What is the position of the heart?
Left of midline, above diaphragm, behind sternum. 3rd to 6th costal cartliages
What is the orientation of the heart?
Right side is more forward, enlarges in anterioposterior direction
What is the normal size of the adult heart?
12cm length x 8cm width x 6cm AP diameter
What are the atrioventricular valves and where are they located?
- Tricuspid - between R atrium and R ventricle
- Mitral - between L atrium and L ventricle
What are the semilunar valves and where are they located?
- Pulmonic - separates R ventricle from pulmonic artery
- Aortic - separates L ventricle from aorta
What is S1 and where is it best heard?
- 1st heart sound (lub), sound is caused by closure of atrioventricular valves, signifies systole
- Best heard at mitral and tricuspid precordial sites
What is S2 and where is it best heard?
- Second heart sound (dub), sound is created by the closure of the semilunar valves, signifies diastole (ventricular filling).
- Sound is louder at the aortic and pulmonic sites
With cardiomyopathy where will the PMI be located?
- to the left of the LMCL
- in 2 ICS in the same phase of respiration
What are the primary signs of cardiac disease?
- chest pain - men under sternum, women more general
- shortness of breath when supine/ on exertion; nocturnal
- ankle edema/neck vein distention
- easily fatigued
- cough, hemoptysis
- tachycardia, palpatations
- weight gain
What are the 5 precordial sites and where are they located?
- Mitral - 5th LICS, slightly medial to the LMCL
- Tricuspid - 4th LICS at L sternal border
- Erb's Point - 3rd LICS at LSB
- Pulmonic - 2nd LICS at LSB
- Aortic - 2nd LICS at RSB
What is the mitral landmark?
The cardiac apex - the PMI will be seen here
What is best heard at Erb's point?
Where should you check for lifts and heaves?
At the 5 precordial sites
What causes a murmur?
turbulent blood flow, often across a valve
What is stenosis?
When valve leaflets are thickened and bloods passage is narrowed so forward blood flow is restricted
What is regurgutation?
when a valve fails to close (the leaflets lose competency) and the slack openings allow backward flow of blood
What are the 8 characteristics of murmurs?
timing, frequency, location, intensity, radiation, quality, effect of respiration, effect of position
What are the 6 grades of murmur?
- I - barely audible
- II - quiet but clear
- III - moderately loud
- IV - louder
- V - very loud, heard with stethoscope partially off chest
- VI - very loud, heard with stethoscope fully off chest
What levels of murmur have a palpable thrill?
IV - VI
What and where are the main arterial pulses?
- External carotid - anterior to sternocleidomastoid along fold of jaw
- Carotid sinus - above thyroid cartilage
- Brachial - medial arm above anticubital fossa
- Radial - medial and ventral side of wrist (thumb side)
- Ulnar - lateral and ventral side of wrist (pinky side)
- Femoral - below inguinal ligament
- Popliteal - behind knee
- Dorsalis pedis - top of foot
- Posterior tibial - behind and inferior to medial malleolus of ankle
What is the scale for grading pulses?
- 0 - absent
- 1+ - diminished, barely palpable
- 2+ - normal
- 3+ - increased, full volume
- 4+ - hyperactive, bounding
What are signs of arterial insufficiency?
- intermittent claudication
- severe advanced perepheral artery disease
- arterial pulses diminished or absent
- color pale
- temperature cool
- skin thin and shiny
- no/mild edema
- hair loss on legs/toes/feet
- nails thickened brittle and ridged
What are signs of venous insufficiency?
- no pain/dull achy pain
- temp. normal
- normal or cynotic color
- brawny pigmentation
- ulceration (esp. at medial malleolus)
What is intermittent claudication?
Pain in calf, thigh or buttocks with activity and relieved with rest progressing to pain at rest. Caused by ischemia (decrease of O2 to muscle).
What is the order of examination in the abdomen?
Inspection, ascultation, percussion, palpation
What are the 4 quadrants of abdomen assessment?
right lower, right upper, left upper, left lower
What are the 9 quadrants of abdomen assessment? What is the advantage to dividing into 9 quadrants?
R&L hypochondriac, R&L lumbar, R&L inguinal, Epigastric, umbilical, hypogastric. Helps difine location of pain
What should be covered in abdominal inspection?
Symmetry and contour, umbilicus midline and inverted, peristalsis down and to the right, pulsation of abdominal aorta, venous network towards head above umbilicus, toward feet if below
What are risk factors of hepatitis?
IV drug use, tattoos, unprotected sex, incarceration
What are the two types of hernia?
- Reducible - contents of hernial sac easily replaced
- Nonreducible/incarcerated - strangulated, if blood supply to protruded contents obstructed becomes medical emergency
What are normoactive, hypoactive and hyperactive bowel sounds?
- Normoactive - irregular, high pitched clicks and gurgles every 5-15 seconds
- Hypoactive - low pitched, >every 15 seconds
- Hyperactive - high pitched, <every 5 seconds
What is paralytic ileus?
a lack of motion in the bowel, when no bowel sounds are heard for 10 minutes
What would you expect when percussing abdomen?
Overall tympany with dullness over organs
What is the normal liver span?
6-12cm in RMCL, 4-8cm in MSL
What is costovertebral angle tenderness?
sharp pain with kidney or paranephric inflammation
What does the lower liver border do with deep inspiration?
It descends below the right costal margin
What is osteoporosis?
porous bones, loss of bone density
What are risk factors for osteoporosis?
- small frame
- short stature
- family history
- diet deficient in CA++ and vitamin D
- prolonged corticosteriod usage
- sedentary lifestyle
- chemo or breast cancer
What is the difference between osteoarthritis and rheumatoid arthritis?
- Osteoarthritis - degeneration of movable joints causing deterioration of articular tissue and new bone formation, asymmetrical, crepitus, joint enlargement
- Rheumatoid - chronic inflammatory disease, symmetrical, constitutional symptoms, swelling
What is distal kyphosis?
hunchback. often occurs with osteoporosis
What is lordosis?
Swayback - accentuation of concavity in lower back
What is scoliosis and how is it assessed?
lateral deviation of the spine, assessed with forward flexion
What is the scale for measuring muscle strength?
- 0 - no contraction
- 1 - contraction but no movement
- 2 - passive ROM without gravity
- 3 - AROM
- 4 - AROM with light to moderate resistance
- 5 - AROM with full resistance
How do you assess cranial nerve X (spinal accessory)
put hands on shoulders and have patient shrug (checks trapezius muscle)
What are the types of range of motion of joints?
- active assistive
What is ankylosis?
abnormal joint mobility and consolidation
What are the types of joints?
- ball and socket - shoulder, hip
- hinge - elbow, ankle, knee
- saddle - thumb
- gliding - foot
- pivot - neck
- slightly movable - vertebral
What are sports medicine recommendations to prevent injury?
warm up, exercise at least 150min/week in 20 min intervals, cool down
What are the 5 assessment components of a neuro. assessment?
mental status, sensory system, motor system, reflexes, 12 pairs of cranial nerves
What is the order of neuro. loss?
- sensory, motor, autonomic - bowel, bladder, sexual.
- Recovery if effective occurs in reverse order
What are 6 parameters evaluated in formal mental status evaluation?
- spatial perception
what behaviors should be noted to evaluate emotional status?
- inability to sense emotions in others
- loss of sympathetic reactions
- unusual docility
- rage reactions
- excessive irritability
What are tests of cognitive abilities?
- State of conciousness
- attention span
- abstract reasoning
- arithmetic calculations
- thought processes and content
What are the levels of consciousness?
- alert and oriented to time place and person
- awake (may sleep more or be somewhat confused when first awakened)
- Lethargic (drowsy but able to follow simple commands)
- Stuporous (very hard to arouse, inconsistantly may follow simple commands or speak short words/phrases)
- Semicomatose (movements purposeful when stimulated, does not follow commands or speak clearly)
- Comatose (reflexive posturing or no response)
What is tested in a quick orientation and short term memory assessment?
- orientation to person
- orientation to place
- orientation to time
- short term memory of facts
- short term recall
What are signs of possible cognititive impairment?
- significant memory loss
- difference in personality
- hazardous behavior
- getting lost in familiar places
- impaired communication
- nocturnal confusion
- personal self care difficulties
- rambling speech
- catastrophic reactions (rage)
How do you apply stimulus to test sensory system?
side to side, distal to proximal with patient's eyes closed
What cranial nerve innervates sensory reception on the face?
Cranial nerve V
How do you test primary sensory functions?
- Light touch with a wisp of cotton
- sharp and dull sensation
- vibratory sensation
How do you test cortical sensory functions?
- stereogenesis (ability to recognize familiar objects by feel)
- graphesthisia (ability to id shapes, # or letters traced onto palm)
- two point discrimination
What is a tandem walk
- tests motor system (cerebellar) function
- heel to toe walk
What is a romberg test?
- patient stands, feet together with arms at sides, with eyes open and then closed for 20-30 seconds
- + with staggering or loss of balance
What are locations for deep tendon reflexes?
tricep, bicep, brachioradialis, pateller, achilles
What spinal nerves are tested in the biceps reflex?
What spinal nerves are tested in the triceps reflex?
What spinal nerves are tested in the brachioradialis reflex?
What spinal nerves are tested in the patellar reflex?
What spinal nerves are tested in the achilles reflex?
How do you score deep tendon reflexes?
- 0 - no response
- 1+ - sluggish, diminished response
- 2+ - active or expected
- 3+ - slightly hyperactive
- 4+ brisk, hyperactive
What kind of reflex is the plantar reflex and what spinal nerve does it test?
superficial, tests L 4,5, S1,2
What is the babinski sign?
- A response to the plantar reflex
- Expected in adult - all toes curl down
- Positive in adult - big toe dorsiflexes and other toes fan
- Expected in children under 2 - big toe dorsiflexes and all other toes fan