Advanced Physical Assessment
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| How to screen for PAD | ankle brachial index- highly specific way to screen for and diagnose PAD. ABI is the ratio of blood pressure measurements in the foot and arm; values < 0.9 are considered abnormal
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| Abdominal aorta | abdominal pain and pulsating abdominal mass- evident in family hx- An AAA is an expansible mass that pushes the examiners hands apart- unlikely to be under belly button
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| Dissecting aneurisms of thoracic aorta | Produce excruciating, tearing, anterior chest pain- hoarseness, while pressure on the superior cervical ganglion may cause a Horner syndrome
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| Syndrome of sudden arterial occlusion | embolism/thrombotic- sudden- loss of sensation- 5 Ps- pain, pallor, paresthesia, loss of pulses, paralysis- Microemboli to the lower extremities cause the "blue toe syndrome".
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| Syndrome of Chronic Arterial Occlusion | intermittent claudication- Viagra does not help-thickened toenails, shiny skin, loss of hair, absence of both pedal pulses, (neuropathic) cutaneous ulcers- don’t feel, atrophy of calf muscles
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| Intermittent claudication | PAD- pain in the calf muscles- arteries are blocked
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| Test question- Raynaud's phenomenon | vasospasm of arteriolar smooth muscle- fingers/toes distal to the MCP/MCT pass into 3 stages- Pallor: d/t cold= vasospasm→ Cyanosis: oxygen desaturation, finally Redness: d/t vasodilation- throbbing in digits
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| Varicose veins | get worse if they do nothing- wear stockings
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| 2 major complications of DVT are | PE and chronic venous insufficiency- Virchow’s triad (stasis, trauma, hypercoagulability/dehydration)- pain and swelling
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| Superficial Venous Thrombosis (Superficial Thrombophlebitis) causes DVT? | no but is does contribute to varicose veins- give NSAIDS
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| Chronic venous insufficiency | Incompetent valves within the deep venous system cause blood to flow back -Cutaneous edema and "brawny induration," prominent just above the medial malleolus- stasis dermatitis (ulcer)
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| Necklace of nodes and arms | Axillary, Epitrochlear (cubital), Parotid, Retropharyngeal (tonsillar), Submandibular, Sublingual (facial),Superficial anterior cervical, Superficial posterior cervical, Pre-auricular, Post-auricular, Sternocleidomastoid, Occipital, Supraclavicular
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| The lower the pain | the more distal the block- lower calf= popliteal, foot= dorsal, upper calf= superficial femoral, thigh= common femoral, buttock= aorta do angiography
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| Food fear | mesenteric arterial occlusion
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| Central venous catheter is a risk for | DVT
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| DVT | cyanosis, hyperpigmentation, Calf swelling/edema especially when legs are dependent, in venous stasis ulcers, Swelling with redness and tenderness, in cellulitis
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| How do we grade the pulse? | 2+ is normal- brisk, 3 is bounding, 1 is diminished
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| Lymphadenopathy | enlarged lymph nodes
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| Lymphangitis | inflammation of the lymphatics that drain an area of infection; tender, red streaks extend proximally from the infected area; regional nodes may also be tender
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| Lymphedema | edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage
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| Drugs that can cause lymphadenopathy | Diphenylhydantoin: in particular- also aspirin, penicillin, tetracycline, cephalosporin, sulfonamide, allopurinol, atenolol, captopril, carbamazepine, hydralazine.
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| Non tender lymph nodes | bad- it’s good if it hurts- it’s bad if it’s firm and nonmobile- matted together is bad
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| Acute Suppurative Lymphadenitis | Infection node; single or localized group-GABH-strep. and staph aureus-capsule is distended causing pain- the cervical region from infections of the teeth or tonsils;also axillary or inguinal lymph nodes
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| Infectious mono | sore throat, exudates,ths is a lymph node dz spleen, inguinal nodes posterior, submandibular ones look at these and mono test
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| Painless lymphadenopathy | look for leukemia or lymphoma- s/s- fever, wt loss and nt sweats- bed sheets 2x night
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| Virchow node | bad- a palpable left supraclavicular node is a significant clue to thoracic or abdominal malignancy
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| Femoral hernia | below the inguinal ligament, protrudes with cough, reducible- ask pt to cough- if it pulsates it’s hernia
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| Raynaud disease | Wrist pulses are typically normal, but spasm of more distal arteries causes episodes of sharply demarcated pallor of the fingers
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| Ankle brachial index | order angio-
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| Ankle brachial pressure | BP higher in the legs- in a sitting pt- for pt with pain in the leg when walking- do left ABI and Rt ABI legs/arm pressure should be 0.9 or greater- do 2x for the average
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| Interpretation of numbers for ankle brachial index | 0.90- 1.30 (normal), 0.89- 0.60 (mild), 0.59- > 0.40 (moderate) and <0.39 is severe
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| Venous insufficiency | varicose veins
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| Diabetes and peripheral neuritis and venous/arterial insufficiency you get | ulcers
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| Shiny, hairless, skin | PAD
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| Buerger test | Marked pallor of the feet on elevation- delayed return 10 seconds- chronic arterial dz
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| Varicose veins and flow | goes from superficial to the deep (saphenous) then up to abdominal- veins in between which ensure- but if you cough, stand too much, they’re leaky- superficial will be dilated and tortuous
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| DVT | know everything chronic venous insufficiency or PE
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| Trendelenberg test for incompetent valves | compress the saphenous vein after having pt lie supine w/leg in 90 degree then have them stand- Rapid filling of the superficial vein indicates incompetent valves
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