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Block C - Circulation > Physical Exam Lecture 1 > Flashcards

Physical Exam Lecture 1 Flashcards

1
Q

9 components of the examination, in order

A 
Inspection of the patient
Blood pressure determination
Assessment of arterial pulse
Determination of respiratory rate
Assessment of jugular venous pulsation
Carotid Pulsation
Palpation of heart
Auscultation of heart
Examination for dependent edema
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2
Q

Patient positioning during physical exam

A

Supine

Head of bed may be slightly elevated

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3
Q

Physician positioning during physical exam

A

Right side of bed

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4
Q

3 questions to ask in terms of general appearance inspection

A

Is the patient in acute distress?
Is the breathing labored?
Are accessory muscles being used?

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5
Q

3 things to look out for when inspecting skin

A

Cyanosis
Temperature
Xanthomata

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6
Q

3 types of xanthomata

A

Tendinous
Tuberous
Eruptive

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7
Q

Describe tendinous xanthomata

A

Stony-hard, slightly yellowish masses in extensor tendons of:

  • fingers
  • Achilles
  • plantar tendons of the soles
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8
Q

Describe tuberous xanthomata

A

Palms, soles, knees, elbows, hands

Occur in 15% of patients with primary biliary cirrhosis

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9
Q

Describe eruptive xanthomata

A

Small 1 - 3 mm in diameter, yellowish papules on an erythematous base found on buttocks, abdomen, back, face and arms

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10
Q

What are Osler’s nodes?

A

Painful lesions in the tufts of fingers and toes

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11
Q

What are Janeway lesions?

A

Non-painful, small erythematous macular on the palms and soles

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12
Q

What do Osler’s ndoes and Janeway lesions indicate?

A

Infective endocarditis

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13
Q

Define splinter hemorrhages upon nail inspection

A

Small, reddish-brown lines in the nail bed

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14
Q

What are splinter hemorrhages a sign of?

A

Infective endocarditis

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15
Q

What is Lichstein’s sign?

A

Oblique earlobe creases, often bilateral, seen in patients over 50 years of age with significant coronary diseease

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16
Q

Two manifestations that can be found upon eye inspection

A

Xanthelasma

Arcus Senilis

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17
Q

Define xanthelasma

A

Yellowish plaques on the eyelids (less specific for dyslipidemia than the xanthoma)

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18
Q

Define arcus senilis

A

Silver rim around dark of eye, seen in patients younger than 40 years of age

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19
Q

What to suspect upon finding arcus senilis

A

Dyslipidemia

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20
Q

Define palatal petechiae

A

Red dots on palate of mouth

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21
Q

What is palatal petechiae a sign of?

A

Endocarditis

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22
Q

2 potential findings upon chest configurations inspection

A 
Pectus excavatum (caved in chest)
Pectus carinatum (Pigeon breast)
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23
Q

What is pectus excavatum a sign of?

A

Marfan’s and mitral valve prolapse

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24
Q

What is pectus carinatum a sign of?

A

Marfan’s syndrome

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25
Q

What is an extra phalanx, finger or toe a sign of?

A

Atrioseptal defect (ASD)

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26
Q

What are long,slender fingers a sign of?

A

Marfan’s syndrome

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27
Q

What is short stature, cubitus valgus and medial deviation of the forearm a sign of?

A

Turner’s syndrome

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28
Q

4 essential ingredients for determining BP

A

The Patient: Preparation and positioning
The Clinician: Positioning
The Instrument: Accuracy
The Procedure: Skill

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29
Q

4 ways to ensure patient preparation and positioning

A

Patient avoids smoking or drinking caffeinated beverages
Patient rests for 5 min in a quiet, comfortably warm room
Arm is free of clothing and should be supported at heart level
Palpate brachial artery

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30
Q

Width requirement for a correctly-sized BP cuff

A

Width of inflatable bladder should be 40% of the upper arm circumference

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31
Q

Length requirement for a correctly-sized BP cuff

A

Length of the inflatable bladder should be 80% of the upper arm circumference

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32
Q

Problem with have a cuff that is too small. Too big?

A 
Small = May overestimate the BP
Big = may underestimate BP
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33
Q

Problem with putting on the BP cuff too loosely

A

May overestimate BP

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34
Q

How should the cuff be positioned on the patient’s arm?

A

The lower border of the cuff should be 2.5 cm above the antecubital crease

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35
Q

How to avoid error by the auscultatory gap

A

As you feel the radial artery with the finger of one hand, inflate the cuff until the radial pulse disappears. Add 30 mm Hg

As you deflate the cuff, the pressure on the manometer at which the radial pulse re-appears = systolic BP by palpation

Deflate the cuff promptly and completely –> wait 15 - 30 sec

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36
Q

How to determine the BP after complete preparation

A

Use bell of stethoscope
Deflate cuff at 2 - 3 mm Hg per second
Systolic BP = first sound of at least 2 consecutive heartbeats
Diastolic BP = muffling and disappearance of the heartbeats (only a few mm apart)
Read these 2 values to the nearest 2 mm Hg
Wait 2 or more min and repeat (in both arms)

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37
Q

Method for assessing heart rate

A

Use radial pulse with the pads of your index and middle fingers
Gradually compress the radial artery until the maximal pulsation is detected
Normal or regular = measure over 30 sec
Fast or slow = measure over 60 sec

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38
Q

If the rhythm is irregular, how do you measure rhythm?

A

Use stethoscope at the cardiac apex

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39
Q

Most common cause of irregular rhythm

A

Premature beat

40
Q

5 things to assess for the respiratory rate

A

Observe the: rate, rhythm, depth and effort of breathing

Count the number of respirations by visual inspection

41
Q

Normal respiratory rate

A

20 breaths/min

42
Q

2 reasons why the assessment of jugular venous pressure is important

A

Provides the astute clinician with an index of RH P and cardiac function

Clinician’s window to the assessment of intra-vascular space and/or intra-cardiac P –> provide invaluable info on the presence or absence of heart disease

43
Q

What doe JVP reflect?

A

Right atrial P = CVP = RV EDP

44
Q

Where is the jugular venous pulsation found?

A

Deep to the sternomastoid muscle

Not directly visible

45
Q

4 steps to JVP technique

A

1 - position patient
2 - distinguish internal jugular with carotid pulsations
3 - estimation of the height of the JVP
4 - evaluation of the various waveforms

46
Q

What does inclination change in determining JVP?

A

Ability to measure the height of the column of the venous blood

47
Q

What do you consider when inclining the patient for JVP?

A

Consider/anticipate the patient’s volume status

Usually start at 30 degrees (head elevation)

48
Q

If hypovolemic, how to incline patient for JVP

A

Lower head of the bed to 0 degrees

49
Q

If hypervolemic, how to incline patient for JVP

A

Elevate bed to 60 - 90 degrees

50
Q

3 considerations for positioning after successfully inclining the patient for JVP

A

Tilt patient’s head away from the side you are inspecting
Tangential lighting
Tangential inspection (i.e. lean towards bed’s midline for examination)

51
Q

What 2 factors make the assessment of the JVP not possible?

A

A large neck

Excessive use of accessory muscles (particularly of the sternomastoid)

52
Q

Difference between carotid pulsation vs. JVP palpability

A 
Carotid = palpable
JVP = rarely palpable
53
Q

Difference between pulsation quality of carotid vs. JVP

A 
Carotid = More vigorous thrust with a single outward component
JVP = Soft, biphasic, undulating quality, usually with two elevations and two troughs per heart beat (a and v waves of AP graph)
54
Q

DIfference in pulsation elimination between carotid vs. JVP

A

JVP = pulsations eliminated by light P on the vein(s) jsut above the sternal end of the clavicle

Carotid = pulsations not eliminated by this P

55
Q

Difference in pulsation height due to position between carotid and JVP

A

JVP = height changes with position, dropping as the patient becomes more upright

Carotid = Height unchanged by position

56
Q

Difference in pulsation height due to inspiration

A

JVP = usually falls with inspiration

Carotid = usually not affected by inspiration

57
Q

What is an elevated JVP?

A

> 3 - 4 cm above sternal angle, or by adding a distance of 5 cm, > 8 - 9 cm above the RA

58
Q

Timing of a wave

A

Precedes the S1/carotid pulse

59
Q

Timing of x descent

A

Coincides with systole

60
Q

Timing of v wave

A

Almost coincides with S2

61
Q

Timing of y descent

A

Almost follows early diastole

62
Q

Why is assessing carotid pulse important?

A

Provides valuable information on:

  • Cardiac function
  • Stenosis or regurgitation of the aortic valve
63
Q

Defining characteristics to assess quality of the carotid pulse

A

Amplitude and contour

Bruits and thrills

64
Q

Patient positioning for carotid pulsation

A

Head of bed elevated to 30 degrees

65
Q

Clinician position for carotid pulsation

A

Stand slightly behind of the patient on right side

66
Q

Location of carotid pulse

A

Medial to a well-relaxed sternomastoid muscle at the level of the cricoid cartilage

67
Q

Method to take the carotid pulse

A

Use index and middle finger (or thumb) in the lower third of neck
Slowly increase P until you feel max pulsation
Slowly decrease P until you sense arterial P and contour

68
Q

Define amplitude of carotid pulsation

A

Pulse pressure

69
Q

Define contour of carotid pulsation

A

Speed of the upstroke, duration, speed of downstroke

70
Q

Define thrills

A

Humming vibrations (i.e. like throat of purring cat)

71
Q

4 positions for cardiac examination, in order of sequence

A

Supine, with head elevated 30 degrees
Left lateral decubitus
Supine, with head elevated 30 degrees
Sitting, leaning forward, after full exhalation

72
Q

Cardiac Examination: how to examine a patient in the first supine position with head elevated 30 degrees

A

Inspect and palpate the precordium: the 2nd right and left interspaces; the right ventricle; the left ventricle, including apical impulse (diameter, location, amplitude, duration)

73
Q

Cardiac Examination: how to examine patient in left lateral decubitus position

A

Palpate the apical impulse if not previously detected

Listen at apex with the bell of the stethoscope

74
Q

Cardiac Examination: how to examine a patient in the second supine position with head elevated 30 degrees

A

Listen at the 2nd right and left interspaces, along left sternal border, across to apex with diaphragm
Listen at right sternal border for tricuspid murmurs and sounds with the bell

75
Q

Cardiac Examination: how to examine a patient sitting, leadning forward, after full exhalation

A

Listen along the left sternal border and at the apex with the diaphragm

76
Q

Accentuated findings in the left alteral decubitus position during cardiac examination

A

Low-pitched extra sounds such as an S3, opening snap, diastolic rumble of mitral stenosis

77
Q

Accentuated findings in sitting position furing cardiac examination

A

Soft decrescendo diastolic murmur of aortic insufficiency

78
Q

What is the apical impulse?

A

The breif early pulsation of the LV as it moves anteriorly during contraction and touches the chest wall. PMI (point of maximal impulse) in most cases.

79
Q

What to assess when palpating for the apical impulse

A

Location (vertical and horizontal)
Diameter
Amplitude
Duration

80
Q

Usual location of apical impulse

A

Vertical location is usually the 5th or even 4th interspace

81
Q

Normal apical impulse diameter

A

Supine = 2.5 cm or only 1 interspace

82
Q

What is the significance of a larger diameter of apical impulse?

A

Enlarged left ventricle

83
Q

Usual apical impulse amplitude

A

Brisk and tapping

84
Q

Normal duration of apical impulse

A

Proportion of systole occupied by the apical impulse (usually does not continue to S2)

85
Q

Where to position fingers when palpating the right ventricular area

A

Place tips of fingers in the left 3rd, 4th and 5th interspaces. Palpate at end-expiration

86
Q

What to assess when palpating right ventricular area

A

Location, amplitude, duration

87
Q

Significance of high amplitude but not duration in right ventricular area palpation

A

Chronic RV volume overload

88
Q

Significance of high amplitude and duration in right ventricular area palpation

A

Chronic RV pressure overload

89
Q

How to “inch your stethoscope” during auscultation

A

Start at apex, inch toward LLSB, 2nd L. interspace and 2nd R. interspace

90
Q

How to use carotid pulse concurrently with auscultation to accurately identify S1 and S2

A

S1 occurs prior to the upstroke

S2 follows the carotid upstroke

91
Q

What kinds of sounds can the diaphragm of the stethoscope hear best?

A

High pitched sounds (S1, S2, murmurs of AR/MR, mid-systolic clicks, ejection sound, opening snap, pericardial friction rubs)

92
Q

What kind of sounds can the bell of the stethoscope hear best?

A

Low-pitched sounds (S3, S4, mitral stenosis)

93
Q

2 maneuvers that increase preload

A

Squatting position

Release of the Valsalva maneuver (phase 4)

94
Q

2 maneuvers that decrease preload

A

Standing for the squatting position

During the strain of the Valsalva maneuver (phase 2)

95
Q

1 maneuver that increases afterload

A

Handgrip

96
Q

8 categories of information to obtain when assessing murmurs

A

1) In systole or diastole?
2) Location
3) Radiation
4) Timing
5) Shape
6) Intensity
7) Pitch
8) Alleviating and aggravating factors

Block C - Circulation (26 decks)

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