PE 2

Created by abrannon 

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High-pitched sounds are better heard with the _______ and low-pitched sounds are better heard with the _______.

diaphragm (hi, di)
bell

Name three sounds best heard with the bell.

S3, S4, AV valve stenosis

Ejection clicks and opening snaps are best heard with the ______.

Diaphragm

The sound that precedes the carotid pulse is ___. The sound that follows the carotid sound is ___.

S1 precedes
S2 follows

Normally, only the _______ of heart valves can be heard.

Closing

What is the first heart sound?

closure of AV valves (mitral and tricuspid)

What sound marks the beginning of systole? What sound marks the end?

S1 marks beginning
S2 marks end

What is the second heart sound?

Closure of semilunar valves (aortic and pulmonic)

Which heart sound has two components?

S2

Physiologic splitting of S2 is best heard on _____ and disappears with ________.

inspiration
expiration

The sound heard when an AV valve is stenotic is called ________.

opening snap

The sound produced when a semilunar valve is stenotic is termed _______.

ejection click

If a person has all 4 heart sounds, what order will you hear them in?

4, 1, 2, 3
ejection click after 1
opening snap after 2

Which heart sound is normal in children or young adults but abnormal in people over 40? How is it produced?

S3
As blood flows from atria to ventricles, it distends the ventricular walls and causes vibrations.

Which heart sound marks atrial contraction, and thus is NEVER heard in the absence of atrial contraction?

S4
It also reflects a pathologic change in ventricular compliance (increased ventricular stiffness)

If your stethoscope has a functional diaphragm, how much pressure do you apply to listen with the bell? The diaphragm?

bell -- light pressure
diaphragm -- press tightly

Which is the most common murmur?

Midsystolic ejection murmur (produced by turbulence across a semilunar valve)

Systolic murmurs: aortic _____ & mitral _____.
Diastolic murmurs: aortic ____ & mitral ______.

Systolic -- aortic stenosis, mitral regurge
Diastolic -- aortic regurge, mitral stenosis

Choose one:
Diastolic murmurs (always/never/sometimes) indicate heart disease.

ALWAYS

In what patient position is aortic stenosis and regurgitation best heard?

With patient sitting up and leaning forward.
For regurgitation, patient should exhale and hold breath.

With which murmur is the Austin Flint murmur associated?

Aortic Regurgitation

Which murmur is located at the aortic auscultation area?

Aortic stenosis

Which murmur is best heard with the patient int he left lateral decubitus position, holding breath in exhalation, and stethoscope placed over the PMI?

Mitral stenosis

Which is the only murmur that doesn't radiate?

Mitral stenosis

Regurgitation and stenosis of the ______ valve is located at the apex.

Mitral

Which murmur is located at the pulmonic, Erb's, and tricuspid auscultation areas?

Aortic regurge

Which murmur is the only low-pitched murmur?

Mitral stenosis

Jugular veins empty directly into the _________, so they reflect activity of the ______ side of the heart.

Superior vena cava
Right

The level at which the jugular pulse is visible gives an indication of ______________, which also equals central venous pressure and right ventricular end-diastolic pressure.

right atrial pressure

On which side of the patient will you examine JVP?

Right

Which vein is used to estimate JVP?

Right internal jugular vein

JVP should be measured at less than ____ cm above the sternal angle, or less than ____ cm in total distance above the RA.

3-4 cm
8-9 cm

If you are trying to estimate JVP, what are some ways to differentiate between internal jugular pulsations and the carotid pulse?

Not palpable
Biphasic, undulating quality -- 2 troughs & 2 elevations per heartbeat
height changes with position and falls with inspiration
eliminated by light pressure

How long should capillary refill time be? What might be indicated by a prolonged capillary refill time?

Less than 2 seconds
May indicate dehydration, shock, peripheral vascular disease, or hypothermia

Presence of a cardiac thrill is indicative of what?

A loud murmur

What will you use to palpate for cardiac thrills?

A bony prominence (heads of metacarpals)

Pulmonic and aortic sounds radiate to which auscultation area?

Erb's point

At which auscultation point will you listen for physiologic splitting of S2 during inspiration?

Erb's point

At which auscultation point will you listen for gallops (S3, S4) in the left lateral decubitus position?

Mitral

ID the following types of vaginal discharge:
1. gray or white; thin; homogenous; coats vaginal walls; not profuse; fishy odor
2. thin; greenish-yellow or gray; frothy/foamy; profuse; may be malodorous
3. White/transparent; thick; mostly odorless
4. white; cloudy; typically thick; not malodorous; could be thick and chunky like cottage cheese

1. bacterial vaginosis
2. trichomonal vaginitis (protozoan)
3. normal
4. candidal vaginitis (candida albicans)

Vaginal discharge in gonorrhea and chlamydia will have what distinct quality?

Purulent

When will normal vaginal discharge become more noticeable?

during pregnancy
use of oral contraceptive pills
close to ovulation (mid-cycle)

Patients who are hypovolemic will have a ____ JVP. Patients who are hypervolemic will have an _____ JVP.

Low
High

Flattening of a normally convex breast suggests ______.

Cancer

Assymetry of the direction in which nipples point suggests underlying _____.

Cancer

New, unilateral nipple inversion or retraction suggests ______. What part of the breast is affected?

Cancer
suspensory ligaments

When performing a breast exam, the examiner palpates in a rectangular area. Name the four borders of that rectangle.

1. clavicle
2. inframammary fold (bra line)
3. mid-sternal line
4. posterior axillary line

Which is the best validated technique for detecting a breast mass?

Vertical strip pattern

If you locate a nodule in the breast, how will you describe its location?

By quadrant or clock face, and by distance in cm from the nipple.

Describe how a cancerous breast nodule will feel.

Single, hard, irregular, poorly defined, and fixed to surrounding tissue

What is the most common non-cancerous tumor found in breasts, especially in adolescent females.

Fibroadenoma

Peau d' orange, a sign of breast cancer, results from ________.

lymphatic obstruction, which produces edema of the skin

Which disease is described?: Red, scaling, crusty skin lesion that usually involves the nipple, areola, and surrounding skin.

Paget's of the breast

What is associated with Paget's of the breast?

An underyling ductal carcinoma

Dimpling of the skin of the breast signifies _______.

Breast cancer (probably a carcinoma of the suspensory ligaments)

Galactorrhea is often due to ______. It may also be a side effect of what type of medications?

Prolactinoma
D2 receptor blockers (such as anti-psychotics)

What percent of breast cancers are found in males?

Less than 1%

Herpes appears slightly differently in males than it does in females. ID the gender of the following infected patients:
1. appear as shallow, small, painful ulcers on red bases
2. appear as smal, scattered or grouped vesicles

1. Female
2. Male

What is the common name for condyloma acuminatum? What is the causal agent?

Genital warts
HPV

The cervical os marks the opening into the endocervical canal. How does it appear in nulliparous women? How does it appear in women who have given birth?

Nulliparous -- small and round
Parous -- slit-like

Describe Chadwick's sign. What does it indicate?

Bluish or violet color of the vaginal mucosa, cervix, and/or labia (due to increased vascularity, increased estrogen, and venous congestion)
Eary sign of pregnancy (6-8 weeks)

What is Pelvic Inflammatory Disease (PID), a.k.a. Salpingitis?

Acute infection of the upper genital tract (fallopian tube or tube + ovaries -- adnexal masses)

What may ensue if PID is left untreated?

A tubo-ovarian abscess, or infertility

Describe the ROS and physical exam results of a patient with PID.

Lower abdominal pain
Pain worsens with coitus or jarring movements
associated discharge
cervical motion tenderness on bimanual exam

What are Clue cells associated with?

Bacterial vaginosis

What are Clue cells?

squamous epithelial cells with smudged borders caused by adherent bacteria

If you suspect __________, you will sniff for fishy odor after applying KOH to a wet mount cervix sample.

Bacterial vaginosis (BV)

ID the following: A herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.

Rectocele

Explain the difference between phimosis and paraphimosis.

Phimosis: a tight prepuce that cannot be retracted over the glans
Paraphimosis: a tight prepuce that, once retracted, cannot be returned to cover the glans. Edema ensues.

Which demographic is at the highest risk for syphilis?

African American and hispanic women

What is the causative agent of syphilis?

treponema pallidum (a spirochete)

Which is characteristic of secondary syphilis? A syphilitic chancre, or condyloma latum? Which is the most contagious phase?

Condyloma latum is secondary syphilis - most contagious.
The chancre occurs first.

Describe a syphilitic chancre.

Firm, painless ulcer with indurated borders. Scraping revelas spirochetes.

How will a patient with non-gonococcal urethritis (NGU) present?

Presents with penile discharge that is clear or white, scanty, and usually observed when inspecting the urethral meatus.

For a patient who presents with penile discharge, how will you differentiate between gonorrhea and NGU (non-gonococcal urethritis)?

A culture and a gram stain

Define priapism.

A long, painful erection (greater than four hours)

Why is priapism a medical emergency?

blood flow is occluded and the tissue may become necrotic

In which patient population is Fournier's (scrotal) gangrene common?

Diabetics

Diabetic patient presents with crepitus of the scrotum. The scrotum is also swollen and erythematous. Diagnosis?

Fournier's Gangrene

What causes Fournier's Gangrene?

A bacterial infection of the skin

Upon palpation of the scrotum in a patient, you notice that there is no palpable testis or epididymis. What is the diagnosis? What is this patient at increased risk for?

Dx: cryptorchidism
Increased risk of testicular cancer

Patient presents with an acutely painful, tender, swollen testicle that is retracted upward in the scrotum. The scrotum is red and erythematous. Diagnosis?

Testicular torsion (twisting of the testicle on the spermatic cord)

Where is a pilonidal cyst located?

In the midline, superficial to the coccyx or the lower sacrum (right above the "butt crack")

If a pilonidal cyst has a small tuft of hair and is surrounded by a halo of redness, what is indicated?

The opening of a sinus tract

In an asthmatic patient, wheezes and crackles may be heard, and tactile fremitus is ______.

Decreased

Thickening of the nipple and loss of elasticity suggests _______.

Underlying cancer

There are four groups of axillary lymph nodes. Three of them drain into the fourth group, called the ______ nodes.

Central

Congenital displacement of the urethral meatus to the inferior surface of the penis is known as ________.

Hypospadius

What results when valves inside the veins along the spermatic cord prevent blood from flowing properly, thus causing the blood to back up, and in turn, causing swelling and widening of the veins?

Varicocele

A scrotal varicocele is most common on which side of the body?

Left

What feels like a soft bag of worms that is separate from the testis, but collapses slowly when the scrotum is elevated in the supine patient?

Varicocele

Your patient presents with a mass that does not illuminate. It is felt when standing, but disappears when the patient is supine. What is the mass?

A varicocele

Bartholin gland infections occur in which gender?

Female!

Name two STDs that may case Bartholin gland infections?

Gonorrhea
Chlamydia

You notice tense, warm, erythematous, very tender abscesses located posteriorly and deeply on both sides of the vaginal opening in your patient. Diagnosis?

Bartholin gland infection

What is the PE exam order in the thorax? In the abdomen?

Thorax: inspect, palpate, percuss, auscultate
Abdomen: inspect, auscultate, percuss, palpate

ID the following chest deformities:
1. sternum is displaced anteriorly, inc. the AP diameter
2. Multiple rib fractures causing ribs to move inward on inspiration and outward on expiration
3. increased AP diameter accompanying old age, COPD, and infancy
4. depression in the lower portion of the sternum
5. Abnormal spinal curvatures & vertebral rotation deform the chest

1. Pectus carinatum
2. Flail chest
3. Barrel chest
4. Pectus excavatum (Funnel chest)
5. Thoracic kyphoscoliosis

What is increased AP diameter often seen in infancy, normal aging, and COPD?

Barrel chest

To measure posterior chest expansion, where should you place your thumbs? Where do you place thumbs for anterior chest expansion?

At the level of the 10th ribs
Along costal margin

Which adventitous breath sound is associated with COPD?

Wheezing

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