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12 PART I PATIENT EVALUATION
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• Maintain a positive attitude. As a medical student, you may feel you are not a crucial part of the
team. Even if you are incredibly smart, you are unlikely to be making the crucial management decisions. So what does that leave? Attitude. If you are enthusiastic and interested, your residents will
enjoy having you around, and they will work to keep you involved and satisfied. A dazzlingly intelligent but morose complainer is better suited for a rotation in the morgue. Remember, your resident
is likely following 15 sick patients, gets paid less than $2/hour, and has not slept more than 5 hours
in the last 3 days. Simple things such as smiling and saying thank you (when someone teaches
you) go an incredibly long way and are rewarded on all clinical rotations with experience and good
grades.
• Have fun! This is the most exciting, gratifying, rewarding, and fun profession—and is light years
better than whatever is second best (this is not just our opinion).
4. What is the best approach to surgical notes?
Surgical notes should be succinct (Box 1-1). Most surgeons still move their lips when they read. With
the advent of EMR, copy and paste are as unoriginal as thinking that most patients and most diseases
are the same or similar. In some instances, it even may be against the institution’s policies. Write
every note, as many people will read this note and judge your care by the quality of your note.
Box 1-1. Best Approach to Surgical Notes
Although since the initial publication of this chapter most notes have become electronic in nature and may even
follow a specific template, the following guidelines for notes are still valid in helping develop a sequence of how to
approach documentation.
Admission Orders
Admit to 5 West (attending’s name)
Condition: Stable
Diagnosis: Abdominal pain; r/o appendicitis
Vital signs: q4h
Parameters: Please call HO for:
Diet: NPO
Fluids: 1000 LR w 20 mEq KCl @ 100 mL/h
Med[ication]s: ASA 650 mg PR prn for T > 38.5 °C
Thank you.
Sign your name/leave space for resident’s signature.
(your beeper number)
Key: r/o = rule out, q = every, HO = house officer, T = temperature, BP = systolic blood pressure, HR = heart
rate, NPO = nothing by mouth (this includes water and pills), ASA = aspirin, PR = per rectum, prn = as needed.
Other useful abbreviations: OOB = out of bed, BRP = bathroom privileges.
Note: You cannot be too polite or too grateful to patients or nurses.
History and Physical Exam (H&P)
Mrs. O’Flaherty is a 55 y/o w/w [white woman] admitted with a cc [chief complaint]: “My stomach hurts.” Pt
[patient] was in usual state of excellent health until 2 days PTA [before admission] when she noted gradual onset
of crampy midepigastric pain. Pain is now severe (7/10 = 7 on a scale of 10) and recurring q5min. Pt described +
vomiting (+ bile, – blood) [with bile, without blood].
PMH [Past Medical History]
Hosp[italizations]: Pneumonia (1991)
Allergies: Codeine, shellfish
ETOH [alcohol]: Social
Tobacco: 1 ppd [pack per day] × 25 years
T > 38 °C
160 < BP < 90
120 < HR < 60
Childbirth (1970, 1972)
Surg[ery]—splenectomy for trauma (1967)
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Box 1-1. Best Approach to Surgical Notes—(Continued)
ROS [Review of Systems]
Resp[iratory]: Productive cough
Cardiac: ō chest pain [ō = not observed, noncontributory, or not here]
Renal: ō dysuria
Neuro[logic]: WNL [within normal limits]
Physical Exam (PE)
BP: 140/90 HR: 100 (regular)
RR [respiratory rate]: 16 breaths/min Temp: 38.2 °C
WD [well developed], WN [well nourished], mildly obese, 55 y/o in moderate abdominal distress.
HEENT [head, eyes, ears, nose, and throat]: WNL.
Resp: Clear lungs bilat[erally]
Heart: ō m [murmur]
Abdomen: RSR [regular sinus rhythm]
Rectal: (Always do; never defer the rectal exam on your surgical rotation)
Pelvic: No masses
Extremities: Full ROM [range of motion]
Imp[ression]: Abdominal pain
Rx (Treatment/Plan):
ō MI [myocardial infarction]
ō frequency
ō wheeze
Mildly distended, crampy, midepigastric pain
High-pitched rushes that coincide with crampy pain
Tender to palpation (you do not need to hurt the patient to find this out)
ō rebound
Hematest—negative for blood
No masses, no tenderness
No adnexal tenderness
No chandelier sign (if motion of cervix makes your patient hit the
chandelier)
No pelvic inflammatory disease (PID; gonorrhea)
ō edema
Bounding (3+) pulses
r/o SB [small bowel] obstruction 2° [secondary] to adhesions
NG [nasogastric] tube
IV fluids
Op[erative] consent
Type and hold
[Signature]
Notes on the Surgical H&P
• AsurgicalH&Pshouldbesuccinctandfocusedonthepatient’sproblem.
• Beginwiththechiefcomplaint(inthepatient’swords).
• Istheproblemneworchronic?
• PMH:Alwaysincludepriorhospitalizationsandmedications.
• ROS:Restrictreviewtoorgansystems(lung,heart,kidneys,andnervoussystem)thatmayaffectthisadmission.
• PE:Alwaysbeginwithvitalsigns(includingrespirationandtemperature);thatiswhythesesignsarevital.
• Reboundmeansinammatoryperitonealirritationorperitonitis.
Preoperative Note
The preoperative note is a checklist confirming that you and the patient are ready for the planned surgical procedure. Place this note in the Progress Notes:
Preop dx [diagnosis]: SB obstruction 2° to adhesions
CXR [chest X-ray]: Clear
ECG [electrocardiogram]: NSR w/ST-T wave changes
Blood: Type and crossmatch x 2 u
Consent: In chart
Continued
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Box 1-1. Best Approach to Surgical Notes—(Continued)
Operative Note
The operative note should provide anyone who encounters the patient after surgery with all the needed information:
Preop dx: SB obstruction
Postop dx: Same, all bowel viable
Procedure: Exp[loratory] Lap[arotomy] with lysis of adhesions
Surgeon: Name him/her
Assistants: List them
Anesthesia: GEA [general endotracheal anesthesia]
I&O [intake and output]: In: 1200 mL Ringer’s lactate (r/L)
EBL [estimated blood loss]: 50 mL
Specimen: None
Drains: None
Out: 400 mL urine
[Sign your name]
PREOPERATIVE EVALUATION
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Harry Dym, Naveen Mohan, Joseph Zeidan, A. Omar Abubaker
1. Which components of the preoperative evaluation are obtained from the patient?
Chief complaint, history of present illness, past medical history, family history, surgical history,
personal/social history, and review of systems.
2. What are the goals of the preoperative evaluation?
The preoperative evaluation consists of gathering information about the patient and formulating
an anesthetic and surgical plan. The overall objective is reduction of perioperative morbidity and
mortality.
Ideally (and through an interview, physical exam, and review of pertinent current and past
medical records), the patient’s physical and mental status is determined. All recent medications
are recorded, and a thorough drug allergy history is taken. The patient should be questioned
about use of cigarettes, alcohol, and illicit drugs. The patient’s prior anesthetic experience is
of particular interest, specifically if there is a history of any anesthetic complications, problems with intubation, delayed emergence, malignant hyperthermia, prolonged neuromuscular
blockade, or postoperative nausea and vomiting. From this evaluation, a decision can be made
whether any preoperative tests or consultations are indicated, and an anesthetic care plan can
be formulated. If done well, the preoperative evaluation establishes a trusting doctor-patient
relationship that significantly diminishes patient anxiety and measurably influences postoperative recovery and outcome.
3. What is the difference between a physical sign and a symptom?
In general, a symptom is an abnormal sensation felt by the patient, whereas a sign can be seen, felt,
or heard by the examiner.
4. What is an informed consent?
Informed consent is communication with the patient so he or she understands the procedures and
the possible intraoperative and postoperative complications, including postoperative pain. The alternatives, potential complications, and risks vs. benefits are discussed, and the patient’s questions are
answered.
5. How do you calculate body mass index (BMI)?
The BMI is calculated by dividing the weight by height in centimeters (weight in kg/height in cm).
The normal BMI is 18.5 to 25, a BMI of 25 to 30 is overweight, and a BMI of >30 is obese.
6. What is the importance of calculating the BMI for a patient?
Being overweight or obese are proven risk factors for diabetes, heart disease, stroke, hypertension,
osteoarthritis, and some forms of cancer.
7. What are the vital signs?
Pulse, blood pressure, temperature, and respirations.
8. Are vital signs really “vital”?
Yes. For example, if heart rate and blood pressure are on the wrong side of 100 (heart rate is >100
beats/min, systolic blood pressure is <100 mm Hg), watch out! Also, tachypnea (respiratory rate
>16) reflects either pain or systemic acidosis. Temperature, however, is less reliable. Fever may
develop late, particularly in the immunosuppressed patient who may be afebrile even in the presence of infection.
9. What are macules, papules, and nodules?
Macules are localized changes in skin color that occur in various shapes, sizes, and colors and are
not palpable. Papules are solid and elevated, with a diameter of less than 5 mm. Nodules are also
solid and elevated but extend deeper into the skin than papules and usually have diameters greater
than 5 mm.
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10. Which ribs are referred to as “floating” ribs?
The eleventh and twelfth ribs.
11. Where is the angle of Louis?
The angle of Louis is located at the junction between the manubrium and the body of the sternum; it
marks the articulation of the second rib on the sternum. It is also known as the angle of Ludwig.
12. Where is the intercostal angle?
The inferior margins of the seventh, eighth, and ninth costicartilages meet in the midline (at the
infrasternal notch) to form the intercostal angle. It normally measures less than 90 degrees and is
increased in obstructive lung disease.
13. Where on the abdomen is the liver percussed?
On the upper right quadrant. A liver span of 6 to 12 cm in the midclavicular line is considered normal.
14. What is rebound? What is the significance of rebound tenderness during an
abdominal exam?
Because the peritoneum is well innervated and exquisitely sensitive, pressure on the abdomen of a
patient with an inflamed peritoneum can elicit a distinctive tenderness. During an abdominal exam,
if you depress the abdomen gently and release and the patient winces, it is an indication that the
peritoneum is inflamed (rebound tenderness).
15. What is the significance of abdominal distention?
Abdominal distention may arise from either intraenteric or extraenteric gas or fluid, or from blood.
Abdominal distention is always significant and concerning.
16. Is abdominal palpation important?
Yes. Tenderness to palpation leads the examiner to the anatomic zone of the diseased area. It is best
to start palpation in an area that does not hurt and proceed toward the painful (tender) region.
17. What is the significance of bowel sounds?
Not unlike other parts of the body, if the part hurts, the patient tends not to use it. Inflamed bowel
is less functional and therefore is quiet. Bowel contents squeezed through a partial obstruction
produce high-pitched tinkles. However, bowel sounds are not always reliable.
18. What is the Hering-Breuer reflex?
When the lungs become overly inflated, stretch receptors activate an appropriate feedback response
to limit further inspiration. These stretch receptors are located in the walls of the bronchi and bronchioles throughout the lungs that, when overstretched, transmit inhibitory signals through the vagus
nerve in the inhibitory center. It seems to be a protective mechanism to prevent overinflation rather
than normal control of ventilation.
19. What is a pterygium?
A raised, yellow plaque, termed the pinguecula, is normal and found on a horizontal plane between
the canthus and limbus of the eye. In response to chronic irritation, the pinguecula will grow to
extend a vascular membrane, termed pterygium, over the limbus toward the center of the cornea.
Vision may become obstructed.
20. What is anisocoria?
Anisocoria refers to inequality of the pupils. It is a common, normal variation of pupil size but can be
an indication of pathology.
21. What are the components of the corneal reflex?
• Sensorylimb:fthcranialnerve(V2)
• Motorresponse:seventhcranialnerve;lookforeyeblinking
22. What is the oculocardiac reflex?
The trigeminal-vagal reflex. Pressure applied to the globe or stretching of the extraocular muscles
results in 10% to 15% reduction in heart rate. It also can cause junctional rhythm and possible
premature ventricular contractions (PVCs). Atropine is not useful in treating this situation.
23. What is the direct light reflex?
The direct light reflex occurs when a light is shone into the eye to the retina and the pupil constricts
(retina-optic nerve-optic tract).
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24. What is the consensual light reflex?
The consensual light reflex occurs when a light is shone into the eye to the retina and the pupil of
the opposite eye constricts.
25. What is nystagmus?
Nystagmus is an involuntary, rapid, rhythmic movement of the eyeball, which may be horizontal,
vertical, rotatory, or mixed. There are various forms of nystagmus, some of which may be indicative
of certain diseases of the vestibular system.
26. What is strabismus?
Strabismusisadeviationoftheeyethatthepatientcannotovercome.Thevisualaxisdeviatesfrom
that required by the physiologic conditions. There are many forms of strabismus, depending on the
direction of the strabismus, whether the condition is affecting one eye or both, and the cause of the
condition.
27. What are important features to be aware of during an otoscopic exam?
Scaling,cerumen,discharge,lesions,erythema,foreignbodies,andbleeding.
28. What important anatomic feature is noted just beyond the canal hair in an otoscopic exam?
The junction between the lateral cartilaginous canal and the medial bony canal.
29. When examining the ear, where is the light reflex normally located and what
conditions will alter its location or appearance?
The light reflex is normally noted at about the five o’clock position. Conditions that can alter its
appearance include retracted drumhead, serous otitis, bulging drumhead, air bubbles in serous
otitis, and a perforated drumhead.
30. What is Darwin’s tubercle?
Darwin’s tubercle is a fusiform swelling that occasionally develops on the surface of the pinna above
the midpoint of the helix on the ear.
31. What is the difference between bone conduction and air conduction when applied to tuning fork tests of hearing?
Air conduction implies sound transmission through the ear canal, tympanic membrane, and ossicle,
to the cochlea, and finally to the eighth, or auditory, nerve. Bone conduction relies on the transmission of sound through the skull to the cochlea and to the auditory nerve.
32. What is the difference between the Rinne and Weber tests of auditory function?
The Rinne test makes use of air conduction and bone conduction, whereas the Weber test makes
use of bone conduction. A Rinne test is considered normal or positive when sound is heard better by
air conduction than by bone conduction. In a Weber test of hearing, a conductive deafness will cause
sound to be referred to the side of the deaf ear. The Weber test checks lateralization.
33. Where is Erb’s point?
On the side of the neck where applied pressure on the roots of the fifth and sixth cervical nerves
causes paralysis of the brachial muscles. Muscles of the upper arm are involved (e.g., deltoid,
biceps, brachialis anterior).
34. What is the difference between a remittent fever and an intermittent fever?
A remittent fever has a diurnal variation of more than 2° F but has no normal readings. Intermittent
fever refers to episodes of fever separated by days of normal temperature.
35. What is quotidian fever?
A daily recurring fever often associated with hepatic abscess or acute cholangitis.
36. What fever pattern is associated with Hodgkin’s disease?
Pel-Ebstein fever. This pattern describes several days of continuous remittent fever followed by
remissions for an irregular number of days.
37. What are Korotkoff sounds?
The sounds produced by the turbulence created when the inflated blood pressure cuff disrupts
normal arterial laminar blood flow.
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38. What is the result of using a blood pressure cuff that is too large or too small for
the diameter of the patient’s arm?
Too large a cuff will result in an erroneously low pressure recording, whereas too small a cuff will
result in an erroneously high measurement.
39. What standardized screening exam is most often used to evaluate mental status
and cognition?
TheMini-MentalStateExamination(MMSE)takesapproximately10minutestoadministerandis
used to screen for dementia. The exam measures orientation, registration, attention and calculation,
recall, and language. Typically a score greater than 26 indicates normal cognitive function.
40. What is the difference between Broca and Wernicke aphasias?
Broca aphasia is an expressive aphasia. The patient’s reading and word comprehension are
intact; however speech and writing are impaired. Wernicke aphasia is a receptive aphasia. The
patient can have fluent speech, however it may be incomprehensible. Reading comprehension
and writing are impaired. It is also possible for a patient to have global aphasia, a combination
of both types.
41. What are some of the key differences between delirium and dementia?
Delirium typically has a sudden onset, symptoms can increase and decrease throughout the day,
and can potentially be reversible. It can often have a clear etiology such as medication, alcohol
withdrawal, infections, or organ failure. Dementia has a slow onset, symptoms are typically stable,
and it is a progressive condition. It is caused by structural diseases of the brain.
42. If a patient has a Marcus-Gunn pupil, how would the affected pupil respond to
light shined in the contralateral pupil?
The affected pupil would constrict. The swinging light test is used to rule out Marcus-Gunn pupil, or
relative afferent pupillary defect. It is most often caused by a lesion of the optic nerve. The efferent
limb of the light reflex relayed by the oculomotor nerve is intact. Light sensed by the unaffected eye
would result in bilateral pupillary constriction.
43. In a patient with known trauma to the periorbital region, what is the likely cause
of an intraocular pressure of 43 mm Hg?
The patient likely has orbital compartmental syndrome, possibly caused by a retrobulbar hematoma.
A lateral canthotomy would be indicated. The normal IOP range is between 10 and 21 mm Hg. A
ruptured globe can cause an abnormally low IOP. Other causes of a high IOP include glaucoma and
hyphema.
44. How are deep tendon reflexes graded?
0 = no response
1+ = diminished; low normal
2+ = normal
3+ = more brisk than average
4+ = hyperactive
45. How is the Babinski sign elicited?
Babinski testing is done by lightly stroking the lateral aspect of the sole of the foot vertically from
the heel to the base of the toes. The course of stimulation is changed as you approach the toes by
medially directing the path of stimulation along the base of the toes toward the great toe. Normal
response is plantar flexion, whereas abnormal response is dorsiflexion of the toe, fanning of the
other toes, and dorsiflexion of the ankles.
46. What is Homans’ sign?
Pain in the calf when the toe is dorsiflexed. This is an early sign of deep venous thrombosis.
47. What are the ocular manifestations of hypertensive retinopathy?
Retinal arteriolar narrowing, arteriovenous nicking, opacity of arteriolar wall, hemorrhage, cotton-
wool spots, hard exudates, and microaneurysms.
48. What descriptors are important in a lymph node exam?
Examination of the lymph nodes should note size, tenderness, shape, and consistency of palpable
nodes. It is also important to note if the nodes are fixed, matted, or discrete.
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49. What are the major lymph node groups of the head and neck region?
Occipital, postauricular, preauricular, parotid/retropharyngeal, submandibular, submental, superficial
cervical, posterior cervical, deep cervical, and supraclavicular nodes.
50. What are the classic symptoms of cardiac disease?
Chest pain, dyspnea, palpitations, syncope, and edema.
51. A patient with heart failure typically exhibits what type of edema?
Edema associated with heart failure is typically pitting edema. The edematous area remains
depressed upon palpation with a finger. Peripheral edema is one of the signs of right-sided heart
failure.
52. What are the common locations for detection and evaluation of a pulse? Which
pulse is most representative of the aortic pulse?
Common locations include the carotid, radial, brachial, femoral, popliteal, posterior tibial, and dorsa-
lis pedis. The carotid pulse is the most illustrative of the aortic pulse. The carotid pulse should be the
only pulse utilized in detecting cardiovascular anomalies.
53. At what percent of arterial oxygen saturation will a patient become cyanotic?
Patients will begin becoming cyanotic around 85% arterial oxygen saturation.
54. At what level of reduced hemoglobin does a patient become cyanotic?
5 g/dL.
55. Which side of the stethoscope is used for high-frequency sounds?
High-frequencysoundssuchassuchasS1andS2, the murmurs of aortic and mitral regurgitation,
and pericardial friction rub are better heard with the diaphragm, while low-frequency sounds such
asS3,S4, and the diastolic murmur of mitral stenosis are best heard with the bell.
56. What is the difference between hyperventilation and hyperpnea?
Hyperventilation is an increase in both rate and depth of respiration, whereas hyperpnea is an
increase in depth only.
57. What is Cheyne-Stokes breathing?
Cheyne-Stokesbreathingisalternatinghyperpnea,shallowrespiration,andapnea.
58. What is stridor?
A high-pitched respiratory sound, such as the inspiratory sound heard often in acute laryngeal
obstruction.
59. When evaluating the pulmonary valve of the heart, where is it best to auscultate?
The left second intercostal space. The aortic valve is best heard in the right second intercostal
space. The tricuspid valve is best heard in the left fourth intercostal space.
The mitral valve is best heard at the cardiac apex or the point of maximal impulse. This is the
location where the cardiac apex, specifically the left ventricle, abuts the chest wall. It is located at
the intersection of the midclavicular line and the fourth or fifth intercostal space on the left side.
60. What is the diaphragmatic effect on the heart?
During inspiration, the diaphragm descends, stretching the heart from its anchorage in the fascia
surrounding the aorta and pulmonary artery. The vertical cardiac axis becomes elongated, the
transverse direction narrowed, and filling of the right ventricle is delayed.
61. When does blood from the coronary arteries perfuse the heart muscle?
During diastole.
62. What is the PMI?
The point of maximum impulse of the heart. At the beginning of systole, the heart is rotated forward
toward the chest wall, where the impulse can be felt. The PMI is normally felt at the fifth interspace
between the ribs, 1 to 2 cm medial to the left midclavicular line.
63. What causes the heart sounds?
At the beginning of systole, the ventricles contract, increasing the ventricular pressure and causing
the mitral and tricuspid valves to close. Blood rebounds in the ventricles, transmitting vibrations to
thechestwall,whichcanbeheardwiththestethoscopeasS1. Blood then courses silently through
20 PART I PATIENT EVALUATION
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the aorta and pulmonary arteries. The second sound occurs when the ventricles relax in diastole,
ventricular pressure decreases, and the aortic and pulmonary valves close. The backflow of blood
againstthesevalvessetsupanotherseriesofvibrationsaudibleasthesecondheartsound,S2.
64. What is the difference between a physiologic and an organic heart murmur?
Heart murmurs are caused by disruption of the normal laminar flow of blood. Causes include
regurgitation of blood, blood flow through narrowed or stenotic valves or vessels, shunting of blood,
increased rate of blood flow, and decreased blood viscosity. An organic murmur is pathologic and
caused by some intrinsic cardiac disease or defect, such as deformed or stenotic heart valves,
ventricular septal defects, or a patent ductus arteriosus. Physiologic murmurs are not pathologic and
usually result from an altered metabolic state, such as in pregnancy or early childhood.
65. What is a flow murmur?
A flow murmur is induced when the velocity of normal blood is increased as it courses through a
normal heart.
66. What is pulse pressure?
Pulse pressure is the numeric difference between the systolic and diastolic blood pressures. The
normal pulse pressure is in the range of 30 to 40 mm Hg. Causes of an increased or widening pulse
pressure include hyperkinetic states (anxiety, fever, exercise, hyperthyroidism), aortic regurgitation,
and increased aortic rigidity (aging, atherosclerosis). A decrease or narrowing of the pulse pressure
can be caused by obstructed ventricular output, as in aortic stenosis, or decreased stroke volume
from shock or heart failure.
67. What are the grades of intensity of heart murmurs?
Intensity of heart murmur is graded on a scale of 1 to 6. The subjectivity of this scale is minimized by
thefollowingguidelines:
• Grade1:Veryfaintandheardonlywhenpayingcloseattention
• Grade2:Faint,butunmistakablypresent
• Grade3:Clearlylouderthanfaint,butnotassociatedwithathrill
• Grade4:Loudandassociatedwithathrill
• Grade5:Veryloudbutrequiringastethoscopepartlyonthechesttobeheard
• Grade6:Abletobeheardwithstethoscopeoffthechest
68. What maneuvers or special positions are used to accentuate abnormalities of
heart sounds?
For accentuation of aortic regurgitation, ask the patient to sit up, lean forward, exhale completely,
andholdbreathinexpiration.ForaccentuatingmitralmurmursorS3, ask the patient to roll onto his
or her left side, then listen at the apical area.
69. What is the difference between stable and unstable angina? How can one
differentiate between pain associated with angina versus an acute myocardial
infarction?
Angina pectoris, or chest pain, is a common symptom of obstructive coronary artery disease.
Reversible myocardial ischemia causes episodes of angina that are often triggered by physical
exertionorstress.Symptomstypicallylast2to10minutesandresolvewithrestornitroglycerin
administration. Patients with stable angina oftentimes “know their limits” regarding the amount
of exertion until symptoms arise. Physical or emotional stress elicits similar symptoms repeatedly.
Patientsexperiencingunstableanginahavechangestothepatternofstableangina.Symptoms
becomemorefrequentorsevere.Symptomsmayalsoarisewithlesserexertionorevenatrest.
Pain associated with myocardial infection is typically more severe and longer lasting than angina.
70. What is pulsus paradoxus?
Normally, systolic pressure will decrease up to 10 mm Hg on inspiration due to negative pressure in
the thorax. Pulsus paradoxus is a condition in which there is a greater decrease with inspiration. This
is seen in pericardial tamponade, obstructive pulmonary disease, hypovolemic shock, and pregnancy.
71. When evaluating a patient’s pulse, what are some of the signs of aortic coarctation, aortic stenosis, and aortic regurgitation?
Coarctation, or narrowing, of the aorta is most commonly found along the aortic arch. To evaluate a
patient for this condition, the brachial and femoral pulse must be palpated simultaneously. A clear
delay in the peak of the pulse will occur between the brachial pulse and the femoral pulse.
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Patients with pronounced aortic stenosis will have a delayed carotid pulse with a small volume.
Often there is also a palpable thrill.
Severeaorticregurgitationproducesapulsewithahighamplitude.Thepulsemayabruptly
collapse, in turn; this pattern is also known as a “water hammer pulse.” This pulse pattern and a
high pulse pressure together are highly suggestive of severe aortic stenosis. A slight splitting of the
peak of the pulse, or bisferiens pulse, is common in aortic regurgitation also.
72. What are the heart sounds, and what physiologic event do they correlate with?
• S1:Closureoftheatrioventricularvalves
• S2:Closureoftheaorticandpulmonaryvalves
• S3:Oscillationofbloodintheventriclesduringmid-diastole.Usuallyassociatedwithheart
failure
• S4:Abnormalturbulenceofbloodassociatedwithstiffventricularwalls
73. What is the STOP-Bang Questionnaire?
ItisascreeningtooldevelopedbyanesthesiologyforObstructiveSleepApnea(OSA).Itisa
questionnaireaboutriskfactors:snoring,feelingtired,observedapnea,BMI>35,age>50,neck
circumference >17″ for males and >16″ for females, and male gender.
74. What are some complications of OSA?
1. PatientswithOSAhaveincreasedratesofdiabetes,hypertension,atrialbrillation,stroke,heart
failure, pulmonary hypertension, and CAD.
2. Ventilation via mask, direct laryngoscopy, endotracheal intubation, and fiberoptic visualization of
theairwayaremoredifcultinpatientswithOSA.
3. Suchpatientsarelikelytohaveperioperativeairwayobstruction,hypoxemia,atelectasis,ischemia,
pneumonia, and prolonged hospitalizations.
75. What time period of smoking cessation reduces the relative risk of cardiac
events?
Eightweeks.Surprisingly,thosewhostopsmokingforlessthan8weekshaveahigherriskthan
those who continue to smoke.
76. How long after an acute respiratory illness should elective surgery be delayed?
Enough time needs to be permitted to allow recovery of the tracheobronchial mucosa; generally
this is 2 to 6 weeks. Mild URIs in adult patients undergoing elective surgeries that do not involve the
chest or abdomen do necessitate postponing surgery due to minimal risk.
77. What information should be gathered in evaluating an asthmatic patient?
1. Number of hospitalizations and emergency room visits in the past 2 years related to asthma
2. Amount of daily inhaler usage
3. History of steroid or other medication
4. Aggravating symptoms
78. What are the lung sounds on auscultation?
1. Vesicular:softorlowpitched.Heardthroughinspiration,continuewithoutpausethroughexpira-
tion, and then fade away about one-third of the way through expiration.
2. Bronchovesicular:inspiratoryandexpiratorysoundsequalinlength,attimesseparatedbya
silent interval. Differences in pitch and intensity are often more easily detected during expiration.
3. Bronchial:louderandhigherinpitch,withashortsilencebetweeninspiratoryandexpiratory
sounds. Expiratory sounds last longer than inspiratory.
79. What is egophony?
Egophony is heard when asking the patient to say “ee” and is heard as “ay” (E-to-A change), seen in
a lobar consolidation from pneumonia.
80. What is pectoriloquy?
Pectoriloquy is increased resonance of the lungs. Whispered sounds are heard louder and clearer.
81. What is Kussmaul breathing?
Kussmaul breathing is a deep and labored breathing often associated with severe metabolic aci-
dosis such as diabetic ketoacidosis (DKA). Hyperventilation by increased rate or depth attempts to
reduce carbon dioxide in the blood.
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