Final Study Guide.docx

(How assessment?) Hypertension (Why) you want to test it (identify) normal and abnormal 這份有所有老師說的話了。 不用去看之前錯的quiz，因為那些都是解剖的問題 把所有abnormal寫 how do you test that, how I find out if abnormal, and how I test. 大寫都特別重要、粗體 點圖的地點 **Cardiovascular**...

(How assessment?) Hypertension (Why) you want to test it (identify) normal and abnormal 這份有所有老師說的話了。 不用去看之前錯的quiz，因為那些都是解剖的問題 把所有abnormal寫 how do you test that, how I find out if abnormal, and how I test. 大寫都特別重要、粗體 點圖的地點 **Cardiovascular** - Anatomy of Heart - IVC/SVC (deoxygenated) → RA → TRICUSPID v → RV → PULMONIC v → PA → lungs (oxygendated) → LA → MITRAL v → LV → AORTIC v → AORTA - Systole - Ventricles contract - Diastole - ventricles relax - Chest pain symptoms - Myocardial ischemia - lack of blood flow to muscle of heart - Stable angina, unstable, variant, MI - Cardiac not by ischemia (not related to blood flow of heart) - Mitral valve prolapse, pericarditis, dissecting aneurysm - PULMONARY causes - Pulmonary embolism, pleurisy, pulmonary HTN, pneumothorax - GI causes - Esophageal spasm, esophogeal reflux (acid reflux) - Dyspnea - shortness of breath - **Orthopnea - dyspnea immediately after pt lies down** - Nocturnal dyspnea -dyspnea after lying down for several minutes or hours - Palpitations - skipped, extra, or irregular heartbeat - Syncope - rapid onset, transient loss of consciousness (blackout/fainting) - Vasovagal - Edema - Cyanosis - Fatigue - Cardiac cause - more fatigue in the evening - Hemoptysis - General order of physical exam - General appearance - Blood pressure - Neck vessels - Precordium (inspect, palpate, auscultate) - Blood pressure (KNOW) - SBP - HEART IS AT WORK (ventricles contract) - Pressure generated by LV ejecting blood into arterial tree - DBP - HEART IS AT REST (ventricles relax) - Pressure generated by blood remaining in arterial tree - Orthostatic hypotension (KNOW) - Drop in SBP \> 20mmHg or DBP \>10mmHg within 3min of standing up - **Take orthostatic readings of pulse and BP when** - **Suspect volume depletion** - **Taking hypertensive meds** - **Reports fainting** - How to take: - Rest supine for 3min, take baseline readings of pulse and BP, repeat with person sitting and then standing - Palpate carotid arteries - One at a time - Grade (+1 weak, +2 normal, +3 full, +4 bounding) - Inspect Neck - Note any distention of jugular vein - **Estimate jugular venous pressure** - Pt's head elevated to 30 deg and head turned to left (right side= bestused - Create 90 deg angle with rulers from oscillation point and the angle of louis - JVP - expressed as vertical height (cm) of column of blood (the head) in relation to sternal angle (angle of louis) or add 5cm to make in relation to right atrium → this number represents hydrostatic pressure within right atrium - HEALTHY - 2-3cm H2O above sternal angle or 6-8 H2) in relation to right atrium - CENTRAL VENOUS PRESSURE = VENOUS PRESSURE IN RIGHT ATRIUM - Inspect and palpate precordium - Inspect anterior chest for visible HEAVES (pulsations/lifts - heart pounding on chest wall) - may/may not see apical impulse at 4th-5th intercostal space midclavicular line - Created when left ventricle rotates against the chest wall during systole - Palpate the general precordium with the palmar aspect of hand in all auscultatory areas for: - THRILLS (**FELT WITH LOUD MURMURS) -** vibrations on chest wall - Assess point of maximal impulse (PMI) - Using finger pads, palpate **apex (bottom of heart)** for PMI - Note: - Amplitude - short gentle tap - Duration - short, first half of systole - Left ventricular DILATION (volume overload, like CHF) PMI will be - Displaced down and to left - Increased size - more than one intercostal space - Left ventricular HYPERTROPHY (pressure overload) PMI will be - Increased FORCE and DURATION but no change in location - Percussion - Begin at axillary line at 5th intercostal space and move medially until you reach DULLNESS. Also resonance over lungs, then cardiac DULLNESS at heart - Auscultatory areas - 5 areas "APE To Man" - Aortic (2nd intercostal space sternal border) - Pulmonic (2nd intercostal space SB) - erb's point (3rd intercostal space SB) - Tricuspid (5th intercostal SB) - Mitral (5th intercostal at midclavicular line) - DIAPHRAGM - high-pitched sounds - S1, S2 - Most murmurs - BELL - low pitched sounds - S3, S4 - Rumble of mitral stenosis - **Pt sits/leans forward** - brings heart closer to chest wall - DIAPHRAGM at A and P for murmurs and friction rub - Supine position - Listen to all 5 with DIAPHRAGM - Identify S1 (apex) and S2 (base) - Note rate and rhythm and ANY MURMURS - Listen to all 5 with BELL - S3, S4 - LEFT LATERAL DECUBITUS - Listen in mitral with BELL for S3, S4 or murmur of mitral stenosis - When pt lies on left side, mitral valve is closest to chest wall - NORMAL SOUNDS - **S1** - **LOUDEST IN APEX** - Coincides with carotid artery pulse and R wave on ECG - **Sound = closure of AV valves** (mitral and tricuspid) - LUB - dub - **S2** - **LOUDER AT BASE** - **Sound = closure of semilunar valves** (aortic and pulmonic valves) - Hear lub - DUB - ABNORMAL SOUNDS - S3 - ventricular gallop - CAUSED BY: blood from LA slamming into already overfilled ventricle during early diastolic - Blood SLOSHES INto already filled ventricle - Occurs in EARLY DIASTOLE - during rapid filling phase. Heard just after S2 ("slosh -- ing -- IN") - S1 - S2 - S3 - Might be EARLIEST PHYSICAL SIGN OF HF - S4 - atrial gallop - CAUSED BY: blood try to enter a stiff, noncompliant left ventricle during atrial contraction - Heard IMMEDIATELY BEFORE S1 (A - stiff - wall) - S3 - S1 - S2 - Associated with LV HYPERTROPHY → results in HTN - clicks/snaps/other extra heart sounds - EARLY systolic click (aortic) - Aortic stenosis - Pulmonic stenosis - aortic/pulmonic valve leaflets "pop" under pressure - Usually before murmur - MID systolic click (aortic) - Mitral regurgitaion - Mitral valve prolapse, leaflets are loose - CAUSED BY: overstretched flaps snapping aginst each other other during contraction - Usually before murmur - Snap (DIASTOLIC) mitral stenosis - Normally opening of AV valves = silent - Mitral valve stenosis - hear an opening snap - SHARP AND HIGH PITCHED - Heard best with DIAPHRAGM at APEX - MURMURS - blowing/whooshing sound (turbulent blood flow) - Almost always pathological - TIMING - are they systolic or diastolic - LOCATION - apex, base, sternal border - SHAPE - plateau, crescendo, decrescendo/ both (diamondshape) - GRADE & INTENSITY - garde on cale of 1-6 - Pitch - high, med, low - Quality - harsh, musical, soft, blowing, rumbling - RADIATION - to neck - POSITION OF PT - standing, sitting, squatting - - Timing - S1 -- S2 -- S1 -- S2 - If it's between S1 and S2 = systolic (bc S1 is ventricular contraction) - If it's between S2 and S1 = diastolic (bc S2 is ventricular relaxation) - Duration - S1 -- S2 -- S1 -- S2 - Pansystolic (holosystolic) - last from end of S1 to beginning of S2 - Pandiastolic (holodiastolic) - lasts from end of S2 to beginning of S1 - IF IT LASTS THE WHOLE GAP = PAN - Shape - shape of volume change - Crescendo - low to high volume - Decrescendo - high to low volume - Both - crescendo → decrescendo (DIAMOND SHAPE) - Is also PAN because lasts the whole gap - Plateau - PAN same volume - Grade - 1/6 - softer in volume than S1/S2, VERY FAINT - 2/6 - EQUAL in volume to S1/S2, HEARD IMMEDIATELY - 3/6 - LOUDER than S1/S2, MODERATELY LOUD - 4/6 - LOUDER than S1/S2 with PALPABLE THRILL - 5/6 - LOUDER than S1/S2 with PALPABLE THRILL (could be heard with stethoscope PARTIALLY on skin) - 6/6 - LOUDER than S1/S2 with PALPABLE THRILL (could be heard with stethoscope OFF skin) - **Grades 4 - 6 HAVE PALPABLE THRILLS** - Structural changes - Normal valve - one way - Stenotic valve - STIFF hard to get blood through - Incompetent valve - PROLAPSED, BACKFLOW - Regurgitation - backflow - Abnormal opening - Types of murmurs (BE ABLE TO ID MURMUR CHARACTERISTICS) - S1 -- S2 -- S1 -- S2 - SYSTOLIC - MIDSYSTOLIC ejection murmur - Aortic and pulmonic STENOSIS - G:\\Q27153.wbs\\jpgs\\tables jpeg\\found\\17u30.jpg - PANSYSTOLIC regurgitant murmur - Mitral and tricuspid REGURGITATION -  - DIASTOLIC - Diastolic rumbles of AV valve - Mitral and tricuspid STENOSIS - G:\\Q27153.wbs\\jpgs\\tables jpeg\\found\\17u36.JPG - Early diastolic murmur - Aortic and pulmonic REGURGITATION -  - Extra cardiac sounds - Pericardial friction rub - rubbing sound every time heart beats - Inflammation in sac around heart - Developmental considerations - fetal/newborn heart - Ductus venous - shunts blood away from the lungs bc fetus is not breathing in womb - Acrocyanosis in infant is normal - Auscultation of pediatric heart - PMI = 4TH intercostal space - Auscultate child in sitting and reclining position - If adventitious sounds are detected - evaluate child stranding, sitting, leaning forward, lying on left side **Peripheral/Vascular** - ARMS - Artery = higher pressure system. Veins = lower pressure system - inspect/palpate - size/symmetry/swelling - Skin (color, temp, texture) - ABNORMAL: - Pallor - white skin → RAYNAUD'S (white hands) - erythema/swelling - due to blood back up (DVT, infections) - Cyanosis - Profile sign (CLUBBING) - Normal finger \ 180 (decreased oxygen levels over tiem - CAPILLARY REFILL - Normal: \ - Reinforcement - Pt locks fingers and pulls arms while you test DTRs - DTRs - Biceps - Triceps - Brachioradialis - Quadricep - Achilles - Clonus - Superficial - Abdominal - Cremasteric plantar - Arm reflexes - Biceps - Contraction of bicep and flexion of forearm - Triceps - Extension of forearm - Brachioradialis - Flexion and supination of the forearm - Leg reflexes - Quadriceps - Extension of knee and palpable contraction of quadricep - Achilles - Foot plantar flexion - Plantar (Babinski) Reflex - Use handle to swipe upward in \"L\" shape - Toes should flex, curl under - Testing for clonus - Pt lying flat in bed - Support lower leg in one hand - Use other hand to move foot up and down - Then let go - Normal: motion should stop - If pt has clonus, foot will continue moving **Pediatrics** - Normal changes in pediatric vital signs as they move from infancy to adolescence - Older you get: - HR and RR DECREASE - BP INCREASE - RR DECREASE - Blood pressure norms - Newborn - 6months: 65-90 / 45-65 - 6month - 3yrs: 80-105 / 55-70 - 4 - 12yrs: 95-120 / 60-75 - Over 12yrs: 110-120 / 65-85 - Correct method for taking pediatrics vital signs - Temperature - Infant: axillary and oral choice - NORMAL RANGE 97.9-99 (36.6-37.2) - Heart Rate - APICAL PULSE - neonates, infants, young children, and all children with cardiac problems - Listen for FULL MINUTE. NO EXCEPTIONS - Warm stethoscope with hands and place directly on skin - Children UP TO 7YRS - 4TH INTERCOSTAL - Children OVER 7yrs - 5th intercostal - Reparations - Place hand on chest/abdomen and observe full respirations for ONE FULL MINUTE - Children UP TO 7YRS - DIAPHRAGMATIC - Children OVER 7yrs - THORACIC - Blood pressure - FOR CHILDREN OVER 3YR - Right arm - Cuff should be 40% of arm circumference - INFANTS - taken on leg and young children - Understand progression of Tanner stages - Tanner stages used to assess for premature puberty - Change from normal could be a tumor - Stage 1. Preadolescent: - Male and female: NO SEXUAL HAIR - Stage 2. Downy hair - Male: sparse, pigmented, long, straight, mainly along labia and at base of penis - Female: breast budding - Stage 3: scant terminal hair - Male: darker, coarser, curlier hair - Female: continued enlargement - Stage 4: terminal hair that fills entire triangle overlying pubic region - Male: adult, but decreased distribution - Female: areola and papilla form secondary mound - Stage 5: terminal hair that extends beyond the inguinal crease onto the thigh - Male: adult in quantity and type with spread to medial thighs - Female: mature female breast - Normal findings in a newborn (benign cyanosis) vs what constitutes as abnormal and represents central cyanosis - NORMAL: - Acrocyanosis - cyanosis in extremities (palms of hands, soles of feet), around lips BUT NOT TONGUE OR MUCOUS MEMBRANE - Resolves when they're warmed up - ABNORMAL: - Central cyanosis - MOUTH, HEAD, TORSO cyanosis - Linked with lower amount of oxygen in blood - At what age does each fontanel close by - **Anterior fontanelle -** closes in ABOUT 18 MONTHS - **Posterior fontanelle -** CLOSES between 2-3 MONTHS (6-8wks) - Differences in the assessment of the adult ear vs the pediatric ear - PEDIATRIC - Pull DOWN AND BACK - Understand at what ages patients are obligatory abdominal breathers vs thoracic breathers - Abdominal breathers until 6-7yrs, then becomes thoracic - Infants are obligate nose breathers - Correct place to palpate the PMI of children under 4 and above age 4 - UNDER 4 - 4th intercostal space - OVER 4 - 5th intercostal space - Know all the different types of assessments/tests for hip dysplasia of the newborn, including the names, how to perform, and what a positive test is/means. - Ortolani test - Attempt to reduce a dislocated hip. Lift the GT and ABDUCT a hip - Positive test - femoral head slips into the socket with a palpable CLUNK - Most likely positive in 1-2 months of age - Barlow's test - Attempt to dislocate. Hip is ADDUCTED, gentle push to slide hip POSTERIOR, thumb medially, apply a posterolateral force - Positive test - hip felt to slide out of acetabulum - Once force stopped, the hip slides back - Galeazzi sign - Flex legs, bend knees, check if knees are level - Unequal skin folds - Unequal skin folds → the folds that are lower = hip dislocated - Name and describe test to evaluate for scoliosis - Scoliosis - spinal deformity of lateral curvature and rotation of vertebrate in spine greater than 10 deg - Adams bend forward test - Bend forward, extend arms, pray - Use scoliometer and place on hump - Degree 7 or higher = more evaluation - Screening tool - Hip disease - trendelenburg sign - Pelvis tilts toward unaffected hip when weight is borne on affected side - Causes: weakness of hip abductors due to superior gluteus nerve palsy, Legg-Calve Perthes Disease and congenital hip dysplagia - Gait - observe standing and walking barefoot from front and behind - Leg length discrepancy - may accompany hip disease - Normal infant vs adult thorax - INFANT - anterior/posterior EQUAL to transverse diameter - Chest circumference EQUAL to head circumference until 1yr - Respiratory distress - TACHYPNEA first sign, nasal flaring/grunting - Breath sounds - louder in CHILDREN bc of thin chest walls - Normal infant plantar reflex (Babinski) - Babinski - dorsiflexion of great toe, fanning of other toes - Disappears by 12-18 months - Moro - disappears by 4 months - Normal vs abnormal findings when inspecting/assessing the newborn abdomen - Inspection of INFANT ABDOMEN - Shape: - NORMAL: - Infants and young children have less well developed muscles → abdomen more ROUND and protuberant - Children up to 4 → potbellied appearance while supine/standing due to lordosis of spine - ABNORMAL - Distended - intestinal obstruction/organomegaly/ascites - Scaphoid - malnutrition/displaced abdominal organs - PAIN - face grimace, high pitch cry, inability console, knees up to chest → CHECK HYDRATION STATUS - Umbilicus - NORMAL: - Umbilical hernia - failure of abdominal wall to completely close. DOESN'T REQUIRE SURGERY - usually detach by 10th day -3 wks - KEEP STUMP CLEAN to prevent infection - Diastasis recti - caused by weakness of fascia between rectus abdominal muscles - HEALS ON OWN - Due to intrabdominal pressure - Abnormal: - Pyloric Stenosis - thickening/swelling of pyloris - Doesn't allow poop to empty out of stomach - Symptoms: VOMITING, small mass after vomiting in upper abdomen. ABLE TO PALPATE - Intussusception - Portion of small and large intestine MEET and one slips inside the other - Symptoms: sausage shaped mass palpated in RUQ, vomiting, current jelly stools - EMERGENCY - air enema/surgery **Genitalia** - Menstrual hx - Ask ab age of menarche (when first menses started) - US → age 9-16 - Ask ab menstruation patterns - How often does pt have menses (NORMAL: every 24-32 days) - How long are menses (NORMAL: 3-7 days) - How heavy are the menses? (\# of pads/tampons is an indicator) - If applicable, at what age did menopause occur - Menopause = no menses for 12 months - US average = 51 years old - May have more frequent periods leading up to menopause - Hysterectomy: uterus removed, BUT may still have hormone fluctuations - Salpingo-oophorectomy: fallopian tubes and ovaries removed, then menopause occurred at that time - Physical exam - AFAB - inspect external genitalia - Inspect the pt's external genitalia - Mons pubis - Labia majora and minora - Clitoris - Urethral meatus - Introitus - Perineum - Note any inflammation, discharge, swelling or nodules; palpate any lesions - Typically not done by RN - Pt has emptied bladder - Pt is in lithotomy position - Be mindful of language, "relax the knees" rather than "open the legs" - Can provide a mirror for pt to watch exam - Groin is common place for sebaceous cyst, folliculitis - AMAB - inspect and palpate external genitalia - Inspection of skin, hair, corona - Phimosis - narrowed opening of prepuce, foreskin cannot retract - Paraphimosis - painful constriction of glans by retracted foreskin - Both may be uncomfortable for uncircumcised males - Important to replace the foreskin back to original position after inserting catheter - Can cut off blood flow - Base of penis, hair distribution follows Tanner stages, no inhabitants - Dorsal vein might be apparent = normal - Ask pt to retract foreskin for you to inspect - Inspection of urethra - Note the location of the urethral meatus - Hypospadias - ventral location of meatus - Epispadias - dorsal location of meatus - Should be midline, smooth without discharge, should not be red inside - Discharge may indicate chlamydia or gonorrhea (take a sample for testing) - Compress the gland gently between your index finger above and thumb below to open the urethral meatus and allow inspection for discharge (normally there is none) - Palpation of scrotum and testes - Ask pt to hold the penis up - lift the scrotum to inspect the posterior aspect - should be no lesions aside from occasional sebaceous cyst - Palpate each testis and epididymis - note size, shape, consistency, and tenderness; feel for any nodules - Epididymis is a soft, nodular, cordlike structure at the back of the testicle - Palpate each spermatic cord - note nodules or swelling - Abnormals - **Varicocele** - **Dilated tortuous internal spermatic veins; varicose veins caused by incompetent valves; can cause impotence** - Pt can feel aching, uncomfortable - Feels like a bag of worms around testis - Dx by ultrasound - 15% of males develop this by age 15 - - Testicular torsion - Excruciating unilateral pain, usually sudden onset - May alos have lower abdominal pain and nausea/vomiting with no fever - Can happen while sleeping or usually due to direct trauma - Scrotom us red and swollen, one testis is higher than the other due to rotation and shortening - Cord feels thick and the epididymis may be anterior - EMERGENCY - Rare after age 30 - Twisting cuts off blood flow, twisted testicle can become gangrenous within hours - Testicular cancer - Firm, painless lump associative swelling found on exam -- may have family hx - Usually a solitary mass - Most cancers occur between ages 18-35 - Most common in white AMAB - Undescended testis (even if surgically corrected) is a known risk factor - Single painless lump on testicle = more likely cancer - Hernias - Inspection - Sit comfortably in front of standing pt - Note any areas of bulging or asymmetry - Ask pt to strain and bear down, making it easier to detect any hernias - Palpation - Inguinal and femoral hernias - Use forefinger to locate inguinal canal, insert finger into canal - Have pt cough - Common if job has a lot of heavy lifting or pt does CrossFit, lots of lifting motions - Rectum - Perianal inspection - Skin - Anal opening - Anus looks MOIST, with coarse folded skin that is more pigmented than the perianal skin - The anal opening tightly closed -- no leakage - No lesions/masses - Palpate - Gently place index finger in anus; palpate for hemorrhoids and masses - If needed, check for occult blood with hemoccult test - Always ask pt to get dressed before discussion findings - Prostate - AMAB - First prostate exam by age 50 - During rectal exam -- find median sulcus and palpate the entire prostate in a fan like motion - Only palpable parts are posterior and part to the lateral portion - Press lightly into gland on each side -- note nodules or abnormal enlargement/tenderness - NORMAL - 2.5CMX4CM, should not protrude more than 1 cm into the rectum - Heart shaped with palpable grove - Smooth, elastic and rubbery - Slightly mobile and nontender - Consistency: sponge like, not too hard or boggy - ABNORMAL - Prostatitis - fever/chills, malaise, urinary frequency - Tender, enlarged prostate with dull perineal/rectal aching - Benign prostatic hypertrophy (BPH) - Urinary frequency, urgency, hesitancy (difficult to initiate stream of urine) - Symmetric, nontender, enlargement - Pt is MIDDLE AGED - Prostate feels smooth, rubbery, firm with median sulcus obliterated due to swelling - Prostate cancer - Frequency, nocturia, weak stream, hematuria, hesitancy, pain or burning with urination - Continuous pain in the lower back/pelvis - Usually starts as a single hard nodule on the posterior surface (producing asymmetry on exam) and change in prostate consistency - As cancer progresses, there are multiple hard nodules or the entire gland can feel like a stone - Median sulcus is obliterated - Usually slow growing and treatable - Prostate cancer risk - Age - AFTER AGE 50 - More than 60 dx after 65 - Family hx - Ethnicity - Black/african american most common - Lifestyle - Overweight, high fat diet, do not exercise regularly