ICM - Block 1 - Part 1

davidwurbel7's version from 2016-06-05 23:25

Interviewing and History Taking

Insert 29

General Survey

Slide 8
Question Answer
Responsive to you and others in the environmentAwake, alert
Appears drowsy but opens eyes and looks at you, responds to questions and then falls asleepLethargic
Opens the eyes and looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreasedObtunded
Arouses from sleep only after painful stimuli. Verbal responses are slow or even absent; pt. lapses into unresponsive state when stimulus stops; minimal awareness of self or environmentStuporous
Patient remains unarousable with eyes closed; no evident response to inner need or external stimuliComa
Higher brain function lost. Some relexes may still be present/circadian rhythmic fucntions/breathe on own and have heart beatVegetative State
Patient in vegetative state for 1 monthPersistent Vegetative State
Patient in vegetative state for 3 monthsPermanent Vegetative State
No brainstem function. No spontaneous breaths or heartbeat. No blood flow to brain. Flat EEG. Apneic if ventilator turned offBrain Death
Clutching chest, diaphoresis, pallor wheezing, cyanotic, labored breathing, cough are signs of thisCardiac or Respiratory Distress
Wincing, Sweating, pale, guarding the painful area, facial grimacing, unusual posture favoring one limb or body area are signs of thisPainful Distress
Fidgety movements, cold moist hands, anxious face, inexpressive or flat affect, poor eye contact, inattentiveAnxious or Depressed Distress
Malaria, thalassemia, sickle cell anemia, G6PD deficiency are causes to this condition due to increased destruction of RBCsPre-Hepatic Jaundice
Hepatitis and cirrhosis are causes to this condition due to the inability to conjugate bilirubinHepatic Jaundice
Gall stones in common bile duct, and pancreatic cancer are causes to this condition due to obstruction of the bile duct causing backup of bilirubinPost-Hepatic Jaundice

Vital Survey

Question Answer
The pulse alternates in amplitude from beat to beat even though the rhythm is basically regular: strong and then weakPulsus Alternans
Left Ventricular Heart Failure can show this pulse pattern Pulsus Alternans
An increased arterial pulse with double systolic peakPulsus Bisferiens
Aortic regurgitation or the combination of aortic regurgitation plus aortic stenosis can show this patternPulsus Bisferiens
Caused by a normal beat alternating with a premature contractionBigeminal pulse
Hypertrophic cardiomyopathy can show this patternBigeminal pulse
A drop of greater than 10mmHg during inspiration signifies thisPulsus Paradoxicus
Pericardial tamponade, pericardial effusion can show this patternPulsus Paradoxicus
Take pulse at lower level (below heart and pulse weak); when you raise arm above heart, pulse is very strongWater Hammer Pulse
Aortic Regurgitation can show this patternWater Hammer Pulse


Question Answer
Deep rapid breathingKussmaul breathing
Periods of deep breathing in a crescendo/decrescendo pattern alternate with periods of apneaCheyne-Stokes Breathing
Prolonged expiratory phaseObstructive Breathing
Shallow breathing with periods of apnea in betweenCluster (Biot's) Breathing

Peripheral Vascular System

Question Answer
90% of the blood returns to the heart in thisDeep Venous System
10% of the blood returns to the heart in thisSuperficial Venous System
Common symptoms of this include diffuse limb (arm/leg) pain, Intermittent claudication, Rest pain, Cold or numbness, pallor in legs, Swelling (edema) and Color changes in fingertips or toes in cold weatherPeripheral Vascular Disease
Pain in the muscles of leg, comes on walking (exercise-induced) & relieved by rest. Characterized by deep seated ache or cramping. Progressive Pain makes the patient stop walking. Occurs in the calf, thigh, buttock, and foot. Remits in < 10 minutes after rest or inactivity. pain occurs after a consistent distance travelled, expressed in terms of city blocksIntermittent Claudication
Color changes in fingertips or toes in cold weather. Color change goes from pale to blue to reddishRaynaud's Phenomenon
Pain when leg is elevated. Pain is relieved when leg is lowerArterial Vascular Problem
Pain when leg is lower or standing. Pain is relieved when leg is elevatedVenous Vascular Problem
Limb is cold to touch could indict thisArterial Vascular Problem
Limb is warm to touch could indict thisVenous Vascular Problem
An increase in hydrostatic pressure or a decrease in oncotic pressureEdema
Swelling of a limb could indict thisVenous Vascular Problem
Age > 50 , Diabetes, Smoking, Dyslipidemia, Hypertension and Known atherosclerotic coronary, carotid, or renal artery disease are risk factors for thisPeripheral Arterial Disease
Female gender, Recent trauma, Immobility, Coagulation abnormalities, Congestive heart failure, Malignancy, Pregnancy and Use of OCP’s and HRT are risk factors for thisPeripheral Venous Disease
Venous stasis, Vascular injury and Hypercoagulable states are risk factors for thisVenous Thromboemblism
Venous stasis, Vascular injury and Hypercoagulable states are part of thisVirchow's Triad
Stenotic, occlusive and aneurysmal disease of Aorta, its branches and arteries of lower extremities caused by atherosclerosisPeripheral Arterial Disease
Age of onset > 50 years. A leading cause of disability among people older than 50 years and in those with diabetes. Affects femoral and popliteal arteries, followed by the tibial and peroneal arteriesPeripheral Arterial Disease
Clinical finding include pain, pallor, paresthesia, pulselessness, and paralysis possibly indicts thisAcute Peripheral Arterial Occlusion
Most common in lower extremities, Intermittent claudication, Progressive pain and night/rest pain relieved by dependency, Lower extremities coldness, Pallor on elevation, rubor on dependency, Absent pulse, bruits & thrills, Gangrene and atrophy, Non healing ulcers: painful, deep. Low Ankle-Brachial IndexChronic Peripheral Arterial Occlusion


Question Answer
Ankle -Brachial Index (A-BI) 0.90 - 1.30Normal
Ankle -Brachial Index (A-BI) 0.60 - 0.89Mild PAD
Ankle -Brachial Index (A-BI) 0.40 - 0.59Moderate PAD
Ankle -Brachial Index (A-BI) < 0.39Severe PAD


Question Answer
Recurring inflammation and thrombosis of small and medium arteries and veins of the hands and feet. Strongly associated with use of tobacco products, primarily from smokingThromboangiitis obliterans (Buerger disease)
Clinical manifestations are cold sensitivity; ischemia: claudication of leg, foot, arm, or hand. Ulceration and gangrene in the extremities. Often requires amputationThromboangiitis obliterans (Buerger disease)
Entrapment of the popliteal artery occurs as it passes medial to both heads of the gastrocnemius, causing compression. A congenital anomalyPopliteal Artery Entrapment Syndrome
This is due to thrombotic occlusion of the abdominal aorta just above the site of its bifurcation. Intermittent bilateral claudication. Inability to maintain penile erection. Absent femoral pulsesLeRiche Syndrome
Subclavian artery compression: Pain, skin color change. Subclavian vein compression: Edema, venous distension. Brachial complex compression: Pain, paresthesia, paresisThoracic Outlet Syndrome
(Insert 27)
Question Answer
History of recent trauma, needle or cathetor insertion. Dull pain in the region of the involved vein. Subsides after 2 weeksSuperficial Thrombophlebitis
Most commonly affects the popliteal and superficial femoral veins. Swelling and redness of the overlying skin. Painful, tender veins. Fever. Homan’s sign positiveDeep Vein Thrombosis (DVT)
Chronic venous engorgement secondary to venous occlusion or incompetency of venous valves. History of previous DVT or trauma. Itching and dull discomfort made worse by prolonged standing. Pain if with ulceration. Swelling of the limb may be relieved with leg elevationChronic Venous Insufficiency
Dilated & tortuous veins. 1. primary: intrinsic abnormality of vein wall. 2. secondary: deep &/ superficial venous insufficiency. Unsightly appearance, diffuse pain, legs may feel heavy, tired, restless. Standing or sitting for too long may worsen the symptoms. Edema, hyper-pigmentation, ulcers, phlebitis etc. Night cramps can be experiencedVaricose Veins
Sharply defined, irregularly shaped, relatively shallow with a sloping border, and usually painful. Complain of limb heaviness, swelling associated with standing and worsening in the evening, and pain worse in dependent state. Commonly found on the medial lower aspect of the calfVenous Ulcers
Painful, Punched out, with sharply demarcated borders. Characteristically painful at night and often quite severe; may be worse when legs are elevated, improving on dependency. Occur on the lower leg, usually over sites of pressure and trauma: pretibial, supramalleolar (usually lateral), and at distant points, such as toesArterial Ulcers
Pressure areas. Associated with diabetes. Arterial ulcer signs can sometimes also be seen. Callous formation.Neural Ulcers
Swelling without ulceration, varicosities, or stasis. Edema-nonpitting. Most commonly occurs on the lower extremities but may also arise on the arm and handLymphedema
The non-pitting edema seen lymphedema starts as pitting edema transitions non-pitting edema due to thisFibrosis
Pressure builds from trauma or bleeding into major muscle compartments in the limbs. Excruciating pain that is out of proportion to injury. Feeling of tightness or fullness of muscles. Affected area: swollen, shiny, dusky red skin. Sensation problemsCompartment Syndrome


Question Answer
Number, Location, Size, Tender, Matted - (Sign of Malignancy)Lymph node Discription
A difference of >1cm just above the ankle or >2 cm at the calf suggests thisEdema
Ask the patient to make a tight fist with one hand; then compress both radial and ulnar arteries firmly between your thumbs and fingers. Next, ask the patient to open the hand into a relaxed, slightly flexed position. The palm is pale. Release the pressure over the ulnar artery. If the ulnar artery is patent, the palm flushes within ~ 3 to 5 seconds. Similarly you can test the radial arteryAllen Test
(Insert 54-55)
Question Answer
With the patient supine, elevate one leg to about 90° to empty it of venous blood. Next, occlude the great saphenous vein in the upper thigh by manual compression, using enough pressure to occlude this vein but not the deeper vessels. Ask the patient to standTrendelenburg Test
Trendelenburg test results -, -Normal
Trendelenburg test results +,+Deep and Superficial
Trendelenburg test results +,-Deep Vein
Trendelenburg test results -,+Superficial Vein

Cardiac Assessment

Question Answer
Represents atrial contraction on the grapha
Represents atrial relaxation on the graphx
Represents atrial filling on the graphv
Represents atrial emptying on the graphy


Question Answer
Normal JVP3 cm Above the Sternal Angle
This is normally 3 cm above the sternal angleJVP
JVP rises with inspiration, drops with expirationKussmaul's Sign
Kussmaul's sign is usually seen with this conditionPericardial Effusion

Cardiac Symptoms

Question Answer
Sub sternal pain with radiation to the trapezius ridge relied by shallow breathing and by sitting up and leaning forward and worsened by lying down and inspirationAcute Pericarditis
Friction rub heard over lower left sternal border. Chest X-ray shows symmetrically increased size of cardiac silhouette. EKG shows ST elevation and PR depressionAcute Pericarditis
Sudden, severe “tearing” pain, radiating to the abdomen, neck, or back, depending on where the dissection is going Aortic Dissection
Weak asymmetric pulses. Chest X-ray shows wide mediastinumAortic Dissection
Associated with Hypertension or Marfans syndromeAortic Dissection
Squeezing, crushing, strangling, constricting pain in center of chest, radiate to left shoulder, arm, jaw. Precipitated by some activity and disappears at rest or rest and after sublingual nitroglycerineStable Angina
This is diagnosis with a stress test which shows ST segment depression, that reverses after disappearance of ischemia. No elevation in cardiac biomarkers. Confirmed by angiographyStable Angina
Treatment of this is Nitroglycerin sublingualStable Angina
This is caused by coronary vasospasm. Not by the obstruction. Unrelated to exercise, relieved by nitrates. Precipitated by smoking and cocainePrinzmetal’s Angina
This is diagnosis by ECG shows transient ST elevation with no elevation in cardiac biomarkers. Angiography demonstrates not significant coronary obstructionPrinzmetal’s Angina
Treatment of this is by Nitrates and Calcium channel blockers. Beta blockers are contraindicatedPrinzmetal’s Angina
This drug is contraindicted in the treatment of Prinzmetal's AnginaBeta Blockers
Dyspnea occurring with patient in the supine positionOrthopnea
Sudden onset of dyspnea and occurs only after the patient has been lying down at rest for at least an hourParoxysmal Nocturnal Dyspnea (PND)
Signs and symptoms of this condition are extreme anxiety, dyspnea (Orthopnea), air hunger, fear of death, pink and frothy sputum, crackles/ralesPulmonary Edema
An unpleasant awareness of one’s own heart beat. Often described as skipping a beatPalpitations