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Vitals

100

List all vitals and the qualities to report for pulse.

Pulse: rate, rhythm, contour, symmetry; Respiration rate; Temperature; Blood pressure; SpO₂

200

One of two alternative positions/configurations in which you would measure blood pressure and what you are looking for.

• Ans: Standing: postural hypotension if systolic decreases by more than 20 mmHg and/or diastolic by 10 mmHg
• Ans: The other arm: asymmetric pressure if difference in SBP>20 mmHg

300

What is Kussmaul breathing and what does/can it indicate?

Deep, and rapid breathing pattern (hyperpnea) the body uses to compensate for severe metabolic acidosis, especially from Diabetic Ketoacidosis (DKA)

400

What is Cheyne-Stokes breathing?

Abnormal breathing pattern characterized by cycles of progressively deeper and faster breaths, followed by a gradual decrease in breathing and periods of a temporary stop in breathing called apnea. It is most often associated with heart failure, stroke, and the end of life

500

Define one of the following and note at least one potential cause: Pulsus Alternans, Pulsus Parvus Tardus, Pulsus Bisferiens, Hyperkinetic pulse.

• Pulsus alternans is a clinical finding characterized by a regular alternation of strong and weak beats in the arterial pulse, which can be detected by a healthcare provider or on an arterial waveform tracing. This phenomenon is almost always a sign of severe left ventricular systolic dysfunction and is often associated with conditions like heart failure and can indicate a poor prognosis.
• Pulsus parvus tardus is a term used in medicine to describe a pulse that is both weak ("parvus") and slow to rise ("tardus"). This is a classic physical exam finding for severe aortic stenosis and is also known as a "slow-rising" or "anacrotic" pulse. The pulse feels small in amplitude and its peak is delayed and ill-defined.
• Pulsus bisferiens is a "twice-beating pulse" with two strong systolic peaks and a dip in between, best felt in peripheral arteries, signaling severe conditions like aortic regurgitation (AR) or hypertrophic obstructive cardiomyopathy (HOCM), where rapid ventricular ejection creates the first peak and a reflected wave or Venturi effect causes the second, reflecting significant hemodynamic issues.
• A hyperkinetic pulse (or bounding/water-hammer pulse) is a strong, forceful, rapidly rising, and collapsing pulse felt under the fingers, indicating a large stroke volume from the heart into low-resistance arteries, seen in conditions like severe aortic regurgitation, anemia, fever, anxiety, large A-V fistulas, or patent ductus arteriosus, and can also occur with high output states like thyrotoxicosis or during exercise/fever.

SPLEEN

100

Describe the location of the spleen.

Posterior and lateral to the stomach behind the left 9th - 11th ribs, just inferior to the left diaphragm and superior to the left kidney - Will extend towards the RLQ if enlarged.

200

Explain how to percuss for the spleen using Nixon’s method.

Patient in right lateral decubitus position, dullness that extends > 8 cm above the costal margin (begins at the midpoint of the left costal margin and moves superiorly, perpendicular to the costal margin)

300

Explain how to percuss for the spleen using Castell’s Method.

Patient supine, dullness on inspiration with percussion over the lowest ICS in the anterior axillary line.

400

Explain how to percuss for the spleen using Traube’s Space.

Patient supine, dullness on inspiration with percussion within the triangle formed by the 6th rib superiorly, the left anterior axillary line laterally, and the left costal margin inferiorly.

500

Explain how to palpate the spleen using the Hooking Maneuver of Middleton.

Patient supine with their fist under their left CVA, stand to the patient’s left facing their feet, curl the fingers of both your hands under their left costal margin while asking the patient to take a deep breath, to assess for an enlarged spleen descending on inspiration.

RESPIRATORY

100

What is the normal respiratory rate of an adult?

12 or 16 to 25

200

What are the three special tests of the respiratory exam, how are they performed, and what do they (as a group) identify?

• Hoover Sign: Place hands along the costal margin w/thumbs close to the xiphoid process Positive if thumbs move closer together on inspiration
• Laryngeal Height LH = distance b/w thyroid cartilage and suprasternal notch, can be REDUCED in COPD LH ≤ 4 cm increases the likelihood of COPD Forced
• Expiratory Time FET = me to completely empty the lungs a er a deep inhalation, can be PROLONGED in patients with COPD - Place the bell of the stethoscope over the trachea in the suprasternal notch - Ask the patient to inhale deeply, then forcefully exhale with an open mouth - Time the dura on to exhale and take the avg of 2-3 attempts. FET ≥ 6 seconds INCREASES the likelihood of COPD

300

What are the three vocal resonance tests of the respiratory exam, how are they performed, and what do they (as a group) identify?

Bronchophony: Auscultate while the patient speaks (e.g. repeatedly say “ninety-nine”)   Present if the voice can be heard clearly/loudly

Whispered Pectoriloquy: Auscultate while the patient whispers (e.g. repeatedly whisper “ninety-nine”);Present if the whisper can be heard clearly 

Egophony: Auscultate while patient says “EEE” repeatedly Present if higher-pitched nasal/bleating and sounds like “A” or “AAH”

Increased vocal resonance (presence of bronchophony/whispered pectoriloquy/egophony) may be heard over areas of consolidation or atelectasis Vocal resonance often reduced over areas pleural effusion, but may be increased just above the effusion  

400

List 5+ indications of respiratory distress and three of impending respiratory failure on inspection

• Tripod postion - Diaphoresis - Tachypnea - Drooling - Stridor - Pursed lip breathing - Grunting* - Head bobbing* - Inability to speak full sentences (or at all) - AMU (scalene, SCM, abdominal obliques) - Retractions (supraclavicular, suprasternal, intercostal, subcostal, substernal) - Paradoxical movement of CW/abdomen - Cyanosis (central, peripheral) *more common in peds
• Impending respiratory failure: Fatigue Somnolence (drowsiness) Decreased level of consciousness Altered mental status (confusion, agita on, restlessness) Bradypnea

500

What do you palpate for in the respiratory exam (list 4+)?

• Masses, tenderness, crepitus, tracheal displacement, chest wall expansion, tactile fremitus

PRECORDIAL

100

Describe the location at which each of the heart valves are auscultated.

• Apical impulse/Mitral valve area: Expected location near the left MCL in the 5th ICS Left lower sternal area; Tricuspid valve area: 4th ICS LSB
• Pulmonic valve area: 2nd ICS LSB; Right base/Aortic valve area: 2nd ICS RSB

200

Describe one of two area in which you may observe movement of the heart on inspection, and a possible cause.

• Epigastric area (RV movements may appear here in patients w/COPD) 
• Sternoclavicular area (dissecting aneurysm, aortic disease w/proximal dilation)

300

Describe the location, timing, and size of the apical impulse, and note in what fraction of adults is it palpable?

left MCL in the 5th ICS Left lower sternal area; 2/3 of systole; 3 cm

400

If you detected a murmur, what qualities would you describe (list 5)?

Location, radiation, timing, shape, intensity

500

Describe the shape and timing of a mitral regurgitation murmur.

Pansystolic/holosystolic

LIVER

100

What is auscultated for in the liver exam?

Friction rubs

200

List at least 10 stigmata of liver disease

Jaundice; Excoriations; Spider telangiectasia; Palmar erythema; Gynecomastia; Testicular atrophy; Decrease/loss of secondary sexual hair; Dilated abdominal wall veins; Hematemesis; Fetor hepaticus; Ascites Edema; Hepatic encephalopathy; Petechiae; Bruising; Clubbing; Terry’s nails; Dupuytren’s contracture

300

List and describe two methods of identifying ascites other than observation.

• Fluid wave
• Shifting dullness

400

Describe how you would identify the margins of the liver?

Percussion; palpation of lower edge may be possible if enlarged.

500

What is the direction of abdominal vein flow in portal hypertension?

Away from the umbilicus