Advanced Physical Assessment
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| 1. Dyspnea | - murmur
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| 2. pneumothorax and p. effusion_______ and atelectasis and tumor________ | push away- pull towards
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| 3. Rhonchi | - cleared by cough
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| 4. Sputum | putrid and rusty- also bronchitis
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| 5. Hemoptysis | - scant is bronchitis
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| 6. Chest pain questions | - mix and match
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| 7. Respiratory distress | - tachypnea- same with pneumonia- xr
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| 8. Kussmals (acidosis) and Cheyne stokes (hyperventilation/apnea) | we continue breathing d/t CO2, acidosis/central chemoreceptors and hypoxia/peripheral chemoreceptors
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| 9. Inspection of the chest diaphragm | descends during inspiration- active process, and exhalation is a passive process- paradox is (Pigeon) during inspiration the chest goes out and abdomen goes in
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| 10. SQ crepitus | is something you feel- Patients with subcutaneous crepitus should all be assumed to have-a PNEUMOTHORAX unless it has been excluded
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| 11. Tactile fremitus- | vibration and pneumonia
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| 12. Tracheal deviation | - he was supposed to ask this the last time- caused by pneumothorax or pleural effusion, or left sided atelectasis- airway collapse- more room- lung tumors- mass
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| 13. Pleural effusion | - dull to percussion d/t fluid beneath- all other percussion/resonance has no significance
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| 14. Bronchovesicular and bronchial breath sounds | abnormal when detected over periphery- bronchovesicular and bronchial breath sounds develop whenever there is a ↓ in the air/water ratio of the pulmonary parenchyma/consolidation- pneumonia, atelectasis, pulmonary edema, pulmonary fibrosis
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| 15. Lung auscultationTopography | mix and match?
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| 16. Wheeze- | expiratory- no wheeze is bad
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| 17. Wheezes, crackles, etc… | mix and match???
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| 18. Stridor- | emergency obstruction
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| 19. Late inspiratory crackles indicate the presence of | interstitial edema (heart failure or pneumonia) or interstitial scarring (pulmonary fibrosis)
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| 20. Bronchophony, egophony, whispered pectoriloquy | present in consolidation/pneumonia
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| 21. Low pitch and high pitched crackles | bronchitis vs pulmonary fibrosis (Velcro) and pneumonia/edema
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| 22. Test question- “In pneumonia, you will also find | normal lung on one side and consolidation on the other side”
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| 23. Diaphragmatic excursion is reduced to | 2-3cm in copd/p. fibrosis when normally it’s 3-6
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| 24. Consolidation | pneumonia and left ventricular failure- atelectasis
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| 25. Atelectasis refers to the process where | a segment of lung collapses because air contained within it is reabsorbed into the blood stream. Atelectasis increases water density of lung tissue and produces consolidation
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| 26. Pulmonary embolism- | acute dyspnea, hx
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| 27. JVD- 2 prominent bulges- | a wave in pulmonary HTN-– absent in atrial fibrillation- too much pressure- and the v wave- tricuspid regurgitation, ASD pericarditis
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| 28. Test question- Decrescendo | usually diastolic murmurs as AR & mild MS- loud S1, opening snap- use bell- left lateral w/prego
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| 29. When to use the bell | for s3, s4, mitral stenosis murmur- open snap- low pitched sounds
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| 30. Systole | MT close (S1) and then AP open Diastole
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| 31. Possible Test question- Hand grip | increases the afterload- for regurgitations-will make it louder- goes in an abnormal direction- mitral regurgitation
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| 32. Hand grip will put more blood in the heart for | MR, AR and VSD- amyl nitrate does the opposite
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| 33. You hear a systolic murmur over the apex- what are 2 conditions | MR ASS Mitral regurg and atrial stenosis- ask pt to squeeze his hand
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| 34. Squatting and leg raise | increase preload for thus all murmurs except MVP&HOCM
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| 35. Splitting S2 | the right side gets filled with inspiration- the pulmonic will have more work to do and closes late because there’s too much pressure- heard on inspiration- longer and louder
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| 36. Test ?- Wide split- abnormalities of S2 | any condition that increases the pressure or volume on the right side of the heart- pulmonary htn- pulmonic condition happens later and aortic happens earlier so it widens the split.
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| 37. Test ?- fixed splitting of s2 | the same thing, in inspiration and expiration, it’s the same- asd- atrial septal defect
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| 38. Opening snap- | diastolic- (MS)- early diastole- LLSB-click
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| 39. Aortic ejection click- | aortic stenosis- heard at the base/everywhere clicks during systole because that’s when it opens and it’s stiff- mitral stenosis is early diastole because that’s when it opens
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| 40. Mitral valve prolapse click- | mid systole- leaflets loose when there’s less blood in the heart- blood goes back the other way- the jacket is big when you lose wt- mid systole (closes)- high pitch
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| 41. An S1 or S2 caused by a mechanical valve | (following MVR or AVR respectively), will acoustically sound similar to a click- An absent mechanical valve click =valve dysfunction
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| 42. Abnormal systolic click | MVP, aortic ejection click
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| 43. S3 has very high specificity but low sensitivity for | LV failure, S4 is nothing
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| 44. PDA | continuous and mechanical
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| 45. Test question | left ventricular gallop S3
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| 46. Gallop | word for s3- heart failure- order lasix
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| 47. Test question- Unusually tall woman | marfan- loose connective tissue- aortic regurgitation- lean forward- fist grip- decrescendo- blowing-
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| 48. MVP click/mitral valve prolapse | leaflets loose when there’s less blood in the heart- blood goes back the other way- the jacket is big when you lose wt- mid systole (closes)- high pitch- vasalva and standing= you hear better
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| 49. Pericarditis | treat with nasids- pr interval depression on ecg- ST segment elevation in the majority of leads
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| 50. Hypertrophic obstructive cardiomyopathy (HOCM) | (decreased murmur intensity) systolic murmur like AS but more blood makes AS more loud but not this one (squatting, leg raise or supine)→ echo
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| 51. AS murmur radiate to the | carotid arteries MR murmur radiates to the axilla
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| 52. Grade 4 | you can feel vibration of murmur
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| 53. mitral regurgitation | caused by HTN and ischemia
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| 54. Quality of murmurs | MS quality- rumbling MR quality- musical blowing AR quality- blowing AS quality- harsh PDA quality- machine-like
Still’s Murmur- musical vibratory
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| 55. a-fib | synchronized cardioversion except for v-fib
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| 56. You hear a systolic murmur over the apex- what are 2 conditions | MR ASS Mitral regurg and atrial stenosis- ask pt to squeeze his hand
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| 57. SYSTOLIC MURMUR WHICH RADIATES TO THE AXILLA | MRASS- MR, if he wants you to say aortic, he would chose the carotid
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| 58. VSD- VSD/ventricular septal defect is | a hole between the left ventricles-If left untreated, the Lt to Rt shunt (red)can --NOT CYANOTIC HERE BUT can turnninto Rt to Lt one (blue) and the patient becomes cyanotic- too late (Eisenmenger syndrome)
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| 59. Ankle brachial pressure | BP higher in the legs- 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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| 60. young female with chest pain | MVP
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| 61. malleolous | below is arterial and above is venous
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| 62. Superficial Venous Thrombosis (Superficial Thrombophlebitis) causes DVT? | no but is does contribute to varicose veins- give NSAIDS
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| 63. Varicose veins will get worse | use compression stockings
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| 64. Chronic venous insufficiency know s/s | above medial malleoli, associated with edema, varicose veins, Hyperpigmentation, possible cyanosis, especially when legs are dependent, in venous stasis ulcers-above ankles- virchows triad- stasis/trauma, hypercoagulability/dehydration
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| 65. Alarming- lymph nodes that do not hurt | firm is bad- doesn’t move- malignant
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| 66. Matted lymph nodes | bad- also, they do not pulsate-
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| 67. virchows node | is bad- a palpable left supraclavicular node is a significant clue to thoracic or abdominal malignancy
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| 68. S1 you can hear it sometimes higher than normal | mild mitral stenosis- cannot even hear the murmur- may miss it
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| 69. Pulmonary htn | abnormal S2 1) 2nd heart sound is loud 2) 2nd heart sound is widely split because the pulmonic component occurs late- loud P2- valve closes late- higher pressure
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| 70. Test question- S3 and S4 diastolic heart sounds | heard with the bell- also mitral stenosis murmur- low pitched sounds- he will ask “all these sounds are low pitched except”---
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| 71. S3 has high_____ but low_________ | specificity, sensitivity- you can say pt has chf if s3 is present, but if not present, you cannot exclude chf
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| 72. Left ventricular gallop s3 is softer during inspiration because | we put more blood on the right side- ask pt to exhale to hear better
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| 73. Ventricular Septal Defect in child | systolic- recurrent respiratory infections- If left untreated, the Lt to Rt shunt turns into Rt to Lt one and the patient becomes cyanotic (Eisenmenger syndrome)
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| 74. 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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| 75. 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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| 76. 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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| 77. 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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| 78. Syndrome of Chronic Arterial Occlusion | intermittent claudication- Viagra does not help-thickened toenails, shiny skin, loss of hair, absence of both pedal pulses, cutaneous ulcers
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| 79. 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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| 80. 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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| 81. Virchow node | bad- a palpable left supraclavicular node is a significant clue to thoracic or abdominal malignancy
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| 82. Painless lymphadenopathy | look for leukemia or lymphoma- s/s- fever, wt loss and nt sweats- bed sheets 2x night
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| 83. Prominent ”a” waves | pulmonary HTN and absent in a-fib
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| 84. Maneuvers that affect/increase the Preload (venous return) | Squatting/Leg raise: increase venous return, thus increase all murmurs except MVP&HOCM
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| 85. Valsalva/Standing: decrease venous return, thus decrease all murmurs except | MVP&HOCM
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| 86. Maneuvers that affect the Afterload (Systemic vascular [arterial] resistance) | Handgrip: ↑ afterload, thus ↑ regurgitation murmurs, and ↓/not affecting stenotic murmurs, decreases MVP, HOCM, nothing to MS
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| 87. Amyl nitrate | decreases afterload, thus decreasing regurgitation murmurs, and increasing/not affecting stenotic murmurs, increases MVP and HOCM, nothing to MS
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| 88. V waves seen in | tricuspid regurgitation, ASD pericarditis
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