ICM 2 Quiz 2

Bates Reading: Vital Signs (pages 114-125, 134)

• The blood pressure cuff should be:
  • Width = 40% of upper arm circumference
  • Length = 80% of upper arm circumference
• If the wrong sized cuff is used:
  • If too small, blood pressure will read too high
  • If too large, blood pressure will read too low on a small arm, but high on a large.
• To ensure an accurate blood pressure reading:
  • Avoid smoking, don’t drink caffeine for 30 min.
  • Have arm at heart level, preferably seated for at least 5 min
  • Be in quiet place. Have patient’s arm free of clothing.
• What is an auscultatory gap? What kind of errors can they cause?
  • A gap of silence sometimes heard between systolic and diastolic pressures, which can lead to overestimation or underesteimation of blood pressure. It is associated with arterial stiffness.
• How do you classify blood pressure according to JNCVII?
  • Less than 120/80 is normal
  • Prehypertension is through 140/90
  • Hypertension I is through 160/100
  • Hypertension II is above 160/100
• Physically you’d expect someone with coarctation of the aorta to have:
  • Hypertension in the upper extremities, low blood pressure in the lower extremities. Delayed femoral pulse.
• Orthostatic hypotension is:
  • The drop of systolic by 20 points and diastolic by 10 within 3 minutes of standing.
• Normal heart rate is:
  • 50-90 beats/min
• Hyperpyrexia and hypothermia are:
  • Hyperpyrexia = extreme elevation in body temperature (“fever”) above 106 (41)
  • Hypothermia = drop in body temperature below 95 (35)
• Oral vs. rectal vs. tympanic temperatures
  • Rectal is higher than oral (axillary → oral → rectal → tympanic)
  • Axillary is lower than oral
  • Tympanic membrane temperature measures core body temperature, which is higher than oral temperature.
• Normal respiratory rates:
  • 14-20 per minute
• Abnormal breathing rhythms:
  • Tachypnea – rapid shallow breathing
  • Bradypnea – slow breathing
  • Hyperpnea – “Cheyne-Stokes breathing” – periods of breathing alternating with periods of apnea.
• What’s the significance of an irregularly irregular pulse?
  • Atrial fibrillation

Bate’s Reading: Peripheral Vascular System (pages 471-499)

• Common signs of peripheral vascular disease:
  • Pain in arms and or legs
  • Cold, numbness in legs
  • Color changes in fingertips or toes in cold weather
  • Swelling in calves, legs or feet
  • Intermittent claudication (cramping)
• Raynauds phenomena:
  • Wrist pulses normal, but distal arteries have spasms.
• Risk factors for PAD:
  • Younger than 50: diabetes, atherosclerosis, smoking, dyslipidemia, hypertension, hyperhomocysteinemia
  • 50-69 years old: smoking, diabetes
  • 70 years or older
• Ankle-brachial Index to screen for PAD:
  • Take measurements in ankle and brachium and compare with ABI to assess Peripheral Arterial Disease (PAD).
  • Below 0.39 = severe PAD
  • 0.59-0.40 = moderate PAD
  • 0.89 to 0.60 = Mild PAD
  • Above 0.90 = normal.
• Current recommendation for screening of aortic aneurysm:
  • Do ultrasound to men between 65 and 75 yrs with history o “ever smoking” (100 cigarettes in lifetime).
• Current recommendations for screening of renal artery disease”
  • Hypertension before 30 or severe hypertention after 55, or accelerated hypertension
  • New worsening of renal function
  • Unexplained small kidney
  • Screen with ultrasound
• Peripheral artery examination:
  • Measure blood pressure in both arms
  • Palpate carotid upstroke, auscultate for bruits
  • Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior arteries.
  • Inspect ankles and feet for color, temperature, skin integrity, etc. hypertrophic nails.
• Grading pulses:
  • 0 = absent, can’t palpate
  • 1+ = diminished, weaker pulse than expected
  • 2+ = brisk, expected (normal)
  • 3+ = bounding
• Examining the epitrochlear and superficial inguinal lymph nodes:
  • Feel between biceps and triceps muscle, about 3 cm above medial epicondyle for node
• Signs of venous thrombosis:
  • Tight, bursting pain, usually in calf. May be painless. Feel for tender veins when you squeeze calf.
• Allen test:
  • Wrist in ball
  • Press ulnar and radial artery together
  • Let go if ulnar… if hand still white, then have occlusion there
  • Do same for radial.
• Color changes of arterial insufficiency
  • Pallor when raise arm or leg.
• Signs and symptoms of advanced chronic arterial vs. venous insufficiency:
  • Chronic Venous insufficiency: Venous engorgement, normal pulse, browning of skin, ulcers, edema, normal temperature
  • Chronic Arterial insufficiency: decreased pulse, pale on elevation, cool temperature.
• Bates Reading: Head and Neck exam (pages 195-205,236-243, 249-253,281)
• How does thyroid disease cause hair change?
  • Course hair = hypothyroidism
  • Fine hair = hyperthyroidism
• Hirsutism:
  • Excessive facial hair
• Hyperopia vs Presbyopia vs. Myopia
  • Hyperopia = far-sighted
  • Presbyopia = aging vision
  • Myopia = near-sighted
• Diplopia
  • Diplopia = double-vision
• Tinnitus vs. Vertigo
  • Tinnitus = ringing
  • Vertigo = dizziness (spinning sensation)
• Rhinnorrhea vs. epistaxis
  • Rhinnorrhea = leaky nose
  • Epistaxis = bleeding nose
• Signs and symptoms of hyper vs. hypothyroidism
  • Hyperthyroidism – intolerance to warmth, preference for cold, increased sweat, bulging eyes.
  • Hypothyroidism – intolerance to cold, preference for warm, decreased sweating, goiter
• anterior vs. posterior triangle of the neck
  • Anterior – Mandible, SCM, Midline of neck
  • Posterior – SCM, Traps, Clavicle. Omohyoid runs across
• Where is the thyroid gland?
  • Below and around cricoids cartilage
• Where are the cervical lymph nodes
  • Around Sternocleidomastoid
• Enlarged supraclavicular lymph nodes mean…
  • Metastasis from a thoracic or abdominal malignancy
• Tender vs. hard and fixed lymph nodes
  • Tender = inflammation
  • Hard and fixed = malignancy
• Shotty nodes and their significance:
  • Small, mobile, discrete, nontener (like a “shot”) – found in normal people.
• Examining the thyroid gland:
  • Feel below the cricoids cartilage
  • Tell patient to swallow water.
  • Feel the thyroid rise.
• Migraine vs. cluster vs. tension headaches
  • Migraine – unilateral, throbbing, fairly rapid,
  • Tension – temporal, tightening pain, gradual
  • Cluster – unilateral, retro-orbital, deep pain, abrupt
• Compare symptoms: Cushing’s Syndrome vs. myxedema vs. nephrotic syndrome vs. acromegaly
  • Cushing’s Syndrome – moon face, red cheeks, hirsuitism, due to excessive adrenal cortisol production.
  • Myxedema (hypothyroidism) – goiter
  • Nephrotic Syndrome – edematous, pale face. Swollen eyes.
  • Acromegaly – increased bone growth due to too much growth hormone.