NR 509 Final Exam Study Guide

NR 509 Final Exam Study Guide. Chapter 5 Ashley (1-6)/ Catlin (7-9) Behavior/Mental Health Assessment and Modification for Age -Unexplained conditions lasting >6weeks should prompt screening for depression, anxiety, or b ...

NR 509 Final Exam Study Guide. Chapter 5 Ashley (1-6)/ Catlin (7-9) Behavior/Mental Health Assessment and Modification for Age -Unexplained conditions lasting >6weeks should prompt screening for depression, anxiety, or both -PRIME-MD (Primary Care Evaluation of Mental Disorders). 26 questions and take 10 minutes to complete. Used for the 5 most common=anxiety, depression, alcohol, somatoform, and eating disorders. -Patient indications for Mental Health Screening: 1.Medically unexplained physical symptoms-more than half have depression and anxiety disorders 2. Multiple physical or somatic symptoms or high symptom count 3.High severity of the presenting somatic symptoms, chronic pain 4.Symptoms for more than 6 weeks 5. Physician rating as a “difficult encounter” 6. Recent stress 7.Low-self rating of overall health 8.Frequent use of health care services 9.Substance abuse. -CAGE=substance-related and addictive disorders Modification for Age Elderly: -Complain of memory problems but usually is due to benign forgetfulness -Retrieve and process data more slowly and take longer to learn new information -Slower motor responses and their ability to perform complex task may diminish -Important to distinguish age-related changes from manifestations of mental disorders -More susceptible to delirium which can be the first sign of infection, problems with medications, or impending dementia Infant: Assess mental status of a newborn=observing newborn activities 1.Look at human faces and turn to parents voice 2.Ability to shout out repetitive stimuli 3. Bond with caregiver 4.Self-soothe Normal VS. Abnormal Findings and Interpretation -Mood disorders: compulsions, obsessions, phobias, and anxieties -Lethargic: drowsy, but open their eyes and look at you, respond to questions, and then fall asleep. -Obtunded: open their eyes and look at you, but respond slowly and are somewhat confused. -Agitated depression: crying, pacing, and hand-wringing -Depression: the hopeless slumped posture and slowed movements. -Grooming and personal hygiene may deteriorate: Depression, schizophrenia, and dementia -Manic Episode: the agitated and expansive movement of a manic episode -Obsessive-Compulsive Disorder: Excessive fastidiousness -Lesion parietal cortex: one side neglect in the opposite parietal cortex, usually in the nondominant side -Parkinsonism: facial immobility -Paranoia: anger, hostility, suspiciousness, or evasiveness -Mania: Elation and euphoria -Schizophrenia: flat affect and remoteness -Apathy (dull affect with detachment and indifference): dementia, anxiety, and depression -Hallucination: schizophrenia, alcohol withdrawal, and systemic toxicity -Amnestic Disorders: impaired memory or new learning ability and reduce social or occupational functioning, but lack the global features of delirium and or dementia. Anxiety and depression, and intellectual disability may also cause recent memory impairment. -Calculating ability: poor performance = dementia or aphasia -Variations and abnormalities in thought processes: 1.Circumstantiality: The mildest thought disorder, consisting of speech with unnecessary detail, indirections, and delay in reaching the point. Some topics may have a meaningful connection -Occurs in people with obsessions 2. Derailment: Tangential, speech with shifting from topics that are loosely connected or unrelated. The patient is unaware of the lack of association -Schizophrenia, manic episodes, and other psychotic disorders 3.Flight of ideas, an almost continuous flow of accelerated speech with abrupt changes from one topic to the next. Changes are based on understandable associations, play on words, or distracting stimuli, but ideas are not well connected. -Manic episodes 4.Neologisms: invented or distorted words, or words with new and highly idiosyncratic meanings -Schizophrenia, psychotic disorders, and aphasia 5.Incoherence: Speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. Flight of ideas, when severe, may produce incoherence -Schizophrenia 6.Blocking: Sudden interruption of speech in mid sentence or before the idea is completed “losing the thought” -Schizophrenia 7.Confabulation: Fabrication of facts or events, to fill in the gaps from impaired memory -Korsakoff syndrome from alcoholism 8.Perseveration: persistent repetition of words or ideas -Schizophrenia or other psychotic disorders 9. Echolalia: Repetition of the words and phrases of others -Manic episodes or Schizo 10.Clanging: Speech with choice of words based on sound, rather than meaning, as in rhyming and punning. Example: “look at my eyes and nose, wise eyes and rosy nose. To to one, the ayes have it!” -Schizo and manic episodes Abnormalities of Perception 1. Illusions: misinterpretations of real external stimuli, such as mistaking rustling leaves for the sounds of voices -Grief, delirium, PTSD, Schizo 2.Hallucinations: Perception-like experiences that seem real but, unlike illusions, lack actual external stimulation. The person may or may not recognize the experiences as false. May be auditory, visual, olfactory, gustatory, tactile, or somatic. -PTSD, Schizo, delirium, dementia, alcoholism Abnormalities of Thought Content 1.Compulsions -repetitive behaviors feel driven to perform in response to an obsession (anxiety disorders) 2.Obessions -Recurrent persistent thoughts, images, or urges 3.Phobias -Persistent irrational thoughts, compelling desire to avoid provoking stimulus 4.Anxieties 5.Feelings of unreality 6.Feelings of Depersonalization 7.Delusions Erotomanic: the belief that another person is in love with the individual Somatic: involves body functions Unspecified: includes delusions of reference without a prominent persecutory or grandiose component Speech Patterns -Slow speech: depression -Accelerated speech: mania -Articulation: are the words clear and distinct: does the speech have a nasal quality -Dysarthria: defective articulation “slurred speech” -Dysphonia: results from impaired volume, quality, or pitch of voice. Difficulty speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords. -Aphasia: the loss of ability to understand (receptive/Wernicke) or express speech (expressive/Broco aphasia) -Brocas aphasia: patients articulate very slowly and with a great deal of effort. Nouns, verbs, important adjectives are usually present and only small grammatical words are dropped from speech "Well…..cat and…..up……..um, well, um…forget it" -Wernicke's aphasia the patient can speak effortlessly and fluently, but his words often make no sense “the coffee cat looks crazy still” -Cerebrovascular infarction -Fluency: fluency reflects the rate, flow, and melody of speech and the content and use of words. Abnormalities -Hesitancies and gaps in the flow and rhythm of words -Disturbed inflections, such as monotone -Circumlocutions: phrases or sentences are substituted for a word the person cannot think of. Example “what you write with for “pen” -Paraphasia: malformed, wrong, or invented -Testing for Aphasia -Word comprehension: ask the patient to follow one-stage commands such as “Point to your nose” -Repetition -Naming -Reading comprehension -Writing Mental Status Examination Brief test used to screen for cognitive dysfunction or dementia, and follow the patients course over time. 1. Orientation 2.Short-term memory-retention/recall 3.Language 4.Attention 5.Calculation 6.Constructive Praxis Example of findings that suggest dementia: “The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is oriented to person, place, and time. Digit span, serial 7s, and calculations accurate, but responses delayed. Clock drawing is good. Screening for Depression High Yield Screening Questions for office practice: 1. over the past 2 weeks, have you felt down, depressed, or hopeless? 2. Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)? Symptoms of depression: low self-esteem, loss of pleasure (anhedonia), sleep disorder, difficulty concentrating. Depression tends to be long-lasting and can recur. Suicide is the second leading cause of death among 15-24 year old. Suicide rate are the highest among those ages 45 to 54, followed by elderly adults 85 years old or older. 90 % of suicide is non-hispanic whites. Other symptoms of depression: headaches, muscle aches, fatigue Generalized Anxiety Disorder -Most common mental disorder in primary care - High Yield Screening Questions for office practice: 1. Over the past 2 weeks, have you been feeling nervous, anxious, on edge, unable to stop or control worrying? 2. Over the past 4 weeks, have you had an anxiety attack-suddenly feeling fear or panic? You can screen for core anxiety symptoms by asking the first two questions from the 7-item generalized anxiety disorder (GAD) scale. Scores on this GAD subscale range from 0 to 6; a score of 0 suggests that no anxiety disorder is present. A score of 10 on the GAD-7 identifies GAD; scores of 5, 10, and 15 represent mild, moderate, and severe levels of anxiety. Depressive Disorders Depression and anxiety disorders are a common cause of hospitalization in the United States, and mental illness is associated with increased risks for chronic medical conditions, decreased life expectancy, disability, substance abuse, and suicide. About 19million adult American or almost 7% have major depression with other co-existing anxiety disorder or substance abuse. Depression is as common in women as men, and the prevalence of postpartum depression is about 7% to 13%. Most patients with chronic medical conditions have depression. Symptoms of depression in high-risk patients may be subtle and may include; 1. Low self-esteem 2. Loss of pleasure in daily activities (Anhedonia) 3. Sleep disorder, 4. Difficulty concentrating or making decisions. Look carefully for symptoms of depression in vulnerable patients, especially those who are young, female, single, divorced or separated, seriously or chronically ill, bereaved, or have other psychiatric disorders, including substance abuse. A personal or family history of depression also places patients at risk. Asking two simple questions about mood and anhedonia appears to be as effective as using more detailed instruments. All positive screening tests warrant full diagnostic interviews. Failure to diagnose depression can have fatal consequences—the presence of an affective disorder is associated with an 11-fold increased risk for suicide. Depression screening 1. Over the past 2 weeks, have you felt down, depressed, or hopeless? 2. Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)? Depression tends to be long-lasting and can recur. Because of these two factors, a wait-and-see approach to treatment is not desirable and timely treatment is necessary. Schizophrenia 1. Grooming and personal hygiene may deteriorate 2. flat affect and remoteness 3. Hallucinations: lack actual external stimulation 4. Derailment: Tangential, speech with shifting from topics that are loosely connected or unrelated. The patient is unaware of the lack of association. 5. Neologisms: invented or distorted words, or words with new and highly idiosyncratic meaning 6. Incoherence: Speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. 7. Flight of ideas, when severe, may produce incoherence 8. Blocking: Sudden interruption of speech in mid sentence or before the idea is completed “losing the thought” 9. Clanging :speech with choice of words based on sound, not meaning 10. Echolalia: repetition of the words and phrases 11. Illusions: mistinterpretations of real external stimuli (mistaking rustling leaves for the sound of voices) 12. Usually occurs in late teens, early 20s (college students, common psych break) 13. Commonly seen in other family members Suicide Risk and Prevention Protective factors buffer individuals from suicidal thoughts and behavior. To date, protective factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding protective factors are, however, equally as important as researching risk factors. Protective Factors ● Effective clinical care for mental, physical, and substance abuse disorders ● Easy access to a variety of clinical interventions and support for help seeking ● Family and community support (connectedness) ● Support from ongoing medical and mental health care relationships ● Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes Cultural and religious beliefs that discourage suicide and support instincts for self-preservation Suicide is the second leading cause of death among 15- to 24-year olds. Suicide rates are highest among those ages 45 to 54 years, followed by elderly adults ≥age 85 years. Men have suicide rates nearly four times higher than women, though women are three times more likely to attempt suicide. Men are most likely to use firearms to commit suicide, while women are most likely to use poison. Overall, suicides in non-Hispanic whites account for about 90% of all suicides. American Indian/Alaska Native women ages 15 to 24 years have the highest suicide rates of any racial/ethnic group. Substance Use Disorders, Including Alcohol and Prescription Drugs. The harmful interactions between mental disorders and substance use disorders also present a major public health problem. Rates of drug-induced deaths continue to increase and are highest among whites and American Indian/Alaska Natives. The Centers for Disease Control and Prevention reports that prescription drugs have replaced illicit drugs as a leading cause of drug-induced deaths. Every patient should be asked about alcohol use, substance abuse, and misuse of prescription drugs Suicide Risk and Prevention Risk Factors ● Family history of suicide ● Family history of child maltreatment ● Previous suicide attempt(s) ● History of mental disorders, particularly clinical depression ● History of alcohol and substance abuse ● Feelings of hopelessness ● Impulsive or aggressive tendencies ● Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma) ● Local epidemics of suicide ● Isolation, a feeling of being cut off from other people ● Barriers to accessing mental health treatment ● Loss (relational, social, work, or financial) ● Physical illness ● Easy access to lethal methods ● Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts Chapter 9 & 12 Kailey/Jenna Cardiac/Vascular Assessment and Modification for Age Normal VS. Abnormal Findings and Interpretation -Acute aortic dissection: anterior chest pain, often tearing or ripping and radiating into the back or neck. -Sudden dyspnea: PE, PNEUMO, and anxiety -PMI (point of maximal impulse) APEX OF THE LEFT VENTRICLE identified during palpation of the precordium, locates the left border of the heart and is normally found in the 5th intercostal space at or just medial to the left midclavicular line (or 7 to 9 cm lateral to the midsternal line). Normal diameter 1 to 2.5 cm. The left ventricle, behind the RV and to the left, forms the left margin of the heart, its tapered inferior tip is often termed the cardiac apex which produces the apical impulse, identified during palpation of the precordium as the PMI. Abnormal PMI 1. Situs inversus and dextrocardia->PMI located at the right side of chest 2. PMI>2.5cm-> left ventricular hypertrophy from HTN or aortic stenosis causing pressure overload in the left ventricle 3. Displacement of the PMI lateral to the midclavicular line or > 10 cm lateral to the midsternal line-> LVH and Ventricular dilatation from a MI or heart failure 4. COPD patients-> the PMI may be in the xiphoid or epigastric area due to right ventricular hypertrophy 5. Hyperkinetic high-amplitude=hyperthyroidism severe anemia, HTN, aortic stenosis, and aortic regurgitation 6. Sustained high amplitude- increased LVH from HTN Cardiac chambers, valves, and circulation 1. AV valves= Mitral and Tricuspid (based on location) 2. Semilunar valves= Aortic and Pulmonic (based on half-moon shape) 3. S1 & S2=vibrations emanating from the leaflets, the adjacent cardiac structures, and the flow of blood. 4. S1=Closure of the mitral valve 5. s2=Aortic valve closure 6. S2 split= Closure of aortic valve and then pulmonic valves, best heard over the pulmonic area with the bell of the stethoscope 7. S3 & S4= Heart failure or acute myocardial ischemia 8. S3=caused by rapid deceleration of blood against the ventricular wall 9. S4= increased left ventricular end diastolic stiffness which decreases compliance 10. Systolic blood pressure=maximal left ventricular pressure 11. Diastole= left ventricular pressure continues to drop and falls below left atrial pressure. The mitral valve opens, event usually silent but may be audible if valve leaflet motion to restricted (mitral stenosis) 12. Right ventricle is the chamber that you can assess by palpation since it occupies most of the anterior surface of the heart. Events in the Cardiac Cycle 1. Systole= Ventricular contraction 5mm HG to 120 mm HG. Blood ejected into Aorta. Aorta valve open and mitral closed. 2. Diastole= Ventricular relaxation blood flows from atrium to ventricular. Aorta valve closed, and mitral valve open. Normal JVP: 3 cm above the sternal angle, in patients with obstructive lung disease, JVP can appear elevated on expiration but veins collapse on inspiration. 1. Jugular venous pressure-reflect right atrial pressure which in turn equals central venous pressure and right ventricular end-diastolic pressure.Lies deep in SCM muscles. Abnormal JVP: falls with loss of blood or decreased venous vascular tone and increases with right or left heart failure, HTN, tricuspid stenosis, AV dissociation, increased vascular tone, and pericardial compression or tamponade. Jugular Venous Pulsations 1. A-atrial contraction, C-carotid transmission, V-venous filling 2. Abnormally prominent waves occur: increased resistance to right atrial contraction, tricuspid stenosis, 1st/2nd/3rd degree AVB, SVT, junctional tachycardia, pulmonary HTN, pulmonic stenosis. 3. Absent a waves=A FIB 4. Systolic phenomenon is the X descent 5. Increased V waves=occur in tricuspid regurgitation, atrial defects, and constrictive pericarditis. 6. Abnormal: >3 cm above sternal angle (NOT NOTCH) or > 8 cm above right atrium, best measured at the end of expiration 7. The vertical height of the blood column in centimeters, plus 5 cm, is the JVP Carotids Characteristics: amplitude, contour, timing of upstroke in relation to S1 and S2 Normal: 2+, no bruits or thrills Abnormal: small, thready or weak in cardiogenic shock, and bounding in aortic regurgitation 1. Carotid upstroke is delayed in aortic stenosis 2. Carotid pulse mall, thready, or weak= cardiogenic shock 3. The pulse pounding= aortic regurgitation 4. Bruit-murmur like sound arising from turbulent arterial blood flow. Caused by-atherosclerotic luminal stenosis 5. Carotid vs. Jugular: carotid is palpable Dextrocardia-a rare congenital transposition of the heart, the heart is situated in the right chest cavity and generates a right-sided apical impulse. Pulsus alternans: a bigeminal pulse that varies from beat to beat, almost always indicates LV dysfunctions Paradoxical pulse: varies with respiration, greater than normal drop in BP during inspiration, suspected with cardiac tamponade Cardiovascular Risk Factors Screening - Heart Disease: long asymptomatic latent period. Assess lifetime risk in asymptomatic patients starting at age 20 since many deaths occurs from lack of prior warning signs or cardiac diagnosis. -AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse -The physical examination criteria for identifying metabolic syndrome include a waist of 40 inches or greater for males, a waist of 35 inches or greater for females, and a blood pressure of 130/85 or greater (in both males and females). - Women: o CVD and CHD higher in black women then white women. o Women> 65: higher prevalence of HTN than men. o Stroke 60% deaths o Unique risk factors: pregnancy, hormone therapy, early menopause, preeclampsia. More likely to have a-fib, migraine with aura, obesity, and metabolic syndrome. - Major cardiovascular risk factors and screening frequency o Family hx of CVD o Cigarette smoking o Poor diet o Physical inactivity o Obesity (especially central) o Hypertension o Dyslipidemias: screen for men >35 and women >45 with increase risk of CHD; screen by age 20 in those who have DM, HTN, obesity, tobacco use, noncoronary atherosclerosis, or family hx of early CVD. o Diabetes: Screen at age 45 and repeat every 3 years; screen at any age when BMI >25 with additional risk factors. o Pulse o Metabolic syndrome: cluster of risk factors that increase both CVD and DM. Presence of 3 of the 5 risk factors: § Waist circumference men>102cm; women >88cm § Fasting plasma glucose: >100; or being treated for high BS § HDL cholesterol: men <40 women ;<50; or being treated § Triglycerides: >150; or being treated § BP: >130/85; or being treated Heart Disease Heart Sounds (jen) Heart Sounds - Closure of the heart valves creates a pair of audible heart sounds. - The first sound, S1, arises from closure of the mitral valve. - Tricuspid valve closure may also contribute to S1. - The second sound, S2, arises from closure of the aortic valve. - Pulmonic valve closure may also contribute to S2. - Ventricular diastole occurs between S2 and the next S1. - After the mitral valve opens, there is a period of rapid ventricular filling as blood flows early in diastole from left atrium to left ventricle. - Third heart sound: S3 o In children and young adults (35-40 and last trimester of pregnancy), may arise from rapid deceleration of the column of blood against the ventricular wall. o An S3 in adults over age 40 years (an S3 gallop) is usually pathologic, arising from high left ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of diastole. Causes include decreased myocardial contractility, heart failure, and ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts. o Left-side S3; heard at apex with pt on left lateral position o Right-sided S3: heard at lower left sternal border or below xiphoid with pt supine; louder on inspiration - Fourth heart sound, S4, o not often heard in normal adults, and marks atrial contraction. o It immediately precedes S1 of the next beat and can also reflect a pathologic change in ventricular compliance. o Causes of a left-sided S4 include hypertensive heart disease, aortic stenosis, and ischemic and hypertrophic cardiomyopathy. o Left-sided S4 best heard at apex in left lateral decubitus position. o Right-sided S4 heard along lower left sternal border or below xiphoid. Louder with inspiration. - The fact that diastole usually lasts longer than systole is helpful in distinguishing the two sounds. o The aortic and pulmonic valves are closed, and the mitral and tricuspid valves are open, as seen in diastole o Systole: period of ventricular contraction o Diastole: period of ventricular relaxation. o Cardiac cycle: § During systole • Aortic valve is open, allowing ejection of blood from the left ventricle into the aorta. • The mitral valve is closed, preventing blood from regurgitating back into the left atrium. • During systole the pulmonic valve opens and the tricuspid valve closes as blood is ejected from the RV into the pulmonary artery § During diastole • The aortic valve is closed, preventing regurgitation of blood from the aorta back into the left ventricle. • The mitral valve is open, allowing blood to flow from the left atrium into the relaxed left ventricle. • During diastole, the pulmonic valve closes and the tricuspid valve opens as blood flows into the right atrium A second-degree A-V block can result in a pulse rate less than 60 Auscultation of Heart Sounds - Diaphragm is better for detecting higher pitched sounds such as S1 or S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs. - The bell is more sensitive to low-pitched sounds such as S3 or S4 and the murmur of mitral stenosis. - Correlate heart sounds with the patient’s jugular venous pressure and carotid pulse. For example, if there is a diffuse PMI and an S3 suggesting congestive heart failure, look for an elevated JVP. - You will listen for S1 and S2 in each of the six listening areas: in the aortic area in the right 2nd interspace close to the sternum, in the pulmonic area in the left 2nd interspace close to the sternum, in the left 3rd interspace, in the tricuspid area in the left 4th and left 5th interspaces, and in the mitral area at the apex. - Note the cardiac rate and rhythm. Normally the rate is 60–100 beats per minute, and the rhythm is regular. - Identify S1 and S2, in the aortic area, S2 is usually louder than S1. - S2 is also usually louder than S1 in the pulmonic area. - Listening in the pulmonic area, identify the inspiratory splitting of S2 into its two components. o Its first component, A2, is from aortic valve closure. § A2 louder than P2 § A2 heard over precordium § P2 heard over 2nd and 3rd left interspace close to sternum. Here you search for splitting of S2. o Its second component, P2, comes from pulmonic valve closure. o This “physiologic split” of S2A (aortic) and S2P (pulnomic) normally occurs during inspiration. Use the bell with light pressure over the 2nd left intercostal space to hear the s2 split best. o During expiration, however, these two components are fused into a single sound, S2. - S2 usually diminishes in intensity while S1 becomes louder as you proceed down through the 3rd interspace and into the tricuspid and mitral areas. - If patient has emphysema, listen to heart sounds in the epigastrium area. - Use bell of the stethoscope and listen along the lower left sternal border in the left 4th and 5th interspaces. Then listen at the apex. - To hear S3, S4, and the murmur of mitral stenosis, place patient in left lateral decubitus position. o This brings the left ventricle closer to the chest wall and makes low pitched sounds more audible. Then, recheck the position of the apical impulse and place the bell lightly over that location. Is there an audible S3. Now, notice how the third heart sound disappears when the bell is placed more firmly on the chest wall. Listen again with light pressure o In most adults over age 40 years, the diastolic sounds of S3 and S4 are pathologic, and are correlated with heart failure and acute myocardial ischemia. o an S3 corresponds to an abrupt deceleration of inflow across the mitral valve, and an S4 to increased left ventricular end diastolic stiffness which decreases compliance. Murmurs Heart murmurs: distinct heart sounds distinguished by their pitch and their longer duration. They are attributed to turbulent blood flow and are usually diagnostic of VALVULAR DISEASE. Identify when the murmur occurs (systolic or diastolic) by palpating the carotid artery at the same time Chest Wall Location and Origin of Valve Sounds and Murmurs R 2nd Interspace to the apex Aortic Valve Left 2nd and 3rd interspaces close to the sternum, but also at higher or lower levels Pulmonic Valve At or near the lower left sternal border Tricuspid At and around the cardiac apex Mitral Valve Midsystolic Murmurs 1. Innocent Murmur: Left 2nd to 4th interspace between the left sternal border and the apex. Minimal radiation. Grade 1 to 2, possibly 3. Soft to medium pitch. Variable quality. Usually decreases or disappears on sitting. Turbulent blood flow, probably generated by Ventricular ejection of blood into the aorta from the left and occasionally right ventricle. VERY COMMON IN CHILDREN AND YOUNGER ADULTS. Older adults= CVD 2. Physiologic Murmurs: Similar to innocent murmur. Turbulence due to temporary increase in blood flow in predisposing conditions such as anemia, pregnancy, fever, and hyperthroid Pathologic Murmurs/Midsystolic 1. Aortic Stenosis: Right 2nd and 3rd interspaces. Radiation, often to the carotids, down the left sternal border, even to the apex. Sometimes soft but often loud with a thrill intensity. Medium, harash; crescendo-decrescendo may be higher at the apex for pitch. Often harsh, may be more musical at apex for quality. Heard best with patient sitting and leaning forward.Significant stenosis causes turbulent blood flow across the valve, and increased LV afterload. CAUSE: VALVE CALCIFICATION in older adults. Second most common cause: CONGENITAL BICUSPID AORTIC VALVE. 2. Hypertrophic Cardiomyopathy: 3rd and 4th IS. Medium pitch. Harsha quality. Intensity decreases with squatting and Valsalva release phase (increased venous return), increases with standing and valsalva strain phase. The carotid upstroke rises quickly, unlike aortic stenosis.The apical pulse is sustained. S2 may be single. S4 is usually present at the apex, unlike mitral stenosis. Usually benign, but can progress to syncope, ischemia, AFIB, dilated cardiomyopathy and heart failure, and increase stroke, and sudden death. Unexplained diffuse or focal ventricular hypertrophy with myocyte disarray and fibrosis associated with unusually rapid ejection of blood from the left ventricle during systole. lus and from leaflet, papillary muscle, or chordae tendineae dysfunction. 3. Tricuspid Regurgitation: Lower left sternal border, if RV pressure is high=murmur is loud a the apex and confused for mitral regurgitation. Blowing, holosystolic quality. Precordial Rock. JVP elevated. Pulsatile liver, ascites, edema. When the tricuspid valve fails to close fully in systole, blood regurgitates from RV to right atrium, producing a murmur. Common causes: RV failure and dilatation, with resulting enlargement of the tricuspid orifice, often induced by pulmonary HTN or LV failure; and endocarditis. 4. Ventricular Septal Defect: 3rd, 4th, 5th. Radiation often wide. Very loud with thrill. S2 obscured by loud sound. Larger defects cause, left to right shunts, pulmonary HTN, RV overload. Congenital abnormality. 5. Mitral valve prolapse: short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2, best heard over the apex. A great test would be having pt squat, the noise will move later in systole along with the murmur Diastolic Murmurs 1. Aortic Regurgitation: use diaphragm for high pitch. Heard better when patient is upright leaning forward. Blowing decrescendo quality. Diastolic pressure drops to as low as 50 mm Hg; pulse pressure can widen to > 80.Apical pulse becomes diffuse.Corrigan pulse. Duroziez sign. Quincke pulses. The aortic valve leaflets fail to close completely during diastole, causing regurgitation from the aorta back into the left ventricle and left ventricle overload. Austin Flint. Causes: leaflet abnormalities, marfan syndrome, subvalvular abnormalities such as subaortic stenosis or an atrial septal defect 2. Aortic insufficiency: usually associated with a bounding carotid pulse 3. Mitral insufficiency: produces a murmur of equal intensity throughout systole 4. Mitral Stenosis : Apex. Little to no vibration. Low pitched rumble with presystolic accentuation. USE BELL. A FIB occurs in about a third of symptomatic patients, increasing the risk of blood clots. The stiffened mitral valve leaflets move into the left atrium in mid systole and narrow the valve openings, causing turbulence. Common causes: Rheumatic fever, which causes fibrosis, calcification, and thickening of the leaflets and commissures, and chordal fusion. 6. Pulmonic Stenosis: Left 2 & 3 IS. If radiation loud, toward the left shoulder and neck. Intensity is soft to loud, if loud associated with thrill. JVP prominent a wave. The RV is often sustained. An early pulmonic ejection sound is present in mild to moderate. Severe, s2 is widely split and P2 softens. May hear a right-sided s4 over the left sternal border. Congenital disorder with valvular, supravalvular, or subvalvular stenosis. Pansystolic (Holosystolic) Murmurs 1. Mitral regurgitation: apex. Radiation to the left axilla. Intensity does not change with inspiration. Occurs when the mitral valve fails to close in systole, blood regurgitates from left ventricle to the left atrium causing the murmur and increasing LV preload=LV dilation. Causes: structural, from mitral valve prolapse, infectious endocarditis, rheumatic heart disease, collagen vascular disease. Stenotic Valve (aortic stenosis)- abnormally narrowed valvular orifice that obstructs blood flow Regurgitant Murmur-a valve allows blood to leak backward into a retrograde direction Congestive Heart Failure Orthopnea: dyspnea that occurs when lying down and improves when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure. Maneuvers to identify Murmurs and Heart Failure (jen) - Standing position: venous return to the heart decreases, as does peripheral vascular resistance. Arterial blood pressure, stroke volume, and the volume of blood in the left ventricle all decline. Squatting position: vascular and volume changes occur in the opposite direction. o These maneuvers help (1) to identify a prolapsed mitral valve and (2) to distinguish hypertrophic cardiomyopathy from aortic stenosis. - Valsalva maneuver: Used to identify hypertrophic cardiomyopathy, heart failure, and pulmonary hypertension. o The murmur of hypertrophic cardiomyopathy is the only systolic murmur that increases during the “strain phase” of the Valsalva maneuver due to increased outflow tract obstruction. o Identify HF and Pulmonary HTN by using blood pressure cuff kept at 15 mmHg above SBP during Valsalva Maneuver. In patients with severe heart failure, blood pressure remains elevated and there are Korotkoff sounds during the phase 2 strain phase, but not during phase 4 release, termed “the square wave” response. This response is highly correlated with volume overload and elevated left ventricular end-diastolic pressure and pulmonary capillary wedge pressure, in some studies outperforming brain natriuretic peptide o In healthy patients, phase 2, the “strain” phase, is silent; Korotkoff sounds are heard after straining is released during phase 4. - Isometric handgrip: increases systolic murmurs of mitral regurgitation, pulmonic stenosis, and ventricular septal defect; also diastolic murmurs of aortic regurgitation and mitral stenosis. - Transient Arterial Occlusion: Transient compression of both arms by bilateral blood pressure cuff inflation to 20 mm Hg greater than peak SBP augments the murmurs of mitral regurgitation, aortic regurgitation, and ventricular septal defect. Signs of heart failure on assessment: (jen) - An elevated JVP is highly correlated with both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis - In patients with obstructive lung disease, the JVP can appear elevated on expiration, but the veins collapse on inspiration. This finding does not indicate heart failure. - An elevated JVP is >95% specific for an increased left ventricular end diastolic pressure and low left ventricular EF, although its role as a predictor of hospitalization and death from heart failure is less clear. - Displacement of the PMI lateral to the midclavicular line or >10 cm lateral to the midsternal line occurs in LVH and also in ventricular dilatation from myocardial infarction (MI) or heart failure. - Pulsus alternans: Patient will have a strong pulse, then weak pulse, indicative of severe left sided HF - A diffuse apical impulse suggests left ventricular dilatation often found in congestive heart failure. - An S3 in adults over age 40 years (an S3 gallop) is usually pathologic, arising from high left ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of diastole. Causes include decreased myocardial contractility, heart failure, and ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts. - In most adults over age 40 years, the diastolic sounds of S3 and S4 are pathologic, and are correlated with heart failure and acute myocardial ischemia. - Orthopnea and PND occur in left ventricular heart failure and mitral stenosis and also in obstructive lung disease Peripheral Artery Disease PAD-refers to stenotic, occlusive, and aneurysmal disease of the abdomen aorta, its mesenteric and renal branches, and the arteries of the lower extremities, exclusive of the coronary arteries. Atherosclerotic disease leading to obstruction of peripheral arteries causing exertional claudication (muscle pain relieved by rest) and atypical leg pain; may progress to ischemic pain at rest. Usually in calf but also in the buttock, hip, thigh, or foot depending on the level of obstruction; rest pain may be distal in the toes or forefoot. PAD timing: may be brief if relieved by rest; if there is rest pain, may be persistent and worse at night. PAD aggravating factors: Exercise such as walking; if rest pain, leg elevation and bedrest. Coronary heart disease risk equivalent: peripheral arterial disease, abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus. Relief factors: Rest usually stops the pain in 1-3 min; rest pain may be relieved by walking (increases perfusion), sitting with legs dependent. Associated manifestations: local fatigue, numbness, progressing to cool dry hairless skin, trophic nails, diminished to absent pulses, pallor with elevation, ulceration, gangrene. Asymmetric BPs can be sign of: aortic dissection or coarctation/congenital narrowing of the aorta PAD risk factors: 1. > 50 2. Smoking, dm, htn, elevated cholesterol, african american, or CAD Symptom location suggests the site of arterial ischemia: 1. Buttock, hip-aortoiliac 2. Erectile dysfunction- iliac-pudendal 3. Thigh- common femoral or aortoiliac 4. Upper calf- superficial femoral 5. Lower calf- popliteal 6. Foot- tibial or peroneal Peripheral arterial disease warning signs: these symptoms suggest= intestinal ischemia of the celiac or superior or inferior mesenteric arteries 1. Fatigue, aching, numbness, or pain that limits walking or exertion in the legs; if present, identify the location. Ask also about erectile dysfunction. 2. Any poorly healing or non-healing wounds on the legs or feet 3. Any pain present when at rest in the lower leg or foot and changes when standing or supine. 4. Abdominal pain after meals and associated “food fear” and weight loss 5. Any 1st degree relatives with AAA (15 %-28%) PAIN IN CALVES great indicator of PVD!!!! Upper extremity DVT- central venous catheters. Ask about arm discomfort, pain, paresthesias, and weaknesses. Most patients are asymptomatic with thrombosis detected on routine screening. Screening tool/diagnostic for all patients with suspected DVT: WELLS CLINICAL SCORE AND THE PRIMARY CARE RULE Risk factors for lower-extremity peripheral arterial disease 1. > 65 year or > 50 years with a hx of dm or smoking 2. Leg symptoms with exertion 3. Non-healing wounds The ankle-brachial index: noninvasively diagnose PAD. The ABI is the ratio of blood pressure measurements in the foot an arm; values <0.9 are abnormal. Mild disease: ABI of 0.71 to 0.9. Moderate disease: ABI 0.7 and 0.41. Severe disease is ABI 0.4 or less. As the internal diameter of a blood vessel changes, the resistance changes as well...Resistance varies proportionally to the fourth power of the diameter Treatment for PAD: supervised exercise program, tobacco cessation, treatment of hyperlipidemia, optimal control of diabetes and htn, use of antiplatelet agents, meticulous foot care and well fitting shoes, revascularization. -expanding hematoma from triple A= may cause symptoms by compressing the bowel, aortic branch arteries, or ureters. -Mesenteric ischemia: food fear, weight loss, or dark stool. These symptoms suggest mesenteric ischemia from arterial embolism, arterial venous thrombosis, bowel volvulus or strangulation, or hypoperfusion. Failure to detect acute symptoms can cause bowel necrosis or death. -Atherosclerotic PAD: symptomatic limb ischemia with exertion. Ask about any pain or cramping in the legs during exertion that is relieved by rest within 10 minutes, called intermittent claudication, pain in calves. -Neurogenic claudication: Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet. -Spinal stenosis: the positive likelihood ratio LR of spinal stenosis is>6 if the pain is relieved by sitting and bending forward, or if there is bilateral buttock or leg pain. Decreased arterial perfusion: hair loss over the anterior tibiae. Ask about coldness, numbness, or pallor in the legs or feet or loss of hair over the anterior tibial surfaces, and thin, shiny, atrophic skin Venous insufficiency: scaling, redness, varicosities, hyperpigmentation, and painful ulcerative lesion near the medial malleolus. Lymphatics from the ulnar surface of the forearm and hand, the little and ring fingers, and the adjacent surface of the middle finger, drain first into the epitrochlear nodes. Patients with spinal stenosis, have a relief of leg pain when they bend over. Sometimes leg pain can look like claudication, but if the pain is relieved by the patient bending over, it is likely that spinal stenosis, not PVD. Valve Stenosis Arterial/Venous Insufficiency Arterial/Venous Insufficiency Venous Insufficiency (brown) -Venous insufficiency: Often painful. Mechanism is venous stasis and HTN. Pulses are normal, although may be difficult to palpate through the edema. Normal, or cyanotic on dependency petechiae and then brown pigmentation appear with chronicity. Normal temperature. Edema often present. Often brown pigmentation around the ankles, stasis dermatitis, and possible thickening of the skin and narrowing of the leg as scarring develops. If ulceration occurs; develops at sides of ankle, especially medially. NO GANGRENE. Arterial insufficiency (Rubor and ischemic ulcer) Arterial insufficiency: Intermittent claudication, progressive to pain at rest. Tissue ischemia. Decreased or absent pulses. Pale, especially on elevation; dusk and red on dependency. Cool temperature. Absent or mild edema; may develop as the patient tried to relieve rest pain by lowering the leg. Trophic skin changes; thin, shiny, atrophic skin; loss of hair over the foot or toes; nails thickened and rigid. Ulceration involves the toes or points of trauma on feet. Gangrene may develop. Buerger Test: raise both legs to about 90 % for up to 2 minutes until there is maximal pallor of the feet. Light skinned-expect to see normal color or slight pallor. Dark skin-inspect soles of feet. 1. normal=return to pinkness about 10 sec or less. Filling of the veins in the feet and ankles, normally take 15sec. 2. Abnormal= Foot still pale and the veins are just starting to fill The Allen Test: compares the patency of the ulnar artery and radial arteries 1. Ask patient to make a tight fist then compress the radial and ulnar arteries w 2. Ask the patient to open the hand into a relaxed, slightly flexed position, the palm is pale 3. Release your pressure over the ulnar artery, if the ulnar artery is patent, the palm flushes within 3 to 5 sec. When drawing an arterial blood gas in the radial artery, perform the allen test to be sure that the ulnar artery is patent. Results : negative= palmar flushing positive= palmar pallor MARKED PALLOR SUGGESTS ARTERIAL INSUFFICIENCY Chapter 10 Kelly Breast/Axillae Assessment The Breast pg. 434 The most significant risk factors for breast cancer: age (65 years old), BRCA status 1 and/or BRCA 2, breast density on mammogram, personal history of breast cancer, family hx of breast cancer, and reproductive factors affecting duration of uninterrupted estrogen exposure. At the age of 50, the risk of breast cancer for someone with the BRCA1 gene is 50%. A thorough examination of the breasts includes careful inspection for skin changes, symmetry, contours, and retraction in four views. The risk of a breast mass being cancerous is 10% Breast tend to swell and become more nodular before menses from increasing estrogen. Best time for exam= 5-7 days after menstruation Inspect: Arms at side: note the appearance of the skin, color, thickening of the skin, pores. 1. Redness suggests local infection or inflammatory carcinoma 2. Thickening and prominent pores suggests breast cancer Inspect size and symmetry of the breasts. Some differences in the size of the breasts and areolas are common and usually normal.Contour of the breasts. Look for changes such as masses, dimpling, or flattening. Compare one side with the other.The characteristics of the nipples, including size and shape, direction in which they point, any rashes or ulceration, or any discharge. 1. Flattening of the normally convex breasts suggest cancer 2. Asymmetry 3. Eczematous changes with rash, scaling, or ulceration on the nipple extending to the areola occurs in Paget disease of the breast, associated with underlying ductal or lobular carcinoma 4. A nipple pulled inward, tethered by underlying ducts signal retraction from a possible underlying cancer. The retracted nipple may be depressed, flat, broad, or thickened. 5. Clear or bloody nipple discharge (esp if unilateral) is suspicious of breast cancer. Arms Over Head: Hands Pressed Against Hips; Leaning Forward. To bring out dimpling or retraction that may otherwise be invisible, ask the patient to raise her arms over her head, then press her hands against her hips to contract the pectoral muscles. Inspect the breast contours care- fully in each position. If the breasts are large or pendulous, it may be useful to have the patient stand and lean forward, ), supported by the back of the chair or the examiner’s hands. Palpate: Palpation is best performed when the breast tissue is flattened. The patient should be supine. Palpate the rectangular area extending from the clavicle to the inframammary fold or bra line, and from the midsternal line to the posterior axillary line and well into the axilla to ensure that you examine the tail of the breast. A thorough examination takes at least 3 minutes for each breast. Palpate in small, concentric circles applying light, medium, and deep pressure at each examining point. Press more firmly to reach the deeper tissues of a large breast. Examine the entire breast, including the periphery, tail, and axilla. Examining the lateral portion of the breast. To examine the lateral portion of the breast, ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed or examining table. This flattens the lateral breast tissue. Begin palpation in the axilla, moving in a straight line down to the bra line, then move the fingers medially and palpate in a vertical strip up the chest to the clavicle. Continue in verti- cal overlapping strips until you reach the nipple, then reposition the patient to flatten the medial portion of the breast. Examining the medial portion of the breast. To examine the medial portion of the breast, ask the patient to lie with her shoulders flat against the bed or examining table, placing her hand at her neck and lifting up her elbow until it is even with her shoulder (Fig. 10-13). Palpate in a straight line down from the nipple to the bra line, then back to the clavicle, continuing in vertical over- lapping strips to the mid-sternum, like mowing the lawn. Examine the breast tissue carefully for: Consistency of the tissues. Normal consistency varies widely, depending on the proportions of firmer glandular tissue and soft fat. Physiologic nodularity may be present, increasing before menses. Note the firm inframammary ridge, which is the transverse ridge of compressed tissue along the lower margin of the breast, especially in large breasts. This ridge is sometimes mistaken for a tumor. Tenderness that may occur prior to menses. Nodules. Palpate carefully for any lump or mass that is qualitatively different from or larger than the rest of the breast tissue. This is sometimes called a dominant mass that may be pathologic when evaluated by mammogram, aspiration, or biopsy. Assess and describe the characteristics of any nodule Location—by quadrant or clock, with centimeters from the nipple Size—in centimeters Shape—round or cystic, disc-like, or irregular in contour Consistency—soft, firm, or hard Delimitation—well circumscribed or not Tenderness Mobility—in relation to the skin, pectoral fascia, and chest wall. Gently move the breast near the mass and watch for dimpling. The Axillae Although the axillae may be examined with the patient lying down, a sitting position is preferable. Inspect: Inspect-skin, rash, infection, unusual pigment. Palpate: Palpate- To examine the axilla, ask the patient to relax with the arm down and warn the patient that the examination may be uncomfortable. Support the patient’s wrist or hand with your hand. Cup together the fingers of your hand and reach as high as you can toward the apex of the axilla. Place your fingers directly behind the pectoral muscles, pointing toward the midclavicle. Now press your fingers in toward the chest wall and slide them downward, trying to palpate the central nodes against the chest wall. Of the axillary nodes, the central nodes are most likely to be palpable. The central nodes at the apex of the axilla are most commonly involved in breast cancer If the central nodes feel large, hard, or tender, or if there is a suspicious lesion in the drainage areas for the axillary nodes, palpate for the other groups of axillary lymph nodes: ■ Pectoral nodes—grasp the anterior axillary fold between your thumb and fingers, and with your fingers, palpate inside the border of the pectoral muscle. ■ Lateral nodes—from high in the axilla, feel along the upper humerus. ■ Subscapular nodes—step behind the patient and, with your fingers, feel inside the muscle of the posterior axillary fold. ■ Infraclavicular and supraclavicular nodes—Also re-examine the infraclavicular and supraclavicular nodes Normal VS. Abnormal Findings and Interpretation Palpable Masses of the Breast. Breast masses show marked variation in etiology, from fibroadenomas and cysts seen in younger women, to abscess or mastitis, to primary breast cancer. All breast masses warrant careful evaluation, and definitive diagnostic measures should be pursued. Age Common Lesion Characteristics Age 15–25: Fibroadenoma Usually smooth, rubbery, round, mobile, nontender Age 25–50: Cysts Usually soft to firm, round, mobile; often tender Fibrocystic changes: Nodular, ropelike Cancer Irregular, firm, may be mobile or fixed to surrounding tissue Over 50: Cancer until proven otherwise As above Pregnancy/ lactation Lactating adenomas, cysts, mastitis, and cancer As above Paget’s disease of the nipple, galactorrhea Tenderness-infection/premenstrual tenderness Nodules-cyst, fibroadenoma, cancer The Male Breast Gynecomastia-mass suspicious for cancer, fat Lymphadenopathy One third of men have breast tissue underlying their nipple Visible Signs of Breast Cancer Skin dimpling Abnormal Contours Nipple Retraction and deviation Edema of the skin (breast) Paget Disease of the Nipple (scaly eczema-like crust around the nipple) Breast Cancer Self-Breast Examination Breast Cancer Self-Breast Examination Yearly mammography for women 40 years of age and older. For women at increased risk, many clinicians advise initiating screening mammography between ages 30 and 40, then every 2 to 3 years until 50 years of age. Although self-examination has not been shown to reduce mortality and is not recommended by all groups making screening recommendations, many choose to teach women a systematic method in which to examine their breasts. A high proportion of breast masses are detected by breast self-examination. Clinical breast examination (CBE) by a health care professional every 3 years for women between 20 and 39 years of age, and annually after 40 years of age ● Regular breast self-examination (BSE), in conjunction with mammography and CBE, to help promote health awareness ● The BSE is best timed 5 to 7 days after menses, when hormonal stimulation of breast tissue is low. ● Masses, nodularity, and change in color or inflammation, especially in the incision line (mastectomy), suggest recurrence of breast cancer. Patient Instructions for the Breast Self-Examination— American Cancer Society Lying supine- ● Lie down with a pillow under your right shoulder. Place your right arm behind your head. ● Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right breast. The finger pads are the top third of each finger. Make overlapping, dime-sized circular motions to feel the breast tissue. ● Apply three levels of pressure in each spot: light, medium, and firm, using firmer pressure for tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. Standing- ● While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes.) ● Examine the breast in an up-and-down or “strip” pattern. Start at an imaginary straight line under the arm, moving up and down across the entire breast, from the ribs to the collarbone, until you reach the middle of the chest bone (the sternum). Remember how your breast feels from month to month. ● Repeat the examination on your left breast, using the finger pads of the right hand. ● If you find any masses, lumps, or skin changes, see your clinician right away. ● Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder. Chapter 11 & 12 Tripti (1-6) / Joysline (7-11); Jenna Abdominal/Peritoneal/Rectal Assessment and Modification for Age Abdominal assessment: Sequence: Inspection, auscultation, percussion, palpation Auscultation: for bowel sounds, bruit, and friction rub. Possible abnormal sounds: increased or decreased motility, bruit of renal artery stenosis, liver tumor, splenic infarct. . Percuss the abdomen for patterns of tympany and dullness. Possible abnormalities: Ascites, GI obstruction, pregnant uterus, ovarian tumor Palpate all quadrants of the abdomen for abdominal tenderness. Light palpation for guarding, rebound, and tenderness. Possible abnormalities: Firm, board like abdominal wall—suggests peritoneal inflammation. Guarding if the patient flinches, grimaces, or reports pain during palpation. Rebound tenderness from peritoneal inflammation; pain is greater when you withdraw your hand than when you press down. Press slowly on a tender area, then quickly “let go. If you feel a mass, examine with the abdominal muscles tensed, usually, abdominal wall masses can be observed, whereas intra-abdominal masses are more concerning. A left upper quadrant mass is more likely to be a kidney if there is no palpable “notch,” you can push your fingers between the mass and the costal margin, there is normal tympany over this area, and you cannot push your fingers medial and deep to the mass Rectal assessment: Rectal assessment is a part of regular GI assessment over age of 40. Inspection: Check for fissures, lesions, scars, inflammation, discharge, rectal prolapse, skin tags, and external hemorrhoids. Palpation: The rectal walls should feel soft and smooth, without masses, fecal impaction, or tenderness. Peritoneal assessment: Check for ascites, a large accumulation of fluid in the peritoneal cavity caused by advanced liver disease, heart failure, pancreatitis, or cancer. Do not palpate a rigid abdomen. Peritoneal inflammation may be present, in which case palpation could cause pain or rupture an inflamed organ Pancreatitis- In acute pancreatitis, epigastric tenderness and rebound tenderness are usually present, but the abdominal wall may be soft. Intrapancreatic trypsinogen activation to trypsin and other enzymes, resulting in autodigestion and inflammation of the pancreas. Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure Chronic pancreatitis: Usually steady. Irreversible destruction of the pancreatic parenchyma from recurrent inflammation of either large ducts or small ducts. Epigastric, radiating to the back Severe, persistent, deep. Peptic Ulcer Disease Mucosal ulcer in stomach or duodenum >5mm, covered with fibrin, extending through the muscularis mucosa; H.pylori infection in 90 % of peptic ulcers Location-epigastric, may radiate straight to the back Quality-Variable, epigastric gnawing or burning(dyspepsia) may also be boring or aching, or hunger like Timing- wakes patient up at night. Occurs immediately over a few weeks, disappears for months, then recurs Aggravating factors- variable Relieving factors-food and antacid may bring relief Associated symptoms- n/v, belching, bloating, heartburn, weight loss Gastric ulcers: over 50 yrs old Duodenal ulcer: 30-60 years old GERD- Epigastric pain. If patient reports heartburn and regurgitation together or more than once a week, the accuracy of diagnosis of GERD is 90 %. H.pyloria may be present. Usually occurs after meals, especially spicy foods. Aggravated by- lying down, bending over, physical activity, diseases such as scleroderma, gastroparesis, drugs like nicotine that relaxes the lower esophageal sphincter. Relieved by-Antacids, PPI, avoiding alcohol, smoking, fatty meals, chocolate, theophylline, CCB Associated symptoms- Wheezing, chronic cough, SOA, hoariness, choking sensation, dysphagia, regurgitation, halitosis, sore throat, increases risk for Barrett esophagus and esophageal cancer Risk factors- salivary flow which prolongs acid clearance by damping action of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; hiatal hernia. Appendicitis: Joysline Appendicitis - The appendix is a small, finger-like appendage attached to the cecum just below the ileocecal valve. Because it empties into the colon inefficiently and its lumen is small, it is prone to becoming obstructed and is vulnerable to infection (appendicitis). The obstructed appendix becomes inflamed and edematous and eventually fills with pus. It is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity and the most common cause of emergency abdominal surgery. Males are affected more than females, teenagers more frequently than adults. - Visceral periumbilical pain suggests early acute appendicitis from distention of an inflamed appendix. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum. In the elderly, signs and symptoms of appendicitis may vary greatly. Signs may be very vague and suggestive of bowel obstruction or another process; some patients may experience no symptoms until the appendix ruptures. The incidence of perforated. Appendix is higher in the elderly because many of these people do not seek health care as quickly as younger people. - In women, consider pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy. Combining signs with laboratory inflammatory markers and CT scans markedly reduces misdiagnosis and unnecessary surgery. -Obturator sign: right hypogastric pain with the right hip and knee flexed and the hip internally rotated CLINICAL MANIFESTATIONS - Lower right quadrant pain usually accompanied by low-grade fever, nausea, and sometimes vomiting. -At McBurney’s point (located halfway between the umbilicus and the anterior spine of the ilium), local tenderness with pressure and some rigidity of the lower portion of the right rectus muscle. - Rebound tenderness may be present; location of appendix dictates amounts of tenderness, muscle spasm, and occurrence of constipation or diarrhea. -Rovsing’s sign (elicited by palpating left lower quadrant, which paradoxically causes pain in right lower quadrant). - If appendix ruptures, pain becomes more diffuse; abdominal distention develops from paralytic ileus, and condition worsens. ASSESSMENT AND DIAGNOSTIC METHOD - Diagnosis is based on a complete physical examination and laboratory and radiologic tests. -Leukocyte count greater than 10,000/m -Neutrophil count greater than 75%; -Abdominal radiographs, ultrasound studies, and CT scans may reveal right lower quadrant density or localized distention of the bowel. Surgery is indicated if appendicitis is diagnosed and should be performed as soon as possible to decrease risk of perforation. -Administer antibiotics and intravenous fluids until surgery is performed. -Analgesic agents can be given after diagnosis is made. - The major complication is perforation of the appendix, which can lead to peritonitis Visceral periumbilical pain early signs of appendicitis. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum. Acute inflammation of the appendix with distention or obstruction. Quality- mild but increasing, possibly cramping, steady and more severe Timing- last 4-6 hrs., depending on intervention Aggravating factors- movement or cough Relieving factors- it if subsides temporarily suspect perforation of the appendix Associated factors- anorexia, nausea and possibly vomiting following onset of pain, low fever Twice as likely in the presence of RLQ tenderness, Rovising sign, and the psoas sign; it is three times more likely if there is McBurney point tenderness. Localized tenderness anywhere in the RLQ, even in the right flank suggests appendicitis. Rovsing sign: pain in the RLQ during left sided pressure Psoas Sign Positive : increased abdominal pain while placing your hands just above the patient’s knee and ask to raise thigh against hand. Then asking patient to turn onto left side. Then extend the right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. Classic Sign= Begins near the umbilicus, then migrates to the RLQ. Diverticulitis: Joysline Diverticulitis- Inflammation of the diverticula. Left lower quadrant pain, especially with a palpable mass. Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses. The pain may be cramping at first, then steady. - Diverticulosis is necessary for the development of diverticulitis. Diverticulosis is a condition in which outpouchings, or diverticula, develop in the colon. The majority of patients with diverticulosis are asymptomatic. However, 1–4% of patients with di