ࡱ>  giZ[\]^_`abcdef` <bjbjss TDDD\ ii0Fj&֌ hhhhhhh$khmikkki#ik+hkh$2p^$ N|\D[(N^T 9i0ii&QJ nn4p^np^$4ii)iikkkkd Respiratory system and breast exam - TEST 1 Respiratory Exam Part of a complete physical exam Complaints Risk factors Magnitude of Pulmonary Ds. (disease) 1998 (you will not be tested on numbers) 5 mill some degree of Pulm Ds. 20 mill people c/o symptoms 112,584 deaths due to COPD Due to smoking now Chronic bronchitis (3 months of chronic cough for 2 consecutive years) and emphysema will cause this disease state 91,871 deaths due to pneumonia/flu Sedentary and hospitalized patients get this more often 5,400 deaths due to asthma 164,100 new cases of lung cancer 156,900 deaths ****Risk Factors for the Respiratory System**** Gender: plays a role in younger individuals > Males, difference decreases w/aging Age: increases with advancing age By the age of 60 to 70 the ratio is 1:1 By the age of 50, 50% of adults in this country have arterial stenosis Family Hx: Asthma, CF (cystic fibrosis), TB, other contagious diseases; neurofibromatosis TB - immediate family can be influenced more if one person has it. There has been a gene found that can increase sensitivity Neurofibromatosis - the respiratory system is not the first place that this ds attacks. Attacks the neuro skeletal system first Smoking Sedentary life-style/immobilization Can't take in deep breaths Cellular activity creates bi-products, however they cannot be cleared out by a cough and so forth when immobilized Occupational Exposure Extreme Obesity Pickwickian syndrome - diaphragm elevated causes an effect on gas exchange, this causes person to fall asleep Difficulty swallowing Weakened chest muscles Hx. Of frequent respiratory infections Severe cardiovascular disease Relevant history Employment (exposure to irritants) Inhaled irritants at work Home environment (allergens) Animals, plants, chemicals Tobacco (pack yrs=#yrs X #packs/day) Exposure to respiratory infections Nutritional status Health, over or under weight Travel exposures Hobbies (exposure to irritants) Use of alcohol Use of illegal drugs Exercise tolerance Immunizations (TB) Current chest x-rays Symptoms of the Respiratory System Cough Productive vs Non-productive Hemoptysis (coughing up blood) Dyspnea (SOB) Cyanosis Wheezing Chest Pain Stridor (noisy breathing) Voice changes (vocal cords) Apnea Swelling of the ankles (dependent edema) (right side of heart issue possible) < These can be symptoms of a cardiac disorder too > MOVIE SHOWN from BATES Table 6.3******* Table 6.6******** Describe the coughis it dry, hacking, nocturnal. Is there sputum associated with it? Is it moist, dry Descriptors of Coughing Dry, hacking - early stage viral infection, smoking, viral pneumonia may start as this Chronic Productive / non-productive - chronic bronchitis, bronchectasis Wheezing - bronchio spasms (asthma), too much fluid (pneumonia), tumor, COPD, Barking - Croup (usually not associated with a high fever and does not have extensive mucous production) Moist warm air will help alleviate this, then use cold air to sooth the bronchioles **Stridor - noisy breathing, inspiratory in nature, can be caused by partial obstruction of the trachea or bronchiole (this is emergency) Morning - smoking, post nasal drip Nocturnal - smoking, post nasal drip (could be sign of congestive heart failure) Associated w/ intake - a problem with the esophagus usually Inadequate - Severity of Coughing Acute inflammation Mucoid sputum - mycoplasm, pneumococal Purulent sputum - klebsiella (red sticky jelly like) Bacterial pneumonia Conditions associated with blood and those not********* Chronic Inflammation Chronic Bronchitis Bronchiectasis - chronic cough and seen with cystic fibrosis Post nasal drip Pulmonary tuberculosis - at first a dry cough and no symptoms, then it becomes mucoid and possible purulentthen night sweats, fever, fatigue.then anorexia Lung Abscess - sputum purulent and foul smelling (may be bloody) ***Asthma - cough, with thick mucoid sputum, especially at night or early in the morning Gastroesophageal reflux - chronic cough, especially at night or early in the morning Neoplasm Cancer of the lung - cough, dry to productive (blood streak or bloody), usually associated with a smoking issue Cardiovascular disorders Left ventricular failure or mitral stenosis*** Questions relative to conditions with blood and those not associated with blood, pulmonary edema, chronic bronchitis, asthma, pulmonary tuberculosis, post nasal drip******* Chronic bronchitis - know the definition from the first part of the notes Hemoptysis Onset (sudden or recurrent) How often, whne did it start Descriptor (blood tinged, clots) History of smoking, infections, meds, surgery, (females - oral contraceptive) Associated symptoms Hemoptysis vs Hematemesis Hemoptysis vs Hematemesis**** Hemoptysis - coughing up blood Coughing Hx of CR disease Frothy Bright red Mixed w/pus Dyspnea Hematemesis - throwing up blood Nausea/vomiting Hx. Of GI disease Airless Dk red, brown or "coffee ground" Mixed w/food Nausea Table 6-2 What makes it better, worse position wise? Activities, symptoms, any other conditions, environmental, Exertional, positional, environmental Has there been treatment Dyspnea on Exertion (DOE) Grading 1-5 1 - excessive activity 2 - moderate activity 3 - mild activity 4 - minimal activity 5 - rest Dr. Degeer General Approach Sheet (read examination of the thorax carefully) Patient should undress to the waist Inspect, palpate, percuss, and auscultate Compare both sides & develop a pattern as in from the apices to the bases of the lungs Visulize under lying tissue Examine the posterior seated Fold patients arms across the chest , this way you do not loose points on comp boards Supinate patient for anterior chest exam Wheezes are more audible Peripheral Signs Posture - usually used to ease breathing problems Seated leaning forward using arms to raise up Pulmonary edema - when sleeping the fluid tends to accumulate around the heart, causing pressure (in the end they sleep with multiple pillows) (could be associated with left sided heart failure which causes R sided heart failure) Patient will wake up with possible angina, and sit up making the fluid going to the bottom of the lungs. PND (paroxymal nocturnal dyspnea) - this is the term for what is happening Orthopnea - associated with dyspnea when the patient lays down Facial expression - look into the eyes Use of accessory respiration muscles Diaphragm, intercostal, serratus anterior, pec minor, SCM, scalenes, abs Clubbing of nails COPD Cyanosis Too little O2 in circulation Central cyanosis is most dangerous Look inside mouth and look at the color of mucosa and tongue (red/blue) Cardiovascular disorder Peripheral cyanosis is nothing to worry about (happens when in cold room) Clubbing of Nails (caused by chronic condition) Intrathoracic Tumors Congenital heart malformations Mixed venous-to-arterial shunts Acquired cardiopulmonary disease Chronic pulmonary disease Emphysema - caused by smoking Chronic hepatic fibrosis Inspection of the Chest/Thorax Note shape & movement of chest Using accessory muscles (could indicate severe lung disease) AP diameter may increase in COPD Pg 222 @ beginning of initial survey Observe effort of breathing Rate, rhythm, depth, audible sounds Children & men use abdomen to breathe more Women breathe more shallow (using thoracic) Note any skin lesions Slope of ribs and motion Symmetrical with no retraction or lag Pathology could be present if they are not symmetrical Ds. Of chest expansion/lag Chronic fibrotic disease (lung or Pleura) Pleural effusion - fluid in pleural space Pneumothorax - air in pleural space Lobar pneumonia Pleural pain (splinting) Unilateral bronchial obstruction Decreased Expansion or lag Obesity - MORBID (bilateral) COPD - bilateral Diaphragm issues - elevation of the diaphragm Ascites organomegaly Know the anatomy of the chest and Lungs RML, RUL, RLL At the 5th rib mid axilary line is the horizontal fissure RML cannot be ausculated on the posterior LLL, LUL Heart Lungs go to about T10 on Posterior aspect Landmarks? Manubriosternal junction - 2nd rib and space Trachea bifricates at T4 Apex of lungs inch and a half above the 1st third of the clavicle Know the 9 LINES TABLE 6-4 Barrel chest Chronic emphysema Funnel Chest (pectus excavatum) Congenital anomaly (cosmetic) Could cause breathing problems and heart problems Depression of the lower sternum Pigeon Chest (pectus Carinatum) Ribs cause sternum to point outward Can be related to other skeletal problems Congential (cosmetic) Thoracic Kyphosis Traumatic flail chest When patient gets several rib fractures (trauma) A section of the thorax is loose, so when the patient breaths you can see this part suck in and move out (paradoxial movement) appears on inhale and exhale due to pressure changes Table 3-12 - rate & rhythm of breathing Normal 12-20 BPM 30-60 BPM in New Borns Rapid Shallow Breathing (low volume) Tachypnea Volume of air is limited Pleuritic chest pain (can be from pneumonia) Elevated diaphragm Rapid Deep Breathing (larger volume) Hyperventilation (natural physiologically) when exercising Asthma attack Metabolic acidosis can cause this (Kussmal Breathing) Midbrain/pons when effected Slow Breathing Bradypnea Alkalosis Diabetic coma, drugs, respiratory depression, intracranial pressure Cheyne-stokes breathing Hyperpnea then apnea (periods of deep breathing followed by no breathing) Seen in older adults and children ***Heart failure can cause this Sleep apnea Obesity Ataxic Breathing Can be unpredictable (Biots breathing) Sighing Respiration A deep breath in the middle of normal breathing Used to get rid of CO2 Obstructive Breathing Causes prolonged expiration and air trapping due to airway resistance Inspiration is more than expiration volume Due to obstructive lung disease (asthma, chronic bronchitis, emphysema, COPD) Influences of rate & depth of breathing Increase with: Acidosis CNS lesions-Pons Anxiety, pain Hypoxemia Aspirin poisoning (acid) Decreases with: Alkalosis CNS - Cerebrum Severe obesity Myasthenia gravis Narcotic overdose (heroin, morphine) Palpation of the Chest and Thorax Tender areas Evaluate skin lesions, abnormal bulges or depressions Determine tracheal position (midline?) Assess chest expansion (rib excursion) (respiratory lag) Place thumbs at T10 and view them as they inhale and exhale Tactile (vocal) fremitus Estimate level of diaphragm Chest Expansion Posterior: 3-4 cm on inspiration @ T10 Anterior: Apex - symm. Slight motion Upper lobe ribs 2 & 3 - (1-2 cm motion) Lower lobe ribs 5 & 6 - (2-3 cm motion) Lateral: depends on levels and look for symmetry Tracheal Deviation*** Displaced: Atelectasis - distal part of respiratory tree is collapsed (pulled) Fibrosis - scar tissue in the lung, could make lung smaller (pulled) Thyroid enlargement - tumor (pushed) Pleural effusion - if a lot of fluid could push lung (pushed) *Pushed: Tension pneumothorax Tumor Nodal enlargement Large pleural effusion *Pulled: Tumor (infiltrative(, open pneumothorax, fibrosis Pushed posterior: Mediastinal tumor Pushed anterior Mediastinitis Tactile or vocal fremitus Palpable or auditory vibration of chest wall resulting from speech or other verbalizations "99", "1,1,1" Ulnar surface of the hand, MCP, Pads Simultaneous or alternating side to side, down and across Pneumothorax - hyperresonant Pleural effusion - dull (decrease transmisson) There are 4 areas, compare side to side Increased (localized) Pneumonia (consolidation - tissues infiltrated) Atelectasis (upper lobe) - AIRLESS LUNG, mucous plug, Large Tumor (size & area dependent) Decreased (unilaterally) Pneumothorax Pleural effusion Obstructed bronchus Infiltrative tumor (severity dependent) Atelectasis (lower lobe) Decreased (bilaterally) Soft speech Thickend chest wall COPD Chronic bronchitis Severe asthma or during an attack Emphysema Estimate level of the diaphragm Approximation through tactile fremitus Abnormally high: Pleural effusion Paralysis of diaphragm Organomegaly Phrenic nerve damage Atelectasis (Lower lobe) Percussion (pg 225) Creates sound waves that travel inward 4-7 cm deep **Percussion note (DIP, Duration, intensity, pitch) Know the chart on pg 225 Flatness, dullness, resonance, hyperresonance, tympany Know the sound and why this sound would be present Flatness - large pleural effusion Dullness - Lobar pneumonia, pleural effusion Resonance - bronchitis, tumor, cancer **Hyperresonance - emphysema, pneumothorax, asthma attack Tympany - large pneumothorax Diaphragmatic excursion Level between the resonance / dullness on full inspiration vs expiration. (3-6cm) different from pg 226 which says different ranges Decrease B/L: emphysema, thickened chest wall, elevated diaphragm, ascites, B/L organomegaly, B/L collapse Pregnancy could also cause the elevated diaphragm Decrease U/L: same conditions as Lag - U/L pleural effusion, pneumothorax, bronchial obstruction, organomegaly, consolidation Absent: inflammation of diaphragm or visceral below, phrenic nerve palsy KNOW THE UNDERLYING ANATOMY OF THE CHEST***** Auscultation of lungs Breath sounds Pg 227 Auscultation is performed in the across down method Breath sounds (type, intensity) Adventitious sounds Vocal resonance Bronchophony Egophony Whispered Pectoriloquy **4 breath sounds (note location) - due to vortices, narrowing, recoil, Tracheal - heard over the extra thoracic trachea, harshest loudest sound, high pitch, inspiratory component is equal to the expiratory component Bronchial - over the manubrium if heard at all, loud, relatively high pitched, expiratory sounds last longer than inspiratory, 3-1 ratio Bronchovesicular - often in the 1st & 2nd interspaces anteriorly and between the scapulae, intermediate intensity and pitch, inspiratory and expiratory sounds are about equal Vesicular - Over most of both lungs, soft intensity and low pitch, inspiratory sounds last longer than expiratory ones, 3-1 ratio, (white breath or quiet sounds) Pneumonia can change the sound location Breath Sounds intensity Increase Pneumonia w/ consolidation Atelectasis in the UL or adj. Bronchi ? Diffuse fibrosis Could enhance sounds or diminish sounds in the end stage Decrease COPD Chest wall weak Pleural effusion Pneumothorax Bronchial obstruction Thickened wall Atelectasis in lower lobes ? Diffuse fibrosis This is at the end stage Vocal Resonance pg 240 Transmitted voice sounds "99", "1,1,1" When abnormal breath sounds is heard may help to further delinate the area Enhance: consolidation, airless lung Decrease: blockage of respiratory tree, overinflated lungs, thickend chest wall, pleural involvement Bronchophony - 99 Egophony - E will sound like "ay" with consolidation Whispered Pectoriloque - will be louder and clearer if fluid is present Adventitious Sounds pg 240 (table 6-6)**** Superimposed on the breath sounds (will ask about the conditions associated with sounds) **Crackles (rales) - (interrupted sound) Explosive sound - interstitial lung disease such as fibrosis or early CHF (airbubbles going through lightly closed airways in respiration PNEUMONIA Fibrosis (interstitial lung disease) Asthma Bronchiectasis Early CHF Pleural friction rub (interrupted sound) Pleural crackles - (this could also occur with air in the pericardium) Associated with pain If too much fluid or space, you will not hear this Pneumothorax Pleural effusion Wheezes & Rhonchi (constant) **(know generalized vs localized)******** When air flows rapidly through narrowed airways Generalized Asthma COPD (emphysema) CHF Chronic bronchitis (rhonchi - larger airways) Localized ****Tumor - everything could be normal, yet localized wheezing could be present Stridor (constant) Inspiratory in nature, and is due to PARTIAL obstruction to larynx or airway (emergency situation) Pleural friction rub (pleural space condition) Pneumothorax - dependent on how close the pleural layers are next to each other Small pleural effusions - mesothelioma, neoplasia in pleural space, bacterial or viral infection that gets into the pleural space (pleurisy) Lab Note - IPPA (inspection, palpation, percussion, auscultation) *(CA- cross arms) I - Trachea inline, retraction (clavicles), muscles in use, skin, clubbing of nail, chest shape P -Tactile Fremitus (CA), Rib fracture, Chest expansion P - Diaphragmatic excursion (CA), normal percussion apex to base (CA) A - Breath sounds (CA), Adventitious sounds, Transmitted voice sounds (CA) BATES MOVIE SHOWN Breath sounds Duration Long, short, continuous, interrupted Pitch High Low - normal breath sound Location Chest wall surface R or L side Relative to bony structures and landmarks Anatomy Apex - 2.5 cm above the clavicles Trachea bifricates at sternal angle 2nd rib and intercostal space KNOW THE LANDMARK LINES Inferior border of scapula at 7th vertebra Position can effect what you hear Abnormal breath sounds are audible when the lung tissue changes Bronchial breathing Diminshed sounds TV (transmitted voice sounds) Bronch Egoph Whisp Atelectatic only in the upper areas Early stage pneumonia - crackles NOT all pneumonia's will have consolidation (fluid) KNOW TABLE 6-7 Will not be tested on X-rays Respiratory Exam Hx of chief complaints Peripheral signs Posture, facial expression, use of accessory muscles of respiration, clubbing of finger/toes, cyanosis Inspection Note chest shape & movement Observe effort of breathing - rate, rhythm, depth Note skin lesions, scars, vessels Palpation Tender areas Evaluate skin lesions, abnormal bulges, depression Tracheal position Chest expansion Tactile fremitus Level of diaphragm Percussion Percussion note Flatness (thigh), dullness, resonance (normal), hyperressonance (emphysema), tympany (area of contained air, gastric air bubble, pneumothrax) Diaphragmatic excursion 4-6 cm 3-6 cm (lab) Auscultation Breath sounds Tracheal, bronchovesicular, bronchial, vesicular KNOW WHERE TO FIND THESE NORMALLY Adventitious sounds Crackles/rales Wheezes Rhonchi Mediastinal crunch Stridor Vocal Resonance (Transmitted Voice) Bronchophony Egophony Whispered Pectoriloquy Normal Lung Inspection: EN (essentially normal) - no clubbing or accessory muscle use, trachea inline Palpation: Percussion - resonant & 5 cm of Diaph. Excursion Ausculation: vesicular sounds and no adventitious sounds Bronchitis - inflammation (bacteria low grade fever) Inspection: N to Occassional Tachypnea Shallow breathing Palpation - normal Percussion: resonant Auscultation: prolonged expiration, occasional wheeze and crackles Chronic Bronchitis COPD Inspection: Resp distress, wheezing, cyanosis, Increased JVP (jugular vein dilated) Palpation: dec. fremitus, dec. diaphragm motion Percussion: N to diffuse Hyperresonace Auscultation: Normal to prolonged expiration, Dec. breath sounds, wheezes, crackles, rhonchi X-ray - normal Emphysema (obstructive pulmonary disease) Inspection: tachypnea, dyspnea, pursed lips, potentially barrel shaped chest, weight loss Palpation: dec. fremitus, hyperinflation Percussion: diffuse Hyperresonance, dec diaphragmatic excursion (possible to T10) Auscultation: prolonged expiration, decreased breath sounds, ?Wheezes, crackles Asthma Inspection: Tachypnea & dyspnea Palpation: Tachycardia & dec fremitus Percussion: N to diffuse Hyperresonance Auscultation: Prolonged expiration, dec. breath sounds, wheezes, crackles History - shortness of breath when I exercise, seems like I cannot catch my breath, then I start coughing, its a whitish grayish color Pneumonia w/ consolidation Inspection: Tachypnea, Occasional cyanosis & nasal flaring, splinting Palpationl: inc fremitus Percussion: dull Auscultation: inc breath sounds, bronchophony, crackles, occ rhonchi Atelectasis Ins: tachypnea, dsyppnea, resp. lag, Narrowed ICS Pal: Tachycardia, Dec/inc local fremitus, tracheal shift Per: dull Aus: (upper lobe) bronchial br sound, (lower lobe) dec/absent br s, wheezes, rhonchi, crackles Pleural effusion Ins: dys, resp lag Pal: Tachycardia, dec. fremitus, contralateral tracheal shift Per: Dull to flat Aus: Dec. breath sounds, bronchophony above, ?friction rub Breath Sound Duration Long Short Continuous Interrupted Pitch High Low (normal) Location ID Chest wall surface R/L side ID relative to bony structures and anatomic landmarks Anatomic landmarks of reference: Trachea bifurcates at sternal angle 2nd rib & 2nd intercostal space Midclavicular Midsternal lines Ant axillary line Mid axillary line Post axillary line Scapulae Mid-scapular line Sound matching Areas of well-matched media will increase transmission of sound (eg. Consolidation of lung tissue) Areas of differing media will decrease transmission of sound (eg. Air in lung tissue-- pneumothorax) Wheezes (adjectives) Monophonic Polyphonic Found over consolidated areas: Bronchial breath sounds Louder, higher pitch w/ expiratory lasting longer than inspiratory Bronchophony Louder, speech not as muffled, higher pitch Whispered pectoriloquoy Louder, sound is clearer Egophony E sounds like A BREASTS EXAM Part of a complete physical Mass - 70% of complaints are form this Pain Nipple discharge/deviation Risk factors This exam is usually not performed. Dr. M recommends that they see an OBGYN for a complete exam on the Urogenital system Problems due arise when patients complain about this being part of every exam Breast cancer most common cancer in women, 2nd reason for death in women Men can get breast cancer too - but are unaware that they can get it, so they get a worse off case than the women General Considerations In the USA in 2000 1 in 8 women developed breast CA m/c CA to develop (26% of new CA) 2nd m/c of death (18% of death) in males Risk Factors of Breast Cancer (pg 303) Gender: female Family history Early menarche (before age 12) Late menopause (after age 50) Late age birth of first child (after age 30) Increased breast tissue Lab evidence of specific genetic mutations (BRCA1 and BRCA2) Estrogen replacement tissue No pregnancy Risk Factors benign breast cancer Early menarche (before age 12) Late menopause (after age 50) No pregnancy Late age birth of first child High socioeconomic status Caffeine consumption (controversial) Breast Masses Location Onset (when, how, change) - is it bigger during different times in the month 80 to 90% of women have fibrocystic change, usually not symptomatic, but gets larger during menses Pain (tenderness) pattern Skin lesions, color variations Nipple change Retraction or deviation Pagets Syndrome - associated with a rash Disease of the nipple This is an uncommon form of breast cancer that usually starts as a scaly, eczemalike lesion. The skin may also weep crust or corode. Very aggressive type of carcinoma Edema of the skin Edema of the skin is produced around the nipple on the breast due to lymphatic blockage Called peau d'orange Nipple Change Discharge Depression or inversion Deviation Discoloration Dermatolgical changes Nipple Discharge Location: unilateral/bilateral Onset Sometimes stress Describe change/discharge Related to menses Medications/oral contraceptives Associated symptoms Types of discharge Serous - thin& watery, may appear as a stain: intraductal papilloma, tumors, b/l - oral contraceptives Bloody: malignant in intraductal papillary carcinoma Milky: late pregnancy, persistant lactation, pituitary tumor, certain tranquilizers Breast Pain Location: Unilateral/bilateral OPPQRST Pattern Associated Symptoms Gross cysts Fibrosis Pain From Chart in Book Retraction signs Changes in contour of nipple Skin Dimpling Edema of skin Abnormal contours Nipple retraction or deviation Gross cyst - more well defined, mobile, round, often tender Fibrocystic change - nodular or rope like Taking A picture of the breast tissue Mammography - must be recalibrated constantly If women are in a high risk category then they should get a mammogram every year. Diagnostic Ultrasound & MRI are other ways. Sitting position Pagets disease or carcinoma could cause ulceration of nipple Shaving & use of deoderant can cause central lymphnode calcification Breast Exam Procedures Inspection Comparing Palpation Axillary lymphnode evaluation Inspection: Breast Tissue Sitting & Supine Number, size, shape, symmetry, edema, dimpling, redness, thickening of skin, prominent vessels, rashes Slight asymmetry in size is normal Look for moles or extra nipples Inspection: Nipples Size, shape, symmetry Discharge Depression or inversion (this is normal is they have had it for ever) Deviation Discoloration Dermatologic changes Accentuate Changes - inspect (pg 307) Raise arms over head - stretches pects Press hand against the hips or pressing hands together - contract pects Leaning forward with arms out stretched from waist Palpation of Breast Tissue Seated - bimanual Supine - pillow under ipsilateral shoulder Systematic palpatory approach to assess all breast tissue Optimal exam time frame 5-10 days after the onset of menses Linear Method (lawn mower) Concentric circles Strip method You may use powder or lotion, but use two to three fingers, as the breast is palpated use dime size circles If no breast tenderness, start light and then go deep Do not lift off the breast as you move the palpating fingers Note consistency of tissue -N varies widely with physiologic nodularity noted in most women Tenderness, masses, skin temperature If mass is noted document accordingly as follows: Quadrants Face of clock Documentation of Breast Mass (Pg 309) Location: clock or qudrant method w/ distance noted from nipple Size: length, width, thickness Shape: round (better sign), discoid (fibroadenoma or multiple growth cysts), lobular (fibroadenoma), stellate (not a good sign) (regular or irregular shape) Stellate is not well deliniated from the surrounding breast tissue usually Tenderness: severity Usually more indicative of a physiological situation such as fibro cystic change or gross cysts) IF MASS IS PRESENT - try to squeeze it (is it MOBILE?) Consistency: firm, soft, (normal) hard (not a good sign if loccalized) Borders:: discrete or poorly defined Mobility: moveable (in what direction) fixed to overlying skin or underlying skin or fascia Retraction: presence or absence of dimpling or contour If a mass is immobile with the patient's arm relaxed, it is attached to the ribs & intercostal muscles *****(pg 309)*******NB & her test If a mass becomes fixed when the pt. Presses her hands against her hips, the mass is attached to the pectoral fascia *****(pg 309)***** Nipple & Areola Examination Inspections of 5 D's Deviation, dermatological changes, discharge, depression, discoloration Palpation: note thickening, pain Gently compress or strip nipple Note any discharge Lymph Node Assessment Axillae Inspect: Note any rashes, infection or unusual pigmentation Palpate: make sre patient's arm is relaxed Pectoral (ant/med aka central) Ant chest wall ant lateral breast Lateral wall Most of the arm drained Post axillary wall (subscapular) Infraclavicular Supraclavicular Intramamillary node - goes form one side to another connecting breasts Metastasis can occur into the clavicular nodes Lung , Breast, GI Enlarged axillary nodes from infection, recent immunization, neoplasia, or generalized - check epitrochlear. Nodes that are large (>/= 1 cm) and firm or hard, or matted or fixed to underlying tissue or skin suggest malignant involvement. Why, when & how she should perform the exam COMP BOARD QUESTION 1 in 8 women get cancer in their life time, once a month and 5 - 10 days after the onset of menses, First inspect in mirror & look for asymmetry or variance in tissue. Place hands above headany change? Hands against hips Lean forward In a circular pattern do small dime like circles palpating light then deep. Through out the breast. Look at nipple and see if there are any of the 5 d's also strip the nipple lightly Explain what you are doing while doing the breast exam - there is always a lump (define the lump) - definitely needs to follow with a lymph exam. ------------------------------------------------------------------------------- TEST 2 CARDIAC CONDITIONS Chest Pain OPPQRST & Assoc Sx, Treatments Differential Cardiovascular Aneurysm, emboli, LEVINE'S SIGN, Respiratory Pleural effusion Gastrointestinal Ulcers, GERD, cholecystitis, Chest wall syndrome subluxation, ribs Psychogenic Table 6-1 The most common causes of cardiovascular problems **4 problems** Q & NB Heart Ischemia Angina Pectoris (temporary ischemia) - due to the fact that cardiac work cannot keep up with the demand of O2 needed Retrosternal, across chest and to shoulders, arms, neck, lower jaw, ***When the pain is myocardial in origin the patient tends to close the fist and push it against the chest wallthis is called LEVINE'S SIGN Tight, heavy occasionally burning pain that is mild to moderate in quality Usually lasts 1-3 min, but up to 20 min Exertion, meals, emotional stress, may occur at rest - All these factors aggravate Nitroglycerine = relieve Heart muscle Myocardial infarct Irreversible tissue damage due to prolonged ischemiacould lead to necrosis A more severe pain than angina Pain Lasts longer than 20 min to several hours (this is from a surviving victim (27% or so die immediately) Things that aggravate or relieve are the same Pericardial Sac inflamed Pericarditis Often severe pain Inflammation of the pericardium Breathing, laying down, rest ONLY TWO CONDITIONS MANIFEST FOWLERS CONDITION Fowlers condition = is sitting up leaning forward Pericarditis & Pulmonary Emboli are the two conditions Aorta Aortic Aneuryism Splitting within the layers of the aortic wall RIPPING OR TEARING pain Lose consciousness, weakness, abrupt onset SEVERE pain Palpitations Uncomfortable sensation of heart beats associated w/ various arrhythmias Onset, duration, # of episodes, quality Associated factors: exercise, chest pain, headaches, sweating, dizziness, heat/cold intolerance, alcohol or caffeine usage, medications Conditions Thyroid problems Thyroid hormones have two effects Protein Synthesis - T3, T4 influence the formation of protein O2 consumption also is effect by the basal metabolic activity Hypoglycemia Decreased glucose releases catecholamines Severe Anemia Increased cardiac activity w/ decreased O2 in blood Stress or anxiety Bronchodilators, digitalis, antidepressants, stimulants Heart blocks Effect the conductivity Pre-excitation syndromes Will parkinsons white syndrome These conditions could be pathological, but not always Cough & Hemoptysis Onset (sudden, recurrent) Descriptor (blood tinged, clots) History of smoking, infections, meds, surgery, ( females - oral contraceptives) Associated symptoms Hemoptysis vs hematemesis (vomiting w/ blood) Cardiovascular disorders Left ventricular failure or Mitral Stenosis May progress to the pink frothy sputum of pulmonary edema or to frank hemoptosis Pulmonary Emboli Can lead to deep vein thrombosis Dyspnea Onset (when, mode, progression) Palliative - what makes it better Provocative - (exertional or positional Pattern Associated symptoms Associated conditions Respiratory problems Left sided heart failure - dyspnea on exertion Dyspnea on exertion GRADING 1-5 Excessive activity Moderate activity Mild activity Minimal activity Rest Positional Dyspnea Paroxysmal nocturnal dyspnea (PND): Sudden onset occuring while sleeping relieved by assuming upright position Orthopnea: lying flat requires > pillows Trepopnea: more comfortable on side Platypnea: problems sitting up, pt. Breaths easier in recumbant position Dyspnea of Rapid Onset Pneumonia, pneumothorax, pulm constriction, peanut (foreign object) Cyanosis (bluish discoloration) Central Dec. O2 in lungs Severe C/R ds Lips, oral mucosa, nail beds > with warming Peripheral Venous Stasis Diabetics are more prone to this due to occlusion Exposure to cold Nail beds, nose, lips < with warming Syncope (fainting) (LOC)- loss of consciousness Onset Has it happened before? Pattern? Did they actually lose consciousness? Activity at the time Position before and after Preceding symptoms or warning signs Medications Syncope Cardiac Pulmonary Pyschogenic Metabolic Neurologic medications From Chart in Book Vasodepressor Syncope Sudden peripheral vasodilation, especially in the skeletal muscles, without a compensatory rise in cardiac output. Blood Pressure falls Postural Hypotension Patient may black out or become unsteady Inadaquate vasoconstrictor reflexes Cough Syncope Associated with increase intrathoracic pressure which decreases the venous return to the heart Cardiac disorders Arrythmias Decreased oxygenated blood to brain Aortic stenosis and Hypertrophic cardiomyapathy MI Massive pulomonary embolism ***Know the above that cause syncope Dependent Edema Accumulation of excessive fluid in the interstitial tissues System differential: Cardiac, Kidney, Liver, Peripheral Vascular System ds. Pitting edema, swelling with chronic insufficiency Onset, U/L (vascular system) or B/L (cardiac, kidney, liver), timing palliative or provocative, associated symptoms, ulcers/discoloration/pain, SOB, Meds Cardiac Exam Components Peripheral signs Inspections Palpation Percussion - not performed often on exam, and cannot be performed on females with reliability Auscultation CVS - Peripheral signs Any signs of dyspnea: posture, use of accessory muscles of respiration, DOE, cyanosis, clubbing. Signs of elevated lipid levels: corneal arcus, xanthomas - upper and lower lid Splinter hemorrhage of the nails Little brown or reddish slivers (splinters) assoc, with bacterial endocarditis Lichtstein's sign NOT TESTED ON THIS - have seen on NB Associated in between the lobe and tragus Shows a likely hood of cardiac disease KWB (keith wagner barkner) Depending on the amount of hypertensive retinopathy, you would have some narrowing in stage 1 Stage tow, AV nicking Stage 3 - increased exudate, AV nicking, silvery wiring Stage 4 - papilledema JVP - dilated vessels Present even when not mad Peripheral Edema CVS peeripheral signs Pulse: Rate, rhythm (consistent?), amplitude, contour, symmetry, condition of vessel, wall Blood pressure Jugular Venous Pressure (JVP) Vesus Carotid pulse Capillary Refill Assess both upper & lower extremities Evaluation: 1st time 1 minuter Regular 30 Sec X 2, 20 X3, 15 X 4 Irregular always 60 sec Pulse characteristics 60-90 min, reg rhythm (interval), strong amplitude (2), smooth upstroke & descent, symmetrical After puberty child's pulse decreases to adult Pulse Characteristics (Rate) Rate > 100: Tachycardia Inc. Blood requirement by tissues: Exercise, fever, thyrotoxicosis, severe anemia Decrease stroke volume: CHF, severe anemia, pericardial effusion Meds that increase sympathetic N.S. -stimulants Rate < 60 BPM Bradycardia Decrease blood requirement by tissues: Hypothermia, myxedema Increased stroke volume: Well conditioned athlete Heart blocks or Altered conduction Parasympathetic stimulation: CNS depressants, increase in intracranial Regular vs Irregular Pattern (Rhythm) Regular - consistent interval btn pulsations Irregular - regular or irregular pattern Irregular regular: predictable pattern such as a heart block every 3rd or 4th beat etc Irregular irregular: no pattern such as Atrial ventricular fibrillation No Pattern Amplitude Described on a 0-4 scale 4 = bounding pulse 3 = full, increased 2 = expected, normal 1 = diminshed, barely palpable 0 = absent, not palpable Pulse pressure: 30-40 mm Hg Systolic - diastolic pressure INSERT INFO HERE Pulse Deficit Difference b/w the distal pulse & the apical pulse rate indicates: Vascular occlusion TOS Aneurysm (produces a widened pulse interval) Atrial fibrillation Pulsus alternans (left V-failure or CHF) Apical pulse = left 5th ICS at mid-clavicular line (also area where we assess mitral valve) Blood Pressure Beginning p. 75 p. 79 --> Blood Pressure Classification Chart Postural hypotension== drop of 20 mmHg or more in systolic pressure when going from lying down to standing Systolic Pressure: the force exerted against the arterial wall w/ ventricular contraction (cardiac output & volume) Diastolic pressure: force exerted against the arterial wall when the heart is relaxed (peripheral vascular resistance). Pulse pressure = systolic - diastolic pressure Jugular Venous Pressure (JVP) Method used to asses right side heart status Know what can lead to abnormal JVP: Atrial fibrillation Tricuspid valve stenosis or regurgitation R ventricular failure (causing regurgitation into jugular vein) Pulmonic valve stenosis or regurgitation Pulmonary hypertension p. 267 Use of the Rt. Jugular is optimal The Level at which the pulse is visible gives an indication of R atrial pressure Avg = 2-3 cm above sternal angle Distinguish IJ from Carotid pulse Hepatojugular (abdominojugular) Reflux Test for venous congestion and R sided heart status Pt. is supine breathing through open mouth. Apply firm pressure over the liver for 20-30 sec. Normal response is increased JVP distension< 1cm & returns to normal level within 2 cardiac cycles. Abnormal > 1cm & remains elevated Heart lies underneath and to the left of the sternum R atrium and R ventricle on the anterior aspect of heart (R ventricle largest area of ant. Heart) Remember the valves of the heart Hepatojugular reflex test JVP Inspection of Precordium Abnormal pulses, lesions, shape of chest wall, apical impulse (indicative of LVF contractility Left 5th intercostal midclavicular line) Precordial Inspection Shape of chest wall Apical impulse Pulsations Masses, lesions, vascular distentions Apical Impulse/Distentions Apical Impulse 5th ICS, Left MCL Masses lesions, Vasc Dist Aortic arch dilation w/ aortic regurg Tumors Superior vena cava obstruction Abnormal Pulsations Sternoclavicular: aortich arch aneurysm Sternal Notch: carotid artery transmission Sternal Border: Aorta Aneurysm of ascending portion - UPPER Ventricular Enlargement - LOWER Epigastric Abdominal Aortic Enlargement ventricular enlargement Palpation of the Precordium Confirm inspection findings Locate and define tender areas Locate and evaluate apical impulses Evaluate/ define abnormal pulsations Detect any palpable thrills Compare to the PMI (Point of Maximal Impulse) LEFT LATERAL DECUBITAL POSITION - rolling partly onto the left side form supine (PG 273) Table 7.1 (pg 286) **Know the increased values*** Normal Apical Impulse - assess the pulse like the carotid Located = 5th or 4th ICS, medial to the MCLine (could be above or below) Diameter = a little more than 2cm in adults Amplitude = small gentle Duration = Hyperkinetic - tests, anxiety, severe anemia, hyperthyroidism, fevercould cause this Increased amplitude Pressure overload - increased after load, hypertrophy, hypertension, aortic valve stenosis Increased diameter, amplitude, duration Volume overload - caused by the fatigue of pressure overload (ventricle dilated) Increased location = displaced to the left and possibly downward Increased diameter, amplitude, duration Could lead to mitral regurgitation Palpation around the heart Triscuspid (LL Sternal Border) - RIGHT VENTRICAL - TABLE 7.1 Pt. Instructions: Esxhale & hold breath Location: (L) 4-5th ICS parasternally Tricuspid valve assessment area Normal: Children & thin adults Abn: ventricular enlargement Conditions of increase cardiac output S3 or S4 heart sound conditions COULD BE FROM R VENTRICULAR HEART ENLARGEMENT Left Upper Sternal Border Pt. Instructions: Exhale & hold breath Location: L 2nd ICS parasternally Pulmonic valve assessment area Normal: Children & thin adults Abnormal: Pulmonary hypertension, Pulmonary valve stenosis, Condition of increase cardiac output R Upper Sternal Border Pt instructions: exhale & hold breath Location: R 2nd ICS parasternally Aortic valve assessment area No pulsations felt there normally Conditions: Systemic Hypertension Aortic valve stenosis Dilation/aneurism of aortic arch Percussion of the precordium Purpose: determine myocardial size Left ventricle - 5th ICS on Left Compare cardiac dullness vs resonance Method start parasternally -- lateraly Or Method start laterally -- medially Auscultation of heart sounds Pattern - inch from point to point concentrating on each of the auscultatory locations Assess with both the diaphragm & bell PG 271 in TEXT Patient positioning is talked about Four standard pt. Evaluation positions: Supine with head elevated at 30 degrees 2nd interspace, palpate precordium, listening for RV, Apical Impulse, LV S1, S2, and systolic murmurs in all areas This one accentuates the aortic area, mitral valve, apical activites Left lateral decubitus Apex accentuated Upright Accentuate sounds from aortic and pulmonic Upright, leaning forward Accentuate sounds from aortic and pulmonic Base Heart Sounds Assessment*** Normally, only closing of the heart valves can be heard********** S1 = 1st heart sound = closure of the mitral (left) and tricuspid (right) valve (AV or atrioventricular valves) S2 = 2nd heart sound = closure of the semilunar valves (aortic & pulmonic) S1 & S2 characteristics & changes Increase vs decrease intensity S1 & S2, how does one sound compare to the other in volume & length Extra Discrete HS Splits - physiologic vs Pathologic (S2 splits common) These are very common Ejection click & opening snaps Opening of stenotic valves S3 & S4 (could be either norm or pathological) S3 = Usually CHF, or unknown issue S4 = associated with MI (atriodiastalic gallop) Herd with bell in supine position or lateral position If S3&4 are together - this is a problem Continuous Sounds or Murmurs Physiologic vs pathologic Murmur can be physiological or pathological Many things will effect the sounds of the heart, this is why you should just know thee characteristic features. Chart in library about the different characteristics - LISTENED TO HEART SOUNDS Closure of the mitral valve - this contributes the most to the S1 heart sound However S1 could be diminished if mitral valve disease is present Closure of the aortic contributes the most to the S2 sound The second heart sound is identified at the aortic area first, this way people know which is S2 Systole - begins with the opening and closure of the mitral valve (Mc & Tc sounds) Diastole - is the s2 to s1 beat using the Ac & Pc Pg 280 in text**** Identifying the 1st and second heart sound Splitting may occur from the effect of respiration on the heart JVP Fluttering or palpatory frill Duration of the normal apical impulse The right side of the heart is effected by respiration much more than the left Why? The blood is returing from the right side of the heart into the lungs Inspiration is going to delay the closure of the pulmonic valve & a little bit to the tricuspid More blood flows since there is more room Expiration can step up the tricuspid valve closure Normal respiration can lead to the splitting of sound (especially S2 can be delayed because of respiration Looking for width, timing, intensity, when does it disappear, Variations in the 1st heart sound and second heart sound should be read by wed (table 7.2) Chart 7.2 S1 is often, but not always louder than S2 at the apex This is where the mitral valve is located, tissue can effect the volume What would increase the intensity? S1 - tachycardia, exercise, high cardiac output states, louder in growth spurts Why? - because the ventricles have to contract harder and more frequently Stenosis - causes greater pressure for the valve to open and close Click when they open, and increased intensity when closing What could diminish the intensity? CHF, Coronary heart disease, decreased contractility, Mitral regurgitation, late stage stenosis of the mitral or tricuspid valve causing it to be immobile. What could make it vary? Complete heart block - what would you anticipate would be the intensity of S1 with complete heart block = varying or alternating What could make a split? **************** S1 split - can be normally and will be perceived along the left lower sternal border (heard at the TRICUSPID area) APPEARANCE = Anything that could be associated with increased myocardial activity with respiration, early stage mitral valve stenoisis Usually on young people (growth spurts) or well conditioned athletes EXPIRATION = will accentuate the split Can be heard during inspiration and expiration CARDIAC disease, coronary artery disease, immobility (CALCIFIC STENOSIS, complete mitral valve stenosis) CANNOT appreciate at the mitral valve What increase intensity, decreases intensity, splits*** S2 split - this is common *************** These splits are common and have A2 and P2 (physiologic) These are separate components of S2, Closure of the aortic valve, right second intercostal space, A2 sound, this is caused by systemic hypertension, INCREASE IN A2 = EARLY AORTIC VALVE STEOSIS will increase the intensity of A2 DECREASED OR ABSENT A2 - calcific and immobile aortic valve, aortic valve regurgitation P2 pulmonic valve INCREASED - pulmonary hypertension DECREASE - late stage pulmonic valve stenosis or regurgitation Heart sound sequence Sequence of valve closure MVc TVc M1 T1 -S1 Avc PVc A2 P2 S2 We should only hear the closing of the valve S2 SPLITS***** These are very common, if we hear S1 best at the tricuspid Inspiration is when S2 becomes split more often 2nd or 3rd left ICS 98% of the time it disappears on expiration IF it does not disappear have the patient sit up On any person if there is splitting during inspiration and expiration have them sit up to double check ****Heard at the pulmonic area (erbs point) and is heard during inspiration and merges on expiration ANYTHING different from the above is considered pathological If heard during ins and exp it is ABNORMAL (wide split during inspiration and it approximates during expiration), Fixed Split (wide spilt) during inspiration and expiration Paradoxical split - S2 split on expiration but not inspiration (supposed to be on inspiration) - this is abnormal (bundle branch block) You will be tested on what is normal & what is abnormal Discrete HS Assessment Location S1 - tricuspid area S2 - pulmonic area Intensity Cardiac cycle Which side of the heart is effected by respiration (right side) Affect of respiration Split - timing & width Extra Sounds Cardiac Auscultation Right sided cardiac events are most often affected by respiration ***S1 - McTc & AoPo Blood is ejected into the pulmonic system causing the Aortic & pulmoinc valve to open Early stage stenosis will cause you to hear an ejection click from the Aortic or pulmonic valve opening Location & effects of respiration will tell you what you are listening too PG 289 in text book (extra heart sounds in systole) Table 7-4 Early systolic ejection sounds have to do inconjunction with Opening of A or P valves Ejection click is heard better with diaphragm of the stethoscope HEARD at the aortic valve (AORTIC CLICK) Pulmonary valve heard at 2nd and 3rd interspace *******MITRAL VALVE PROLAPSE - - - any exam when they talk about the click-murmur syndrome (especially heard over the apex) is mitral valve prolapse******** Turbulent blood flow through closed valves More common in females At some point in time we will develop this (if we live long enough) S1 & S2 is heard over all precordium parts S1 - (SYSTOLIC) - S2 - (DIASTOLIC) - S1 McTc AcPc AoPo MoPo EC (early Stenosis) Osnap (early St) S1 split or EC S2 split and an opening snap (how do we tell the difference) Location (early diastole) pulmonic area (erbs point) - S2 split - heard with inspiration Early diastole - at mitral area - early mitral valve stenosis - (accentuates the opening of valve, S2 heart sound increased S3 - Dull and low in pitch, better heard at the apex with the BELL Pathological - decreased myocardial activity, volume overloading, could be left or right sided Heard after opening snap S4 - heard right before S1 Displacement of the ventricle with VOLUME OVERLOAD If it is emanating from the base - lean forward If it is emanating from the apex - sit up Table p. 280 What is it? R 2nd ICS Parasternally Upstroke of cycle Heard in early systole = S1 split What is it? L 5th ICS parasternally Heard just before the upstroke (prior to S1) =S4 (heard best w/ bell and respiration would affect it) Murmur Features Location Cycle-- Timing & Duration Intensity-- how loud is it? Table 9-11 (handout) 6 levels (p. 282) Grade 1 --> 6 Majority of time Grade 1 & 2 are benign (unless a diastolic murmur--all diastolic murmurs are pathologic) Respiration-- Quality & Pitch how does respiration affect it? Bell vs. Diaphragm Radiation Body Position **Began video of heart sounds** Aortic Area, Pulmonic Area, Erbs point, Tricuspid area, Mitral area PMI = Apical impulse Inspection and palaption Found at 4th or 5th ICS medial from the MCL S3 - key sign of heart failure (after S1) S4 - diminshed ventricular compliance (mechanism unclear) Murmur grading system 1-6 1 heard barely 3 moderately loud 5 heard with touching the edge of stethoscope Patient Positioning with murmurs & breathing - know how they effect murmurs Under age 5 about 90% of children have murmurs, till age 10 about 50% have murmurs, still as young adults some people have innocent murmurs Incompetent valve can cause the regurgitation Systole - it is the mitral or tricuspid regurgitation murmur Diastole - it is the pulmonary or aortic regurgitation murmur TABLE 7.6 Innocent or physiological murmurs**** Innocent murmurs - result from turbulent blood flow, there is no evidence of cardiovascular disease. Theses are common in children and sometimes in older adults Grade 1-2 are usually not considered pathological Grade 3 murmur is pathological until confirmed Grade 4-6 are pathological Crescendo decrescendo or DIAMOND shape Charactieristics No thrill, grade 2 or less Systolic (ALL INNOCENT MURMURS WILL BE WITHIN SYSTOLE) No alteration of pulse Short midsystolic ejection murmur Changes with respiration or position Disappears with inspiration Decreased with standing Most common at mitral or pulmonic areas Aortic valvular sclerosis in an elderly pectus excavatum - pulmonary ejection murmur Pts with hyperdynamic circulation Physiological Murmur Turbulance due to temoprary increased blood flow, it is heard over the breast usually Pathological ****** (organic murmur) Any diastolic murmur Loud murmur (3-6 grade) Associated with palpable thrill Increased duration Radiation of sound Ventricular Semtal Defect Systole Mitral or tricuspid regurg (holosystolic) Mitral valve prolapse - click murmur syndrome Aortic or pulmonic stenosis (diamond) NOT concerned about the pattern of diastolic murmur since it is pathological Pericardial friction rub - sound that can be heard in systole or diastole (venus hum) Due to inflammation of the cardial sac Heard above the clavicle (low intensity) Heard above the medial clavicles by the jugular vein Patent ductus arteriosus Cyanosis present Grade 4 mitral valve prolapse (could have systolic and diastolic murmur) Walking up the stairs is too much for this person Peripheral Vascular Exam Older aged individuals Loss of elasticity Stenosis Legs cramp with decreased blood flow (when they sit the cramping goes away (10%)) Skin changes take place Peripheral Vascular Exam Same as cardiac exam PVS Complaints Pain or cramping of muscles Swelling or lymph edema Dysesthesia Changes to the skin Reynauds, loss of hair, increased pigmentation, ulceration, callous formation Poor healing of superficial wounds Prominent vessels Chest pain Shortness of breath Palpitations Cold hands/feet Usually due to decreased fat Risk of vascular insufficiency Risk for deep vein thormbosis Varicose veins Women are more often the recipients Due to pregnancies Factory workers People who are on there feet all day Sedentary life style Genetics Age Race AA - more valves less pooling of blood Vascular insufficiency Recent trauma or surgery Hyperlipidemia Hypertension Smoker History of cancer Diabetes I & II Previous thrombosis or family history HX of cancer Diabetic Neuropathy PVS More common (4 times) Occurs in younger individual Equal incidence in female and males More widespread Progresses more rapidly Multisegmental Bilateral Deep Vein Thrombosis Risk Advanced age Injury, fracture, infections Right sided heart failure, CHF Varicose veins Family history of blood clots Prolonged bed rest For older individuals it could be from a long drive or ride Postpartum Difficult pregnancy History of cancer Post operative Obesity Hormone supplement Arterial Exam Inspection Palpation: temp & pulses Postural color changes Capillary refill Blanching of nails Ankle: Arm index BP Auscultation Carotid, posterior tib, popliteal, dorsalis pedis The arms Size symmetry, skin color Radial pulse, brachial pulse Amplitude scale for pulses Arterial Exam: Palpation Chronic Arterial occlusion: Postural color cahnges Trophic changes to the skin Intermittent claudication PG 454 History of symptoms: pain, coldness, numbness, tingling Constan paine: acute occlusion If excrutiating: major artery If distal pulse diminished or absent : ER If co-lateral circulation is good the patient may only have numbness and coldness as only sx Postural color changes Patient lies supine raises leg 60 degrees until pallor develops usually < 1 min Have patient sit up/ stand & note return of color limb Normal almost immediately, normal - 15-20 seconds, elderly 35 seconds 2 minutes severe claudication TABLE 14.1 - claudication talked about Arteries palpable Brachial, radial , ulnar artery Femoral, popliteal, dorsalis pedis, posterior tibial Arms have two types of veins Superficial (subcutaneous tissue) Deep (thinner walls) Leg Deep Superficial Great and small saphenous vein Perforators Join deep and superficial Lymphatics Lymphnodes form a major part of the Inguinal nodes, horizontal and vertical groups Arterial Exam** Inspection Palpation: temp & pulses Postural color changes Capillary refill Ankle : arm index (BP) ( >1 in a young patient) Ankle (on calf)- 120mmhg Calf - 140mm/hg Above kneee - Take the ankle reading and divide it by the arm (ankle arm index) .7-.9 mild claudication .5-.7 moderate claudication < .3 Severe claudication Auscultation Capillary Refill Blanch Nail bed & observe return to normal color - < 2 sec INSPECTION FROM TABLE 14.2 (MATCHING SECTION)**** Arterial CLAUDICATION CLAUDICATION CLAUDICATION Pain - at rest Pulse - decreased or absent Temp - cool Edema - mild or absent Gangrene Callous - neuropathic ulcers Venous Exam Varicose veins Thrombosis - you won't see much if it is deep (could have pooling discoloration) Swelling of foot and ankle Hyperpigmentation Venous stasis causes the build up of stasis dermatitis Ulcer Pitting edema Manual Compression test Used with dilated vessels on LE Trying to determine if there is back flow Retrograde filling or Trendelenburg Test Is there any rapid filling? Looking for incompetent valve of saphenous vein Edema Measure circumference Forefoot Smallest area above ankle, abn if >1 cm diff Largest point in calf, > 2cm Thigh 5" Pitting Edema Scale Measured on a 4 point scale Dependent Edema - CHF , Right sided heart failure causes this Pitting, venous, Exam procedures for each system for Peripheral vascular exam  EMBED Paper.Document  The Abdomen- Chapter 9 Abdominal Exam Part of a Complete Exam Symptoms or Complaint Risk Factors GI Complaints Abdominal pain Indigestion Nausea/vomiting Change in bowel Dysphagia GI bleeding Abdominal mass Distention Weight change Anorexia Jaundice Pruritis Back pain GI Disorders 3rd largest category of illness 1/3 of all adults have digestive illness = 62 million people 69% at least 1 GI problem/3 months $41 billion a year spent on GI Disorders 229 million lost days of work $500/yr on laxatives (per adult) $1 billion/year on Zantac Risk Factors Family or personal Hx. Malabsorption conditions (lactose intolerance) Multiple polyposis Ds (increases risk for carcinoma) Inflammatory bowel Ds. GI Carcinomas Personal Hx. Excessive alcohol ingestion (liver, pancreatic disease) Smoking (gastritis, peptic ulcers, and complications of those) Diet: foot type & eating habits Obesity (endogenous & exogenous) Sedentary life style Drug/medication abuse GI/GI carcinomas Neurologic & vascular disease Travel outside of the country Digestive Health Problems Mouth ulcers Heartburn Ulcers IBS Celiac disease Constipation Chronic fatigue Yeast infections eczema Tongue problem Belching Gastritis Crohns disease Gallbladder problem Diarrhea Food sensitivities Migraine headaches Psoriasis Periodontal disease Hiatal hernia Bloating and gas Uncreative colitis R. Upper Quadrant Liver Gallbladder Duodenum Pancreas Right kidney and adrenal gland Hepatic flexure Ascending and transverse colon L. Upper Quadrant Stomach Spleen Liver Pancreases Left kidney and adrenal gland Ascending and transverse colon R. Lower Quadrant Cecum Appendix Right ureter Right Ovary and fallopian tube Spermatic Cord L. Lower Quadrant Descending colon Sigmoid colon Left ureter Left ovary and fallopian tube Spermatic cord Midline Structures Aorta Uterus Bladder Abdominal Pain Type of pain Visceral- dull, diffuse Somatic- sharper, well-localized Referred- shared pathways Location (pattern) Onset (mode, change) Acute/Recurrent/Chronic Palliative/Provocative Quality/Character Radiation Severity Timing Previous Hx. of GI problems Treatment Associated symptoms Family Hx. of problems Ameliorating Maneuvers Belching- may relieves gastric distention Eating- may relieves peptic ulcers Vomiting- may relieves pyloric obstruction Leaning forward- may relieve pancreatic Flexing knees- may relieve peritonitis Right thigh flexion- may relieve appendicitis Left thigh flexion- may relieve diverticulitis Back Pain Esophageal Gallbladder Pancreas Spleen Intestinal Vascular Rectum Abdominal Pain Differential Inflammatory conditions- gastritis, enteritis, Diverticulitis, appendicitis Perforations of the GI tract- peptic ulcer, diverticular perforation Obstruction of viscera- renal colic, biliary colic Gynecologic- PID, ruptured or ectopic pregnancy, ovarian cysts Miscellaneous- vascular -shingles, AAA, mesenteric ischemia, IBS, Malabsorption syndrome Connective tissue Metabolic Dictums- Acute Abdominal Pain Detailed hx, in chronologic sequence OPPQRST Rectal exam (females- pelvic exam) Other clinical studies if necessary Consider intrathoracic conditions when pain is in the upper abdomen Acute Abdomen Warning Signs (HMMMMMM) Board-like rigidity Lack of bowel sounds Rebound tenderness Discoloration- rupture of a visceral structure Acute distention Vomiting without relief Diaphoresis & shock Indigestion Describe the quality or exact feeling Heartburn (pyrosis) Excessive gas (bloating, eructation, gas) Regurgitation and/or waterbash When did it start? How often do you have the symptoms? Is it associated with ingested material? If so which food/beverage? What makes it better/worse? Is there radiation? Are there any other associated symptoms? Hx. of GI problems, surgeries? Heartburn, gas, bloating, chest pain, regurgitation Ingested substances Malabsorption syndromes Inflammatory process Hiatal hernias Gallbladder or Pancreatic disorders Nausea &/or Vomiting Nausea- an unpleasant sensation that one is about to vomit Vomiting- (emesis)- forceful oral expulsion of gastric contents Retching- often precedes vomiting and consists of spasmodic and abortive respiratory movements against a closed glottis How long have you had N/V? How often? Is there a pattern? Eating? What is the appearance of the vomitus? Is there an odor? Does nausea precede the vomiting? Are there any associated symptoms? fever, infection, does it provide relief Change in hearing or tinnitus? Nausea &/or Vomiting Causes GI disorders Infections CNS disorders- projectile vomiting Endocrine or hormonal disorders- adrenal insufficiency, early pregnancy, myxedema Drugs and toxins- mucosal irritants, food poisoning Vestibular disorders- CN VIII Cardiovascular disorders- acute MI Change in Bowel Habits Diarrhea or Constipation (Table 9-4) Onset What is normal (#BM, Stool type) Pattern (alternating, progressive, interim) Dietary changes Medications, laxatives, purgatives Any other symptoms Diagnostic Tests- Diarrhea CBC, chemistry profile, UA Stool exam Wrights or methylene blue Occult blood or gross Sudan black B- fat Alkalinization with NaOH- laxative abuse Stool cultures- bacterial pathogens Ova and parasite assessment Constipation Life activities and habits Insufficient food and water intake Obstruction or altered mobility Anal lesions Metabolic disorders Neurological disorders Drugs or medications Constipation History How long have you had this synmptom? 2. How often do you have a bowel mvt.? Describe the stool? Size, color, odor, blood, mucus? Does it alternate with diarrhea How is your appetite? Has there been any weight change? GI Bleeding (p. 356) Hematemesis- vomiting of blood (an emergency situation) Hematochezia- bright red blood per rectum, blood mix with stool, or blood streaked stool (common cause are hemorrhoids) (lower GI, cancer of colon, benign polyps, diverticulitis, anal fissure) Melena- tarry black stool (loss of at least 60ml of blood into the GI tract. ) indicative of an upper GI problem, usually a slower bleed- usually less complicated) Anorexia & Related Problems Anorexia, or loss of appetite is a nonspecific symptom Anorexia nervosa is a complex psychiatric disorder Polyphagia is excessive eating Weight loss > 10 lbs or 5% of body weight without diet modification Anorexia Neoplastic disorders Depression Eating disorders Chronic renal failure Acute viral hepatitis Chronic parenchymal liver disease Chronic infectious disease (TB) Medications Chronic debilitating conditions Cerebral vascular disease Parkinsons MS 10. 1st trimester of pregnancy Weight Loss GI disorders Metabolic disorders- hyperthyroidism, diabetes mellitus, Addisons) Neoplastic Infectious diseases Psychiatric disorders Chronic renal failure Connective tissue disease Abdominal Distention (air, gas, fluid, mass, associated symptoms) Onset? Acute or chronic Progressive or intermittent Associated with eating? Appetite loss? Affected by bowel movement? Females possibility of pregnancy? Protuberant or Distended Abdomen Fat- obesity Fetus Flatulence- gas/intestinal obstruction Fatal growth- neoplasias, cysts Fluid- ascites Feces- intestinal obstruction Masses- Hx. Location/Anatomy Acute or chronic Progressive, intermittent Pulsatile or non- pulsatile Mobile or non- mobile Hx. of hernias, surgery, cancer Associated symptoms Dysphagia Sensation of difficulty with or diminished ability to swallow Oropharyngeal Esophageal Causes of Dysphagia Neurologic and muscular disease (neuromotor disorders) Obstructive lesions Primary esophageal motility disease Secondary esophageal motility disease Infections Medication Psychiatric Dysphagia (Table 9-2) Onset? Pattern? Acute, intermittent, or progressive? Does food seem to hang up in a particular area Does it occur with solids or solids and liquids Is this associated with regurgitation? Skin Discolorations Jaundice (icterus)- yellow appearing akin and sclera, resulting from retention and deposition of conjugated bilirubin Ecchymoses- bruised appearance of the abdomen or flanks in associated with hemoperitoneum- emergency Jaundice Common Causes Viral hepatitis Alcoholic liver disease Drug-induced liver disease Choledocholithiasis, cholecystitis Carcinoma of the pancreas Metastatic liver disease Inspection Shape of abdomen (flat, protuberant, ect..) have patient flex hips and knees slightly Site and shape of umbilicus Dilated veins Skin lesions, scar, striae Movements of 4 quadrants with respiration Any visible peristalsis, epigastric pulsations Auscultation (p. 334) Peristaltic sounds (in 4 quadrants) Bruit over abdominal Aorta, renal artery, and femoral artery Table 12-2 (library handouts) SignDescriptionAssociated ConditionsCullenEcchymosis around umbilicusHemoperitoneum, pancreatitis, ectopic pregnancyGrey TurnerEcchymosis of flanksHemoperitoneum, pancreatitisKehrAbdominal pain radiating to left shoulderSpleen rupture, renal calculiMurphyAbrupt cessation of inspiration on palpation of gallbladderCholecystitisDanceAbsence of bowel sounds in right lower quadrantIntussusceptionBlumbergRebound tendernessPeritoneal irritation, appendicitisRovsingRight lower quadrant pain intensified by left lower quadrant pressurePeritoneal irritation, appendicitis Percussion (enlargement of solid organs or any fluid) Percussion note Liver, spleen Shifting dullness Palpation Any tender areas Muscle guarding Lever, spleen, kidneys, abdominal aorta Fluid thrill Any mass Size, site, shape, surface, margins, consistency, tenderness, mobility, plane Others Spine Supraclavicular nodes (Virchows node) Scrotum and testes Spermatic cord Rectal exam Pelvic exam Females have more costal movement, males have more abdominal movement with respiration. Look for all 4 quadrants to move uniformly, if one does not move, there may be an underlying lesion or inflammation. Peristaltic waves go in the direction of the blockage, in an attempt to remove the blockage. Pyloric- peristaltic waves go left to right. Splenic- peristaltic waves go right to left. Bowel Sounds 4-35 bowel sounds per minute depending on when they last ingested something. Burborgami- prolonged gurgles. Increased- early intestinal obstruction (fecal material, swelling, neoplasias) Decreased- adynamic ileus and peritonitis- peristaltic waves stops High-pitched tinkling sounds suggest intestinal fluid and air under tension in a dilated bowel. Rushes of high-pitched sounds with abdominal cramping suggest intestinal obstruction Early mechanical have loud, high-pitched sounds Late/advanced mechanical obstruction have decreased sounds (adynamic ileus) Other Abdominal Sounds Bruits may be heard due to: atherosclerotic vessels such as the aorta, celiac artery, superior mesenteric artery or renal artery, vascular malformation of congenital origin, distortion of blood vessels by solid tumors, cysts, or inflammatory processes. (often indicative of stenosis) Percuss for overall tympany. An un-emptied bladder can give an impression of dullness, so always have your patient use the restroom before this portion of the exam. Percussion of RUQ can provide an estimate of liver span. 4-8cm in mid-sternal line, 6-8cm in right mid-clavicular line. Percussion of LUQ can allow detection of a splenomegaly. Splenic dullness normally extends down fro the 8/9th intercostal space in the mid-axillary line superiorly to a level above the lowest intercostal space in the anterior axillary line. Dullness on held inspiration (above the lowest intercostal space) is a positive Splenic percussion sign and is produced by a splenomegaly. Dullness extending down into the normally tympanic part of the RUQ suggests hepatic enlargement. Normal liver dullness ranges from the 5th and 7th intercostal spaces superiorly and the R. costal margin inferiorly. Shifting dullness sign- indicative of ascites Bulging flanks Shifting fluid sign When the spleen enlarges it enlarges obliquely (anterior/inferior towards medial aspect). An enlarged spleen can be missed if the examiner starts to high in the abdomen. L. Flank Mass- splenomegaly, or an enlarged L. kidney. Suspect splenomegaly if notch palpated on medial border, edge extends beyond the mid-line, dull percussion, deep probing into the medial and lateral borders. Has to be enlarged 3X for the notch to be appreciated. Kidney palpation is done below the costal margin, and are very difficult to palpate. Palpate for enlargement of abdominal aorta, should be done in males over age of 50, and smoker. Should be no more than 3cm wide. (normal is 2.5cm) Pulse should be greater in AP direction than lateral. Single handed ballotment test- determine if a mass moves, and in what direction. Bi-manual- press in at 90 degrees if mass if freely moveable, it will float up into your hand. Rebound tenderness, Murphys tap Anorectal Exam Part of a complete symptoms exam Complaints or symptoms Risk factors Anorectal Symptoms Mass or swelling (rectal prolapse) Lesions (fistulas, fissures, genital warts) Itching (Pruritis) Pain Change in bowel habit Bleeding Risk Factors for Colorectal Cancer Age over 40 peaks in ages 65-74) Family Hx. of colon cancer Personal Hx. of colon polyps, Crohns disease, other forms of cancer Diet high in beef and animal fats, low in fiber Exposure to asbestos, acrylics, and other carcinogens Internal Anorectal Lesions Hemorrhoids Perirectal abscess Rectal polyp or carcinoma Ruptured bladder Pus from ruptured diverticulum or appendix Rectal prolapse External Anorectal Lesions External &/or internal hemorrhoids Pilonidal cysts Fissures, fistulas, abscesses Rectal prolapse neoplasias STDs Anorectal Lesions More than 50% of AR lesions are within reach of the examiners finger Malignant polyps are more apt. to bleed than benign adenomas Be alert to the increased risk of malignancy in patient with multiple polyps Consider all polyps lesions larger than 1 cm in diameter as malignant until proven otherwise Never conclude that rectal bleeding is due to hemorrhoids present until carcinoma has been ruled out. It is unusual for these two bleeding disorders to coexist. Anorectal Pain Fissures, fistulas, abscesses Thrombosed external hemorrhoids IBD Local STD lesion Trauma Leukemia infiltration Cryptitis Change in Bowel Habit (p. 353) Constipation- Life activities, habits, IBS, obstruction, lesions, drugs, NMS dis. Diarrhea- Acute, drug induces, chronic, intermittent, voluminous Anorectal Bleeding (p. 356) Conditions consistent with Melena (due to an upper GI problem) Conditions consistent with Hematochezia Local lesions including STD Excoriations due to scratching Pruritis Generalized: diffuse skin disorder, chronic renal or hepatic disease Intense: lymphoma or Hodgkins GI disorders: pruritis ani, anal rectal lesions, parasites, skin irritants, local infection Anorectal Exam Anus & Rectum: adult anal canal is about 2.5-4cm, rectal canal is about 10-12cm Lower half of canal: somatosensory innervation is sensitive to painful stimuli Upper half of canal: autonomic and relative insensitive to painful stimuli Inspection & Palpation Patient position- Lithotomy, Sims (side-lying), supported flexion Dr. utilizes gloves & explains process to patient Inspect for any external lesions before tissue is separated Skin characteristics Lesion Excoriations Inflammation Spread tissue apart and inspect anus noting skin, lesions, masses, fissures Ask the patient to bear down, note: Internal hemorrhoids, prolapse, polyps Lubricate gloved index finger Place examining finger against anal opening. Ask patient to bear down and then relax. As relaxation of the external sphincter occurs slip finger into the canal pointed toward the umbilicus. Patient may contract sphincter, which allows for assessment if not ask patient to contract. Normal tone is tight As examining finger is inserted and continues into canal note: contour and any abnormalities Evaluate all walls and superior wall Instruct patient to bear down again to allow for adjacent superior lesions to be appreciated Withdraw finger, examine fecal material: color, consistency, pus, blood Occult blood test Anorectal Exam: Males Prostate gland lies anterior to anterior rectal wall Bi-lobed, hear shaped structure about 2.5-4cm in diameter Normal: smooth, firm with consistency of a hard rubber ball 1cm of protrusion into the rectal wall Anorectal Exam: Females During the gynecological exam, the rectal exam is standard The uterus and cervix may be palpated through the anterior rectal wall. Masses, a fetus, uterine fibroids and a retroverted uterus may all be palpable. Stool Characteristics Intermittent pencil like stools suggest a spasmodic contraction ithe rectal area Persistent pencil like stools indicate permanent stenosis from scarring or from pressure of a malignancy Pipe-stem stools and ribbon stools indicate lower rectal structure A large amount of mucus in the fecal matter is characteristic of intestinal inflammation and a mucus colitis Fatty stools are seen in pancreatic disorder and steatorrhea and Malabsorption syndromes Stools the color of aluminum occur in tropical sprue, carcinoma of the hepatopancreatic ampulla and children treated with sulfonamides for diarrhea. Right Colon Cancer Ill-defined pain Brick red stool Obstruction is common Intermittent pain Left colon Colicky pain Spasmodic Not constant Stool mixed with blood Cancer of the Rectum Steady, gnawing pain Weakness is not commonly seen Bright red-coated stool Obstruction is not common Hernias 2 Types Internal: diaphragmatic (Hiatal) Portion of the stomach lies above the diaphragm External: umbilical, epigastric, inguinal, femoral Protrusion of intestine covered by the peritoneum Predisposing factors for Hernias Weak abdominal musculature Laxity Obesity Intra-abdominal mass/pressure Congenital defects of abdominal wall Chronic increase intra-abdominal pressure Chronic straining Chronic coughing Intra-abdominal mass/pressure Heavy lifting Hernia Terms Reducible: contents of the hernial sac can be easily replaced Irreducible/Incarcerated: contents cannot be replaced. Need to monitor for possible complications Strangulated: blood supply has been compromised. ( Emergency Situation!! Umbilical Hernia Most common in neonates Diameter of opening rather than size of protrusion Max. size usually reached by 1-2 months of age Most spontaneously resolve Auscultation should show bowel sounds Hiatal Hernias Very common: women and older adults Clinically significant: accompanied by acid reflux, producing esophagitis Symptoms: epigastric pain, heartburn, provocative supine, palliative antacids or seated, dysphagia, waterbash Incarceration: vomiting, pain, complete dysphagia 2 Types of Hiatal Hernias Sliding/direct- lack of distinction between the LES and the cardiac. Both slide up into the chest as the angle of HIS disappears. Transient. Rolling- (rapid onset, vomiting without relief) gastric cardia rolls through the hiatus beside the gastroesophageal junction, normally situated in relation to the diaphragmatic hiatus. Also called the parahiatal or paraesophageal hernia. Table 9-1 Abdominal Pain ProblemProcessLocationQualityTimingAggravatedRelieved byAssoc. S/SPeptic Ulcer & DyspepsiaDemonstrable ulcer usually in duodenum or stomach. No ulceration w/ dyspepsiaEpigastric, may radiate to backVariable: gnawing, burning, boring, hunger-likeIntermittent, wakes pt. at nightVariableFood and antacidsNausea, vomiting, belching, bloating, heartburnStomach CancerMalignant neoplasmEpigastricVariablePersistent and slowly progressiveFoodNOT relieved by food or antacidsAnorexia, nausea, weight lossAcute PancreatitisInflammation of pancreasEpigastricUsually steadyAcute onset, persistent painLying supineLeaning forward with trunk flexedNausea, vomiting, alcohol abuseChronic PancreatitisFibrosis of pancreasEpigastric radiating through the backSteady, deepChronic or recurrent courseAlcohol, heavy or fatty mealsPossibly leaning forward with trunk flexedDiarrhea with fatty stools, diabetes mellitus Pancreatic CancerMalignant neoplasmEpigastric in either upper quadrantsSteady, deepPersistent pain, relentlessly progressivePossibly leaning forward with trunk flexedAnorexia, nausea, vomiting, weight loss, jaundice, depressionBiliary ColicSudden obstruction of the cystic duct or common bile duct by a gallstoneEpigastric or RUQ, may radiate to R. scapula and shoulderSteady, aching; not colickyRapid onset, subsides graduallyAnorexia, nausea, vomiting, restlessnessAcute CholecystitisInflammation of the gallbladderRUQ or upper abdominalSteady, achingGradual onset, longer than biliary colicJarring, deep breathingAnorexia, nausea, vomiting, feverAcute DiverticulitisInflammation of colonic diverticulumLLQCramping at first then becomes steadyGradual onsetFever, constipation, brief diarrheaAcute AppendicitisInflammation of the appendix w/ distention or obstructionPeriumbilical, RLQMild but increasing, steady and more severeLasts roughly 4-6 hrMovement or coughingIf it subsides temporarily, suspect perforation of the appendixAnorexia, nausea, possibly vomitingAcute Mechanical Intestinal ObstructionObstruction of bowel lumen by adhesions or hernias (small bowel), cancer or diverticulitis (colon)Small: periumbilical or upper abdominal. Colon: lower abdominal or generalizedSmall: cramping Colon: crampingParoxysmal; may decrease as bowel mobility is impairedVomiting of bile and mucus, or fecal material Mesenteric IschemiaDecreased blood supply due to thrombosis, embolus, or hypoperfusionPeriumbilical then diffuseCramping at first then steadyAbrupt onset then persistentVomiting, diarrhea, constipation, shock Table 9-2 Dysphagia Process and ProblemTimingFactors that AggravateFactors that RelieveAssoc. Signs/symptomsTransfer Dysphagia- due to motor disorders affecting the pharyngeal musclesAcute or gradual onset and a variable courseAttempting to start the swallowing processAspiration into the lungs or regurgitation. Neurologic evidence of stroke.Mucosal rings and webs (mechanical)IntermittentSolid FoodsRegurgitation of the bolos of foodUsually noneEsophageal Stricture (mechanical)Intermittent, slowly progressiveSolid FoodsRegurgitation of the bolos of foodHx. of heart burn and regurgitationEsophageal Cancer (mechanical)Starts intermittent, becomes progressive over monthsSolid foods with progression to liquidsRegurgitation of the bolos of foodPain in chest and back and weight lossDiffuse Esophageal Spasm (motor)IntermittentSolids or liquidsRepeated swallowing, straightening the back, raising arms, valsalva maneuverChest pain that mimics angina pectoris or MI. Possibly heartburnScleroderma (motor)Intermittent, may progress slowlySolids or liquidsSame as aboveHeartburn or other manifestations of sclerodermaAchalasia (motor)Intermittent, may progressSolids or liquidsSame as aboveRegurgitation when lying down, chest pain precipitated by eating Table 9-3 Constipation ProblemProcessAssoc. Symptoms and SettingInadequate time or settingIgnoring the sensation of a full rectum inhibits the defecation reflexHectic schedule, unfamiliar surroundings, bed restFalse expectations of bowel habitsExpectations of regularity or more frequent stools than a persons norm.Beliefs, treatments, and advertisements that promote laxative useDiet deficient in fiberDecreased fecal bulkOther factors such as debilitation and constipating drugsIBSDisorder of bowel motilitySmall, hard stools, often with mucusCancer of rectum, sigmoid colon (mechanical)Progressive narrowingChange in bowel habits, pencil shaped stools, abdominal painRectal Impaction (mechanical)Large, firm, immovable fecal massRectal fullness, abdominal pain and diarrheaDiverticulitis, Volvulus, intussusceptionNarrowing or complete obstruction of the bowelColicky abdominal pain, distention, currant jelly stoolsPainful anal LesionsPain can cause spasm of the external sphincter and voluntary inhibition of the defecation reflexAnal fissures, painful hemorrhoids, Perirectal abscessesDrugsA variety of mechanismsOpiates, Anticholinergics, antacids containing calcium or aluminumDepressionDisorder of moodFatigue, feelings of depression , and other somatic symptomsNeurologic DisordersInterference with the autonomic innervation of the bowelSpinal cord injuries, multiple sclerosis, hirschsprungss diseaseMetabolic ConditionsInterference with bowel motilityPregnancy, hypothyroidism, Hypercalcemia Table 9-4 Diarrhea ProblemProcessStool Character.TimingAssoc. SymptomsSetting, Pt. at RiskSecretory InfectionsInfection by viruses, bacterial toxinsWatery w/out blood, pus, or mucusDuration of a few daysNausea, vomiting, periumbilical cramping painOften travel, a common food sourceInflammatory InfectionsInvasion of intestinal mucosaLoose to watery, often w/ blood, pus, mucusAcute illness of varying durationLower abdominal cramping pain and often rectal urgencyTravel, contaminated food and waterDrug Induced DiarrheaMagnesium, laxativesLoose to wateryAcute, recurrent, or chronicMaybe nausea, little if any painPrescribed or over the counter medicationsIBSBowel motility disorder alternating constipation and diarrheaLoose, mucus, NO blood, small hard stools w/ constipationOften worse in the morningCrampy, lower abdominal pain, constipationYoung and middle age adults, especially womenCancer of Sigmoid ColonPartial obstruction by malignant neoplasmMay be blood streakedVariableChange in usual bowel habits, crampy lower abdominal pain, constipationMiddle aged and older adults, especially over 55yrUlcerative ColitisInflammation of mucosa and submucosa of rectum and colonSoft to watery, often containing bloodOnset ranges from insidious to acute. Diarrhea may wake patient at nightCrampy lower or generalized abdominal pain, anorexia, weakness, feverOften young peopleCrohnsInflammation of bowel wall typically in the ileum and or proximal colonSmall, loose or watery. Usually free of gross bloodInsidious onset, chronic or recurrent. Diarrhea may wake patient at nightCrampy periumbrical or right lower quadrant or diffuse pain. Perianal or Perirectal abscesses and fistulasOften in young people especially in late teens, but also in the middle agedMalabsorption syndromesDefective absorption of fatBulky, soft, light yellow to gray, usually floatsOnset of illness typically insidiousAnorexia, weight loss, nutritional deficienciesVariable, depending on causeLactose IntoleranceDeficiency in intestinal lactaseWatery diarrhea of large volumeFollows ingestion of milk and other dairy products, relieved by fastingCrampy abdominal pain, abdominal distention, abdominal pain, often cramps around abdominal pain African Americans, Asians, native Americans Abuse of osmotic purgativesLaxative habitWatery diarrhea of large volumeVariableOften nonePersons with anorexia nervosa, or bulimia nervosaSecretory diarrheas from infectionsvariableWatery diarrhea of large volumeVariableWeight loss, dehydration, nausea, vomiting, and cramping around pain Variable depending on cause Table 9-5 Black and Bloody Stools Melena- black, tarry, sticky, and shiny stools. Signifies the loss of at least 60 ml of blood into the gastrointestinal tract. Possible causes are peptic ulcer, gastritis or stress ulcers, esophageal or gastric varices, reflux esophagitis Black, Non-sticky- no pathologic significance. Possible cause is the ingestion of iron, bismuth, salts (Pepto-Bismol), licorice, or even chocolate cookies Red Blood- usually originates in the colon, rectum, or anus, and much less frequently in the jejunum or ileum. Possible causes are cancer of the colon, benign polyps, diverticulitis, certain inflammatory conditions, ischemic colitis, hemorrhoids, anal fissure Table 9-6 Frequency, Nocturia, and Polyuria Frequency- Decreased capacity due to: increased bladder sensitivity to stretch due to inflammation (caused by infection, kidney stones, tumor or foreign body in the bladder), decreased elasticity of bladder wall (caused by infiltration by scar tissue or tumor), decreased cortical inhibition of bladder contractors (caused by motor disorder of the CNS). Impaired emptying due to: partial mechanical obstruction of the bladder (caused by most commonly benign Prostatic hyperplasia), loss of peripheral nerve supply to the bladder (caused by Neurologic disease). Nocturia- High Volumes due to: decreased concentrating ability of the kidney (caused by chronic renal insufficiency), excessive fluid intake before bedtime (habit), fluid retaining (caused by CHF, nephritic syndrome. Low Volumes due to: frequency, voiding while up at night without a real urge pseudo-frequency (caused by insomnia). Polyuria- Deficiency of anti-diuretic hormone (caused by a disorder of the posterior pituitary and hypothalamus, renal unresponsiveness to anti-diuretic hormone (cause by a kidney disease), Solute diuresis, Excessive water intake can cause primary Polydipsia. Diuresis, caused by large saline infusion, potent diuretics, certain kidney diseases. Table 9-7 Urinary Incontinence Stress- in women, normally weakens of pelvic floor. Urge incontinent- caused by decreased cortical inhibition of detrusor contractions, hyperexcitability of sensory pathways. Overflow incontinence- incontinence caused by obstruction of the bladder, weakness of the detrusor muscle maker Functional caused by problems in mobility resulting from weakness, arthritis poor vision or on other conditions Incontinence secondary to meds- caused by sedatives, tranquillizers, sympathetic blockers, and diuretics Table 9-8 Localized Bulges in the Abdominal Wall Umbilical- protrudes through an defective umbilical ring. m/c in infants, but can occur in adults. In infants they close spontaneously with in a year or two. Incisional- protrudes through an operative scar. A small defect though which a large hernia has passed, has greater risk of complications than a large defect Epigastric- small midline protrusion though a defect in the linea alba somewhere between the xiphoid process and the umbilicus. Diastasis Recti- separation of the two rectus abdominus muscles which abdominal contents bulge forming a midline ridge. Lipoma- benign, fatty tumors usually located in the subcutaneous tissues. Table 9-9 Protuberant Abdomens Fat- m/c cause of a protuberant abdomen Gas- can be local or generalized. It causes a tympanic percussion note. Tumor- large solid tumor, usually rising out of the pelvis, is dull to percussion. Pregnancy- common cause of a pelvic mass. Listen for fetal heartbeat. Ascitic Fluid- seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. Check for shifting dullness. Table 9-10 Sounds in the Abdomen Bowel Sounds- Increased from diarrhea or early intestinal obstruction. Decreased from adynamic ileus and peritonitis. High-pitched tinkling sounds suggest intestinal fluid and air under tension in a dilated bowel. Rushes of high-pitched sounds w/ an abdominal cramp suggest intestinal obstruction. Bruits- Hepatic suggests carcinoma of the liver or alcoholic hepatitis. Arterial w/ both systolic and diastolic suggest partial occlusion of the aorta or large arteries. Venous Hum- suggests increased collateral circulation between portal and systemic venous systems, like in hepatic cirrhosis. Friction Rubs- suggests inflammation of the peritoneal surface of an organ. **When a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver.** Table 9-11 Tender Abdomen Abdominal Wall Tenderness- when the patient raises their head and shoulders this tenderness persists, whereas tenderness from a deeper lesion decreases Visceral tenderness- an enlarged liver, aorta, Cecum, sigmoid colon may be tender to deep palpation. Acute Pleurisy- pain may be due to pleural inflammation. Chest signs are usually present. Acute Salpingitis (inflammation of fallopian tubes)- frequently b/l, the tenderness is usually maximal just above the inguinal ligaments. Rebound tenderness and rigidity may be present. Acute Cholecystitis- signs are maximal in RUQ. Check for Murphys sign. Acute Pancreatitis- epigastric and rebound tenderness are usually present. Acute Appendicitis- RLQ signs are typical. Acute Diverticulitis- mostly involves the sigmoid colon and then resembles a left-sided appendicitis. **Tenderness associated with peritoneal inflammation is more severe than visceral tenderness.** Table 9-12 Liver Enlargement: Apparent and Real Downward displacement by a low diaphragm- common finding in emphysema. Vertical span in normal. Normal variations include- in persons with a lanky build the liver tends to be elongated so that its right lobe is easily palpable as it projects downward the iliac crest. Riedels lobe represents a variation in shape but not an increase in volume or size. Smooth, Large, Non-tender- associated with cirrhosis. Smooth, Large, tender- hepatitis, venous congestion (right sided heart failure, increase in JVP) Large, Irregular- suggests malignancy. Table 10-4 Differentiation of Hernias in the Groin Indirect Inguinal- most common, all ages, both sexes. Most often in children. Originates above inguinal ligament, near its midpoint and often continues into the scrotum. Direct Inguinal- less common than indirect. Occurs usually in men over 40. Originates above inguinal ligament close to the pubic tubercle, rarely continues into the scrotum. Femoral- least common. More common in women than men. Originates below the inguinal ligament; appears more lateral than an inguinal hernia, never continues into the scrotum. Inguinal canal Exam seen on NB over and over again Two Types of inguinal hernias Indirect passes through the deep inguinal ring, inguinal canal and superficial inguinal ring and may descend into the scrotum (complete) Intestines go out of the external/superficial ring Females: herniated sac goes into the labia majora Direct: occurs through the post wall of the canal in the region of the superficial ring, rarely descends into the scrotum Protrudes out of the side of the canal The pt. May be standing or supine Palpate the inguinal area, instruct the pt to cough or perform a valsava. Note any protrusion/mass. To further investigate: place the R index finger in the scrotum above the testis and invaginate the skin Follow the spermatic cord laterally to (into) the inguinal canal With the finger placed either against the ext. ring or in the canal, instruct pt to cough. A sudden impulse against tip or side of finger suggest a hernia. Indirect is most common hernia Direct is less common Bulges anterior Femoral Hernias Occurs more often in females Loop of intestine covered by peritoneum through the femoral ring Instruct pt to do Valsalva to look for buldge Have pt supine and lightly palpate, the mass may spontaneously reduce. If not, slowly attempt with light pressure Normal consistency of small bowel is firm & non-tender. If tender & irreducible potential compromise Auscultate mass: bowel sounds should be perceived Mass in scrotum transilluminate: light will not pass through a hernia Hiatal Hernias Very common: women & older adults Clinically significant: accompanied by acid reflux, producing esophagitis Symptoms: epigastric pain, heartburn, provocative supine, palliative antacids or seated, dysphagia, waterbash Incarceration: vomiting, pain complete dysphagia Two types of hernias Rolling Sliding PROSTATE, MALE & FEMALE GENITALIA Changes in Micturation Increase Frequency (inc/urine Output) Decrease output Hesitancy or straining Decrease in force or caliber of stream Incontinence Enuresis Changes in Micturation TABLE 9-6 (pg 357) Onset Palliative/provocative Quality/characteristics Pattern Associated symptoms Ave. Voiding---> 4-6 X a day Amount 700-2000 ml/day Increase Frequency Normal output - more often Inflammation - cystitis Decrease in bladder filling capacity - stones, tumors, fibrosis, pressure, neuropathy, protrusion Increase output - more often Polyuria (>2500ml/day)**********************NB Decreased capacity of bladder Increased bladder sensitivity to stretch because of inflammation... ,,,,,, This was from a chart in the book Polyuria *Renal disease (nephritis) Diuretics (drugs, caffeine, alcohol) Diabetes mellitus Diabetes insipidus Central - disorder of the post pituitary and the hypothalamus, deficiency of ADH (vasopressin) Helps to maintain cellular fluid homeostasis Diuresis can occur Nephrogenic Kidneys cannot utilize Vasopressin All may lead to urgency & nocturia KNOW THE URINE FREQUENCY CHART FROM THE ABDOMEN CHAPTER Decrease Urine output Oliguria - <500ml day Anuria- < 100 ml day Prerenal factors Intrinsic renal factors Postrenal factors Prerenal azotema***** handout in library Severe cong heart failure could Decrease in urine output Intravascular volume depletion Loss of fluids Excessive perspiration (heat exhaustion) Diarrhea Diuretics Increased renal resistance or vascular dilation Systemic vaso dilation Impaired renal dilation Anti inflammatory Prerenal disease**** This is off chart in Library Tubular necrosis Nephrotoxins Antibiotics Chemotherapy drugs Kidney stones High calcium intakes High protein Oxalate (high fat) (you should include the magnesium with the calcium) Inflammation Bacterial or viral Drugs Renal Vascular occlusion Renal vein or artery CAUESES of Postrenal azotemia****HMMMM****** Urethral Obstruction Stones** Fungus balls Strictures** Hx of other surgeries or crohns disease Bladder outlet obstruction Prostatic hypertrophy** Bladder carcinoma Urethral obstruction Strictures Cong valves Nocturia (voiding at night) (chart 9-6, pg 357)**** With high output Conditions with polyuria Fluid retaining states (table 5-3, pg 175) Cong heart failure Nephrotic syndrome myxedema High fluid intake With low output Infections Pseudo-frequency Changes in micturation Increase frequency (inc in output) Decrease output Hesitancy or straining Decrease in force or caliber of stream Incontinence Chart 9-7) Enuresis Involuntary bed wetting Girls over 5, men over 6 3:1 , male: female Primary - anticipate seeing more often Child has always had issues with this Secondary RED flag for enuresis which has just set in, and not been there before Red flag for sexual abuse in childrencombined with other signs Symptoms of the UG System Fever, weight change, fatigue Dysuria Harder to tell if it is the urine or not that is creating the pain in women Changes in micturation Nocturia Abnormal discharge Hematuria Genital Pain Risk factors for UG Disorders Recurrent UTI Exposure to STD's Aging Prostatitis vs. PID IBD (Crohn's) Diabetes Group A Beta-Hemolytic Strep Sensitivity Kidney Stones Alcohol/Meds Dysuria Most Common Causes: UTI STD & Complications Syphilis - not painful Gonorrhea - painful Prostatitis PID Chlamydia & Gonorrhea Kidney Stones Neurogenic Conditions Changes in micturation Onset Palliative/provocative Quality/characteristics Pattern Associated Symptoms Ave. Voiding - 4-6x/Day Amount 700-2000ml Day Table 9-6 Frequency Inflammatory conditions - activate the micturation reflex Increased sensitivity Polyuria - Polydipsia (diabetes) Polyuria-Polydipsia-Polyphagia (diabetes mellitus) Decrease Oliguria - <500ml/day Anuria - <100ml/day Prerenal factors Intrinsic renal ds Post renal ds Prerenal Azetema Extensive burns Cardiovascular ds Systemic Vasoconstriction Intrinsic Renal ds Caused by destruction********* Inflammation Renal vascular occlusion Thrombus Postrenal Azotema Uretal obstruction *** Bladder outlet obstruction Urethral obstruction Nephrotoxicity - renal toxicity Changes in micturation Increase frequency (inc/N output) Decrease Output Hesitancy straining Decrease in force or caliber of stream Diabetic pathology Prostatitis Incontinence Pg 358-359 Stress incontinence Transient increases in intrabdominal pressure In women , most often a weakness of the pelvic floor with inadequate muscular support of the bladder and proximal urethra and a change in the angle between the bladder and the urethra. Momentary leakage of urine Urge Incontinence The bladder is typically small, detruser contractions are stronger than normal & overcome the resistance Decreased cortical inhibition of detruser contractions Hyperexcitability of sensory pathways ** Deconditioning of voiding reflexes - frequent voluntary voiding at low bladder volumes The volume tends to be moderate Urgency**** is a KEY FEATURE Overflow Incontinence Bladder is typically large even after the effort to void Obstruction of the bladder outlet .peripheral nerve disease at the sacral level Impaired bladder sensation that interrupts the reflex arc, as from diabetic neuropathy A continuous dripping or dribbling Decreased force of the urine stream LARGE BLADDER found on abdomen exam**** Functional Incontinence Inability to get to the toilet due to a medical condition or not knowing the surrounding Physical disabilities Medical Incontinence Medications could be part of this Diuretics ****Expect matching on this**** KNOW the KEY FEATURES listed above Hematuria Micro or macroscopic Lower UT - No casts cells Kidneys +/- Red cell casts Inflammation, stones - pain Tumors - often painless Bleeding disorders Red casts cells are presentwhere is the lesion? - kidneys - Upper UTI Hematuria March hemoglobinuria - excessive activity Initial - urethra Terminal - bladder neck or posterior urethra Total - massive hemorrhage anywhere Assoc. w/ weight loss - renal cell carcinoma 10-14 days after URI - acute glomerulonephritis Under 20 Congenital - newborns UTI (teen females) Glomerulonephritis (after URTI) Trauma (males) 20-40 MALES Kidney stones** Acute UTI Bladder Tumor 20-40 FEMALES Acute UTI** Kidney Stones Bladder Tumor 40-60 MALESU Bladder tumor** Kidney stone Acute UTI Over 60 MALES Prostatic Path** Bladder tumor Acute UTI 40-60 FEMALES Acute UTI** Kidney Stone Bladder tumor Over 60 FEMALES Bladder Tumor** Acute UTI Other Changes in Urine Completely clear - diluted Orange - urobilinogen Deep yellow - concentrated Brown/black - hemorrhage/meds Milky/cloudy - infection Bluish/Greenish - jaundice/putrefying Coca Cola - obstructive Jaundice Male Reproductive System Pain Lesions or masses (genital or groin) Discharge Itching Hematuria Infertility & impotence Genital or Back Pain OPPQRST, Past Hx, Associated Hx Sudden distention = pain Gradual enlargement = painless Achy costovertebral angle = pyelonephritis or obstructive hydronephrosis Pain down into the inguinal area or is MOVING *** Down..we think Kidney stones Quadratus lumborum syndrome - (twisting pain) Spasmodic or colicky pain with radiation to the testes or scrotum = urethral dilation Lower abdomen. Fullness with suprapubic pain and urgency dilation = bladder distention Testicular/scrotal pain = epididymitis, orchitis, spermatic cord torsion, tumor, or hydrocele Urinary System Pain Infections UTI's STD's Prostatitis - sometimes caused by UTI Obstruction or occlusion Strictures Stones Hypertrophy Groin Pain Hernia Spinal cord tumor Herpes zoster Aneurysm Lymphadenitis - well delineated and mobile Arthritis Disc herniation Pathology of: Testicle Prostate gland Upper & lower GU infections/tumor GI disease Dysuria Location & OPPQRST Infections Obstruction with painful straining (tenesmus) Changes in micturation Explain symptom & obtain Hx frequency, nocturia, urgency, amount, hesitancy, change in force and caliber of stream Incontinence - overflow incontinence (bladder is enlarged) Hematuria - (look at above tables) Discharge - Pg 373 (cont, intermittent, acute, bloody, Abnormal discharge Continuous or intermittent Bloody - Hunner's ulcers (BLADDER - due to repeated infections) Ulcerations, neoplasias, urethritis Purulent Gonococcal urethritis, chronic prostatitis Masses, Lesions, Swellings Groin Masses or swellings Scrotal masses or lesions Penile lesions Hx of complaint Hx of STD's Associated symptoms Changes to lesions, mass or swelling Diff Dx Muscle strain Usually a hx of something happening like physical activity or fall Pain could be over a few weeks Arthritis Groin pain Pain not related to activity and usually nocturnal, no bulge Tends to occur in older people Septic arthritisnot real interested in this Inguinal pain Usually seen in a child Ectopic or undescending testiclenot real interested in this Hydrocele Sudden onset Varicocele Lesions of genitalia***matching .(20 matching questions) Phimosis Paraphimosis Blanitis - inflammation of the glands (STD) Blanaoposthitis - (crabs or scabies) TABLE 10-1 Venereal Warts Multiple wart like lesions (small papules) Result from HPV. Genital herpes Cluster of small vesicles Painful, nonindurated Herpes simplex Syphilitic chancre Indurated (ulceration) Non tender, enlarged inguinal lymphnodes are often associated***** Painless erosion or ulcer***** Hypospaidas Congenital displacement on the inferior surface of the penis Groove extends from the actual urethral meatus Can lead to complications for pregnancy Peyronie's disease Palpable nontender hard plaques Painful erections - that are off center Carcinoma of the penis Elevated (indurated) firm nodule or ulcer Non tender, limited to men not circumcised in childhood Lesion that is present for three weeks & not healing needs to be assessed Table 10-2 Hydrocele Inferior to testicle Will tranes illuminate Scrotal hernia No transillumination Scrotal edema Any scrape - tissue taught Congestive heart failure, atrophy of testicles, liver cirrohsis Cryptochordisim Testicle elevated in scrotum (testicles did not descend in to scrotum) Acute orchitis When the teste is acutely inflamed, tender , and swollen Seen in post puberty males after getting mumps & unilateral Very painful Small testis In adults, length less than 3.5 cm Small firm testes in Klinfelters syndrome (less than 2cm) Small soft are signs of atrophy seen in cirrhosis, mytonic dystrophy, use of estrogens, hypopituitarism, may follow orchitis Tumor of testes Ages 15 -35 is the most common time for carcinoma in young males Hard nodule** warrants investigation Acute Epididumitis An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testis. Scrotum may be reddened and vas deferens inflamed. Usually due to UTI or prostatitis or obstruction Tuberculosis Testis Varicocele Bag of worms** Varicose veins present when male is upright (standing) & testes elevated Torsion of spermatic cord Epidimoid yellow Infertility Failure for pregnancy to occur after 1 year of sexual activity without contraceptive usage 25% of couples experience infertility at some point in their reproductive lives Reproductive disorders or life habits Hx of: orchitis, cryptochordism, small testis, varicocele Impotency OPPQRST w/ associated symptoms or conditions In healthy younger men the most common cause is lack of interest in partner In older men: vascular insufficiency, dementia, neurological disorders, endocrine disorders, organ system failure Exam of Male Genitalia Inspection Palpation Transillumination Inspection of genitalia Inspect skin of genetalia and adjacent tissues note excoriations, lesions, or scars Penis: if not circumcised will need fore-skin retracted to inspect the glans Note ulcers, nodules, inflammation, scars (blanitis or Scrotal contour: swelling, lumps Palpation of genitalia Evaluate the penis noting tenderness or induration (urethral stricture) Note the position of the meatus and gently compress to note any discharge Lift the scrotum up to visualize the posterior aspect Palpate the scrotum contents: Each testis: note size, shape, tenderness, consistency (3-4 cm, round, smooth & somewhat rubbery) Above testis palpate Transillumination Shone light through posterior aspect of the scrotum noting +/- glow above the testis Hydrocele & spermatocele (+) Blood, tumor, hernia (-) Pg 377 - self exam Prostate Gland (Ch 13) - 2nd cancer related cause of death in US Age over 50 Race: Black/african-american descent Family Hx of prostate cancer Diet high in animal fats Alcohol abuse Occupational exposure to carcinogens Petroleum & tar products Symptoms of prostate disorder Hesitancy Intermittent flow Terminal or post void dribbling Impaired size & force of stream Incomplete void sensation Nocturia, dysuria Frequency, urgency Symptom Diff Benign prostatic hypertrophy Prostatitis Bladder neck contracture/stricture Urethral stricture Cystitis Neurogenic bladder dysfunction Table 13-2 Prostate As palpated through anterior rectal wall, the normal prostate is a rounded heart shaped structure about 2.5 cm Benign Prostatic Hyperplasia Starting in the 5th decade of life Cancer of the prostate Area of hardness in the gland, a distinct hard nodule in the gland, median sulcus may be obscured Prostatitis Acute & Chronic Chronic is usually asymptomatic (boggy feelingspongy) May be areas that seem tender or nodularity & fibrosis Acute Prostate Screening Digital rectal exam (DRE) Prostate specific Antigen (PSA) UA & Culture Transurethral Ultrasound (TRUS) Cystourethraoscopy Biopsy Female Reproductive System Abnormal vaginal bleeding Dysmenorrhea Vaginal discharge Vaginal itching Genital masses or lesions Lower abdominal pain or mass Dyspareunia - pain after or during intercourse Changes in hair distribution Infertility Risk factors For other problems Factors associated with endometrial cancer Post menopause Early menarche (before age 12) This is happening more often since hormones are in food.?...?.... Late menopause (after age 50) Infertility or low parity Obesity - the inability to truly assess the vagina structures Personal hx of hypertension, diabetes, endometrial hyperplasia, liver disease Diabetes ABNORMAL circulation** Unopposed estrogens replacement therapy High socioeconomic status More access to health care Family hx of endometrial, breast, or colon cancer Cancer of the Cervix Age between 40 & 50 years Personal hx of cervical dysplasia, condyloma scuminatum, herpes simplex Early age at first coitus (intercourse) Multiple sex partners by patient or sexual partner Smoking Multiple pregnancies Cancer of Ovarian Age between 40 & 60 Personal hx Ovarian dysfunction, anovulation or spontaneous abortions Cancer of the breast or endometrium Irradiation of the pelvic organs Endometriosis Family hx of ovarian or breast cancer Infertility or nulliparity Exposure to talc or asbestos Menstrual Hx Menache: 9-16yoa LMP: date of last menstrual period PNMP: date of last previous normal MP Interval: between periods (24-32 days) Duration (3-7 days) & flow (varies) Dysmenorrhea: Pain with menses Premenstrual Syn: 4-10 days prior to Amenorrhea: absence of menses Oligomenorrhea: infrequent or irregular Polymenorrhea: very infrequent Menorrhagia: increased amount or duration Metrorrhagia: intercycle/irregular intervals Menopause: cessation of menses Postmenopausal bleeding: occurring 12 months after total cessation Urinary incontinence: vaginal discharge, itching, masses or lesions Screening tests: Self breast exam Last gynecological exam including yearly Midcycle spotting is associated with fluxuation of ovulation or estrodials ** this is not uncommon Post menstrual bleeding - if she has not been placed on synthetic hormones then Abnormal Menstrual Bleeding Mid-cycle spotting- mid-cycle estradiol fluctuation associated with ovulation Delayed menstruation w/ excessive bleeding- anovulation or threatened abortion Frequent bleeding- chronic PID, endometriosis, Dysfunctional Uterine Bleeding DUB, anovulation Profuse menstrual bleeding- endometrial polyps, DUB, adenomyosis, submucosus leoimyomas, IUD Intermenstrual or irregular bleeding- endometrial polyps, DUB, uterine or cercal cancer, oral contra. Postmenopausal bleeding- endometrial hyperplasia, estrogen therapy, endometrial cancer Table 11-5***** ONE ON TEST 4 one on FINAL Trichomonas Vaginitis Cause - trichimonas vaginitis Discharge Other symptoms Yeast infection Cause Discharge Other symptoms Bacterial Vaginitis Cause Discharge Other symptoms Atrophic Vaginitis Cause - decreased estrogen production after menopause Discharge Other symptoms GONORRHEA - usually not a lot of discharge, but on examination you will have purulent yellowish discharge AT THE CERVICAL OS. On NB Female UG Abdominal Pain L-OPPQRST (acute/chronic, pattern, progressive, intermittent Association w/menses or mid-cycle Hx of STD's, other infections Associated symptoms: masses, fever, bowel/bladder changes, discharge, dysuria, dyspareunia, pregnant Acute: most often infection unless pregnant (spontaneous abortion, Ectopic tubal pregnancy or rupture, uterine perforation Mittelschmerz: assoc. w/ ovulation Women on fertility drugs Chronic: endometriosis, PID, Laxity of pelvic floor musculature Female Reproductive system Abnormal vaginal bleeding Dysmenorrhea Vaginal discharge Bacterial vaginosis Atrophic vaginitis Vaginal itching Genital masses or lesions Lower abdominal pain or masses Table 11.1 & 11.2 NO QUESTIONS FROM TABLE 11.3 or 4 except for the discharge None from 11.6 or 7 Table 11.1 Epidermoid cysts Small, firm, round cystic nodules in the labia suggests epidermoid cysts. They are sometimes yellowish in color. Venereal Warts Rapidly growing lesions Odor and moist Genital herpes Grouped ulcers Red base Painful Suggests herpes infection Syphilitic Chancre Painless ulcers Internally Indurated base Secondary Syphilis (Condyloma layum) More often in females Multiple flat or slightly raised papules Grayish color with gray exudates when they rupture Carcinoma of the vulva 3 weeks of the sore Appears in older women Rapidly spreading cancer Ulcerative Table 11.2 Cystocele A descent leading to a mass or bulge of the anterior vaginal wall with the bladder, May occur in post menopausal women or after birth Cystourethrocele Entire vaginal wall with the bladder and urethra Rectocele Bulging or mass of the rectum bulging into the post wall of the vagina Hesseries - devices inserted into the opening of the introitis Hard plastic ones that are on springs. Inserted Bartholins Gland infection Warm to the touch, tender Infection of Chlamydia Labial swelling Non tender cyst present if chronic Urethral Caruncle Small, red, benign tumor Abnormal urine flow - spray may occur Occurs chiefly in postmenopausal women Prolapse of the urethral mucosa Swollen red ring around the urethral meatus Could be diagnosed by pure inspection of the area ***Matching on some of the above lesions**** Dyspareunia - pain during or after intercourse Could be from trauma Pathophysiological: infection, tumors, PID, endometriosis, lesions, laxity of the pelvic floor musculature Psychogenic: fear or history of injury or past abuse Changes in hair distribution Increase (hirsutism): adrenal tumors or hyperplasia, ovarian tumors, polycystic ovary ds., endrogenic hormone therapy Decrease (alopecia): aging, cancer, malnutrition, thyroid ds, meds, vascular, insufficiency, crash diets Infertility Failure for pregnancy to occur after 1 year of sexual activity without contraceptive usage 25% of couples experience infertility at some point in their reproductive lives Reproductive disorders or life habits Anovulation, ovarian ds, PID, systemic ds, hypothyroidism, fibroids **RED FLAGS FOR SEXUAL ABUSE** - 1 Q from this section This applies for both males and females ANSWER ALL OF THE ABOVE***** Evidence of physical abuse Trauma, scarring in genital, anal, and perianal areas Unusual changes in skin color or pigmentation in the genital or anal area Presence of STD Enuresis that develops, UTI, itching, bleeding, dysuria, hematuria Inappropriate sexual knowledge Significant behavioral changes FINAL EXAM Respiratory Exam Make sure you are familiar with respiration rates & some of the condition that could effect that Chest Pain 6.1 - KNOW FOR CARDIOVASCULAR & GI Table 6.2 - brieflyCOMMON conditions of dyspnea Cough & hemoptosis - there will not be just 1 exam finding ***6.7 KNOW NORMAL EXAM FINDINGS, chronic bronchitis EARLY vs CONGESTIVE heart failure Pneumonia Atelectasis TB - chest pain, cough, hemoptosis Pulmonary EMBOLI Pneumothorax Exam Systems & findings Breast Exam 4 conditions Table 8.2 Fibroadenomas Cysts Cancer Gross cysts Pg 302 *** Fibroadenoma Cysts Fibrocystic change Cancer 1 Q on breast condition Cardiac Hypertension & pulse patterns Chest pain Chest Pain Chest Pain Pg 97 pulse patterns Pg 93 respiratory patterns Pg 70 hypertension **** Look at the blood pressure readings again*** Table 7-1 Variations on the left ventricle Identifications of extra heart sounds Venous vs Arterial assessment Table 14.1 Acute arterial occlusion Deep Vein thrombosus Chronic arterial vs venous insufficiency Tend to ask a couple question on peripheral vascular disease instead of asking so many heart sounds GI & anorectal Look at Table 9.1 or 13.1 Painful condition**** Fissures & fistulas Not a lot of questions on this but Dysphagia Constipation or diarrhea ***absolutely blood in the stool Table 9.5 Section 4 exam Polyuria, nocturia, incontinence, discharge, Prostate      Phys Dx II  PAGE 1 of  NUMPAGES 71 Fall 05 FINAL MATERIAL PAGE  PAGE 1 Phys Dx II  PAGE 71 of  NUMPAGES 71 Fall 05 FINAL MATERIAL ,.?_`jkwxz    0 1   : ; I J L |   _ ` 6 7 p q 12XYvwyh,uCJaJh,u5CJOJQJ\aJh,uCJOJQJaJh,u5CJOJQJ\aJQ,.?`kxz  1  ; J L | & Fp9D@&^p & F9D@&^@&[$\$^ & F9D@&^ @&[$\$;|  ` 7 q 2Ywy & F9D@&^ @&[$\$@&[$\$^ & Fp9D@&^p & F9D@&^$GZw  .4Qp & Fp9D@&^p & F9D@&^ @&[$\$@&[$\$^ & F9D@&^ & Fp9D@&^p#$FGYZvw .34PQop}~$%]tvrs{|  stQRtu'9:h,u5>*CJOJQJ\aJh,u5CJOJQJ\aJh,uCJaJh,uCJOJQJaJQp~%'[]tvs & F9D@&^ @&[$\$@&[$\$^ & Fp9D@&^p & F9D@&^s| tRu':a G & Fp9D@&^p & F9D@&^ @&[$\$@&[$\$^ & Fp9D@&^p & F9D@&^:`a  FGVW45[\tuSTgh !01BCJKklxy6Prsh,u5CJOJQJ\aJh,uCJaJh,uCJOJQJaJWGW5\uSUTh & Fp9D@&^p & F9D@&^ @&[$\$@&[$\$^ & F9D@&^ & Fp9D@&^ph!1CKly@&[$\$^ & F p9D@&^p & F 9D@&^ @&[$\$@&[$\$^ & F9D@&^46P\s,V<e & F p9D@&^p & F 9D@&^@&[$\$^ & F 9D@&^ @&[$\$+,UV;<de}~? @ b !!_!`!q!r!v!w!!!!!!!""" 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