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Physical Exam 6-7-8

Quiz questions for Week 9, 10, 11 quizzes

The 2 groups of veins in the leg deep and SF
Difference between 2 groups of veins of leg, in terms of support deep veins are well supported by surrounding tissues & carry nearly 90% of venous return.
Name the SF veins of leg great saphenous, small saphenous,
Course of great saphenous vein starts @ dorsum of foot, passes just in front of MM, then up medial leg to join deep vein of femoral system
Location of epitrochlear LNs 3 cm above HT3
Drainage into epitrochlear LNs Lymphatics from ulnar surface of forearm and hand, pinky & ring finger, ulnar side of middle finger drain into the epitrochlear LNs
Two groups of SF inguinal LNs horizontal & vertical
Location of each of 2 groups of SF inguinal LNs horizontal: high in anterior thigh, just below inguinal ligament. vertical: lower (about around area where penis dangles) and near upper portion of saphenous vein
Intermittent claudication episodic muscular ischemia (usually calf but c/b buttock, hip, thigh, foot) induced by exercise d/t obstruction of large or medium sized arteries
Cause of IC atherosclerosis
How can IC be distinguished from leg pain d/t spinal stenosis? spinal stenosis pain alleviated by leaning forward (stretching spinal cord within the narrowed spinal canal). IC alleviated by rest.
Location and sx of ischemia of aortoiliac artery buttock, hip
Location and sx of ischemia of iliac-pudendal artery ED
Location and sx of ischemia of common femoral (or aortoiliac) artery thigh
Location and sx of ischemia of superficial femoral artery upper calf (!!)
Location and sx of ischemia of popliteal artery lower calf (!!)
Location and sx of ischemia of tibial artery foot
Location and sx of ischemia of peroneal artery foot
Ischemia of which artery can cause abdominal pain after meals and thereby "fear of food?" celiac (or superior/inferior mesenteric) arteries
Screening guidelines for abdominal aortic aneurysm in U.S. one-time US screening in men 65-75 with h/o "ever smoking" (=100 or more cigarettes in lifetime)
Causes of asymmetric BP in the two arms coarctation of aorta or dissecting aortic aneurysm
Causes of lymphedema of arm and hand usually d/t radiation destruction or "dissection" (axillary LNs)
Four grades of pulses and character of each Bounding, Increased, Brisk (expected), Diminished (weaker than expected), Absent (unable to palpate)
Cause of asymmetrical diminished pulses arterial occlusion d/t atherosclerosis or embolism
Course of small saphenous vein begins @ lateral side of foot (BL62,61 area) and up posterior aspect of leg (BL57,56,55) to join deep system in popliteal space
Drainage into axillary LNs Lymphatics from radial forearm, thumb, index, radial aspect of middle finger
Pancreatic pain usually refers to... back
Biliary tree pain usually refers to... R shoulder or R posterior "chest" (thorax)
(Possible) causes of doubling over with cramping, colicky pain kidney stone
(Possible) causes of epigastric pain gastritis, GERD
(Possible) causes of doubling over with sudden knifelike epigastric pain pancreatitis or gallstone
Causes of heartburn "aggravated by alcohol, caffeine, acidic foods"
Characteristics of heartburn rising, retrosternal burning pain or discomfort occurring once weekly or more
Appendicitis pain RLQ and refers to umbilicus (usually also abdominal wall ridigity)
Diverticular pain LLQ "with palpable mass"
Signs & sx of colon ca "change in bowel habits"
Causes of regurgitation GERD, stricture, esophageal ca
Causes of coughing blood esophageal or gastric varices, gastritis, peptic ulcer
Causes of early satiety hepatitis
Location of esophageal dysphagia just inferior to sternoclavicular notch
Causes of constipation DM, hypothyroid, hyper Ca+, MS, Parkinson's, systemic scleroris
Obstipation signifies intestinal obstruction
Melena black, tarry stool (upper GI bleeing)
Hematochezia passage of fresh blood (lower GI bledding)
acholic stool a-cholic= no bile (stools become light colored or grayish)
significance of acholic stool viral hepatitis, "obstructive jaundice"
Cause of jaundice with itching "cholestatic or obstructive jaundice" ??
Causes of suprapubic pain "bladder disorder"
Causes of dysuria (painful urination) cystitis, urethritis, acute prostatitis?, stones?, tumor?
Causes of difficult urination BPH, prostatitis, stones, tumor
Fetaures of acute pyelonephritis "Kidney pain," fever & chills
Location of flank pain in acute pyelonephritis posterior costal margin near costovertebral angle
Character of ureteral pain may originate at costovertebral angle, but radiates forward to lower abdomen/upper thigh
caput medusa distended periumbilical veins usually d/t portal vein HTN
"other signs of alcohol abuse" spider angioma, palmar erythema, peripheral edema
Drinking cutoffs for men & women men can have 3. women can have 2. so 4 or more for men and 3 or more for women is considered excessive. Weekly totals: 14 or more for men; 7 or more for women
Colorectal ca screening recs Five options (beginning @ 50): OCCULT BLOOD (SIX SAMPLES) ANNUALLY. Colonoscopy every 50-60-70-80-90. Double contrast barium enema or flexible sigmoidoscopy every 5 years.
Sequence in abdominal examination I'll get back to you
normal location and diameter of Point of Maximal Impulse (aka apical pulse)? 5th interspace 7 cm to 9 cm lateral to the midsternal line
What happens to PMI in LVH? (diameter) >2.5 cm OR/AND moves laterally, >10 cm lateral to midsternal line
two components of second heart sound? A2, P2
In which phase of breathing you can hear 2nd heart sounds (A2, P2)? inspiration
What are the locations on the chest wall where you hear the murmurs originating each of the MITRAL valve? apex
What are the locations on the chest wall where you hear the murmurs originating each of the TRICUSPID valve? LL sternal border
What are the locations on the chest wall where you hear the murmurs originating each of the PULMONIC valve? 2nd,3rd ICS, close to sternum (but a bit Left)
What are the locations on the chest wall where you hear the murmurs originating each of the AORTIC valve? "anywhere from (R) 2nd ICS to apex"
Significance of jugular venous pressure? reflects right atrial pressure, central venous pressure, right ventricular end-diastolic pressure
Where best to measure JVP right internal jugular vein
Conditions included in Acute Coronary Syndrome (aka acute myocardial ischemia) unstable angina and both ST and non-ST elevation MI
Acute aortic dissection sx Ripping, tearing anterior chest pain, often radiating to back or neck
Palpitation unpleasant awareness of heartbeat
Which arrhythmia can be ID´s without EKG A-fib (irregular irregular)
Possible causes of weak pulse Decreased stroke volume (heart failure, hypovolemia, stenosis) and/or increase peripheral resistance ("cold" or severe CHF)
Possible causes of bounding pulse Increased stroke volume (fever, anemia, hyperthyroid, fistulas, regurgitation, PDA, bradycardia, "complete heart block") and/or decreased peripheral resistance (not sure this makes sense)
pulsus alternans pulse alternates in amplitude from beat to beat even though the rhythm is basically regular
paradoxical pulse palpable decrease in the pulse’s amplitude (>10 mm Hg) on quiet inspiration
Cause of paradoxical pulse pericardial tamponade, constrictive pericarditis, COPD
Cause of pulsus alternans LVF
Causes of sudden dyspnea pulmonary embolus, spontaneous pneumothorax, anxiety
orthopnea dyspnea that occurs when the patient is lying down and improves when the patient sits up
Causes of orthopnea left ventricular heart failure, mitral valve stenosis, obstructive lung disease
paroxysmal nocturnal dyspnea duh
Causes of paroxysmal nocturnal dyspnea left ventricular heart failure, mitral valve stenosis
locations of dependent edema? feet, low legs (sacrum if bedridden)
Causes of dependent edema? CHF, hypoalbuminemia, positional
US Preventive Services Task Force recommendation of BP screening? 18 years of age and older
What are the AHA guidelines for screening of BP, BMI, waist circumference? At each routine visit (at least every 2 years)
What are the AHA guidelines for screening of fasting lipoprotein profile and fasting glucose? At least every 5 years. If risk factors for hyperlipidemia or diabetes present, every 2 years
US Preventive Services Task Force recommendation of screening of LDL? 35 men, 45 women, 20 where risk factors for CHD are present
What are the steps in assessing JVP? who cares
What is normal JVP? (<3-4 cm would be normal)
causes of increased JVP? right sided congestive heart failure constrictive pericarditis tricuspid stenosis superior vena cava obstruction
How will you distinguish between internal jugular and carotid pulsations? internal jugular are light, barely palpable, and affected by position change or inspiration; eliminated by light pressure. Carotid pulsations are exactly the opposite.
What are the causes of decreased carotid pulsations? decreased stroke volume atherosclerotic narrowing/occlusion
What are the effects of application of pressure on carotid sinus? ??
What is the cause of delayed carotid upstroke? aortic stenosis
Bruit murmur-like sound of vascular rather than cardiac origin
Bruit caused by stenosis
What is the significance of asymptomatic carotid bruit? threefold increased risk of ischemic heart disease and stroke
Thrill humming vibrations, or thrills, that feel like the throat of a purring cat
Which positions are good for murmurs of mitral stenosis and aortic insufficiency? patient left lateral decubitus?
What are the sequences of cardiac examination? inspection, palpation, auscultation
Causes of thrills aortic stenosis patent ductus arteriosus ventricular septal defect mitral stenosis
Dextrocardia a heart situated on the right side (The apical impulse will then be found on the right)
Physical findings of dextrocardia duh
apical impulse the brief early pulsation of the left ventricle as it moves anteriorly during contraction and touches the chest wall
normal location of apical impulse 4th or 5th ICS and (approximately) midclavicular line (L)
normal diamter of apical impulse <2.5cm
normal duration of apical impulse through the first 2/3 of systole—and often less!
normal amplitude of apical impulse "small, brisk, tapping"
Why might apical impulse be displaced? cardiac enlargement in congestive heart failure cardiomyopathy ischemic heart disease deformities of the thorax mediastinal shift
What is the significance of increased amplitude of apical impulse? pressure or volume overload of LV (hyperthyroid, anemia)
What is the significance of sustained, high-amplitude apical impulse? LVH usually d/t systemic arterial HTN
What is the significance of sustained, low-amplitude apical impulse? dilated cardiomyopathy
What are the two sequences of auscultation of heart (inching the stethoscope)? I´ll get back to you
What are the relations of timing of heart sounds S1 and S2 with carotid pulse? S1, just before the carotid upstroke. S2 after.
How will you determine systole and diastole from heart sounds? systole is between Lub and Dub. diastole is after Dub (before next Lub)
What are the sounds you hear better with each of the diaphragm of stethoscope? high pitched
What are the sounds you hear better with each of the diaphragm of stethoscope? S1, S2, mumurs (aortic) and regurgitation (mitral), PC friction rubs
What are the sounds you hear better with each of the BELL of stethoscope? low pitched
What are the sounds you hear better with each of the BELL of stethoscope? S3,S4 stenosis (mitral)
diaphragm firmly
bell lightly
How will you determine whether a murmur is systolic or diastolic? Murmurs that coincide with the carotid upstroke are systolic.
Which way does a murmur of aortic stenosis radiate? in the direction of arterial flow (i.e., into the neck), especially on the R side.
What are the grades of heart murmurs? 1=faint, 4-5-6 are increasingly loud with thril
Which grades have palpable thrills? 4-5-6
Which murmur increases in intensity with Valsalva maneuvers? murmur of hypertrophic cardiomyopathy
What is the timing of murmur of patent ductus arteriosus (PDA)? Continuous murmur in both systole and diastole (often with a silent interval late in diastole)
What is the radiation of murmur of patent ductus arteriosus (PDA)? to L clavicle
What is the quality of murmur of patent ductus arteriosus (PDA)? harsh, machine-like
Missed quiz question on steatic stool k
Common cause of decreased or absent pedal pulse diabetes
Cause of asymmetrical diminished pulses arterial occlusion from atherosclerosis or embolism
What does popliteal aneurysms sound like k
What does femoral aneurysms sound like k
What causes popliteal aneurysm k
What causes femoral aneurysm k
Symptoms of deep iliofemoral thrombosis k
How specific is the calf tenderness for DVT of calf? k
Signs of superficial thrombophlebitis k
Signs of chronic venous insufficiency of leg k
Causes of thickened brawny skin LYMPHEMDA
Cases of absent or diminished wrist pulses k
Purpose of Allen Test k
Raynaud's k
Location of pain in Raynaud's k
Timing of pain in Raynaud's k
Aggravating factors in Raynaud's k
Ameliorating factors in Raynaud's k
Difference between chronic arterial and chronic venous insufficiency k
Features of chronic venous insufficiency ulcers k
Features of chronic arterial insufficiency ulcers l
Featires pf neuropathic ulcers k
Pitting edema soft, usually bilateral. esp. anterior tibia & foot. NO SKIN THICKENING, ulceration, pigmentation
Chronic venous insufficiency edema soft, pitting, occasionally bilateral. Brawny changes, SKIN THICKENING. BROWNISH PIGMENT. Ankle swelling, ULCERATION !!??
Lymphedema soft in early stages, then indurated/hard, non-pitting. Thickened skin. Rarely ulcerates. NO PIGMENTATION. Bilateral? (He says edema in feet & toes?)
To which location are the pancreatic and biliary tree typically referred? pancreatic to back. biliary to right shoulder/clavicle
Possible causes of doubling over cramping pain pancreatitis
Possible causes of colicky pain renal stones
Possible causes of sudden knifelike epigastric pain gallstone pancreatitis
Causes and characteristics of heartburn rising retrosternal burning pain or discomfort occurring weekly or more often. said to be aggravated by alcohol, coffee, citrus fruits, peppermint (??) or positions like bending over, exercising ((?), lifting, or lying supine
Characteristics of pain in appendicitis Right lower quadrant pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation, peritoneal signs, something else... nausea & vomiting
Characteristics of pain in diverticulitis LLQ pain with a palpable mass
Signs and symptoms of colon cancer Change in bowel habits with mass lesion
Causes of regurgitation of gastric contents Regurgitation occurs in GERD, esophageal stricture, and esophageal cancer
Causes of hematemesis esophageal or gastric varices, gastritis, or peptic ulcer disease
Causes of early satiety hepatitis
Location of esophageal dysphagia Pointing to below the sternoclavicular notch
Usual causes of acute diarrhea infection
Usual causes of chronic diarrhea Crohn’s disease and ulcerative colitis
Causes of steatorrhea malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth
Causes of constipation DM, hypothyroidism, hyperCa+, MS, Parkinson’s, systemic sclerosis
Causes of obstipation intestinal obstruction
Melena as little as 100 ml of (upper gastrointestinal bleeding)
Hematochezia more than 1000 ml of blood (usually from lower gastrointestinal bleeding)
Causes of melena upper gastrointestinal bleeding d/t: Peptic ulcer, gastritis, stress ulcer, esophageal or gastric varices, reflux esophagitis, Mallory-Weiss tear (mucosal tear in the esophagus due to retching)
Causes of hematochezia from lower gastrointestinal bleeding
"A-cholic" stool excretion of bile into the intestine is completely obstructed, and stools become gray or light colored, or "a-cholic": without bile
Common cause of acholic stool viral hepatitis; with obstructive (intra-hepatic, i would t hink) jaundice
Causes of jaundice with itching (cholestatic or obstructive jaundice): distended liver capsule, biliary cholic, or pancreatic cance
Causes of suprapubic pain "Bladder disorders"
Causes of painful urination (cystitis or urethritis): bladder stones, foreign body, tumor; also acute prostatitis. In women, internal burning occurs in urethritis, and external burning in vulvovaginitis
Causes of difficulty in voiding ?
Features of acute pyelonephritis Kidney pain, fever, and chills
Local of flank pain in pyelonephritis at or below the posterior costal margin near the costovertebral angle (may radiate anteriorly to umbilicus)
Character of ureteral pain severe and colicky, originating at costovertebral angle and radiating around the trunk into the LQ of the abdomen (possibly into the upper thigh and testicle or labium)
Caput medusa recanalized umbilical veins radiating up the abdomen
Classic findings in alcohol abuse spider angiomas, palmar erythema, and peripheral edema
Cutoffs for hazardous drinking in men ≥14 drinks per week (3 per occasion)
Cutoffs for hazardous drinking in women ≥7 drinks per week (4 per occasion)
Recommendations for colorectal cancer screening in persons with average risk beginning at age 50. FOBT annually or flex sigmoid 1 5 years. colonoscopy q 10 years.
Sequence of abdominal examinations Inspection, Auscultation, Percussion, Palpation
Cause of suprapubic bulge on abdomen distended bladder, pregnancy, hernia
Causes of pink, purple striae on abdomen Cushing’s syndrome
Causes of dilated veins on abdomen hepatic cirrhosis or obstruction of inferior vena cava
Causes of bulging flanks on abdomen ascites
Causes of increased peristaltic waves intestinal obstruction
Where to listen for bruits of renal artery stenosis Epigstrium, BOTH UQ, Both costovertebral angles
What is the palpation finding of peritoneal inflammation Involuntary rigidity ("myospasm") & rebound tenderness
What is the significane of rebound tenderness usually indicates peritoneal inflammation
How is rebound tenderness elicited press down slow but firm. withdraw QUICKLY
In which condition might liver dullness be displaced downward= diaphragmatic descension d/t COPD
How to palpate the liver L hand under (11th/12th ribs). R hand on lateral abdomen/rectus muscles. Press gently in & up
Site at which liver is palpable 3cm below R costal margin in MIDCLAVICULAR line
Causes of tenderness of liver inflammation (as in hepatitis,)or congestion (as in heart failure)
Directions of enlargement of the spleen anteriorly, downward, and medially, (often replacing the tympany of stomach and colon with the dullness of a solid organ)
Causes of splenomegaly portal hypertension, blood cancers, splenic infarct, hematoma, HIV
Causes of enlarged kidney hydronephrosis, cysts, and tumors
Findings on pressue and percussion in pyelonephritis Pain with pressure or fist percussion
Causes of bladder outlet obstruction urethral stricture, prostatic hyperplasi. Also medications sfx and neurologic disorders such as stroke, MA
Risk factors for abdominal aortic aneurysm age 65 years or older, history of smoking, male gender, and a first-degree relative with a history of AAA repair.
Exam findings in AAA A periumbilical or upper abdominal mass with expansile pulsations that is 3 cm or more wide
Causes of ascites Increased HYDROSTATIC pressure: cirrhosis, CHF, constrictive PC, obstruction of inferior vena cava or hepatic vein. Decreased OSMOTIC pressure: nephrotic syndrome, malnutrition, ovarian cancer (!!)
What happens to dullness and tympany with position change in patient with ascites dullness shifts to the more dependent side, whereas tympany shifts to the top
Characteristics pain in appendicitis classically begins near the umbilicus, then shifts to the right lower quadrant, where coughing increases it.
Rovsing's sign Pain in the right lower quadrant DURING LEFT-SIDED PRESSURE (!!)
Referred rebound tenderness right lower quadrant pain on quick withdrawal
Psoas sign Ask the patient to flex his thigh at the hip. If abdominal pain results, it is a "+ psoas sign". A + psoas sign on the R may suggest appendicitis. (may also be positive with other sources of retroperitoneal irritation)
Obturator sign (aka Cope) Right hypogastric pain (Via flexion and internal rotation of the R hip, an inflamed appendix may come into physical contact with the obturator internus muscle. This causes pain and is evidence in support of an inflamed appendix.)
How Murphy's sign is elicited (see below)
What is positive Murphy's sign (of cholecystitis)? A sharp increase in tenderness with a sudden stop in inspiratory effort
How to distinguish a mass on abdominal wall from intra-abdominal mass A mass in the abdominal wall remains palpable; an intraabdominal mass is obscured by muscular contraction
Location of pain from acute pancreatitis Epigastric, may radiate to the back or other parts of the abdomen; may be poorly localized
Aggravating factors in acute pancreatitis Lying supine
Ameliorating factors in acute pancreatitis Leaning forward with trunk flexed
Location of pain in acute cholecystitis Right upper quadrant or upper abdominal
Radiation of pain in acute cholecystitis right scapular area
Causes of stress incontinence in men prostatic surgery
Causes of stress incontinence in women often a weakness of the pelvic floor with inadequate muscular support of the bladder and proximal urethra
Causes of increased pulsations visible on the abdomen aortic aneurysm or of increased pulse pressure
Sx of SF thrombophlebitis redness, warmth, tenderness, induration(along route of vein, just below skin)
Signs of chronic venous insufficiency low leg & ankle swelling (esp. after extended standing), achiing/tired legs, new varicose veins, LEATHERY ("brawny") looking skin; flaking or itching skin on legs/feet. STASIS ULCERS
causes of brawny edema (thickened brawny skin) chronic venous insufficiency
Sx of iliofemoral (deep vein) thrombosis pain, swelling, redness, warmth, engorged superficial veins
Specificity of calf tenderness for DVT occurs in 50% of patients, but this is entirely nonspecific
Raynaud’s smaller arteries that supply blood to your skin narrow, limiting blood circulation to affected areas
Location of pain in Raynaud's distal portion of 1 or more fingers, sometimes face
Timing of pain in Raynaur's brief but recurrent
Aggravation in Raynaud's exposure to cold, stress, emotional upset
Amerlioration in Raynaud's warm
Chronic venous insufficiency (Mechanism is venous HTN.) All the brown stuff. EDEMA. Ulcers @ medial ankle. (No gangrene). He says "often painful" but other sources say Arterial Insufficiency is the really painiful one...
Chronic arterial insufficiency (Mechanism is ischemia.) Intermittent Claudication. PAIN AT REST!? Absent or diminished pedal pulse. Cool skin. Little to no edema. Skin is THIN, SHINY, loss of hair! Ulcers on TOES & FEET. Gangrene is possible.
Venous leg ulcers often @ medial malleolus (irregular edges, shallow, granulation)
Arterial leg ulcers toes and web spaces (smooth edges, deep, lack of granulation)
Created by: mrbarr