- Cyanosis even with O2
5 tanner stage descriptions in boys
Stage 3
- Pubic hair: Darker, coarser, curlier hair spreading sparsely over the pubic symphysis
- Penis: Larger, especially in length
- Testes and scrotum: Further enlarged
Ventricular Septal Defect (VSD)
most common cardiac abnormality
Often not heard at birth, but as the ductus arteriosus closes and the pressure gradient between the two ventricles becomes greater the murmur intensifies
Best heard at the left lower sternal border as a harsh murmur often on day 2 or 3.
Holo- or pansystolic murmur
Many VSDs will close spontaneously over the course of several weeks to months.
How many lobes of the lungs are there?
A.3
B.4
C.5
D.6
C.5
Colorectal cancer
older than 50, median age is 68
family history is very important
3 - 10% have first degree relative
Male, black, highest incidence
45 years and older to get screening
A patient you are seeing complains of a sore on his lower leg that does not seem to get better. Based on examination findings, you suspect venous insufficiency. Which of the clinical findings below would suggest venous insufficiency as the cause of his problem?
a. Leg discomfort is exacerbated by dependency
b. Hyperpigmentation is present around the lower calf area
c. Ulceration is present on the medial side of the ankle
d. Affected leg feels warm to the touch
e. All the above
e.All the above
- Leg discomfort is exacerbated by dependency
- Hyperpigmentation is present around the lower calf area
- Ulceration is present on the medial side of the ankle
- Affected leg feels warm to the touch
Grade of edema
1+ slight pitting no visible distortion, disappears rapidly
2+ somewhat deeper pit, still no readily detectable distortion and disappears in 10-15 seconds
3+Pit is noticeably deep and may last more than a minute
4+ Pit is very deep, lasts as long as 2-5 minutes
What is that practitioner checking for?
A.Regurgitant murmurs
B.PMI
C.S3
C.S3
parietal pain
Parietal pain is more severe and is usually easily localized (appendicitis)
S 2 splitting occurs more with
A.Inspiration
B.Expiration
A.Inspiration
What do jugular veins represent in the heart
Right atrial pressure
Causes of snoring / gurgling
Disorders in nasopharnyx
Hypertrophied tonsils (palatine)
Hypertrophied adenoids (pharyngeal tonsils)
nasla polyps
Foreign body
rhinitis
Diastasis recti
Abdominal muscles seperate
Hypospadias
displacement of the urethra
(underneath/back/ventral)
What to listen fo with Bell of Stethoscope
•Accentuates lower frequency sounds & murmurs
–Diastolic “gallops”
- S3
- S4
–Diastolic rumbles
- Mitral
- Tricuspid
–Don’t press the bell into the skin thus creating another diaphragm, just rest the bell on the skin
Cardiac output
Stroke volume x heart rate
Where does the trachea bifurcate
at the carina into mainstem bronchi at sternal angle anteriorly T4 spinous process posteriorly
Right lung demarcation lines
horizontal fissure (top) oblique fissure
Menopause
absence of menses for 12 consecutive months
typically around 55 years of age
Best evaluation of a murmur
A.EKG
B.Echocardiogram
C.CPR
D.Cardiac cath
B.Echocardiogram
Blood pressure formula
Cardiac output
x
systemic vascular resistance
Visceral pain
Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize
Hollow or solid organs
Depth of deep abdmoinal palpation
2-3 inches
Breast exam guidlines
U.S. Preventative Services Task Force
U.S. Preventative Services Task Force—average risk women
Mammogram = 50–74 years—biennially
Clincial breast exam = over 40
Breast self exam = recommend against BSE
High risk breast cancer screening
MRI at 25 for BRCA1 and BRCA2
MRI at 30 if famiy member
high risk women should have clinical exam every 6-12 months
Thrills
turbulence
damaged heart valve
Tanner stages Males
What are 3 charecterisitics
Pubic hair
penis size
testes/scrotum
Pediatric SVT symptoms in infants
Pallor, fussiness, poor feeding, cyanosis
sweating while eating
S3 Heart sound
Caused by rapid ventricular filling in early diastole
low pitched
best heard with bell at apex
occurs just after S2
resembles galloping horse
normal in children
pathological in 30-35 (LV failure, anemis, thyotoxicosis)
menarche
Age of onset of menstuation
HPV test women
tested with PAP
Cough durations
Acute less than 3 weeks
sub acute 3-8 weeks
chronic 8 weeks or longer
Tachypnea
20-25 Breaths per minute
Metabolic acidosis
DKA
Hypoxemia
stimulants
anxiety
Pain
Epididymis
On the posterolateral surfcae of each teste
soft, comma shape
is a reservoir for storage, maturation and transport of sperm
Which of the following statements about hernias is true?
a. Indirect inguinal hernias are the most common form of hernia
b. Femoral hernias are the least common form and are more common in women
c. Direct inguinal hernias are more common in men over age 40
d. Indirect inguinal hernias originate above the inguinal ligament near its midpoint
e. All of the above
e.All of the above
Crackles
(Rales)
Discontinuous (more obvious on inspiration)
Does not clear with cough
Etiology
Fibrosis
atelectasis
pneumonia
fluid (CHF)
STD Rates and number in florida
- Two out of every three reported STD cases in Florida were under the age of 25.
- One out of every 33 persons with a reportable STD in Florida is co-infected with HIV.
- Floridians between the ages of 15 and 24 represented only 13 percent of Florida’s population in 2011, but accounted for 70 percent of reported cases of Chlamydia infections.
- Gonorrhea rates for 15 to 24 year olds are at least twice as high as any groups over age 25 in Florida.
- 40 percent of older adolescents surveyed incorrectly believe that the contraceptive “pill” and “shot” protect against STDs and HIV.
Foramen ovale
An opening in the septum between the two atria of the heart that is normally present only in the fetus
After birth, the pressure in the pulmonary circulation drops, and the foramen ovale closes.
Breathing that involves changing rates and depths with apneic periods is.
A.Cheyne-Stokes
B.Kussmaul’s
C.Obstructive
D.Biot’s/ataxic
A.Cheyne-Stokes
Peripheral Cyanosis- Acrocyanosis
Painless condition where the small blood vessels in your skin constrict, turning the color of your hands and feet bluish
The blue color comes from the decrease in blood flow and oxygen moving through the narrowed vessels to your extremities
Conditions which limit diaphragmatic excursion
Pulmonary (COPD)
Abdominal (massive ascites, tumor)
Superficial (fractured rib)
diaphragm paralysis
Smoking risk reduction due to quitting
Quitting reduces CV risk of MI and death from CAD by one half after year 1
Stroke risk is reduced within 2-5 years to the same level
Lung cancer risk is cut in half after 10 years
Systole
Contraction of ventricles
Semilunar valves open
Syncope
caused by decreased perfusion to brain
also can be associated neurological symptoms
What does vocal resonance test for
Egophony, bronchophony, whispered pectoriloquy
Checks for pneumonia
Consolidation
Egophony EEE (A means pneumonia)
Bronchophony 99
Whispered pectoriloquy Whisper 99
Normal breath sounds
Bronchial region:
Louder, higher pitch
Bronchovesicular
intermediate intesity and pitch
Vesicular
Soft and low pitched
Pectus carinatum
Outward protruding chest
can occur secondary to childhood asthma
however, predominatley congenital
With the five A’s involved with tobacco cessation, which “A” don’t belong?
A.Advise patient to stop smoking
B.Assess patient readiness to quit
C.Assess patient mental status
D.Assist patient to set stop dates
C.Assess patient mental status
Sleep apnea
Defined as breathing cessation for greater than 10 seconds
Periodic breathing patterns
Cyclical / repetitive pattern increase / decrease in depth of respiration with periods of apnea Cheyne-stokes breathing (CHF)
Perscussion sound : Tympany
Tympanic
Air : Loud, high pitch
name lung membranes
Serous membranes
parietal pleura (outer)
Visceral pleura (inner)
Levines sign
a clenched fist over chest Angina
Murmur workup
Echo checks the valves
Only thing better is cath but its invasive
Murmurs in children
•Heart murmurs are common in infants and children, but only a minority of patients with murmurs have heart disease
Children > 1 year
- Innocent Still murmur
- Cervical venous hum
- Atrial septal defect
- Mitral regurgitation
- Bicuspid aortic valve
- Pericarditis
POst menopausal bleeding
occurs at least 6 months after menopause
Perscussion sound : resonance
Loud low pitch aound
Striking a surface which covers an air filled structure
Rhonchi
Low pitch
Continuos, more on expiration
Loud, snorting
Causes
thicker secretions in larger airways
(cough may clear sound)
peyronies disease
Bent or crooked penis
due to fibrous black on corpus
Testicular cancer cure rate
90% of new cases can be cured
A patient you are seeing complains of severe pain in her right foot. Based on examination findings, you suspect arterial insufficiency. Which of the clinical findings below would suggest arterial insufficiency as the cause of her problem?
a. Brisk posterior tibial and dorsalis pedis pulses
b. Pallor of the foot upon elevation
c. Pitting edema of the lower leg
d. Warmth of the right foot
b. Pallor of the foot upon elevation
- Decreased posterior tribal and dorsalis pedis pulses
- No edema of the lower leg
- Cool right foot
Tripod position
Emphysema
Pursed lips
leaning forward to breath easier
Which of the following tests is not used for appendicitis?
A.Obturator sign
B.Psoas sign
C.Murphy’s sign
D.Rovsing’s sign
C.Murphy’s sign
Prostate cancer screening
DRE
or
PSA
Sternocleidomastoid muscle use
SCM Retractions
last to be recruited and patients tire very quickly
sign that patient will soon need to be intubated
5 T’s of Cyanosis
Transposition of great arteries
Tetralogy of Fallot
Truncus arteriosus
Total anomalous pulmonsry venous return
Tricuspid valv abnormalities
Prostate cancer info
3rd leading cause of death in men in US
Risk factors are age, ethnicity, family history
- one of the most common types of cancer that affects men.
- In the United States, the lifetime risk of being diagnosed with prostate cancer is approximately 11%, and the lifetime risk of dying of prostate cancer is 2.5%.
The median age of death from prostate cancer is 80 years
African americans have highest risk
All of the following breath sounds are considered normal breath sounds except for..
A.Rubs
B.Vesicular
C.Bronchial
D.Bronchovesicular
A.Rubs
Diastole
Ventricles relax
AV valves open
STD’s
- The US has the highest rate of STI in the industrialized world
- Chlamydia is the most commonly reported and most common in women
- HPV is the most common STI among both male and female.
- Sixth consecutive year for increased cases of gonorrhea, chlamydia and syphilis
- A total of 2.4 million infections that were diagnosed and reported in last year. Undiagnosed cases are estimated significantly higher.
Pleural Rub
Low or medium pitch
Raspy, dry, scratchy
inspiration or expiration (sound disappears with breath holding)
Loudest at end of inspiration or begginning of expiration
Caused by pleural irritation and inflammation
Dextrocardia
an abnormal condition in which the heart is situated on the right side and the great blood vesselsof the right and left sides are reserved
Similar to situs inversus
Tissue in shaft of penis
3 columns of vascular erectile tissue
Corpus spongiosum (containing urethra)
Forms bulb of penis, ending in the cone shaped glans
2 columns of Corpora cavernosa
Patent Foramen Ovale (PFO)
Flap fusion is complete by age two in 70 - 75 % of children,
the remaining 25% have a PFO which persists into adulthood.
Most patients with a PFO remain asymptomatic
Systolic BP
Pressure generated by Left ventircle during systole (contraction)
Pressure waves in the arteries create pulses
Pursed lip breathing
Obstructive lung disease
This allows for controlled expiration
Ankle brachial index
ABI normal = 0.90 - 1.30
ABI mild = 0.41 - 0.90
ABI Severe = 0.00 - 0.40
Testes size
about 4.5cm
Left is lower than right
sperm and tesosterone
A 21-year-old male presents complaining of a “nodule” on the back of his left testicle found during testicular self-examination.
- On examination, you find both testicles to be of normal size, shape, and consistency.
- On the back of the left testicle in the area of the “nodule,” you find a soft, nodular, tube-like structure with no areas of abnormal tenderness.
a. Acute epididymitis
b. Cyst of the epididymis
c. Normal epididymis
d. Carcinoma of the epididymis
c.Normal epididymis
Epispadias
displacement of urethral opening
(Top/front/dorsal)
All of the following are considered conditions that present with increased fremitus except..
A.Atelectasis
B.Emphysema
C.Lung Cancer
D.Pneumonia
B.Emphysema
Inncent heart murmur is peds
1/3 - 3/4 have an innocent murmur noted between ages 1-14 y/o
WHat are adventitious sounds
Added sounds
Snore, crackles / rales (fine medium, coarse), wheezes, stridor, rub or rhonchi
Dark, tarry stools is best described by this term?
A.Hematochezia
B.Melena
C.Hematemesis
D.Hemoptysis
A.Melena
What is the preferred order for examination of the abdomen?
a. Inspection, auscultation, percussion, palpation
b. Percussion, auscultation, palpation, inspection
c. Auscultation, inspection, palpation, percussion
d. Inspection, palpation, auscultation, percussion
a.Inspection, auscultation, percussion, palpation
Caput medusae
Dilated veins seen on the badomen of a patient with cirrhosis of the liver
portal hypertension
A patient with dyspnea, pinkish skin, pursed-lip breathing, barrel chest most likely has this condition..
A.Asthma
B.Chronic bronchitis
C.Pleural effusion
D.Emphysema
D.Emphysema
Causes arrhythmias
Infections
chemical imbalances
fever
medications
heart defect
cardiomyopathy
Listening for regurgitant murmurs in upright leaning forward position, what part of the stethoscope should be used?
A.Bell
B.Diaphragm
B.Diaphragm
Rapid breathing patterns
Kussmaul (DKA)
5 tanner stage descriptions in boys
Stage 1
- Pubic hair-none except for the fine body hair (vellus hair) similar to that on the abdomen
- Penis is same size and proportions as in childhood.
- Testes and Scrotum—same size and proportions as in childhood
S4 heart sound
caused by atrial contraction against a stiff ventricle
low pitched best heard with bell
heard before S1
always abnormal
COPD 2 types
Chronic bronchitis = long term cough with mucous
Emphysema = destruction of lung over time
What are the stages of change (tobacco)
Precontemplation
Contemplation
Preperation
Action
Maintenance
5 A’s of tobacco cessation
Ask about smoking each visit
Advise patient to regularly stop smoking
Assess patient readiness to quit
Assist patient to set stop dates
Arrange for followup visits
5 tanner stage descriptions in girls
Stage 3
Stage 3: Scant terminal hair. Breast tissue palpable outside areola; no areolar development.
Abdominal Percussion
- Tympany is normally present over most of the abdomen in the supine position.
- Unusual dullness may be a clue to an underlying abdominal mass
Arrhythmias in an asymptomatic child
Sinus arrhythmia
PVC’s
PAC’s
Pediatric SVT Symptoms in children / adolescents
palpitations, chst discomfort, fatigue, lightheadedness
syncope is less common but is a sign risk of sudden death
abrupt onset and termination
can occur at rest
How to evaluate competency of venous valves
Trendelenberg test
Perscussion sound : dullness
replacment air filled lung tissue with fluid
mass or consolidation (diminished air exchange)
solid organ
Muted tone, medium pitch
What is emphysema
One type of COPD destruction of lungs over time
Tactile fremitus
Think pneumonia
vibrations of spoken sounds palpated through chest wall
best felt in intrascapular spaces
less felt in lower lung fields
cant feel below diaphragm
Occurs when sound vibrations travel through medium of abnormal density
Aortic width
AAA = greater than 4 cm with pulsations
Which of the following breath sounds are most often auscultated over the majority of both lungs?
a. Vesicular
b. Bronchial
c. Bronchovesicular
d. None of the above
a.Vesicular
- Bronchial - usually heard over the manubrium
- Bronchovesicular - usually heard over the 1st and 2nd interspaces
PAP cytology results
- Normal
- ASCUS: Atypical squamous cells of undertermned significance
- AGUS: Atypical glandular cells of undertermned significance
- LSIL: Low-grade squamous intraepithelial lesion encompassing: HPV/mild dysplasia/CIN1
- HSIL: High-grade squamous intraepithelial lesion encompassing: moderate and severe dysplasia, CIN2, CIN3, and carcinoma in situ
What is bronchiectasis
destruction and widening of the large airways
Pectus excavatum
Sunken chest
poor posture
pot belly
funnel chest
usually benign, no treatment
Causes of Bounding Pulse
•Hyperkinetic circulation states
–Hyperthyroidism
–Fever
–Anxiety
–Exercise
–Anemia
- Patent ductus arteriosis
- Aortic rigidity
- Atherosclerosis
- Marked vasodilatation
Factors that increase breast cancer risk
BRCA1, BRCA2
1st degree relatives with mutation as well
History of cancer or hyperplasia
family history
other gene mutations
Perscussion sound : hyper-resonance
Processes that lead to
chronic (emphysema) or
acute (pneumothorax)
air trapping in lung or pleural space, respectively, will produce hyper-resonant (more drum like) notes on percussion.
Recto-vaginal Exam- Three primary purposes
To palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa
To screen for colorectal cancer in women ages 50 years or older
To assess pelvic pathology
3 different signs of chest pain
clenched fist = angina
finger point = muscoskeletal
hand moving from neck down = GERD
5 tanner stage descriptions in boys
Stage 5
- Pubic hair: Hair adult in quantity and quality, spreads to the medial surfaces of the thighs but not up over the abdomen
- Penis: Adult in size and shape
- Testes and Scrotum: Adult in size and shape
5 tanner stage descriptions in girls
Stage 4
Stage 4: Terminal hair that fills the entire triangle overlying the pubic region. Areola elevated above contour of the breast, forming “double scoop” appearance.
Smoking statistics
19% of adults smoke
23% of high schoolers smoke
7% of middle schoolers
50% of long term smokers lose an average of 10 years
Paraphimosis
inability to reduce foreskin back to anatomical position
Urological emergencey
Surgical emergency
“para”-phimosis = “para”-medics
PAP test recommendations
screening with cytology every 3 years for women age 21 – 65
women 30-65 who want to lengthen the screening interval – screen with combo of cytology and HPV testing every 5 years.
•Not to screen women under age 21 unless there is immune compromise, in utero exposure to diethylstilbestrol.
S2 heart sounds
Second heart sound
Closure of semilunar valves
indicates end of systole
higher pitched and shorter than S1
Smegma
Secretions of the glans
Normal heart rates in Peds
Newborn = 100-205
Infant = 100-180
Toddler = 98-140
Preschool = 80-120
Schol-age = 75-118
Adolescent = 60-100
Gnawing, cramping, or aching and is often difficult to localize describes this type of pain?
A.Parietal pain
B.Visceral pain
C.Somatic pain
D.Referred pain
B.Visceral pain
4 positions of breast exam
- Sitting with arms at side
- Sitting with arms over head
- Sitting with hands on hips
- Leaning forward.
Dyspnea of heart disease vs lung disease
Heart disease is not usually exertional, may occur at rest
Orthopnea helps
occurs when sleeping
Increasd tactile fremitus
Coarser rougher feel
Consolidation: lobar pneumonia
tumor
heavy bronchial secretions
segmental atelectasis
Bradypnea
less than 12 Breaths per minute
Metabolic alkalosis
volume depletion,
vomiting
Narcotics
elevated ICP
Extreme obesity
Murmur causes
Thyrotoxicosis
anemia
pregnancy
VSD or ASD
PDA
Pleural effusion
can be asymptomatic
chest pain
dullness to percussion, decreased breath sounds
pleural friction rub heard
Tanner Scale Female
Breasts, genitals, pubic hair
Stage 1: No hair. No glandular breast tissue palpable
Stage 2: Downy hair. Breast bud palpable under the areola (1st pubertal sign in females)
Stage 3: Scant terminal hair. Breast tissue palpable outside areola; no areolar development.
Stage 4: Terminal hair that fills the entire triangle overlying the pubic region. Areola elevated above contour of the breast, forming “double scoop” appearance.
Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh. Areolar mound recedes back into single breast count with areolar hyperpigmentation, papillae development and nipple protrusion
Splinter hemorrhage
Bacterial endocarditis
Perscussion sound : Flatness
Muscle
soft tone
high pitch
The bell of the stethoscope is most useful for auscultating:
a. Diastolic murmurs
b. High-pitched heart sounds
c. Low-pitched heart sounds
d. Systolic clicks
e. Systolic murmurs
c.Low-pitched heart sounds
•The bell is best for detecting low-pitched sounds like S3 and the rumble of mitral stenosis
Inguinal canal
forms a canal for the vas deferens
lies above and parallel to inguinal ligament
exterior opening of tunel is external inguinal ring
internal opening is internal inguinal ring
Intercostal muscle use
COPD patients
Deeper breathin and retractions
Phimosis
inability to retract foreskin
can be normal up to 3 y/o
clinically significant after 4
Leading cause of preventable death in the US
Smoking
Liver percussion
•Percuss over the liver in both the midclavicular line
and at the midsternal line
•Begin in an area of tympany both above and below the liver, percussing to an area of dullness
–Midclavicular percussion should be 6–12 cm; longer than this indicates an enlarged liver
–Midsternal line percussion should be 4–8 cm; shorter than this can indicate a small, hard cirrhotic liver
Central venous pressure estimation
Inspect and measure JVP
Mammogram guidelines
•Typically should start screening mammography at age 40-44
Nail clubbing
Associated with pulmonary and CVD
Colitis
cirrhosis
neoplastic and thyroid disease
Murmur intesity scale
1 - 6
4 - 6 must have accompanied thrill
What to listen fo with Diaphragm of stethscope
•Accentuates higher-pitched sounds & murmurs
–S1 and S2
–Systolic ejection murmurs (SEM)
–Systolic clicks
–Diastolic regurgitant mumurs
–Pericardial friction rubs
–Opening snaps
Asthma
airway obstruction
airway hyper responsiveness
airway inflammation
can be episodic or chronic
Wheezing, dyspnea or cough
Worse at night or in early morning
GP FPAL
Gravida = total number of pregnancies
Para = outcomes after 24 weeks
F = Full term
P = Premature
A = Abortion
L = Living Children
lower genitourinary tract
the vas deferns, a cordlike structure, begins at the tail of the epididymis
it ascends within the scrotal sac (as the spermatic cord) and passes through the external inguinal ring on its way to the abdomen and pelvis
Behind bladder, iti is joined by the duct from the seminal vesicle and enters the urethra within the prostate gland
diaphragmatic excursion
distance is 3 - 6 cm
Arrhythmia definition
Definition: a condition in which the heart beats with an irregular or abnormal rhythm
an alteration in rhythm of the heartbeat either in time or force
Acites
Free fluid in pertoneal cavity
Age related changes
- Pre-menstrual syndrome – mood changes, cramping – typically emerges in teen years
- Menopause, vaginal wall thinning, decrease in vaginal secretions – typically in late ‘40’s – early 50’s
- Breast pain – expected with menses prior to menopause
- Loss of tone, pendulous breasts – typical as age progresses
Cullens sign
Necrotizing pancreatitis
Which of the following statements about percussion is true?
a. Use the lightest percussion that produces a clear note
b. Percussion should be done up and down each side of the chest rather than side to side (one side of the chest to the other)
c. Strike using the pad of your tapping finger
d. The heart normally produces an area of tympany to the left of the sternum from the 3rd to 5th rib interspaces
a. Use the lightest percussion that produces a clear note
•The heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces
pneumonia
Infection of lung parenchyma
usually acute
exertion and smoking can make worse
reast can improve
Sources of chest pain
MI
Angina
Pericarditis
Aoritc dissection
Bronchitis
Pneumonia
PE
Pneumothorax
Costochondritis
Zoster
Gerd,spasm, tear ETC
Contractility
Ventricles contract during sytole
Amplitude of arterial pulses
3+ Bounding
2+ Brisk, expected (normal)
1+ Diminished, weaker than expected
0 Absent, unable to palpate
Decreased tactile fremitus
feels muffled or diminshed sound
Emphysema
Pleural effusion, fibrosis or thickening
Massive pulmonary edema
hemothorax
Chronic disorder of the airways characterized by variable airway obstruction, airway hyperresponsiveness, and airway inflammation best describes this..
A.COPD
B.Asthma
C.Pleural effusion
D.Pneumothorax
B.Asthma
Pulmonary embolism
Dyspnea
chest pain
hempotysis
syncope
tachypnea
widened alveolar arterila PO2 difference
Arrhythmias in a symptomatic child
● Atrial arrhythmias
● Supraventricular tachycardia
● Ventricular tachycardia
● Sinus node dysfunction
● Second degree heart block
Chest tube insertion site
4th or 5th intercoastal space Anterior axillary line
Percussion sound : hyperinflation
Very loud,
very low pitch
Markle test
Heel jar test
standing or lying flat
Patent Ductus arteriosus (PDA)
Washing machine like sound
Best heard at the left upper sternal border
present just after birth, as part of a normal transition, it usually occurs as a soft systolic murmur which disappears in a few hours or a few days
Closes in approximately 90% of full-term neonates by 48 hours
Anal Canal sphincters
External (voluntary
Internal (involuntary)
Lots of somatic nerves
5 tanner stage descriptions in girls
Stage 5
Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh. Areolar mound recedes back into single breast count with areolar hyperpigmentation, papillae development and nipple protrusion
What is chronic bronchitis
One type of COPD long term cough with mucous
Normal respiration rate
12-20 with no discomfort periodic deep breaths (less than 5 per minute)
Order of exam techniques
Inspect Palpate Percuss Auscultate
Lobes of the lung
3 on right 2 on left
