Ross University ICM semester 3 ICM secondaries study guide
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| What are the causes + presentation of anemia | Hemolysis, nutritional deficienies (b12, follate, Fe, hemorrhage, etc. Pt will appear pale due to decreased oxyhemoglobin.
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| What are the causes + presentation of jaundice | Biliary obstruction, hemolytics anemia, liver failure, etc. Pt will present with yellow tone to skin and sclera.
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| What are the causes and presentation of clubbing | Causes: chronic hypoxia, heart failure, pulmonary htn, lung ca, etc. Pt will present with an increased convexity of the nail bed (>180 degrees) and nail bed may be spongy
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| What are the causes and presentation of edema? | Cause: Hydrostatic pressure exceeds osmotic pressure, so fluid accumulates resulting in swelling. Pitting edema --> right sided heart failure. Non-pitting --> inflammation.
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| What is the cause of peripheral edema? | Accumulation of fluid in parts of the body most affected by gravity, such as the legs. It is caused by increase hydrostatic pressure of the veins which leds to poor resorption and fluid accumulation
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| What is the cause of central cyanosis? | Circulatory or ventilatory problems that leads to poor blood oxygenation or slowed blood low causing increase tissue resorption and decreased blood O2 levels. Ie; CHF, hypothermia, high altitude, hypoventillation, lung disease.
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| What is the cause of peripheral cyanosis? | Decreased O2 perfusion in the extremities. Caused by reynaud disease, cold exposure, vasoconstiction or arterial occlusion
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| What is the significance of a radio-femoral dela? What may it indicate? | A radiofemoral delay is when there is a loss of simultaniaty between the radial pulse and the femoral pulse. It may indicate coarction of the aorta.
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| What are trophic changes? | Trophic changes are differencs in size and growth of the arms and legs. This is an indicator of tissue atrophy and could be caused by an occulusion causng a reduction of circulation to the tissue, causing a size difference due to reduced growth.
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| Mechanism of varicose veins? | When the leaflet valves of the veins are damaged due to increased bloodflow (due to gravity), blood collects and accumulates leading to enlargement of the veins.
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| What are sign of arterial occlusion and obstruction in the periphery? | Bruits may indicate an arterial occlusion, as would peripheral cyanosis (due to reduced blood flow). Also, assymetric pulses may indicate an embolism or artherosclerosis
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| What is indicated by an assymetrical pulse? | Arterial sclerosis or emobolism causing arterial obstruction.
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| What is a sinus arrythmia? | Sinus arrhythmia is a normal finding that is characterized by an increase in pulse upon inspiration due to increased veinous return from the decreased intrathoracic pressure. The pulse then slows upon expiration.
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| What is meant by a irregularly irregular pulse? | A pulse that is non-rhythmic (no pattern)that has no consistency between pulse cycles.
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| What condition is usually associated with a irregularly irregular pulse. | Usually associated with A-fib.
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| Possible Causes of small weak pulse? | Decreased pulse pressure and slow upstroke. Caused by decreased stroke volume (ie heart failure), hypovolemia, aortic stenosis, Increaed TPR, CHF
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| Possible causes of a large, bounding pulse? | Increased pulse pressure with strong upbounding pulse. Cause by increased stroke volume, decreased TPR, Ie; Fever, anemia, hyperthyroid, Aortic regurge, decreaed compliance of aortic walls.
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| What is Bisferiens pulse? Causes? | Increaed arterial pulse with a double systolic peak. Pure aortic regurge or hypertrophic cardiomyopathy.
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| Pulsus alternans? Causes? | Alternation is amplitude of pulse from beat to beat. Sign of LEFT ventricular failure and is usually associated by an S3 sound.
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| Pulsus alternans is indicative of what condition? | LEFT ventricular failure.
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| Bigeminal Pulse? Cause? | Normal beat with alterating premature contraction. Usually normal.
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| Paradoxical Pulse? | Palpable decrease in pulses amplitude upon inspiration. Seen in pericardial tamponade and obstructive lung disease, as well as constricive paracarditis.
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| What does the A wave represent in a JVP | Right atrial contraction... corresponds to peak fillig time of the jugular vein.
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| No A wave is indicative of? | A-fib
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| Large A-wave is indicative of? | Pulmonary hypertension.
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| Giant A-wave is indicative of? | Total heart block
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| What does the V-wave represent in a JVP? | Passive phase of atrial filling during ventricular systole.
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| What does the x-descent represent in JVP? | Decreased jugular filling do to relaxation of atrium. Follows a-wave.
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| What does the Y-descent represent. | a brief decrease in jugular filling due to opening of tricuspid valve.
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| Outline the phases of the jugular waves | A wave: Increased jugular filling due to right atrial contraction. V wave: Increased jugular filling due to ventricular contraction (passive phase of atrial filling).X descent: Decreased jugular filling due to relaxtion of atria. A-->X-->V-->Y
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| What is Kussmaul's neck sign?. | Test of hepatojugular reflux. NORMALLY When pressure is applied to abdomin, JVP will briefly increase and then decrease. Positive sign = JVP remains elevated. Indicates Right sided heart failure or cardiac tamponade.
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| Prominant A wave = | Increased right atrial contraction. Possible due to tricuspid stenosis.
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| Absent A wave = | A-FIB
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| Large V wave = | Tricuspid regurge.
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| What is an auscultory gap? | A silent interval that may be present between the systolic and diastolic pressure. This leads to underestimating the systolic pressure and overestimating diasolic. Avoided by increased pressure to 30mmhg above palpated systolic.
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| What is the diagnosti criteria of orthostatic htn? | Decrease in systolic pressure of >20mmhg when pt is standing.
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| Pre-hypertensive range? | 120-139/80-89
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| Hypertensive range? | >139/>89 (ie 140/90 and above)
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| Causes of HTN | Anxiety, increased Na intake, hypervolemia
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| Persistent HTN is a risk factor for? | Stroke, MI, renal failure.
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| Define a thrill? | Fine palpable rushing vibration or a harsh rumbling murmur. Suggestive of aortic stenosis, VSD, or patent ductus arteriosis.
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| Describe findings of left ventricular hypertrophy? | Parasternal heave
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| What is a parasternal heave indicative of? | LV hypertrophy.
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| What side of stethescope is used for S1, S2, S3, and S4 | S1 and S2 = Diaphragm. S3 and S4 = Bell
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| Where is S1 loudest? | At the apex
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| Where is S2 Loudest | At the base.
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| Describe relationship of systole and diastole to s1 and s2 | S1--systole--S2--diastole--S1
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| What is the purpose of rolling patient into the lat. decubitus position. Where is steth. plaed? What side of steth is used? | BELL of Steth is placed at apex. Purpose is to listen for mitral regurg.
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| What is the purpose of auscultation with the pt leaning forward? Where is steth placed? What side is used? | DIAPHRAGM of steth is placed at 3rd left parasternal border and at APEX. Pt is told to exhale and stop breathing momentariliy. This is too listen for aortic murmers
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| Describe how aortic murmers are best heard (procedure)? | Tell pt to sit up right nad lean forard, exhale and stop breathing for a moment. Diaphragm is placed at left sternal boarder and then at APEX.
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| Explain mechanism of S2 splitting. Where is this best heard? | Aortic valve closure preceeds pulmonic valve closure during inspiration due to increased right atrial filling 2ry to increased veinous return from inspiration. Best heard in the pulmonic region.
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| What does S1 represent? | Closing of mitral and tricusp valves. Best heard at apex.
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| What does S2 represent? | Closing of aortic and pulmonic valves. Best heard at base. Split most often heard in athletes and slended individuals.
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| What does S3 represent? When is it abnormal and what pathology does it indicate. | Galloping sound right after S2. Normal in children / adolecents. >30 y/o could mean left vent. failure.
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| What does S4 represent? When is it abnormal and what pathology does it represent? When is it heard in relation to other sounds? | ALWAYS PATHOLOGICAL. Heard just before S1. Indicative of decreased compliance and MI.
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| Stenosis is a ____ pitched sound. | Low
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| Regurgiation is a _____ pitched sound. | High
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| Where is a mitral regurg/stenosis ausculatated at? | Mitral area (left side near apex)
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| Where is aortic regurge / stenosis auscultated at? | Left sternal border.
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| Describe a Kussmaul breathing pattern. In what condition is the pattern seen? | Rapid deep breaths. Seen in metabolic acidosis/
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| Describe a Cheyne stokes breathing pattern | Rhymic waxing and waning in rate and depth.
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| What is flail chest? | An injury to the ribs where a section of the ribcage os detached due to multiple fractures. It has a collapsed lung.
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| How is bronchophony tested? | Auscultation at all 12 sites on the back while patient says "99"
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| How is egophony tested? | Auscultation at all 12 sites on back while patient says "ee". Should sound like "ee". If it sounds like "aa" the test is positive and may indicate lobar consoldiation from pneumonia.
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| How is whisperd pectoriloquy tested? | Pt whispers 123 each time stethoscope touches the back. Should not be audible in healthy individuals.
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| positive bronchophony, egophony, or whispered pectroiloquy are indicative of. | Lobar consolidation due to pneumonia.
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| Where are the apices of the lungs auscultated. What side of steth is used? | Above the clavical. Use bell.
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| Where are bronchovesicular sounds heard? | Between first and second intercoastals.
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| Where are vesicular sounds heard | Through all of posterior thorax, and most of anterior thorax (excluding IC 1 & 2 where broncho-vesicular sounds are heard).
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| What is meant by a vesicular sound? | Insp > expiratory.
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| What is meant by a bronchovesicular sound? | Insp = Exp
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| What is meant by a broncial sounds? | Insp < Exp
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| What is meant by a trachea sound ? | Insp = Exp
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| Crackles aka? | Rales.
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| What are crackles indicative of? | pneumonia, fibrosis, early CHF, or bronchitis
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| What are wheezes indicative of? | Narrowed airways, COPD, or bronchitis
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| Describe crackles | Discontinuous and brief. Sounds like hair being rubbed together.
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| Describe Rales. | Discontinuous and brief. Sounds like hair being rubbed together. (rales are another word for crackles!!!)
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| Descrive weezes | Continuous, musical and prolonged with a hissing or shrill quality.
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| Describe a plural friction rub. | Inflamed an roughened plural surfaces rubbing against each other as they are momentarily and repeatadly delayed by increased friction. Produces a creaking sound!
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| During abdominal exam, how should percussion sound? | Normally tympanic. Dull in the presence of fluid.
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| Rebound tenderness is indicative of? | Peritonitis.
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| When are bowel sounds NORMALLY hypoactive? | Sleep or if pt hasn't eaten in a while.
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| When are bowel sounds normally hyperactive? | After a meal or in diarrhea.
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| What is the cause of absent bowel sounds? | Ileus (condition where there is a lack of activity) there may be accumulation of gas, intestinal contents or secretions that could rupture the bowels. Mechanical bowel obstruction would also cause absent bowel sounds. Also with insuff. blood flow.
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| What is the cause of visible peristalsis. | Seen physiologically in newborns and very thin individuals. Pathologically in the presence of a bowel obstruction (peristaltic wave will increase in force to try to dislodge the obstruction.
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| Things to look for during general survey of liver. | Jaundice, palmar erythema, fetor hapaticus (sweet garlicky odor), asterixis (flapping tremor), spider nevi, and gynecomastia.
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| Describe Murphy's sign and what it indicates. | Murphy's sign is tested by placing hand on right coastal margin when patient has exhaled all air in lungs. Gentle pressure is applied as patient inhales. Since liver and gall bladder lower with inhalation,if pt stops inhaling(pain)indicates cholecystitis.
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| How is a spleen palpation performed? | Pt it in supine position. Palpate from right iliac fossa to left hypochondrium as pt breathes normally. watch for signs of pain. Palpate to mid-ax line and put pt in right lat. decub posish. Have them rest their arm on your shoulder and continue palp.
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| What is a friction rub over the spleen indicative of? | Splenomegally. Enlarged spleen is rubbing against the peritoneum
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| How is splenic enlargement differentiated from kidney enlargement? | Spleen is notched medially and nothing is palpable of the spleen in splenomegally. In kidney enlargement, kidney would be palpable above the spleen
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| Why is ascites seen in liver disease? | Hypoalbuminemia --> reduced osmotic pressure ---> fluid accumulation.
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| What is the mechanism of ascites in portal HTN | portal HTN leads to vasodilation of due to NO release. As a result of this, fluid leaves the vessels and accumulates in the abdominal cavity. At the same time, arterial volume drops triggering Na retention, leading to further fluid accum.
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| What causes distended veins over the abdomen? | Obstruction of IVC, liver cirrhosis (caput medusae), portal vein thrombosis, distended abdomen.
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