physical exam final written exam study guide 2

5/26/2018 Physical Exam Final Written Exam Study Guide 2

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1. Describe the steps to properly transition from the patient interview to the physical exam.

2. Describe how to perform proper hand washing technique.

Cant find anything in the book yet (so definitely change it if this is wrong), but at the OSCE Dr. Chen said to:

1. Roll down the paper towel

2. Wash hands (not sure about a specific time / method)

3. Grab paper towel to dry hands

4. Use paper towel to turn off sink

3. Explain the proper technique for taking a blood pressure.

Setup:

- Avoid smoking or caffeine for 30 min prior

- Quiet and comfortably warm room

- Sit quietly in chair for 5 min with arm supported at heart level

- Arm free of clothing with no fistulas

- Palpate brachial artery

- Position antecubital crease at arm level

Procedure

- Center cuff over brachial artery with lower border 2.5 cm above antecubital crease

- Secure cuff snugly and slightly flex arm

- First estimate systolic by palpation with radial artery inflate cuff until radial disappears, then add 30 mm Hg

Helps avoid auscultatory gap(silent interval that may be present between sp and dp)- Deflate cuff, wait 15-30 s

- Place BELL over brachial (Korotkoff sounds are low-pitched)

- Inflate cuff to determined level, then deflate 2-3 mmHg/s

- Note the level when beats start (systolic)

- Lower until sounds are muffled and disappear (dp)

Read table on pg. 115 until the end of BP instructions on p.117. In addition, this is what I have down from small

group:

1. Place BP cuff around arm with label artery facing down into cubital fossa

2. Feel for pulse with right hand and pump cuff with left hand while listening to pulse

3. Pump up to 30 mmHg above loss of pulse

4. Slowly release pressure while looking at meter to note the first measurement at which pulse returns. This is

their systolic pressure.

5. Continue to release pressure and on the way down listen to pulse until the last beat. The pressure at which the

pulse is lost is their diastolic pressure.

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4. Identify common potential errors of blood pressure measurement.

- If brachial artery 7-8 cm below heart level, bp will read 6 cm higher

- If brachial artery 6-7 cm higher, bp will read 5 cm lower

- If cuff is too SMALL, bp reads HIGH

- If cuff is too LARGE, bp reads LOW ON SMALL ARM and HIGH ON LARGE ARM

- Avoid slow or repetitive inflations of cuff (venous congestion can cause false readings)

- If sounds are faint, consider erroneous placement of scope, failure to make full skin contact with bell, venous

engorgement, or shock

5. Recognize the normal and abnormal ranges of a blood pressure for an adult.

Category Systolic Diastolic

Normal standing

- Abnormal: systolic drops 20 mmHg or diastolic drops 10 within 3 minutes standing

- Orthostatic hypotension fall in systolic 20, especially accompanied by tachycardia (p. 119)

7. Explain the proper technique for taking a respiratory rate.

- Count the # of respirations in 1 minute either by visual inspection or subtly listening over trachea with stethoscope

during HEENT or chest exam

- Normal = 20 breaths/min (p. 119)

8. Recognize the normal and abnormal ranges of a respiratory rate for an adult. Define tachypnea.

9. Explain the different methods for taking a temperature.

- Oral temp = 37 C or 98.6 F

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- Rectal = higher by .4-.5 C or .7-.9 F, axillary = lower by 1 degree

- Oral temperature shake glass thermometer down to 35C/96F or below, insert under tongue, tell patient to

close both lips, and wait 3-5 min. Then read, reinsert for 1 min, and read it again. Repeat until temp is stable. Hot or

cold liquids and smoking can alter temp

- Electronic temp place disposable cover over probe and insert under tongue, ask patient to close both lips.

Usually takes 10 s

- Rectal temp ask pt to lie on one side with hip flexed, insert 3-4 cm into anal canal pointing toward umbilicus.

Remove after 3 min. If using electronic therm, lubricate probe and wait 10 s for reading

- Tympanic membrane temp make sure canal is clean of cerumen which can lower reading. Aim infrared

beam at tympanic membrane, wait 2-3 s. Higher than normal body temp by about 0.8 C (1.4 F). More variable than

other measurements.

10. Explain the proper technique for taking a pulse.

- Use pads of index and middle fingers and compress radial artery until a max pulsation detected

- If regular rhythm, count for 30 s and multiply by 2

- If unusual or slow rate, count for 60 s

- Normal = 50-90 bpm

11. Recognize the normal and abnormal ranges of a pulse for adults. Define bradycardia and tachycardia.

Sinus bradycardia:


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17. Demonstrate proper handwashing technique and perform measurement of the vital signs.

18. Demonstrate the assessment of visual acuity and visual fields by confrontation.

Purpose of testing visual acuityis to assess any deviation from normal vision

1. Use a Snellen eye chart

2. Position patient 20 feet from chart

3. Patients who use glasses other than for reading should put them on

4. Ask patient to cover one eye with a card and read the smallest line of print possible (encourage patient to

attempt the next line)

5. A patient who cannot read the largest letter should be positioned closer to the chart; the intervening distance

should be noted

6. Determine the smallest line of print from which the patient can identify more than half the letters

7. Record the visual acuity designated at the side of this line, along with the use of glasses, if any

8. Visual acuity is expressed as two numbers (ex: 20/40) the first number indicates the distance of thepatient from the chart; the second number indicates the distance at which a normal eye can read the line of

letters

Purpose of testing visual fieldsby confrontation is to assess any deviation from normal boundaries

1. Imagine the patients visual fields projected onto a bowl that encircles the front of the patients head

2. Ask the patient to look with both eyes into your eyes

3. While you return the patients gaze, place your hands about 2 feet apart, lateral to the patients ears

4. Instruct the patient to point to your fingers as soon as they are seen

5. Then slowly move the wiggling fingers of both your hands along the imaginary bowl and toward the line of

gaze until the patient identifies them

6. Repeat this pattern in the upper and lower temporal quadrants7. Usually a person sees both sets of fingers at the same time; if so, fields are usually normal

19. Define pupillary reactions.

Pupillary reactions: pupillary size changes in response to light and to the effort of focusing on a near object.

Sensory pathway: retina --> optic nerve --> optic tract --> midbrain --> impulses transmitted through the

oculomotor nerve --> constrictor muscles of the iris of each eye

a. Ask patient to look into the distance, and shine a bright light obliquely into each pupil in turn (darken the room if

necessary); look for:

b. Direct reaction (pupillary constriction in the same eye)

c. Consensual reaction (pupillary constriction in the opposite eye)

If the reaction to light is impaired or questionable, test the near reaction in normal room light (test one eye at a

time)

a. Hold your finger about 10 cm from the patients eye

b. Ask the patient to look alternately at it and into the distance directly behind it

c. Watch for pupillary constriction with near effort

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d. Coincident with this constriction, but not part of it, are convergence of the eyes and accommodation, or an increased

convexity of the lens

20. Demonstrate the assessment of visual fields and describe the abnormalities of horizontal defect, blind right eye,

homonymous hemianopsias, bitemporal hemaianopsia, and homonymous quadrantopsias.

21. Identify and describe the actions of the 6 muscles involved with extraocular movements.

Techniques to examine:

1. Ask the patient to follow your finger as you sweep through the six cardinal direction of gaze

2. Making a wide H in the air, lead the patients gaze (1) to the patients extreme right, (2) to the right and upward,

(3) down on the right; then (4) without pausing in the middle, to the extreme left, (5) to the left and upward, and

(6) down on the left

3. Pause during upward and lateral gaze to detect nystagmus

22. Recognize the different abnormal extraocular movements including dysconjugate gaze, nystagmus, and lid lag.

23. Explain how to properly use the ophthalmoscope.

24. Describe the different parts of the normal fundoscopic exam.

25. Identify the anatomy/common structures in the head region which are routinely assessed on the physical exam

including: eye, external ear, nose, sinuses, mouth, and throat

26. Describe the proper techniques for examining the nose and sinuses.

27. Identify the normal landmarks of the tympanic membrane.

28. Explain and demonstrate the proper way to use the otoscope.

29. Describe how to perform the auditory acuity test.

30. Explain the Weber and Rinne tests, and how they are used to distinguish between conduction hearing loss and

sensorineural hearing loss.

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1. Identify the anatomy of the neck and lymph nodes.

For descriptive purposes, divide each side of the neck into two triangles bound by the SCM. This gives you

the anterior and posterior triangles. Deep to the SCM run the carotid artery and internal jugular vein. The external

jugular vein passes diagonally over the surface of the SCM. In the midline, be able to identify the mobile hyoid bone

just below the mandible, the thyroid cartilage (Adams apple), cricoid cartilage, tracheal rings, and thyroid gland. For

lymph nodes, see the picture in the text but be able to identify tonsillar, supraclavicular, submandibular and

submental lymph nodes.

2. Describe normal findings of the neck, lymph nodes, trachea, and thyroid gland.

Inspect the neck, noting its symmetry and any masses or scars. Look for enlargement of the parotid or

submandibular glands, and note any visible lymph nodes. Palpate the lymph nodes. Using the pads of the 2nd and

3rd fingers, palpate the lymph nodes with a gentle rotary motion. The patient should be relaxed, with neck flexed

slightly forward and, if needed, slightly toward the side being examined. You can usually examine both sides at once.

(For the submental node, it is helpful to feel with one hand while bracing the top of the head with the other.) Feel in

sequence for the following lymph nodes: preauricular, posterior auricular, occipital, tonsillar, submandibular,

submental, superficial cervical, posterior cervical, deep cervical chain, supraclavicular. Note their size, shape,

delimitation (discrete or matted together), mobility, consistency, and any tenderness. Small, mobile, discrete,

nontender nodes, sometimes termed shotty, are frequently found in normal persons. Enlarged or tender nodes, if

unexplained, call for reexamination of the regions they drain, and careful assessment of lymph nodes elsewhere so

that you can distinguish between regional and generalized lymphadenopathy. Occasionally you may mistake a band

of muscle or an artery for a lymph node. You should be able to roll a node in two directions: up and down, and side to

side. Neither a muscle nor an artery will pass this test.

3. Describe and demonstrate the steps for palpating the thyroid gland.a. Find landmarks

i. Notched thyroid cartilage and the cricoid cartilage

ii. Locate the thyroid isthmus (over the 2nd, 3rd, 4th tracheal rings)

b. Steps for palpation (posterior approach)

i. Ask the patient to flex the neck slightly forward to relax the sternomastoid muscles

ii. Place the fingers of both hands on the patients neck so that your index fingers are just

below the cricoid cartilage

iii. Ask the patient to sip/swallow water as before. Feel for the thyroid isthmus rising up under your

finger pads (often palpable)

iv. Displace the trachea to the right with the fingers of the left hand, with the right hand fingers,

palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and

the relaxed sternomastoid. Find the lateral margin. In a similar fashion, examine the left lobe. The lobes aresomewhat harder to feel than the isthmus, so practice is needed.

v. Note the size shape and consistency of the gland and identify any nodules or tenderness.

vi. If thyroid gland is enlarged, listen to the lateral lobes to detect a bruit

4. Identify landmarks and anatomic correlations of the lung and thorax.

The sternal angle is adjacent to the 2nd rib and costal cartilage. This is the level at which the trachea

bifurcates.

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The inferior tip of the scapula is at the level of the 7th rib

The oblique fissure of the lung can be approximated by a string that runs from the T3 spinous process

around the chest to the 6th rib to the midclavicular line

The horizontal fissure runs close to the 4th rib and meets the oblique fissure midaxillary near the 5th rib

The lower border of the lung crosses the midclavicular line at the 6th rib, the 8th rib midaxillary, and

posteriorly at the border of T10

5. Describe the mechanisms of inspiration and expiration.

During inspiration: the diaphragm contracts, the thorax expands, and this decreases intrapleural pressure -

draws air into the alveoli and expands the lungs

Oxygen goes into the capillaries, Carbon Dioxide goes from the blood into the alveoli

As inspiratory efforts stop, chest wall recoils, diaphragm relaxes and rises passively, decreasing thoracic

volume - air flows outward

6. List and describe the common symptoms of the thorax and lung.

Common or concerning symptoms: chest pain, dyspnea, wheezing, cough, blood-streaked sputum

(hemoptysis). Complaints of chest pain or chest discomfort raise the specter of heart disease, but often arise from

structures in the thorax and lung as well. Sources of chest pain are the myocardium, pericardium, aorta, trachea and

large bronchi, parietal pleura, musculoskeletal system and skin of chest well, esophagus, and extrathoracic

structures such as the neck, gallbladder, and stomach. A clenched fist over the sternum suggests angina pectoris; a

finger pointing to a tender area on the chest wall suggests musculoskeletal pain; a hand moving from neck to

epigastrum suggests heartburn. Anxiety is the most frequent cause of chest pain in children. Dyspnea is a nonpainful

but uncomfortable awareness of breathing that is inappropriate to the level of exertion. Anxious patients may haveepisodic dyspnea during both rest and exercise, and hyperventilation, or rapid, shallow breathing. At other times, they

may have frequent sighs. Wheezes are musical respiratory sounds that may be audible to the patient and to others.

Wheezing suggests partial airway obstruction from secretions, tissue inflammation, or a foreign body. Cough is a

common symptom that ranges in significance from trivial to ominous. Typically cough is a reflex response to stimuli

that irritate receptors in the larynx, trachea, or large bronchi. Although cough typically signals a problem in the

respiratory tract, it may also be cardiovascular in origin. Cough can be a symptom of left-sided heart failure. In

Mycoplasma pneumoinia there is a dry hacking cough; there is a productive cough in bronchitis, viral or bacterial

pneumonia. Mucoid sputum is translucent, white or gray; purulent sputum is yellowish or greenish. Foul-smelling

sputum is anaerobic lung abscess; tenacious sputum occurs in cystic fibrosis. Hemoptysis is the coughing up of

blood from the lungs; it may vary from blood-streaked phlegm to frank blood. Try to confirm the source of thebleeding. Blood or blood-streaked material may originate in the mouth, pharynx, or GI tract. Blood originating in the

stomach is usually darker than blood from the respiratory tract and may be mixed with food particles.

7. Describe what inspection can detect.

From a midline position behind the patient, note the shape of the chest and the way in which it moves,

including: deformities or assymetry, abnormal retraction of the interspaces during inspiration (retraction is most

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apparent in the lower interspaces, supraclavicular retraction is often present, retraction occurs in severe asthma,

COPD, or upper airway obstruction), impaired respiratory movement on one or both sides or a unilateral lag in

movement. Unilateral impairment or lagging of respiratory movements suggests disease of the underlying lung or

pleura.

For the anterior chest, observe the shape of the patients chest and the movement of the chest wall. Look

for deformities or asymmetry, abnormal retraction of the lower interspaces during inspiration (due to severe asthma,

COPD, or upper airway obstruction), and local lag or impairment in respiratory movement (underlying disease of lung

or pleura).

See Table with pictures of barrel chest (COPD), traumatic flail chest (multiple rib fractures), funnel chest

(pectus excavatum, what I, Yoni Litwok has), pigeon chest (pectus carinatum, opposite of what I have, sternum sticks

out), and thoracic kyphoscoliosis (abnormal spinal curvatures and vertebral rotation).

8. List and describe normal and the different deformities of the thorax.

a. Chest pain

i. Thoracic and cardiac causes

ii. Keep in mind the myocardium, pericardium, aorta, trachea/large bronchi, parietal pleura,

chest wall (including musculoskeletal system and skin), esophagus, extrathoracic structures

such as the neck, gallbladder and stomach

b. Shortness of breath (Dyspnea) and wheezing

i. Dyspnea = nonpainful but uncomfortable awareness of breathing that is inappropriate for

the level of exertion (shortness of breath)

1. Cardiac or pulmonary disease

ii. Wheezes musical respiratory sounds that may be audible to the patient and to others

c. Cough

i. Reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi

ii. Stimuli include mucus, pus, and blood as well as external agents such as dust, foreign

bodies, or even extremely hot or cold air

iii. Inflammation of the respiratory mucosa and pressure/tension in the air passages from a

tumor or enlarged peribronchial lymph nodes

iv. Cough typically is for a problem in the respiratory tract (it may also be cardiovascular in

origin.

v. Dry? Sputum? Phlegm?

d. Hemoptysis

i. Coughing up of blood from the lungs

1. Be careful b/c blood can come from mouth, pharynx, GI tract and can be mislabeled

9. Describe what palpation can detect and how to perform these maneuvers.

For posterior wall: identify tender areas, assess any observed abnormalities such as masses or sinus tracts, testchest expansion, feel for tactile fremitus, and palpate and compare symmetric areas of the lungs. To test chest

expansion ask the patient to inhale deeply as your thumbs are placed at the level of the 10th ribs and your fingers on

the lateral rib cage. Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the

chest wall when the patient speaks. To detect fremitus, use either the ball or the ulnar surface of your hand to

optimize the vibratory sensitivity of the bones in your hand. Ask the patient to repeat the words ninety-nine or one-

to-one.

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For anterior chest: identify tender areas, assessment of observed abnormalities, further assessment of chest

expansion and assessment of tactile fremitus.

See pic for locations of where to feel fremitus. Fremitus is decreased or absent when the voice is soft or when the

transmission of vibrations from the larynx to the surface of the chest is impeded. Causes include an obstructed

bronchus; COPD; separation of the pleural surfaces by fluid, fibrosis, air, or an infiltrating tumor; and a very thick

chest wall.

10. Describe what percussion can detect, and what each percussion note implies and how to perform the technique.

Percussion helps you establish whether the underlying tissues are air-filled, fluid-filled, or solid.

Intensity Pitch Duration Location Pathologic

examples

Flatness Soft High Short Thigh Large pleural

effusion

Dullness Medium Medium Medium Liver Lobar pneumonia

Resonance Loud Low Long Normal lung Simple chronic

bronchitis

Hyperresonance Very Loud Lower Longer None normally Emphysema,

pneumothorax

Tympany Loud High Gastric air

bubble or puffed-

out cheek

Large

pneumothorax

11. Describe the normal sounds that can be detected during auscultation, including location, duration, intensity, and

pitch of the sounds.

Vesicular, or soft and low pitched. They are heard through inspiration, continue without pause through expiration, and

then fade away about one third of the way through expiration.Bronchovesicular, with inspiratory and expiratory sounds about equal in length, at times separated by a silent

interval. Detecting differences in pitch and intensity is often easier during expiration.

Bronchial, or louder and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory

sounds last longer than inspiratory sounds.

Tracheal breath sounds are very loud, harsh sounds that are heard by listening over the trachea in the neck

**There is a good table of this info in the text

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12. Describe the abnormal lung sounds, including duration, intensity, and pitch of the sounds.

Crackles: discontinuous, intermittent, non-musical, brief

Fine crackles are soft, high pitched and very brief - 5-10 ms

Course crackles are louder, lower pitched and a little longer - 20-30 ms

Wheezes and Rhonchi: continuous, greater than 250 ms, musical, prolonged but not necessarily persisting

throughout the respiratory cycle

Wheezes: high pitched with hissing/shrill quality

Rhonchi: low pitched with snoring quality

Strider: Wheeze that is predominantly inspiratory, louder in neck than over chest wall

Pleural Rub: creaking sounds that resemble crackles accoustically

Mediastinal Crunch: series of precordial crackles that are synchronous with heart beat, not respiration

13. List common lung diseases associated with each abnormal lung sound.

Crackles: pneumonia, fibrosis, early CHF, bronchitis

Wheezing: asthma, COPD, bronchitis

Rhonchi: secretions in large airways, often clear with coughing

Strider: partial obstruction of larynx or trachea

Pleural rub: inflamed pleural surfaces

Mediastinal crunch: mediastinal emphysema

14. Describe the techniques for measuring transmitted voice sounds and understand what they can detect.

If you hear abnormally located broncho-vesicular or bronchial breath sounds, assess transmitted voice sounds. Witha stethoscope, listen in symmetric areas over the chest wall as you:

Ask the patient to say ninety-nine. Normally the sounds transmitted through the chest wall are muffled and

indistinct. Louder, clearer voice sounds are called bronchophony.

Ask the patient to say ee. You will normally hear a muffled long E sound. When ee is heard as ay, an

E-to-A change (egophony)is present, as in lobar consolidation from pneumonia. The quality sounds nasal.

Ask the patient to whisper ninety-nine or one-two-three. The whispered voice is normally heard faintly

and indistinctly, if at all. Louder, clearer whispered sounds are called whispered pectoriloquy.

15. Explain how to assess the pulmonary function.

A simple but informative way to assess the pulmonary function is the walk test. Time an 8-foot walk at the patients

normal pace. Repeat the walk and note the faster time. Also observe the rate, effort, and sound of the patients

breathing.

16. Explain how to assess the expiratory phase of breathing.

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The forced expiratory time test assesses the expiratory phase of breathing, which is typically slowed in obstructive

pulmonary disease. Ask the patient to take a deep breath in and then breath out as quickly and completely as

possible with mouth open. Listen over the trachea with the diaphragm of a stethoscope and time the audible

expiration. Try to get three consistent readings, allowing a short rest between efforts if necessary. Patients older than

60 years with a forced expiratory time of 6 to 8 seconds are twice as likely to have COPD (p. 309).

17. Describe how to identify a fractured rib.

Local pain and tenderness of one or more ribs raise the question of fracture. By anteroposterior compression of the

chest, you can distinguish a fracture from a soft tissue injury. With one hand on the sternum and the other on the

thoracic spine, squeeze the chest. Is it painful, and where? An increase in the local pain (distant from your hands)

suggests rib fracture rather than just soft-tissue injury (p. 309).

18. List and describe both normal and abnormal breathing patterns.

Here are the descriptions of normal and abnormal breathing patterns, it might also be worthwhile to look at page 134

in bates to see graphical descriptions of each individual breathing pattern.

Type of Breathing Finding

Normal Respiratory rate is about 14-20 per min in normal adults and

up to 44 per min in infants

Slow Breathing (Bradypnea) May be secondary to such causes as diabetic coma, drug-

induced respiratory depression, and increased intracranial

pressure

Sighing Respiration Breathing punctuated by frequent sighs should alert you to thepossibility of hyperventilation syndrome - a common cause of

dyspnea and dizziness.

Rapid Shallow Breathing (Tachypnea) Has a number of causes, including restrictive lung disease,

pleuritic chest pain, and an elevated diaphragm

Cheyne-Stokes Breathing Periods of deep breathing alternate with periods of apnea (no

breathing). Children and aging people normally may show this

pattern in sleep. Other causes include heart failure, uremia,

drug-induced respiratory depression, and brain damage

(typically on both sides of the cerebral hemispheres)

Obstructive Breathing In obstructive lung disease, expiration is prolonged because

narrowed airways increase the resistance to air flow. Causes

include asthma, chronic bronchitis, and COPD.

Rapid Deep Breathing (Hyperpnea, Rapid deep breathing has several causes, including exercise,

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Hyperventilation) anxiety, and metabolic acidosis. In the comatose patient,

consider infarction, hypoxia, or hypoglycemia affecting the

midbrain or pons. Kussmaul breathing is deep breathing due

to metabolic acidosis. It may be fast, normal in rate, or slow.

Ataxic Breathing (Biots Breathing) Ataxic breathing is characterized by unpredictable irregularity.

Breaths may be shallow or deep, and stop for short periods.

Causes include respiratory depression and brain damage,

typically at the medullary level.

Physical Exam Session 3

1. Describe the sequence of steps in the cardiac exam.

Page 354 in Bates:

Patient Position Examination

Supine, with head elevated 30 Inspect and palpate the precordium (portion of the body over

the heart): the second right and left interspaces; the right

ventricle; and the left ventricle, including the apical impulse

(diameter, location, amplitude, duration)

Left lateral decubitus (lying on left side) Palpate the apical impulse if not previously detected. Listen

at the apex with the bellof the stethoscope.

Supine, with head elevated 30 Listen to the 2nd right and left interspaces, along the left

sternal border, across to the apex with the diaphragm.

Listen at the right sternal border for tricuspid murmurs and

sounds with the bell.

Sitting, leaning forward, after full exhalation Listen along the left sternal border and at the apex with the

diaphragm.

2. Discuss the anatomy and physiology of the cardiovascular system.

The right ventricle occupies most of the anterior cardiac surface. This chamber and the pulmonary artery form a

wedge-like structure behind and to the left of the sternum. The inferior border of the right ventricle lies below the

junction of the sternum and the xiphoid process. The right ventricle narrows superiorly and joins the pulmonary artery

at the level of the sternum or base of the heart - a clinical term that refers to the superior aspect of the heart at the

right and left 2nd interspaces next to the sternum.

The left ventricle, behind the right ventricle and to the left, forms the left lateral margin of the heart. Its tapered inferior

tip is often termed the cardiac apex. It is clinically important because it produces the apical impulse, identified

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during palpation of the precordium as the point of maximal impulse (PMI). This impulse locates the left border of the

heart and is normally found in the 5th interspace 7 - 9 cm lateral to the midsternal line.

Im not going to go through heart chambers/valves because if youve learned anything in medical school so far thats

probably it. As far as physiology goes, heres a brief synopsis of the events in the cardiac cycle (read pages 326-328

if you want to get more in depth):

during diastole, pressure in the blood-filled left atrium slightly exceeds that in the relaxed left ventricle, and

blood flows from left atrium to left ventricle across the open mitral valve. Just before the onset of ventricular

systole, atrial contraction produces a slight pressure rise in both chambers.

during systole, the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial

pressure, shutting the mitral valve. Closure of the mitral valve produces the first heart sound, S1.

As left ventricular pressure continues to rise, it quickly exceeds the pressure in the aorta and forces the

aortic valve open. In some pathologic conditions, an early systolic ejection sound (Ej) accompanies the

opening of the aortic valve. Normally, maximal left ventricular pressure corresponds to systolic blood

pressure.

As the left ventricle ejects most of its blood, ventricular pressure begins to fall. When left ventricular

pressure drops below aortic pressure, the aortic valve shuts. Aortic valve closure produces the second heart

sound, S2, and another diastole begins.

3. Distinguish when to use the bell versus the diaphragm.

p. 363 - The diaphragm is better for picking up relatively high-pitched sounds of S1 and S2, the murmurs of aortic

and mitral regurgitation, and pericardial friction rubs. Listen through the precordium with the diaphrgam, pressing it

firmly against the chest.

The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Apply the bell

lightly, with just enough pressure to produce an air seal with its full rim. Use the bell at the apex, then move medially

along the lower sternal border. Resting the heel of your hand on the chest like a fulcrum may help you maintain light

pressure. Pressing the bell firmly on the chest makes it function more like a diaphragm by stretching the underlying

skin. Low-pitched sounds such as S3 and S4 may disappear with this technique; an observation that may help to

identify them. In contrast, high-pitched sounds such as midsystolic click, an ejection sound, or an opening snap will

persist or get louder.

4. Describe the anatomic locations best suited for auscultation of S1 and S2.

- The best place to hear the S1 sound is at the apex of the heart or approximately the 5th interspace on the left lateral

to the midsternal line and the best place to hear the S2 sound is at the base of the heart or the 2nd interspace on the

right parasternally.

5. Describe the physiologic correlates of S1 and S2.

**S1is the first heart sound and it occurs due to closure of the mitral/tricuspid valves (AV Valves). The first heart

tone, or S1, forms the "lub" of "lub-dub". It is caused by the sudden block of reverse blood flow due to closure of the

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atrioventricularvalves,i.e.tricuspid andmitral (bicuspid), at the beginning of ventricular contraction, orsystole.When

the ventricles begin to contract, so do the papillary muscles in each ventricle. The papillary muscles are attached to

the tricuspid and mitral valves via chordae tendineae, which bring the cusps or leaflets of the valve closed (chordae

tendineae also prevent the valves from blowing into the atria as ventricular pressure rises due to contraction). The

closing of the inlet valves preventsregurgitation of blood from the ventricles back into the atria. The S1sound results

from reverberation within the blood associated with the sudden block of flow reversal by the valves.

**S2is the second heart sound and it occurs due to closure of the pulmonic/aortic valves (semilunar valves). The

second heart tone, or S2, forms the dub of lub-dub. It is caused by the sudden block of reversing blood flow due

to closure of thesemilunar valves which are theaortic valve andpulmonary valve, at the end of ventricularsystole,

i.e. beginning of ventriculardiastole.As theleft ventricle empties, its pressure falls below the pressure in theaorta,

aortic blood flow quickly reverses back toward the left ventricle, catching the aortic valve pocketlike cusps and is

stopped by aortic (outlet) valve closure. Similarly, as the pressure in theright ventricle falls below the pressure in the

pulmonary artery, the pulmonary (outlet) valve closes. The S2sound results from reverberation within the blood

associated with the sudden block of flow reversal.

6. Identify physiologic and paradoxical splitting of S2.

Listen for physiologic splitting of S2 in the 2nd or 3rd left interspace. The pulmonic compononent of S2 is usually too

faint to be heard at the apex or aortic area, where S2 is a single sound derived from aortic valve closure alone.

Normal splitting is accentuated by inspiration and usually disappears on expiration. In some patients, especially

younger ones, S2 may not become single on expiration. It may emerge when a patient sits up.

Paradoxical or reversed splitting refers to splitting that appears on expiration and disappears on inspiration. Closure

of the aortic valve is abnormally delayed so that A2 follows P2 in expiration. Normal inspiratory delay of P2 makes

the split disappear. The most common cause of paradoxical splitting is left bundle branch block.

7. Describe what palpation in the cardiac exam can detect.

p. 356 - palpation is valuable for detecting thrills, the timing of S1 and S2, and the ventricular movements of S3 or S4

Begin with general palpation of the chest wall. First palpate for heaves, lifts, or thrills, using your fingerpads.

Hold them flat or obliquely on the body surface. Ventricular impulses may heave or lift your fingers.

Check for thrills, formed by the turbulence of underlying murmurs, by pressing the ball of your hand firmly on

the chest. If subsequent auscultation reveals a loud murmur, go back to that area and check for thrills again.

Use firm pressure for an S1 and S2 and lighter pressure for S3 and S4. When palpating for S1 and S2 place

your right hand on the chest wall and your left index and middle fingers on the right carotid artery in the

lower third of the neck. Identify S1 which occurs just before the carotid upstroke. Now identify S2 which

occurs after the carotid upstroke.

Be sure to assess the right ventricle by palpating the right ventricular area at the lower left sternal border

and in the subxiphoid area, the pulmonary artery in the left 2nd interspace, and the aortic area in the right

2nd interpsace

8. Describe how to assess the point of maximal impulse.

14
http://en.wikipedia.org/wiki/Heart_valveshttp://en.wikipedia.org/wiki/Heart_valveshttp://en.wikipedia.org/wiki/Heart_valveshttp://en.wikipedia.org/wiki/Tricuspid_valvehttp://en.wikipedia.org/wiki/Tricuspid_valvehttp://en.wikipedia.org/wiki/Mitral_valvehttp://en.wikipedia.org/wiki/Mitral_valvehttp://en.wikipedia.org/wiki/Mitral_valvehttp://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Regurgitation_(circulation)http://en.wikipedia.org/wiki/Regurgitation_(circulation)http://en.wikipedia.org/wiki/Semilunar_valveshttp://en.wikipedia.org/wiki/Aortic_valvehttp://en.wikipedia.org/wiki/Pulmonary_valvehttp://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Left_ventriclehttp://en.wikipedia.org/wiki/Left_ventriclehttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Right_ventriclehttp://en.wikipedia.org/wiki/Right_ventriclehttp://en.wikipedia.org/wiki/Pulmonary_arteryhttp://en.wikipedia.org/wiki/Heart_valveshttp://en.wikipedia.org/wiki/Tricuspid_valvehttp://en.wikipedia.org/wiki/Mitral_valvehttp://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Regurgitation_(circulation)http://en.wikipedia.org/wiki/Semilunar_valveshttp://en.wikipedia.org/wiki/Semilunar_valveshttp://en.wikipedia.org/wiki/Aortic_valvehttp://en.wikipedia.org/wiki/Aortic_valvehttp://en.wikipedia.org/wiki/Pulmonary_valvehttp://en.wikipedia.org/wiki/Pulmonary_valvehttp://en.wikipedia.org/wiki/Systole_(medicine)http://en.wikipedia.org/wiki/Diastolehttp://en.wikipedia.org/wiki/Left_ventriclehttp://en.wikipedia.org/wiki/Left_ventriclehttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Right_ventriclehttp://en.wikipedia.org/wiki/Right_ventriclehttp://en.wikipedia.org/wiki/Pulmonary_arteryhttp://en.wikipedia.org/wiki/Pulmonary_artery


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p. 357 - the apical impulse represents the brief early pulsation of the left ventricle as it moves anteriorly

during contraction and touches the chest wall. Note that in most examinations the apical impulse is the point

of maximal impulse, or PMI; however, some pathologic conditions may produce a pulsation that is more

prominent than the apex beat, such as an enlarged right ventricle, a dilated pulmonary artery, or an

aneurysm of the aorta

if you cannot identify the apical impulse with the patient supine, ask the patient to roll party only the left side

(left lateral decubitus position); palpate again, using the palmar surfaces of several fingers. If you cannot

find the apical impulse, ask the patient to exhale fully and stop breathing for a few seconds

when you have found the apical impulse, make finer assessments with your fingertips, and then with one

finger

Assess the location, diameter, amplitude and duration of the apical impulse

Location: try to assess the location with the patient supine, because the left lateral decubitus

position displaces the apical impulse to the left; locate two points: the interspaces, usually the 5th

or possibly the 4th, which give the vertical location; and the distance in centimeters from the

midsternal line, which gives the horizontal location

Diameter: it usually measure less than 2.5 cm and occupies only one interspace; it may feel larger

in the left lateral decubitus position

Amplitude: estimate the amplitude; it is usually small and feels brisk and tapping; some young

people have an increased amplitude, or hyperkinetic impulse, especially when excited or after

exercise; its during, however, is normal

Duration: duration is the most useful characteristic of the apical impulse for identifying hypertrophy

of the left venticle; to assess duration, listen to the heart sounds as you feel the apical impulse, or

watch the movement of your stethoscope as you listen at the apex. Estimate the proportion of

systole occupied by the apical impulse. Normally it lasts through the first of systole, and often

less, but does not continue to the second heart sound

9. Explain how to screen for coronary heart disease and stroke.

p.341

The challenge for health care professionals is to engage greater numbers of patients, at an earlier stage of

their disease, in comprehensive cardiovascular risk reduction to expand the benefits of primary prevention.

The continuing message is that adoption of healthy life habits remains the cornerstone of primary

prevention.

The imperative is to prevent the first episode of coronary disease or stroke or the development of aorticaneurysm and peripheral vascular disease because of the still-high rate of first events that are fatal or

disabling.

As a first step, clinicians need to identify not only elevated blood pressure but also other well-studied risk factors for

coronary heart disease (CHD).

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Risk factor screening for adults beginning at 20 years

Global absolute CHD risk estimation for all adults 40 years and older. The goal of global risk estimate is to

help patients keep their risk as low as possible. Note that diabetes, or 10-year risk of more than 20%, is

considered equivalent to established CHD risk equivalents.

10. Understand the lifestyle modifications to reduce high blood pressure.

p. 345 - Lifestyle modifications for hypertension can lower systolic blood pressure from 2 to 20 mm Hg

Optimal weight, or BMI of 18.5-24.9 kg/m2

Salt intake of less than 6 grams of sodium chloride or 2.4 grams of sodium per day

Regular aerobic exercise such as brisk walking for at least 30 mins per day, most days a week

Moderate alcohol consumption per day of 2 drinks or fewer for men and 1 drink or fewer for women (2 drinks

= 1 oz ethanol, 24 oz beer, 10 oz wine, or 2-3 oz whiskey)

Dietary intake of more than 3,000 mg of potassium

Diet rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fats

11. Describe how to evaluate jugular venous pulse, the carotid upstroke, and detect the presence of carotid bruits.

p351 Jugular venous pulse -

Observe the amplitude and timing of the jugular venous pulsations.

To time them, feel the left carotid artery with your right thumb or listen to the heart simultaneously. The a wave just

precedes S1 and the carotid pulse, the x descent can be seen as a systolic collapse, the v wave almost coincides

with S2, and the y descent follows early in diastole. Look for absent or unusually prominent waves.

P353 - Carotid upstroke

After increasing pressure until you feel maximal pulsation, slowly decrease pressure until you best sense arterial

pressure and contour; then assess:

The contour of the pulse wave (speed of the upstroke), the duration of its summit, and the speed of the

downstroke. The normal upstroke is brisk. It is smooth, rapid, and follows S1 almost immediately. The summit is

smooth, rounded and roughly midsystolic. The downstroke is less abrupt than the upstroke.

RED TEXT - Delayed carotid upstroke - AORTIC STENOSIS

P353 - BRUIT

During palpation of the carotid artery, you may detect humming vibrations, or thrills, that feel like the throat

of a purring cat. Routinely, but especially in the presence of a thrill, listen over both carotid arteries with the

diaphragm of your stethoscope for a bruit, a murmur like sound of vascular rather than cardiac origin.

Listen for carotid bruits if patient middle aged or elderly, or if you suspect cerebrovascular disease.

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To assess: ask the patient to hold breathing for a moment so that breath sounds do not obscure the

vascular sound, then listen with the bell. Heart sounds alone do not constitute a bruit.

RED TEXT - Note that an aortic valve murmur may radiate to the neck and sound like a carotid bruit

The prevalence of asymptomatic carotid bruits increases with age (8 percent in people 75 years or older),

with 3 fold increase risk of ischemic heart disease and stroke. presence of carotid bruit does not predict the

degree of underlying stenosis.

12.Describe and characterize heart murmurs.

Murmurs can be described in many different ways, the first way they are described in by when they occur:

- Midsystolic murmur: begins after S1 and stops before S2. There are brief gaps between the murmur and the

heart sound. The easiest one to identify is the gap between the murmur and S2 which also helps distinguish this

murmur from a pansystolic murmur.-Pansystolic murmur: also called a holosystolic murmur starts at S1 and ends at S2 with no gaps between the

murmur and the heart sounds.

-Late systolic murmur: usually starts in mid or late systole and persists up to S2.

-Early Diastolic murmur: starts immediately after S2 with no discernible gap and then fades into silence before S1.

-Middiastolic murmur: Starts a short time after S2 and it may fade away or merge into a late diastolic murmur.

-Late diastolic murmur: Starts late in diastole and continues into S1.

Murmurs can also be characterized by its shape (determined by its intensity over time) there are four ways to classify

these:

- a crescendo murmur grows louder, a decrescendo murmur grows softer, a crescendo-decrescendo murmur first

rises in intensity then falls and a plateau murmur that has the same intensity throughout.

Finally murmurs can also be classified by the location of maximal intensity (site where the murmur originates), the

radiation or transmission from the point of maximal intensity (can tell you the direction of blood flow) and its intensity

(graded on a 6 point scale)

13. Explain how to grade murmurs using the 6 point scale.

p. 368

Grade 1 Very faint, heard only after listener has tuned in may not be heard in all positions

Grade 2 Quiet, but heard immediately after placing the stethoscope on the chest

Grade 3 Moderately loud

Grade 4 Loud, with palpable thrill

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Grade 5 Very loud, with thrill . May be heard when the stethoscope is partly off the chest

Grade 6 Very loud, with thrill . May be heard with stethoscope entirely off the chest

14. Describe and discuss the techniques to help distinguish between the murmurs of mitral valve prolapse,

hypertrophic cardiomyopathy from aortic stenosis.

- A murmur from a mitral prolapse will be heard over the apex of the heart and it will radiate to the left axilla. It is soft

to loud in intensity (if loud it is associated with apical thrill). It is of medium to high pitch and is harsh and holosystolic

(pansystolic). Unlike tricuspid regurgitation, it doesnt get louder in inspiration.

- A murmur from aortic stenosis is heard over the right second intercoastal space and it often radiates to the carotids,

down the left sternal border even to the apex. It is sometimes soft but often loud, with a thrill. Its pitch is medium,

harsh; crescendo-decrescendo may be higher at the apex. It is often a harsh sound and it is heard best with the

patient sitting and leaning forward.

- A murmur from hypertrophic cardiomyopathy is heard at the 3rd or 4th left interspaces and radiates down the leftsternal border to the apex, possibly to the base but not to the neck. The intensity is variable, the pitch is medium and

the quality is harsh. The sound decreases with squatting, increases with straining down from valsalva and standing.

15. Describe pulsus alternans and paradoxical pulse.

p. 370 - In pulsus alternans, the rhythm of the pulse remains regular, but the force of the arterial pulse alternates

becomes of alternating strong and weak ventricular contractions. Pulsus alternans almost always indicates severe

left-sided heart failure and is usually best felt by applying light pressure on the radial or femoral arteries. You can use

a blood pressure cuff to confirm your finding. After raising the cuff pressure, lower it slowly to the systolic level; the

initial Korotkoff sounds are the strong beats. As you lower the cuff, you will hear the softer sounds of the alternating

weak beats.

Paradoxical pulse is a greater than normal drop in systolic pressure during inspiration. As the patient breathes,

quietly if possible, lower the cuff pressure slowly to the systolic level. Note the pressure level at which the first sounds

can be heard. Then drop the pressure very slowly until sounds can be heard throughout the respiratory cycle. Again

note the pressure level. The difference between the two levels is normally no greater than 3 or 4 mm Hg.

16. Describe anatomically the location of the major structures of the peripheral vascular system.

p. 472 - 474

Arteries, Upper limb:

Brachial artery, at the bend of the elbow just medial to the biceps tendon

Radial artery, on the lateral flexor surface

Ulnar artery, on the medial flexor surface, although overlying tissues may obscure the ulnar artery

Two vascular arches (deep and superficial palmar arches, yeah Anatomy!) within the hand in interconnect

the radial and ulnar arteries, doubly protecting circulation to the hand and fingers against possible arterial

occlusion

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Arteries, Lower limb:

Femoral artery, just below the inguinal ligament, midway between the ASIS and pubic symphysis

Popliteal artery, an extension of the femoral artery that passes medially behind the femur, palpable just

behind the knee.

Dorsal pedis artery, on the dorsum of the foot just lateral to the extensor tendon of the big toe

Posterior tibial artery behind the medial malleolus of the ankle

Leg veins have weaker wall structure, thus they are more susceptible to irregular dilation, compression, ulceration

and invasion by tumors. One-way valves and contraction of the calf muscles during walking both serve as a venous

pump, squeezing blood upward against gravity and preventing backward flow.

Great saphenous vein, originates on the dorsum of the foot, passes just anterior to the medial malleolus,

continues up the medial aspect of the leg, and joins the femoral vein of the deep venous system below the

inguinal ligament

Small saphenous vein, which begins at the side of the foot, passes upward along the posterior calf, and

joins the deep venous system in the popliteal fossa.

17. Identify the anatomy of the lymphatic system and lymph nodes.

p. 475-476 - Lymph nodes are round, oval, or bean-shaped structures that vary in size according to their location.

Some lymph nodes, such as the preauriculars, if palpable at all, are typically very small. The inguinal nodes, in

contrast, are relatively larger; often 1 cm in diameter and occasionally even 2 cm in an adult. Only the superficial

lymph nodes are accessible to physical examination. These include the cervical lymph nodes, the axillary nodes, and

the nodes in the arms and legs.

The axillary lymph nodes drain most of the arm. Lymphatics from the ulnar surface of the forearm and hand, the littleand ring fingers, and the adjacent surface of the middle finger, however, rain first into epitrochlear nodes. These are

located on the medial surface of the arm approximately 3 cm above the elbow. Lymphatics from the rest of the arm

drain mostly into the axillary nodes. A few may go directly into the infraclaviculars.

The superficial inguinal nodes of the lower limb include two groups. The horizontal group lies in a chain high in the

anterior thigh below the inguinal ligament. It drains the superficial portions of the lower abdomen and buttock, the

external genitalia (but not the tests), the anal canal and perianal area, and the lower vagina. The vertical group

clusters near the upper part of the saphenous vein and drains a corresponding region of the leg. In contrast,

lymphatics from the portion of the leg drained by the small saphenous vein (the hell and outer aspect of the foot) joint

he deep system at the level of the popliteal space.

18. Describe the grading system for the peripheral pulses.

p. 482 - Recommended Grading of Pulses

3+ Bounding (carotid, radial, and femoral pulses in aortic insufficiency)

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2+ Brisk, expected (normal)

1+ Diminished, weaker than expected (asymmetric diminished pulses in arterial occlusion from

atherosclerosis or embolism)

0 Absent, unable to palpate

19. Describe how to assess and grade pitting edema.

p. 487 - Press firmly but gently with your thumb for at least 5 seconds over the dorsum of each foot, behind each

medial malleolus, and over the shins. Look for pitting; a depression caused by pressure from your thumb. Normally

there is none. The severity of edema is graded on a four-point scale, from slight to very marked.

20. Describe how to evaluate the arterial supply to the hands and legs, the competency of venous valves, and how to

map varicose veins.

p. 488 - If you suspect arterial insufficiency in the arm or hand, try to feel the ulnar pulseas well as the radial and

brachial pulses. Feel for it deeply on the flexor surface of the wrist medially. Partially flexing the patients wrist may

help you. the pulse of a normal ulnar artery, however, may not be palpabale. The Allen testis useful to ensure the

patency of the ulnary artery before puncturing the radial artery for blood samples. See page 489.

p. 490 - If pain or diminished pulses suggest arterial insufficiency, look for postural color changes. Raise both legs to

about 60 degrees until maximal pallor of the feet develops, usually within a minute. Then ask the patient to sit up with

legs dangling down. Compare both feet, noting the time required for:

Return of pinkness to the skin, normally about 10 seconds or less.

Filling of the veins of the feet and ankles, normally about 15 seconds.

Look for any unusual rubor (dusky redness) to replace the pallor of the dependent foot. Normal responses

accompanied by diminished arterial pulses suggest that a good collateral circulation has developed around an arterial

occlusion. Color changes may be difficult to see in darker-skinned persons, so inspect the soles of the feet for these

changes.

The physical exam of the Abdomen

1. Apply health promotion and counseling to patients on topics such as alcohol abuse, Hepatitis A, B, C, and Colon

Cancer.

When asking about alcohol use, recall current definitions of risky or hazardous drinking and harmful drinking. Risky or

hazardous drinking for women is more than 7 drinks per week or more than 3 drinks per occasion; for men it is more

than 14 drinks per week or more than 4 drinks per occasion. Sorry Sandra. Harmful drinking is drinking that causes

physical social, or psychological harm from alcohol use but does not meet the criteria for dependence. Use the 4

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CAGE questions. Initial counseling of 15 minutes with follow up reduces consumption by 13-34% over 6-12 months.

Know FRAMES:

Feedback based on thorough assessment

Responsibility

Advice on behavior change

Menu of options for making change

Empathy about the difficulty of changing

Self-efficacy in achieving change

Transmission of Hepatitis A is fecal-oral (yummy). Fecal shedding in food handlers leads to contamination of water

and foods. A vaccine is recommended for certain populations. Hepatitis B poses more serious risks. Transmission

occurs during contact with infected body fluids such as blood, semen, saliva and vaginal secretions. Because up to

30% of patients have no identifiable risk factors, hepatitis B vaccine is recommended for all young adults not

previously immunized. Pregnant women should be screened at their first prenatal visit. Hepatitis C is transmitted by

repeated percutaneous exposures to blood and is present in 2% of U.S. adults. Infected patients are often

asymptomatic. More than 70% develop chronic liver disease. Routine screening is not recommended since it is rare.

For colorectal cancer, one of the following tests should be done beginning at age 50: fecal occult blood test annually,

flesible sigmoidoscopy every 5 years, annual FOBT plus flexible sigmoidoscopy every 5 years, double-contrast

barium enema every 5 years, and colonoscopy every 10 years. Most colorectal cancers are sporadic, but 20% occur

in patients with risk factors including prior colon cancer and family history.

2. Describe the proper techniques for assuring patient comfort for the abdominal exam.

p. 434

Before you begin palpation, ask the patient to point to any areas of pain so you can examine these areaslast.

Warm your hands and stethoscope. To warm your hands, rub them together or place them under hot water.

You can also palpate through the patients gown to absorb warmth from the patients body before exposing

the abdomen.

Approach the patient calmly and avoid quick, unexpected movements. Watch the patients face for any

signs of pain or discomfort. Make sure you avoid long fingernails.

Distract the patient if necessary with conversation or questions. If the patient is frightened or ticklish, begin

palpation with the patients hand under yours. After a few moments, slip your hand underneath to palpate

directly. lol.

3. Demonstrate the proper technique for draping the patient for the abdominal exam.

-Your goal with draping is to visualize one area of the body at a time. For the abdominal exam, only the abdomen

should be exposed. Adjust the gown to cover the chest and place the sheet or drape at the inguinal area.

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4. Identify and describe the anatomical landmarks of the abdominal wall and pelvis.

-See picture at beginning of chapter. Anatomical landmarks include xiphoid process, rectus abdominis muscle,

costal margin, midline overlying linea alba, umbilicus, iliac crest, anterior superior iliac spine, inguinal ligament, pubic

tubercle, and symphysis pubis.

5. Describe the location of the major organs in the abdomen using anatomic terms.

-In the right upper quadrant you have the liver (the lower margin is palpable at the right costal margin), the

gallbladder and duodenum (which are not generally palpable). At a deeper level the lower pole of the kidney may be

felt. The abdominal aorta often has visible pulsations in the upper abdomen. The stomach is located under the ribs

and is not palpable

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-In the left upper quadrant the spleen is lateral to and behind the stomach. it upper border rest against the

diaphram and it is protected by ribs 9, 10 and 11. The pancreas is located here, but in healthy people it is not

palpable.

-In the lower left quadrant you can feel the sigmoid colon and portions of the transverse colon. In the lower midline

are the bladder, the sacral promontory and in women the uterus and ovaries.

-In the lower right quadrant are bowel loops and the appendix at the tail of the cecum. In healthy people there are

no palpable findings in the lower right quadrant.

- Also in the abdomen are the kidneys that are posterior organs which are protected by the 11th and 12th

ribs.

6. Describe the sequence for performing the abdominal exam.

Inspect, Auscultate, Percuss, Palpate

7. Describe the normal and abnormal findings that can be detected with inspection of the abdomen.

--On inspection of the abdomen note:

-The skin - describe or diagram any scars, look for any old silver striae or stretch marks that are abnormal (pink-

purple striae are characteristic of Cushings syndrome) Note any dilated veins which can be indicative of hepatic

cirrhosis or inferior vena cava syndrome. Also note any rashes or lesions

Observe the contour and appearance of the umbilicus and any inflammation or bulges suggesting a hernia.

Observe the contour of the abdomen and see if it is round, protuberant (caused by fat, a tumor, being

pregnant, or have ascitic fluid or scaphoid (markedly concave or hollowed). Also look to see in the flanks bulge

which is common in ascities. You can also have suprapubic bulges that are seen with a distended bladder, pregnant

uterus or hernias. You want to make sure the abdomen is symmetric because asymmetry can be caused by an

enlarged organ or tumor. Look for a large spleen or liver that has descended below the rib cage, in a normalabdomen this would not be found.

To check for peristalsis observe for several minutes because increased peristaltic waves are indicative of

intestinal obstruction. You should not see peristalsis on a normal person

The normal abdominal aortic pulsation is frequently visible in the epigastrum. Increased pulsation is a sign

of an aortic aneurysm or of increased pulse pressure.

8. Describe the technique of auscultation of the abdomen and describe normal and abnormal findings.

9. Describe the technique of percussion in the abdominal exam and describe normal and abnormal findings.

Percussion helps assess the amount and distribution of gas in the abdomen and to identify possible massesthat are solid or fluid-filled

Percuss the abdomen lightly in all four quadrants to assess the distribution of tympany and dullness.

Tympany usually predominates because of gas in the GI tract, but scattered areas of dullness from fluid and

feces are also typical.

A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction

Note any large dull areas that might indicate an underlying mass or enlarged organ

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Pregnant uterus, ovarian tumor, distended bladder, large liver or spleen

On each side of a protuberant abdomen, note where abdominal tympany changes to the dullness of solid

posterior structures

Dullness in both flanks prompts further assessment for ascites

Briefly percuss the lower anterior chest, between the lungs above and costal margins below. On the right,

you will usually find the dullness of the liver; on the left, the tympany that overlies the gastric air bubble and

the splenic flexure of the colon

In situs inversus (rare), organs are reversed: air bubble on the right, liver dullness on the left

10. Describe the techniques of light and deep palpation in the abdominal exam and recognize normal and abnormal

findings.

Light palpation:feeling the abdomen gently is especially helpful for identifying abdominal tenderness,

muscular resistance, and some superficial organs and masses. It also serves to reassure and relax the

patient.

Keeping your hands and forearms on a horizontal plane, with fingers together and flat on the abdominal

surface, palpate the abdomen with a light, gentle, dipping motion. When moving your hand from place to

place, raise it just off the skin. Moving smoothly, feel in all quadrants.

Identify any superficial organs or masses and any area of tenderness or increased resistance to your hand.

If resistance is present, try to distinguish voluntary guarding from involuntary guarding. To do this:

Try all the relaxing methods you know

Feel for the relaxation of abdominal muscles that normally accompanies exhalation

Ask the patient to mouth-breath with the jaw dropped open

Involuntary rigidity (muscular spasm) typically persists despite these maneuvers. It indicates peritoneal

inflammation

Deep palpation:This is usually required to delineate abdominal masses. Again using the palmar surfacesof your fingers, feel in all four quadrants. Identify and masses and note their location, size, shape,

consistency, tenderness, pulsations, and any mobility with respiration or with the examining hand. Correlate

your palpable findings with their percussion tones.

Abdominal masses may be categorized in several ways: physiologic (pregnant uterus),

inflammatory (diverticulitis of the colon), vascular (an abdominal aortic aneurysm), neoplastic

(carcinoma of the colon), or obstructive (a distended bladder or dilated loop of bowel)

11. Describe the manuevers for the complete examination of the liver.

p. 439-443

Percussion: Measure the vertical span of liver dullness in the right midclavicular line. Starting at a level

below the umbilicus (in an area of tympany, not dullness), percuss upward toward the liver. Identify the

lower border of dullness in the midclavicular line. Next, identify the upper border of liver dullness in the

midclavicular line. Starting at the nipple line, lightly percuss from lung resonance down toward liver dullness.

Now measure in centimeters the distance between your two points; the vertical span of liver dullness.

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Normal liver spans are generally greater in men than in women and greater in tall people than in short

people.

To assess percussion tenderness of a nonpalpable liver, place your left hand flat on the lower right rib cage

and then gently strike your hand with the ulnar surface of your right fist. Ask the patient to compare the

sensation with that produced by a similar strike on the left side.

Palpation: Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs

and adjacent soft tissues below. Place your right hand on the patients right abdomen lateral to the rectus

muscle, with your fingertips well below the lower border of liver dullness, and gently press in and up. Ask the

patient to take a deep breath, and and try to feel the liver edge as it comes down to meet your fingertips.

Note any tenderness. If palpable at all, the normal liver is soft, sharp, and regular, with a smooth surface.

On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line. Try to

trace the liver edge both laterally and medially. Describe or sketch the liver edge, and measure its distance

from the right costal margin in the midclavicular line.

12. Describe the manuevers for the complete examination of the spleen.

p. 443-445

Splenomegaly: when a spleen enlarges, it expands anteriorly, downward, and medially, often replacing the

tympany of the of stomach and colon with dullness of a solid organ. It then becomes palpable below the

costal margin. Percussion suggests but does not confirm splenic enlargement (60-80% sensitivity, 72-94%

specificity).

Percussion: Percuss the left lower anterior chest wall between lung resonance above and the costal

margin, an area termed Traubes space. As you percuss along the routes (see p. 443 pictures), note the

lateral extent of tympany. Check for a splenic percussion sign by percussing the lowest itnerspace in the left

anterior axillary line; this area is usually tympanitic. Then ask the patient to take a deep breath, and percussagain. When spleen size is normal, the percussion note usually remains tympanitic.

Palpation: With your left hand, reach over and around the patient to support and press forward the lower

left rib cage and adjacent soft tissue. With your right hand below the left costal margin, press in toward the

spleen. Ask the patient to take a deep breath, and try to feel the tip or edge of the spleen as it comes down

to meet your fingertips. Note any tenderness, assess the splenic contour, and measure the distance

between the spleens lowest point and the left costal margin. Repeat with the patient lying on the right side

with legs somewhat flexed at the hips and knees. In this position, gravity may bring the spleen forward and

to the right into a palpable location.

13. Describe the manuevers for the complete examination of the kidneys.

p. 445-446

Palpation, left kidney: Move to the patients left side, and place your right hand behind the patient, just

below and parallel to the 12th rib, with your fingertips just reaching the costovertebral angle. Lift, trying to

displace the kidney anteriorly. Place your left hand gentily in the left upper quadrant, lateral and parallel to

the rectus muscle. Ask the patient to take a deep breath. At the peak of inspiration, press your left hand

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firmly and deeply into the light upper quadrant, just below the costal margin, and try to capture the kidney

between your two hands. Ask the patient to breathe out and then to stop breathing briefly. Slowly release

the pressure of your left hand, feeling at the same time for the kidney to slide back into its expiratory

position. If the kidney is palpable, describe its size, contour and tenderness.

Palpation, right kidney: To capture the right kidney, return to the patients right side. Use your left hand to

left from in back and your right hand to feel deep in the left upper quadrant. Proceed as before.

Percussion: You may note tenderness when examining the abdomen, but also search for it at each

costovertebral angle. Pressure from your fingertips may be enough to elicit tenderness, but if not, use fist

percussion. Place the ball of one hand in the costovertebral angle and strike it with the ulnar surface of your

fist. Use enough force to cause a perceptible but painless jar or thud in a normal person.

14. Describe the maneuvers for assessing ascites, appendicitis, pyelonephritis, acute cholycystitis, ventral hernias,

and mass in the abdominal wall.

p. 448-451 Ascites: A protuberant abdomen with bulging flanks suggests the possibility of ascitic fluid. Because ascitic

fluid characteristically sinks with gravity, whereas gas-filled loops of bowel float to the top, percussion gives

a dull note in dependent areas of the abdomen. Look for such a pattern by percussion outward in several

directions from the central area of tympany, and map the border between tympany and dullness.

Test for shifting dullness: After mapping the borders of tympany and dullness, ask the patient to

turn onto one side. Percuss and mark the borders again. In a normal person without ascities, the

borders between tympany and dullness usually stay relatively constant.

Test for a fluid wave: Ask the patient to press the edges of both hand firmly down the midline of the

abdomen. This pressure helps to stop the transmission of wave through fat. While you tap one

flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through thefluid.

Appendicitis: Ask the patient to point to where the pain began and where it is now. Ask the patient to

cough. Search carefully for an area of local tenderness. Feel for muscular rigidity. Perform a rectal

examination and, in women, a pelvic examination. Check the tender area for rebound tenderness.

Check for Rovsings sign (pain the in the right lower quadrant during left-sided pressure) and for

referred rebound tenderness, a psoas sign, an obturator sign, and cutaneous hyperesthesia (see p.

450 for details).

Pyelonephritis: Pain with pressure or fist percussion of the kidneys suggests pyelonephritis but may also

have a musculoskeletal cause.

Acute cholycystitis: Look for Murphys sign. Hook your left thumb or fingers of your right hand under the

costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. A

sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphys sign.

Ventral hernias: If you suspect but do not see an umbilical or incisional hernia, askt he patient to raise both

head and shoulders off the table. The bulge of a hernia will usually appear with this action.

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Mass in the abdominal wall: Ask the patient either to raise the head and shoulders or to strain down, thus

tightening the abdominal muscles. A mass in the abdominal wall remains palpable; an intra-abdominal mass

is obscured by muscular contraction.

Session 5: Physical Exam of the Upper Musculoskeletal System

1. Distinguish between the three primary types of joint articulation.

Synovial joints: bones do not touch each other and joint articulations are freely moveable. ex. knee, shoulder

Cartilaginous joints: joints are slightly moveable. ex. vertebral bodies of the spine

Fibrous joints: intervening layers of fibrous tissue or cartilage hold the bones together. The bones are almost always

in direct contact, which allows no appreciable movement. ex. skull sutures

2. Explain the structure of synovial joints.

Spheroidal (ball and socket) joints have a convex surface in a concave cavity. They allow a wide range of rotatory

movement. ex. shoulder, hip

Hinge joints are flat, planar, or slightly curved, allowing only a gliding motion in a single plane. ex. interphalangeal

joints of hand and foot; elbow.

In condylar joints the articulating surfaces are convex or concave, termed condyles. The movement of two articulating

surfaces is not dissociable. ex. knee, TMJ

3. Identify the anatomy of the temporomandibular joint, shoulder, elbow, wrist and hand joints.

p. 586-603

TMJ: Most active joint in the body. It is formed by the fossa and articular tubercle of the temporal bone andthe condyle of the mandible. It lies midway between the external acoustic meatus and the zygomatic arch. It

is a condylar synovial joint.

The principle muscles opening the mouth are the lateral (external) ptyerygoids. Closing the mouth

are the muscles innervated by CN V3, the masseter, temporalis, and medial (internal) pterygoids.

Shoulder: Largely uninhibited by bony structures. Derives mobility from shoulder girdle, structures are

divided into dynamic and static stabilizers. Dynamic stabilizers = SITS muscles; Static stabilizers = bony

structures, labrum, articular capsule, and glenohumeral ligaments. Three different joints articulate at the

shoulder:

Glenohumeral joint: Head of humerus articulates with shallow glenoid fossa of the scapula; ball-

and-socket joint, allowing flexion, extension, abducction, adduction, rotation, and circumduction of

the arm.

Sternoclavicular joint: medial end of clavicle articulates with upper sternum

Acromioclavicular joint: lateral end of clavicle articulates with acromion process of scapula.

Muscle groups: SITS (supraspinatus, infraspinatus, teres minor, subscapularis); axioscapular

group (trapezius, rhomboids, serratus anterior, leavtor scapulae) rotate the scapula;

axiohumeral group (pectoralis major, minor, latissimus dorsi) internal rotation of shoulder

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Elbow: Formed by humerus, radius, and ulna. The bones have three articulations; the humeroulnar joint,

the radiohumeral joint, and the radioulnar joint, which share a large common articular cavity and an

extensive synovial lining.

Muscles traversing the elbow include the biceps and brachioradialis (flexion), the triceps

(extension), the pronator teres (pronation), and the supinator (supination).

Olecranon bursa between the olecranon process and skin; normally not palpable but swells and

becomes tender when inflamed.

Wrist and Hands: Wrist includes distal radius, ulna, and eight small carpal bones. Hand includes five

metacarpals, with proximal, middle and distal phalanges. Thumb lacks a middle phalanx.

Wrist joints: Radiocarpal joint, distal radioulnar joint, intercarpal joints. Radiocarpal joint provides

most of flexion and extension at wrist because ulna does not articulate directly with carpal bones.

Hand joints: Metacarpophalangeal jionts, proximal interphalangeal joints, distal interphalangeal

joints.

Muscle groups: Two radial and one ulnar muscle provide wrist extension. Intrinsic muscles of hand

attaching to metacarpals are involved in flexion (lumbricals), abduction (dorsal interossei), andadduction (palmar interossei) of the fingers.

Carpal tunnel: a channel between the palmar surface of the wrist and proximal hand, contains the

sheath and flexor tendons of the forearm muscles and the median nerve provides sensation to

palm and palmar surface of most of thumb, second and third digits, half of fourth digit, innervates

thumb muscles of flexion, abduction and opposition.

Flexor retinaculum: transverse ligament that holds the tendons and tendon sheath in place.

4. Describe how to assess the range of motion for the TMJ, shoulder, elbow, wrist, and hand joints and be able to

identify the principle muscles affecting movement.

TMJ - (muscles of mastication: the masseter, medial pterygoid, lateral pterygoid and the temporalis)Range of motion

is three-fold: Ask the patient to demonstrate opening and closing, protrusion and retraction (by jutting the jaw

forward), and lateral, or side-to-side, motion.

Shoulder- (SITS muscles) Watch for smooth, fluid movement as you stand in front of the patient and ask the patient

to

1. raise (abduct) the arms to shoulder level (90) with palms facing down (tests pure glenohumeral motion);

2. raise the arms to a vertical position above the head with the palms facing each other (tests

scapulothoracic motion for 60, and combined glenohumeral and scapulothoracic motion during adduction for the

final 30;

3. place both hands behind the neck, with elbows out to the side (tests external rotation and

abduction);

4. place both hands behind the small of the back (tests internal rotation and adduction). (Placing your hand on the

shoulder during these movements allows you to detect any crepitus.)

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Elbow - (Brachialis, Brachioradialis, Triceps brachii and Anconus, Supinator, With the patients arms at the sides

and elbows flexed to minimize shoulder movement, ask the patient supinate, or turn up the palms, and to pronate, or

turn down the palms.

Wrist- (wrist extensors and flexors)At the wrist, test flexion, extension, and ulnar and radial deviation.

1. Flexion: With the patients forearm stabilized, place the wrist in extension and place your fingertips in the patients

palm. Ask the patient to flex the wrist against gravity, then against graded resistance

2. Extension: With the patients forearm stabilized, place the wrist in flexion and put your hand on the patients dorsal

metacarpals. Ask the patient to extend the wrist against gravity, then against graded resistance

3. Ulnar and radial deviation: With palms down, ask the patient to move the wrists laterally and medially

Hand- (Extensors, Flexors, Thenar, Hypothenar) Test flexion, extension, abduction, and adduction of the fingers

1. Flexion and extension: Ask the patient to make a tight fist with each hand, thumb across the knuckles, and then

extend and spread the fingers. The fingers should close and open smoothly and easily. At the MCPs, thefingers may

extend beyond the neutral position. Also test flexion and extension at the PIP and DIP joints.

2. Abduction and adduction: Ask the patient to spread the fingers apart (abduction) and back together (adduction).

Check for smooth, coordinated movement.3. Thumb: Assess flexion, extension, abduction, adduction, and opposition. Ask the patient to move the thumb

across the palm and touch the base of the 5th finger to test flexion, and then to move the thumb back across the

palm and away from the fingers to test extension. Next, ask the patient to place the fingers and thumb in the neutral

position with the palm up, then have the patient move the thumb anteriorly away from the palm to assess abduction

and back down for adduction. To test opposition, or movements of the thumb across the palm, ask the patient to

touch the thumb to each of the other fingertips.

5. Describe the techniques to examine the temporomandibular joint.

Inspection and palpation: Inspect face for symmetry. Inspect TMJ for swelling or redness. (Swelling may appear asa rounded bulge about cm in front of the external auditory meatus). To locate and palpate the joint, place tips of

your fingers just in front of the tragus of each ear and ask pt to open his/her mouth. Fingertips should drop into the

joint spaces as the mouth opens. Check for smooth range of motion; note swelling or tenderness. Snapping or

clicking may be felt or heard in normal people.

Palpate the muscles of mastication:1) masseters - externally at the angle of the mandible; 2) temporal muscles -

externally during clenching and relaxation of the jaw; 3) pterygoid muscles - internally between the tonsillar pillars at

the mandible.

Range of motion and maneuvers:TMJ has glide and hinge motions in its upper and lower portions, respectively.

Grinding or chewing consists primarily of gliding movements in the upper compartments. Range of motion is 3 fold,

so ask pt to demonstrate all: 1) opening & closing, 2) protrusion & retraction (jutting jaw forward), 3) lateral (side-to-

side). [Note: Normally, as mouth opens wide, 3 fingers can be inserted between incisors. With normal protrusion of

the jaw, bottom teeth can be placed in front of the upper teeth.]

6. Describe the techniques to examine the shoulder.

p591-599

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Inspection.

Observe the shoulder and shoulder girdle anteriorly, and inspect the scapulae and related muscles posteriorly. Note

any swelling, deformity, muscle atrophy or fasciculations (fine tremors of the muscles), or abnormal positioning.Look

for swelling of the joint capsule anteriorly or a bulge in the subacromial bursa under the deltoid muscle. Survey the

entire upper extremity for color change, skin alteration, or unusual bony contours.

Palpation.

Begin by palpating the bony landmarks of the shoulder; then palpate any area of pain.

Beginning medially, at the sternoclavicular joint, trace the clavicle laterally with your fingers. Find acromion,

coracoid process, greater tubercle, biceps tendon in intertubercular groove.

To examine the subacromial and subdeltoid bursae and the SITS muscles,first passively extend the humerus by

lifting the elbow posteriorly. This rotates these structures so that they are anterior to the acromion. Palpate carefully

over the subacromial and subdeltoid bursae. The underlying palpable SITS muscles are:

Supraspinatusdirectly under the acromion

Infraspinatusposterior to supraspinatus

Teres minorposterior and inferior to the supraspinatus rupture of therotator

(The fourth muscle, the subscapularis, inserts anteriorly and is not palpable

Ask patient to flex/extend, abduct/adduct, internally/externally rotate.

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7. Describe the techniques to examine the elbow.

1. Locate and palpate ulna, olecranon process and bursa, medial and lateral epicondyles, ulnar nerve. Note

tenderness, swelling, warmth, redness, nodules.2. Assess range of motion:

a. flexion/extension

b. supination/pronation.

3.

4. Normal range of motion is:

5. Flexion 135+

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6. Extension 0-5

7. Supination 90

8. Pronation 90

9.

10. 8. Describe the techniques to examine the wrist and hands.

a. Observe hands for:

i. symmetry, swelling, erythema, deformities of wrist, fingers, angulation from radial or ulnar

deviation.

ii. thenar and hypothenar eminences.

iii. Note any thickening of flexor tendons, flexion contractures.

b. Locate and palpate

i. radiocarpal joint noting and swelling, bogginess or tenderness.

ii. anatomical snuffbox, the 8 carpal bones and the 5 metacarpal bones and proximal, middle

and distal phalanges.

iii. compress MCP joints noting swelling, tenderness, nodules or bo

physical exam final written exam study guide 2

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