Physical Diagnosis II
Terms
-
a and v wave examination
-
lie on back, without pillow, head of bed 15-30 degrees above horizontal.
head turned slightly down and right to relax sternocleidomastoid muscle
shadows of light seen on sheet behind patient
time with cardiac or carotid pulse&nb
-
a wave
- increase in right atrial pressure due to right atrial contraction
- A2
- closing of aortic valve
-
Abstraction
- Similarities/Differences Questions
- Agitation
- Increased activity that is apparently purposeless
- Akinesia
-
No movement
-
amplitude of pulse
- normal, diminished, increased, double-peaked
-
Aortic Auscultation
-
2nd intercostal spac, right sternal border (2ICS-RSB)
- Apnea
-
Temporary cessation (i.e. cardiac arrest)
-
Approach to treat patient with acute respiratory infection
-
- upper vs. lower respiratory tract
- causative agents
- virulence vs. host response
- preventive interventions
-
Arterial Pulse
-
Produced by ejection of blood into the aorta during systole
Smooth and rapid upstroke following S1, followed by anacrotic notch
Peak is smooth and dome shaped, followed by a less steep descent to dicrotic notch
-
Barrel Chest
-
AP diameter equals lateral diameter
i.e. advanced COPD
- Base
-
2nd Intercostal Space to right and left of atrium
-
Best location to hear S2
- Base
- Best Location to hear splitting of S1
-
Tricuspid area
-
Best location to listen to S1
-
Cardiac Apex
- Biot
- irregular with long periods of apnea; i.e. increased intracranial pressure, drug-induced, brain damage
-
Boundaries of lungs
-
Pyramidal Shape
3-4 cm above medial end of clavicle
Inferiorly to rib 6 at midclavicular line, rib 8 at midaxillary line, posteriorly to level of T9 and T12
- Bradykinesia
-
Slow movement
- Bradypnea
-
abnormal slowing
-
Breathing muscles
-
- Sternocleidomastoid (SCM)
- Intercostal
- Diaphragm
- Abdominal
- Bronchial
-
loud, high pitched like air rushing through a tube over manubrium
expiratory is longer and louder
pause btwn components
- Bronchophony
-
Increased transmission of spoken word
"ninety-nine" is louder if consolidation
- Bronchovesicular
-
heard in carina and mainstem bronchi
Inspiratory = expiratory
-
c wave
-
increase in right atrial pressure due to tricuspid valve closure secondary to right ventricular contraction
-
Cardiac Rhythm
-
- regular
- regularly irregular
- irregularly irregular
-
Characterization of Murmurs
-
- location
- radiation
- duration
- intensity (I-VI)
- pitch
- quality
- relationship to ventilation or body position
-
Chemoprevention of CHD
-
- anti-hypertensives
- low dose aspirin
- dietary supplement
- estrogen replacement
-
Chest Wall Expansion
-
normal expansion shows symmetry
localized pulmonary disease may result in lack of symmetry
- Cheyne-Stokes
-
irregular with periods of increased and decreased rate and depth and apnea (i.e. drug-induced, brain damage, congestive heart failure (CHF))
- Chorea
- Brief, rapi, sudden, arrythmic, involuntary; dance over body
- claudication
-
cramps in calf brought about by exercise and relieved by rest, due to insufficient blood flow to the extremity
Dorsalis pedis (pedal) and posterior tibialis pulses impt.
- Cognition
-
Ability of the patient to think and reason. Most cognitive eval. is completed via the Mini Mental State Exam.
Also includes: level of conscious awareness, genearl intellectual function, and abstraction.
- Components of the Mental Status Exam
-
- Appearance and Behavior
- Motor Activity
- Mood and Affect
- Speech and Language
- Thought Content
- Perception
- Insight
- Judgement Cognition
- Congruent
-
Affect and mood in agreement (versus incongruent)
-
Contour of Pulse
- shape of the wave, speed of the upslope, downslope, duration of wave
- COPD
-
Chronic Obstructive Pulmonary Disease
- emphysema
- chronic bronchitis
-
Crackles
-
short, discontinuous, nonmusical sounds heard on inspiration
caused by opening of collapsed distal airways or alveoli
rales, crepitation
pulmonary edema, CHF, pulmonary fibrosis, bronchitis, resp. infection, atelectasis
- Delirium
-
Mental disturbance of short duration, usually reflecting a toxic state, marked by illusions, hallucinations,, delusions, excitement, restlessness, and incoherence.
May be superimposed on demnentia.
- Dementia
-
Organic mental syndrome characterized by a general loss of intellectual abilities, involving impairment in judgement and sbstract thinking as well as changes in personality, but not including that due to clouding of consciousness, depression, or other
-
Diastolic AV murmur
- begins after a finite time after S2 with opening of AV valve (mitral or tricuspid stenosis)
- Diastolic opening snaps
-
high-pitched sharp sound due to opening of defective AV valve
-
diastolic pressure
-
pressure at which sounds vanish
-
Diastolic Semilunar Murmur
- begins immediately after S2 (aortic or pulmonic regurgitation)
-
Dicrotic Notch
- closure of the aortic valve
- dull
-
low amplitude, short duration
solid organ (liver)
- Dysphoric
-
Unhappy-appearing (affect) or unpleasant (mood)
- Dystonia
-
Sustained abnormal posture of muscle spasm
- Egophany
-
spoken word heard through lungs is increased in intensity and takes on a nasal quality
"eee" heard as "aaa" in area of consolidation (fluid-filled)
- Ejection Click
- Early in systole, due to defective opening of semilunar valve
-
Ejection murmur
- turbulent flow across a semilunar valve in systole (aortic or pulmonic stenosis)
- Elements of Medical History
-
- Chief Complaint (CC)
- History of Present Illness (HPI) including Coarse
- Past Medical History/Meds/Allergies
- Family History
- Social History
- Review of Systems
-
Emerging CHD Risk factors
-
- thrombogenic factors
- homocysteine
- c-reactive protein
- psychologic stress
- infection
-
Erb's Point Auscultation
-
3rd Intercostal spac, left sternal border (3ICS-LSB)
Area where aortic and pulmonic sounds radiate
- Euphoric
-
Elated, "high"
- Euthymic
-
Normal mood
-
Examination of Chest
-
Both posterior and anterior:
- Inspection
- Palpation
- Percussion
- Auscultation
-
Femoral pulse
-
2-3 cm inferior from inguinal ligament
Diminished pulse suggests arterial insufficiency
-
Flail Chest
-
one chest wall moves paradoxically inward during inspiration
i.e. multiple rib fractures
- flat
-
high pitched
large muscle mass (thigh)
-
Folstein Mini Mental State exam
-
Abbreviate, standardized mental status exam with 30 point max score.
Tests:
- Orientation
- Registration
- Attention and Calculation
- Recall
- Language
-
General Intellectual Function
- Determined by asking the patient about current events
- Heart Exam
-
- Inspection
- Blood Pressure
- Arterial Pulse
- Jugular Venous Pressure
- Percussion
- Palpation
- Auscultation
- Exam for Dependent Edema (graded 1+ to 4+)
- Heart Murmurs
-
noise events that last longer than a second heart sound, generated by turbulent blookd flow
Causes:
- valvular opening decreases, increases in size, becomes irregular in shape
- ejection velocity increases
- valvular opening decreases, increases in size, becomes irregular in shape
- horizontal fissure
-
only in right lung
separates upper and middle lobes
runs from sternal border at rib 4 to midaxillary line at rib 5
- Hypernea
-
a.k.a. Kussmaul's
increased depth, usually associated with metabolic acidosis
- hyperresonant
-
low pitched, hollow
(emphysemic lung)
-
Inferior wing of scapula
-
Rib 7
-
Inflation pressure
-
inflate cuff until radial pulse disappears, add 30 mm Hg and this is inflation pressure to use
Deflate cuff and wait 15-30 sec
- Insight
-
Observe what patient says about their illness. If understanding is less than complete, need more direct questions.
Impt. component of competency evaluation.
- Judgement
-
How they are handling decisions about their own day-to-day affairs.
Impt. component of competency evaluations
-
Jugular venous pulse
-
considerably increased in certain heart conditions (mitral valve disease)
-
Kortokoff sounds
- low-pitched sounds heard during deflation of BP cuff when determining BP
- Kyphoscoliosis
-
abnormal AP diameter and lateral curvature of the spine
- Labile
- Highly variable and quickly changeable
- Left atrium
- Most posterior portion, moves posteriorly and to the right when enlarged
-
left lung
-
2 lobes: upper, lower
-
Left Ventricle
-
Left and behind right ventricle
-
Left Ventricular Apex
-
5th intercostal space at midclavicular line (5ICS-MCL)
-
Length best heard
-
anteriorly - 1st and 2nd intercostal spaces
posteriorly - scapulae
- Level of Conscious Awareness
-
Posited on a continuum from normal alertness to coma
-
location of diapraghm
-
at end of expiration, passive process producing elastic recoil of the muscle
Anteriorly - rib 5
Posteriorly - T9
right hemidiaphragm is slightly higher than left because of liver on right side
-
Major Diseases of the Heart
-
- Coronary Artery Disease
- Hypertension
- Rheumatic Heart Disease
- Bacterial Endocarditis
- Congenital Heart Disease
- Mannerism
-
An unusual way of performing a functional motor act (i.e. waving goodbye with both hands)
-
Metabolic Syndrome
-
- insulin resistence
- hypertension
- dyslipidemia
- Obesity
-
Midsystolic click
- middle of systole, single or multiple, may change position. May be due to prolapse of mitral or tricuspid valve.
-
Mitral Auscultation
- Cardiac apex(5CIS-MCL)
- Mitral opening snap
- mitral stenosis, occurs after A2
-
Modifiable Risk Factors for CHD
-
- high sat. fat diet
- smoking
- alcohol
- physical inactivity
- High BP
- High LDL
- Low HDL
- High Triglycerides
- Glucose Intolerance
- Obesity
- normal BP
-
up to 120/80
5-10 mm Hg difference btwn arms is normal
-
Normal Chest
-
wider later diameter than AP diameter
-
Normal Jugular Venous Pressures
-
- 0 - sternal angle
- 30 - 6 cm above sternal angle
- 45 - 4-5 cm above sternal angle
-
Normal Respiration Rate
- 10-14 breaths per minute
- oblique fissure
-
separates lower lobe from rest of lung in both lungs
rib 6 at midclavicular line to rib 5 at midaxillary line then posteriorly to T3
- Observation of jugular vein
-
may be a sign of:
- heart failure
- obstruction of SVC
- enlarged supraclavicular nodes
- increased intrathoracic pressure
- P2
- closing of pulmonic valve
-
Palpation of Chest
-
Evauate position of trachea
deviation may be due to a mass or something that would shift the mediastinum
-
Palpation of Heart
-
- apical impulse
- right ventricle
- pulmonary artery
- left ventricular motions
- PMI
- PMI after running for 1 min
- second interspace
- aortic area
- pulmonic area
- generalized motion
-
Palpation of the arterial pulse
-
Yields information about:
- rate and rhythm of heart
- contour of pulse
- amplitude of pulse
- Parameters of affect
-
- Range
- Intensity
- Stability
- Appropriateness
- Relatedness
- Parameters of Language
-
- Complexity
- Comprehension
- Coherence
- Parameters of Motor Activity
-
- amount
- speed
- posture
- gait
- Parameters of Speech
-
- amount
- speed
- volume
- clarity
- fluency
-
Pectus Carinatum
-
Anterior protrusion of sternum; usually does not compromise ventilation (a.k.a. pigeon chest)
- Pectus Excavatum
-
depression of sternum; usually accompanied by mitral valve prolapse
- Perception
-
Patient usually needs to be asked to elicit information
Occurs in different modalities (auditory, olfactory, visual, gustatory, and tactile)
Can be positive, negative, and distorted
-
Percussion of chest
-
used to detect density of underlying structures - depends on air-to-tissue ratio
-
Period between S1 and S2
- systole
- Period between S2 and S1
- diastole
-
Physiologic Splitting of S2
- A2 normally precedes P2, gap widens due to inspiration
-
pleural rubs
-
grating sound made by pleura that is roughened or thickened by inflammation, neoplasm, or fibrin deposits
best heard on inspiration and beg. of expiration
creaking leather
associated with pneumonia and pulmonary infarction
- PMI
-
point of maximal impulse
left ventricular apex
-
Prevention of TB
-
Primary:
- Prevention of disease after Infection
- Prevention of Transmission
Secondary:
- screening for latent infection
-
Problem List/Clinical Impression
-
- Diagnosis - high resolution
- Collection of symptoms
- Pathophysiologic state
- A physical finding(s)
- A lab abnormality(ies)
- A psycho-socio-economic issue
-
Proper BP cuff size
-
20% wider than the diameter of the extremity
-
Proper level of BP cuff
- heart level for accurate measurement and patient's arm should be supported at level of patient's heart
-
Psychomotor retardation
- Visible generalized slowing of movements and speech
- Pulmonic Auscultation
- 2nd Intercostal Space (2ICS-LSB)
-
Pulse deficit
-
may occur in irregular heart rhythm
Difference between apical (taken at apex of heart) and radial pulse
If exists, then true heart rate can only be obtained by auscultation at apex of heart
-
Pulse sites
-
- Radial (brachial in neonates and infants)
- Carotid
- Femoral
- Dorsalis pedis
- Porterior tibialis
- Regurgitant systolic murmur
- retrograde flow from from higher pressure area to lower pressure area during systole (mitral or tricuspid regurgitation)
- resonant
-
higher amplitude, low pitched
air filled tissue (lung)
- Rhonchi
-
low-pitched
associated with mucous plgging and poor movement of secretions
associated with bronchitis
-
Right Atrium
-
3rd-5th ribs on right of sternum
- Right lung
-
3 lobes: upper, middle, lower
-
Right Ventricle
-
Most of anterior surface of heart
-
Risk Factors for depression
-
- S - sleep disturbances; is sleep increased or decreased?
- I - Interest; what gives the patient pleasure;does he have the same pleasures?
- G - Guilt
- E - Energy Level
- C - Concentration
- A - Appetite
- P - P
- S1
- Closing of the AV valves (tricuspid and mitral)
- S2
- Closing of the semilunar valves (Aortic and Pulmonic)
- S3
-
heard immediately after S2.
Normal in children and young adults
when heard in >30 y.o. may signify volume overload to the ventricle. May be due to regurgitant lesion in valves and congestive heart failure. Produces a gallop sound or rhy
- S4
-
When produced is heard after diastole when atrial contraction occurs.
Normal in young adults and children
when heard in >30 y.o. may indicate noncompliant or stiff ventricle.
-
Social History
-
- Birthplace
- Marital
- Children
- Vocation
- Avocations (Hobbies)
- Habits
- Sounds best heard with bell
-
low-pitched sounds such as gallop rhythms, AV stenosis murmurs
Press lightly against skin
-
Sounds best heard with diaphragm
-
high-pitched sounds such as valve closure, systolic events, regurgitant murmurs
Press tightly to skin
-
Sternal Angle (of Louis)
-
Important landmark for:
- Rib 2
- Bifurcation of trachea to bronchi
- Carina
- T4
-
Symptoms of Cardic Disease
-
- Chest pain
- Palpitations
- Dyspnea
- Syncope
- Fatigue
- Dependent edema
- Hemoptysis
- Cyanosis
-
Symptoms of Pulmonary Disease
-
- Cough
- Sputum production
- Hemoptysis - coughing up blood
- Dyspnea - shortness of breath
- Wheezing
- Cyanosis - bluish discoloration of skin
- Chest pain
-
Systolic Clicks
- high-pitched, short, "click" sounds that are produced by the opening of a pathologically deformed valve.
-
systolic pressure
- pressure level at which you hear 2 consecutive beats
- Tachypnea
-
Abnormal increase
-
Tactile Fremitus
-
vibration felt on the chest wall when the patient is speaking
Provides info on the density of the underlying tissue
Increased density -> increased vibration -> increased tactile fremitus
fat, air, or fluid will decrease density<
-
The sound heard with the carotid pulse
- S1
- Things to Note for Appearance and Behavior
-
- body type
- physical stigmata
- posture
- bearing
- clothes
- grooming
- alertness
- level of comfort
- ambulation status
- unusual or repetitive behaviors
- Thought Content
-
- Preoccupations
- Disturbances (such as delusions)
Can be transient or fixed. Can make some observations but in general, the patient must be asked about this part of the MSE.- Suicidal Thoughts or plans
- Hom
- Tic
- An involuntar, sudden, rapid, recurrent, non-rhythmic, stereotyped movement or vocalization
- Tracheal
-
harsh, loud, high pitched
heard over trachea
inspiratory and expiratory are equal in length
- Tremor
-
Rhythmic oscillation of a body part
-
Tricuspid Auscultation
-
Left lower sternal border (LLSB)
-
tricuspid opening snap
-
tricuspid stenosis, occurs after P2
- tympanic
-
high pitched, hollow
hollow, air filled organ (stomach)
- Types of normal breathing
-
- Tracheal
- Bronchial
- Vesicular
- Bronchovesicular
-
Unmodifiable Risk factors for CHD
-
- Age
- Sex
- family history
- personal history
-
v wave
-
increase in right atrial pressure due to its filling during ventricular systole
- Vesicular
-
soft, low pitched heard over most of lung fields
inspiratory is louder and longer
- Wheezes
-
continuous, musical, high-pitched - heard during expiration
caused by narrowing of bronchi due to swelling, secretion, foreign body, tumor
associated with asthma, pumonary edema, bronchitis, CHF
- whispered pectriloquy
-
intensification of whispered word heard in consolidation of lung
"one-two-three" clearly heard when whispered in consolidation of lung
-
x descent
- decrease in right atrial pressure due to atrial relaxation
-
x' descent
- decrease in right atrial pressure due to increasing size of atrium secondary to right ventricular contraction
- y descent
- decrease in right atrial pressure due to tricuspid valve opening at end of ventricular systole