Clinical Interviewing and Patient Assessment: A Comprehensive Guide, Exams of Nursing

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NR509 rMid-Term rStudy rGuide • Articular rstructures rinclude rjoint rcapsule rand rarticular rcartilage, rthe rsynovium rand rsynovial rfluid, rintra-articular rligaments rand rjuxta-articular rbone o Articular rdisease rinvolves: ▪ Swelling ▪ Tenderness rof rthe rjoint ▪ Crepitus ▪ Instability r“locking” ▪ Deformity ▪ Limits ractive rand rpassive rrange rof rmotion rdue rto rstiffness ror rpain • Extra-articular rstructures rinclude rperiarticular rligaments, rtendons, rbursae, rmuscle, rfascia, rbone, rnerve rand roverlying rskin o Extra-articular rdisease rinvolves: ▪ “point rof rfocal rtenderness rin rregions radjacent rto rarticular rstructures ▪ Limits ractive rrange rof rmotion ▪ RARELY rcauses rswelling, rinstability, rjoint rdeformity Know rthe rsources rof rjoint rpain r(pg. r627 ralgorithm) • Nonarticular rconditions: rtrauma/fracture, rfibromyalgia, rpolymyalgia rrheumatica, rbursitis, rtendinitis • Intra-articular r(acute, r< r6 rweeks): racute rarthritis o infectious rarthritis o gout o pseudogout o Reiter rsyndrome • Intra-articular r(chronic, r> r6 rweeks): rchronic rinflammatory rarthritis rvs rchronic rnoninflammatory rarthritis o Chronic rinflammatory rarthritis rwith r1-3 rjoints rinvolved: ▪ Indolent rinfection ▪ Psoriatic rarthritis ▪ Reiter rsyndrome ▪ Periarticular rJA o Chronic rinflammatory rarthritis rwith r>3 rjoints rinvolved: ▪ Psoriatic rarthritis ror rReiter rsyndrome r(no rsymmetry) ▪ rheumatoid rarthritis rif rnot rRA rthen r rsystemic rlupus, rscleroderma, rpolymyositis *Know rwhat rcauses rsaddle rnumbness rand rurinary rretention r(pg. r678?) • CES r(cauda requina rsyndrome) rmost rcommonly rresults rfrom ra rmassive rherniated rdisc rin rthe rlumbar rregion. • A rsingle rexcessive rstrain ror rinjury rmay rcause ra rherniated rdisc. • However, rdisc rmaterial rdegenerates rnaturally ras ra rperson rages, rand rthe rligaments rthat rhold rit rin rplace rbegin rto rweaken. rAs rthis rdegeneration rprogresses, ra rrelatively rminor rstrain ror twisting rmovement rcan rcause ra rdisc rto rrupture. The rfollowing rare rother rpotential rcauses rof rCES: • Spinal rlesions rand rtumors • Spinal rinfections ror rinflammation • Lumbar rspinal rstenosis • Violent rinjuries rto rthe rlower rback r(gunshots, rfalls, rauto raccidents) • Birth rabnormalities • Spinal rarteriovenous rmalformations r(AVMs) • Spinal rhemorrhages r(subarachnoid, rsubdural, repidural) • Postoperative rlumbar rspine rsurgery rcomplications • Spinal ranesthesia Know rhow rretinal rdetachment rpresents r(p.217) • Sudden, rpainless rvision rloss rthat ris runilateral Know rwhat rthe rword robtunded rmeans r(p. r769) • The robtunded rpatient ropens reyes rand rlooks rat ryou rbut rresponds rslowly rand ris rsomewhat rconfused. rAlertness rand rinterest rin rthe renvironment rare rdecreased. Know rwhat rcranial rnerve ryou’re rassessing rwhen rchecking rlateral rgaze r(p. r237) • Cranial rnerve rVI: rabducens Know rwhat rshould rbe rlisted runder radult rillnesses rin rhealth rhistory r(pg. r10) • Medical rillnesses: rsuch ras rdiabetes, rhypertension, rhepatitis, rasthma, rand rHIV. rAlso rhospitalizations, rnumber rand rgender rof rsexual rpartners, rand rrisk-taking rsexual rpractices • Surgical: rdates, rindications, rand rtypes rof roperations • Obstetric/Gynecologic: robstetric rhistory, rmenstrual rhistory, rmethods rof rcontraception, rand rsexual rfunction • Psychiatric: rillness rand rtimeframe, rdiagnoses, rhospitalizations, rand rtreatments Know rwhat rconditions rdo rnot rhave rred rreflexes r(p. r239) • Absence rof rred rreflex rsuggests ran ropacity rof rthe rlens r(cataract), ror rpossibly rthe rvitreous r(or reven ran rartificial reye). • Less rcommonly, ra rdetached rretina, ror rin rchildren ra rretinoblastoma rmay robscure rthis r eflex. Know rthe rsigns rof rseasonal rallergies r(p. r27) • itching, rwatery reyes, rsneezing, rear rcongestion, rpostnasal rdrainage Know rhow roptic rneuritis rpresents r(p. r217) • Sudden rvisual rloss rthat ris runilateral rand rcan rbe rpainful, rassociated rwith rmultiple rsclerosis Know rhow rpityriasis rrosacea rpresents r(p. r912) • Oval rlesions ron rtrunk, rin rolder rchildren roften rin ra rChristmas rtree rpattern, rsometimes ra rHarold rpatch r(a rlarge rpatch rthat rappears rfirst) • Cherry angioma is a mole-like skin growth made up of small blood vessels or capillaries. • Most common type of angioma • Benign tumors that result from an overgrowth of capillaries • Rare for children to develop these noncancerous lesions Pg. r183 r– Know rthat rcherry rangiomas rare rbenign Pg. r231 r- rKnow rhow rto rinterpret rvisual racuity rresults • Visual racuity ris rexpressed ras rtwo rnumbers r(e.g., r20/30): o First rindicates rthe rdistance rof rthe rpatient rfrom rthe rchart r(20 rfeet), o Second, rthe rdistance rat rwhich ra rnormal reye rcan rread rthe rline rof rletters ▪ Vision rof r20/200 rmeans rthat rat r20 rfeet rthe rpatient rcan rread rprint rthat ra rperson rwith rnormal rvision rcould rread rat r200 rfeet. • The rlarger rthe rsecond rnumber, rthe rworse rthe rvision. • “20/40 rcorrected” rmeans rthe rpatient rcould rread rthe r20/40 rline rwith rglasses r(a rcorrection). • A rpatient rwho rcannot rread rthe rlargest rletter rshould rbe rpositioned rcloser rto rthe rchart; rnote rthe rintervening rdistance. Pg. r73 r- rKnow rthe rorder rof rmeeting ra rpatient rand rconducting ran rinterview rPreparation • Reviewing rthe rClinical rRecord o Provides rimportant rbackground rinformation rand rsuggests rareas ryou rneed rto rexplore • Setting rgoals o Before ryou rtalk rwith rthe rpatient, rclarify ryour rgoals rfor rthe rinterview o The rclinician rmust rbalance rthese rprovider-centered rgoals rwith rpatient-centered rgoals, rweighing rmultiple ragendas rarising rfrom rthe rneeds rof rthe rpatient, rthe rpatient’s rfamily, rand rhealth rcare ragencies rand rfacilities. • Reviewing ryour rclinical rbehavior rand rappearance o Posture, rgestures, reye rcontact, rand rtone rof rvoice rall rconvey rthe rextent rof ryour rinterest, rattention, racceptance, rand runderstanding. o Adjusting rthe renvironment o Private rand rcomfortable Sequence rof rInterview • Greeting rthe rpatient rand restablishing rrapport o How ryou rgreet rthe rpatient rand rother rvisitors rin rthe rroom, rprovide rfor rthe rpatient’s rcomfort, rand rarrange rthe rphysical rsetting rall rshape rthe rpatient’s rfirst rimpressions. o Greet rthe rpatient rby rname rand rintroduce ryourself, rgiving ryour rown rname. rIf rpossible, rshake rhands rwith rthe rpatient. o Use ra rformal rtitle rto raddress rthe rpatient o If ryou rare runsure rhow rto rpronounce rthe rpatient’s rname, rdon’t rbe rafraid rto rask. o When rvisitors rare rin rthe rroom, racknowledge rand rgreet reach rone rin rturn, rinquiring rabout reach rperson’s rname rand rrelationship rto rthe rpatient. o Let rthe rpatient rdecide rif rvisitors ror rfamily rmembers rshould rstay rin rthe rroom, rand rask rfor rthe rpatient’s rpermission rbefore rconducting rthe rinterview rin rfront rof rthem o Always rbe rattuned rto rthe rpatient’s rcomfort. • Establishing rthe ragenda o Begin rwith ropen-ended rquestions rthat rallow rfull rfreedom rof rresponse: r“What rare ryour rspecial rconcerns rtoday?”, r“How rcan rI rhelp ryou?” o Identifying rall rthe rconcerns rat rthe routset rallows ryou rand rthe rpatient rto rdecide rwhich rones rare rmost rpressing rand rwhich rones rcan rbe rpostponed rto ra rlater rvisit. o Identifying rthe rfull ragenda rprotects rtime rfor rthe rmost rimportant rissues. • Inviting rthe rpatient's rstory o Invite rthe rpatient’s rstory rby rasking rabout rthe rforemost rconcern, r“Tell rme rmore rabout...” o Do rnot rinject rnew rinformation ror rinterrupt. rInstead, ruse ractive rlistening rskills o After rthe rpatient’s rinitial rdescription, rexplore rthe rpatient’s rstory rin rmore rdepth. rAsk, r“How rwould ryou rdescribe rthe rpain?”, r“What rhappened rnext?”, ror r“What relse rdid ryou rnotice?” • Exploring rthe rpatient’s rperspective o The rdisease/illness rdistinction rmodel rhelps relucidate rthe rdifferent ryet rcomplementary rperspectives rof rthe rclinician rand rthe rpatient o Disease ris rthe rexplanation rthat rthe rclinician ruses rto rorganize rsymptoms rthat rleads rto ra rclinical rdiagnosis. o Illness ris ra rconstruct rthat rexplains rhow rthe rpatient rexperiences rthe rdisease, rincluding rits reffects ron rrelationships, rfunction, rand rsense rof rwell-being o The rclinical rinterview rneeds rto rincorporate rboth rthese rviews rof rreality. o The rmelding rof rthese rtwo rperspectives rforms rthe rbasis rfor rplanning revaluation rand rtreatment. o FIFE • The rpatient’s rFeelings, rincluding rfears ror rconcerns, rabout rthe rproblem • The rpatient’s rIdeas rabout rthe rnature rand rthe rcause rof rthe rproblem • The reffect rof rthe rproblem ron rthe rpatient’s rlife rand rFunction • The rpatient’s rExpectations rof rthe rdisease, rof rthe rclinician, ror rof rhealth rcare, roften rbased ron rprior rpersonal ror rfamily rexperiences • Identifying rand rresponding rto rthe rpatient’s remotional rcues o Check ron rthese rclues rand rfeelings rby rasking, r“How rdid ryou rfeel rabout rthat?” ror r“Many rpeople rwould rbe rfrustrated rby rsomething rlike rthis.” o Clues rto rpatient’s rperspective ron rillness • Direct rstatement(s) rby rthe rpatient rof rexplanations, remotions, rexpectations, rand reffects rof rthe rillness • Expression rof rfeelings rabout rthe rillness rwithout rnaming rthe rillness • Attempts rto rexplain ror runderstand rsymptoms • Speech rclues r(e.g., rrepetition, rprolonged rreflective rpauses) • Sharing ra rpersonal rstory • Behavioral rclues rindicative rof runidentified rconcerns, rdissatisfaction, ror runmet rneeds rsuch ras rreluctance rto raccept rrecommendations, rseeking ra rsecond ropinion, ror rearly rreturn rappointment o Learn rto rrespond rattentively rto remotional rcues rusing rtechniques rlike rreflection, rfeedback, rand r“continuers” rthat rconvey rsupport. • A rmnemonic rfor rresponding rto remotional rcues ris rNURSE: • Name—“That rsounds rlike ra rscary rexperience” • Under- rstand ror rlegitimize—“It’s runderstandable rthat ryou rfeel rthat rway” • Respect— r“You’ve rdone rbetter rthan rmost rpeople rwould rwith rthis” • Support—“I rwill rcontinue rto rwork rwith ryou ron rthis” • Explore—“How relse rwere ryou rfeeling rabout rit? • Expanding rand rclarifying rthe rpatient’s rstory • You rmust rdiligently rclarify rthe rattributes rof reach rsymptom, rincluding rcontext, rassociations, rand rchronology. • For rpain rand rmany rother rsymptoms, runderstanding rthese ressential rcharacteristics, rsummarized ras rthe rseven rattributes rof ra rsymptom, ris rcritical. • OLD rCARTS, ror rOnset, rLocation, rDuration, rCharacter, rAggravating/ rAlleviating rFactors, rRadiation, rand rTiming, ror • OPQRST, ror rOnset, rPalliating/Provoking rFactors, rQuality, rRadiation, rSite, rand rTiming • Whenever rpossible, rrepeat rback rthe rpatient’s rwords rand rexpressions • Generating rand rtesting rdiagnostic rhypotheses • You rwill rgenerate rand rtest rdiagnostic rhypotheses rabout rwhich rdisease rprocess rmight rbe rpresent. • Identifying rall rthe rfeatures rof reach rsymptom ris rfundamental rto rrecognizing rpatterns rof rdisease rand rto rgenerating rthe rdifferential rdiagnosis. • It is rimportant rto rfully flesh rout rthe rpatient’s rstory. rThis ravoids rthe rcommon rtrap rof rpremature rclosure, ror rshutting rdown rthe rpatient’s rstory rtoo rquickly • Each rsymptom rhas its rown r“cone” • Includes rhealth rmaintenance rpractices rsuch ras rimmunizations, rscreening rtests, rlifestyle rissues, rand rhome rsafety • Family rhistory • Outlines ror rdiagrams rage rand rhealth, ror rage rand rcause rof rdeath, rof rsiblings, rparents, rgrandparents, rchildren, rand rgrandchildren • Documents rpresent ror rabsence rof rspecific rillnesses rin rfamily, rReview reach rof rthe rfollowing rconditions rand rrecord rwhether rthey rare rpresent ror rabsent rin rthe rfamily: rhypertension, rcoronary rartery rdisease, relevated rcholesterol rlevels, rstroke, rdiabetes, rthyroid ror rrenal rdisease, rarthritis, rtuberculosis, rasthma ror rlung rdisease, rheadache, rseizure rdisorder, rmental rillness, rsuicide, rsubstance rabuse, rallergies, ror rtype rof rcancer • Personal rand rsocial rhistory • Describes reducational rlevel, rfamily rof rorigin, rcurrent rhousehold, rpersonal rinterests, rand rlifestyle • Review rof rsystems • Documents rpresence ror rabsence rof rcommon rsymptoms rrelated rto reach rof rthe rmajor rbody rsystems Pg. r649, r655, r700 r- rKnow rhow ra rrotator rcuff rtear rpresents • Patients rcomplain rof rchronic rshoulder rpain, rnight rpain, ror rcatching rand rgrating rwhen rraising rthe rarm roverhead • Weakness ror rtears rof rthe rtendons rusually rstart rin rthe rsupraspinatus rtendon rand rprogress rposterior rand ranterior • Look rfor ratrophy rof rthe rdeltoid, rsupraspinatus, ror rinfraspinatus rmuscles. • Palpate ranteriorly rover rthe ranterior rgreater rtuberosity rof rthe rhumerus rto rcheck rfor ra rdefect rin rmuscle rattachment rand rbelow rthe racromion for rcrepitus during rarm rrotation. • In ra rcomplete rtear, ractive rabduction rand rforward rflexion rat rthe rglenohumeral rjoint rare rseverely rimpaired, rproducing ra rcharacteristic rshrug rof rthe rshoulder rand ra rpositive r“drop rarm” rtest •Atrophyofthesupraspinatusandinfraspinatuswithincreasedprominenceof rscapularspinecanappearwithin2to3weeksofarotatorcufftear;infraspinatus ratrophyhasapositivelikelihoodratio(LR)of2forrotatorcuffdisease Know rsigns rof rsubarachnoid rhemorrhage r(pg. r216) • Severe rand rsudden r“worst rheadache rof rmy rlife!” rNausea rand rvomiting rcan rbe rpresent. rNeck rstiffness rwith rresistance rto rflexion ris rpresent rin r21-86% rof rpatients Know rhow rto rmake ra rpelvic rexam rless rintimidating r(pg. r76) • Avoid rinterviewing ra rpatient rwhen rshe ris ralready rpositioned rfor ra rpelvic rexam Know rthat rif r1 rpatient rreturns rfrom ra rcountry rwith rmalaria ryou rstill rneed rto rbe rselective rof rwhich rpatients ryou rscreen rfor rmalaria. r(pg. r66?) Know rwhat rabsence rseizures rare. r(pg. r781) • A rsudden rbrief rlapse rof rconsciousness, rwith rmomentary rblinking, rstaring, ror rmovements rof rthe rlips rand rhands rbut rno rfalling. • Two rsubtypes rare rtypical rabsence r(lasts rless rthan r10 rsec rand rstops rabruptly) • And ratypical rabsence r(may rlast rmore rthan r10 rsec). • Post rictal rstate: rno raura rrecalled. rIn rtypical rabsence, rthere ris ra rprompt rreturn rto rnormal rand rin ratypical rthere rmight rbe rsome rpostictal rconfusion. Know rwhich rcranial rnerve ryou rassess rwhen ryou rtouch rthe rsoft rpalate rand rview rthe ruvula r(pg. r257). • Cranial rnerve rX r(Vagus) Know rsigns rof rincreased rintracranial rpressure r(pg. r280). • Papilledema rof rthe roptic rdisc r relevated rICP rcauses rintraaxonal redema ralong rthe roptic rnerve rleading rto rengorgement rand rswelling ron rthe roptic rdisc o pink, rhyperemic, rloss rof rvenous rpulsations, rdisc rmore rvisible, rdisc rswollen rwith rblurred rmargins, rphysiologic rcup rnot rvisible) • Headache, rblurred rvision, rfeeling rless ralert rthan rusual, rvomiting, rchanges rin behavior, rweakness ror rproblems rwith rmoving ror rtalking, rlack rof renergy ror rsleepiness Know rthe rsigns ror rrespiratory rdistress r(p. r318) • Tachypnea: rgreater rthan ror requal rto r25 rbreaths/min r rpneumonia rand rcardiac rdisease • Cyanosis ror rpallor r(signals rhypoxia) • Audible rsounds rof rbreathing: raudible rwhistling rduring rinspiration rover rthe rneck ror rlungs o stridor rsignals rupper rairway robstruction rin rthe rlarynx ror rtrachea • Contraction rof rthe raccessory rmuscles rof rthe rneck ror rsupraclavicular rretraction, rcontraction rof rthe rintercostal ror rabdominal roblique rmuscles o Is rthe rtrachea rmidline? Know rwhat robjective rinformation ris r(pg. r6) • What ryou rdetect rduring rthe rexamination, rlaboratory rinformation, r& rtest rdata. rAll rphysical rexam rfindings, ror rsigns. Know rwhat rcan rcause repistaxis r(p. r220) • Trauma r(especially rnose rpicking), rinflammation, rdrying rand rcrusting rof rthe rnasal rmucosa, rtumors, rand rforeign rbodies Know rthe rsigns rof rotitis rexterna r(swimmer’s rear) r(pg. r245) • Painful rmovement rof rthe rauricle rand rtragus r(tug rtest) Movement rof rthe rauricle rand rtragus r(the r“tug rtest”) ris rpainful rin racute rotitis rexterna r(inflammation rof rthe rear rcanal), rbut rnot rin rotitis rmedia r(inflammation rof rthe rmiddle rear). rTenderness rbehind rthe rear roccurs rin rotitis rmedia. in racute rotitis rexterna r(Fig. r7-43), rthe rcanal ris roften rswollen, rnarrowed, rmoist, rpale, rand rtender. rIt rmay rbe rreddened. Know rthe rsigns rof rpneumonia r(pg. r322-340) • Dullness rreplaces rresonance, rcrackles rcan rarise rfrom rabnormalities rof rthe rlung rparenchyma, rpleural rrubs, rlocalized rbronchophony rand regophony r(in rpatients rwith rfever rand rcough rthe rpresence rof rbronchial rbreath rsounds rand regophony rmore rthan rtriples rthe rlikelihood rof pneumonia. • Pleuritic rpain: rsharp, rknifelike, raggravated rby rdeep rinspiration, rcoughing, rmovements rof rthe rtrunk. rOften rpersistent rand rsevere. • Pg r333: rdyspnea, rpleuritic rpain, rcough, rsputum, rfever. rPg. r339 rgoes rover rphysical rfindings rin rlobar rpneumonia Dullness rreplaces rresonance rwhen rfluid ror rsolid rtissue rreplaces rair-containing rlung ror roccupies rthe rpleural rspace rbeneath ryour rpercussing rfingers. rExamples rinclude: rlobar rpneumonia, rin rwhich rthe ralveoli rare rfilled rwith rfluid rand rblood rcells; rand rpleural raccumulations rof rserous rfluid r(pleural reffusion), rblood r(hemothorax), rpus r(empyema), rfibrous rtissue, ror rtumor. rDullness rmakes rpneumonic rand rpleural reffusion rthree rto rfour rtimes rmore rlikely, rrespectively. Dullness rreplaces rresonance rwhen rfluid ror rsolid rtissue rreplaces rair-containing rlung ror roccupies rthe rpleural rspace rbeneath ryour rpercussing rfingers. rExamples rinclude: rlobar rpneumonia, rin rwhich rthe ralveoli rare rfilled rwith rfluid rand rblood rcells; rand rpleural raccumulations rof rserous rfluid r(pleural effusion), rblood r(hemothorax), rpus r(empyema), rfibrous rtissue, ror rtumor. rDullness rmakes rpneumonic rand rpleural reffusion rthree rto rfour rtimes rmore rlikely, rrespectively. Know rthe rphysical rsigns rof rmeningitis r(pg. r765) • Neck rstiffness rwith rresistance rto rflexion ris rpresent rin rapprox. r84% rof rpatients rwith racute rbacterial rmeningitis r(won’t rbe rable rto rtouch rchin rto rchest) Inflammation rin rthe rsubarachnoid rspace rcauses rresistance rto rmovement rthat rstretches rthe rspinal rnerves r(neck rflexion), rthe rfemoral rnerve r(Brudzinski rsign), rand rthe rsciatic rnerve r(Kernig rsign). Neck rstiffness rwith rresistance rto rflexion ris rfound rin r∼84% rof rpatients rwith racute rbacterial rmeningitis rand r21% rto r86% rof rpatients rwith rsubarachnoid rhemorrhage. rIt ris rmost rreliably rpresent rin rsevere rmeningeal rinflammation rbut rits roverall rdiagnostic raccuracy ris rlow. • Its rirregular rpatches rseen rat rdiabetic rand rhypertensive rretinopathy (pg. r270) rKnow rhow ra rsubconjunctival rhemorrhage rpresents • Benign, rno rtreatment rrequired, rresolves rin r2 rweeks r, rLeakage rof rblood routside rthe rvessel rproducing rhomogenous r red rarea. r, rno rocular rdischarge, rvision rnot raffected, rUsually rresulting rfrom rtrauma, ror rsudden rincrease rin rvenous rpressure (pg. r310) rKnow rto rconsider rAngina rPectoris ras ra rdifferentia rwith rCP. • It rcan rbe ra rcause rfor rpain rin rthe rmyocardium. rA rclenched rfist rover rthe rsternum rsuggest rangina rpectoris A rclenched rfist rover rthe rsternum rsuggests rangina rpectoris; ra rfinger rpointing rto ra rtender rspot ron rthe rchest rwall rsuggests rmusculoskeletal rpain; ra rhand rmoving rfrom rthe rneck rto rthe repigastrium rsuggests rheartburn. Olfactory rCN rI r (pg. r736) • The rdecreased rsense rof rsmell ris rnormal rin relderly rpatients, rhead rtrauma, rsmoking, rcocaine ruse rand rParkinson’s rd/e. Shoulder rshrug (pg. r740) • Testing rthe rCN rXI rSpinal rAccessory rnerve. rPut ryour rhands ron rpt rshoulder rand rask rthem rto rshrug ragainst ryour rhands- rasses rfor rstrength rand rcontraction rof rtrapezii. rWeakness rnoted rwith ratrophy rand rpoints rto ra rperipheral rnerve rdisorder. Vasovagal rsyncope rcauses r (pg. r778) • Reflex rwithdrawal rof rsympathetic rtone rand rincreased rvagal rtone rcausing ra rdrop rin rBP rand rHR. • Usually rprecipitated rby rstrong remotions rsuch ras rfear ror rpain, rprolonged rstanding ror rhot rhumid renvironment. • Predisposing rfactors r– rfatigue, rhunger, rdehydration, rdiuretics, rvasodilators Know rhow rto rdistinguish rjugular rvenous rpulsation rvs rcarotid rpulse r(pg. r377) • Jugular: rrarely rpalpable, rsoft rbi-phasic rundulating rquality r(usually rwith r2 relevations rand rcharacteristic rinward rdeflection), rpulsations reliminated rby rlight rpressure ron rthe rvein rjust above rthe rsternal rend rof rthe rclavicle, rheight rof rpulsation rchanges rwith rposition r(normally rdropping ras rthe rpatient rbecomes rmore rupright), rheight rof rpulsations rusually rfalls rwith rinspiration • Carotid: rpalpable, ra rmore rvigorous rthrust rwith ra rsingle routward rcomponent, rpulsations rnot reliminated rby rpressure ron rveins rat rsternal rend rof rclavicle, rheight rof rpulsations unchanged rby rposition, rheight rof rpulsations rnot raffected rby rinspiration Know rwhere rthe rcricoid rcartilage ris r(pg. r258) • Ask rthe rpatient rto rsit rup, rlean rforward, rexhale rcompletely, rand rbriefly rstop rbreathing rafter rexpiration. • Press rthe rdiaphragm ron ryour rstethoscope ron rthe rchest rand rlisten ralong rthe rleft rsternal rborder rand rat rthe rapex, rpause rperiodically rso rthe rpatient rmay rbreathe o You rmay rmiss rthe rsoft rdiastolic rdecrescendo runless ryou rlisten rat rthis rposition Know rwhat rvalve ryou rare rlistening rto rwhen ryou rlisten rto rthe rapex rof rthe rheart rPg. r391 • Mitral rvalve • Have rthe rpatient rroll ronto rleft rlateral rdecubitus rposition rwhich rbrings rthe rleft rventricle rcloser rto rthe rchest rwall o Place rbell rof ryour rstethoscope rlightly ron rthe rapical rimpulse r rS3 r& rS4, rmitral rmurmurs r& rmitral rstenosis Possibly rnot rcovered ryet Know rwhat rperseveration ris rwhen rtalking rabout rusing rwords rrepeatedly r(pg. r162) rPerseveration ris rrepetition rof rthe rwords rand rphrases rof rothers, roccurs rin rschizophrenia rand rother rpsychotic rdisorders Know rthat rin ra r47-year-old rman rED ris rusually rpsychologic rrather rthan rtestosterone r(pg. r546) Erectile rdysfunction rmay rbe rfrom rpsychogenic rcauses, respecially rif rearly rmorning rerection ris rpreserved; rit rmay ralso rreflect rdecreased rtestosterone, rdecreased rblood rflow rin rthe rhypogastric rarterial rsystem, rimpaired rneural rinnervation, rand rdiabetes When rperforming ra rbreast rexam, rknow rwhat rabnormal rmasses rshould rdo rwhen rthe rarm rmoves r(pg. r436, r439, r444) Fibroadenoma: rvery rmobile rCysts: rmobile Cancer: rmay rbe rfixed rto rskin ror runderlying rtissues r(may rcause rdimpling rof rskin ror rretraction rwhen rarms rare rlifted rover rhead ror rhands rare rpressed ragainst rhips) Know rthat ra rhigh rproportion rof rbreast rmasses rare rnoted rduring rBSE Know rTanner rstaging rof rbreasts rin rfemales r(pg. r897 rtable rwith rpictures) Stage r1: rpreadolescent- relevation rof rnipple ronly Stage r2: rbreast rbud rstage- relevation rof rbreast rand rnipple ras ra rsmall rmound; renlargement rof rareolar rdiameter Stage r3: rfurther renlargement rof relevation rof rbreast rand rareola, rwith rno rseparation rof rtheir rcontours Stage r4: rprojection rof rareola rand rnipple rto rform ra rsecondary rmound rabove rthe rlevel rof rbreast rStage r5: rmature rstage- rprojection rof rnipple ronly; rareola rhas rreceded rto rgeneral rcontour rof rthe rbreast r(although rin rsome rindividuals rthe rareola rcontinues rto rform ra rsecondary rmound) Know rwhere rpain ris rlocated rwith rpancreatitis r(pg. r488) Acute: repigastric, rmay rradiation rstraight rto rthe rback rof rother rareas rof rthe rabdomen; r20% rwith rsevere rsequelae rof rorgan rfailure Know rwhere rlymph rnodes rshould rbe rwith rstrep r?pg r260 r+ rgoogle • Strep rthroat r streptococcal rpharyngitis, rbacterial rinfection rthat rmay rcause ra rsore, rscratchy rthroat • Common rchildhood rinfection rhas ra rclassic rpresentation rof rerythema rof rthe rposterior rpharynx rand rpalatal rpetechiae • Enlarged rswollen rcervical rlymph rnodes r rsuperficial rcervical rlymph rnodes o Superficial rcervical rsuperficial rto rthe rsternocleidomastoid ~— External lymphatic drainage —y Internal lymphatic drainage (from mouth and throat)  What rvaccines rare rsafe rduring rpregnancy rpg. r937 • Tdap rduring reach rpregnancy r r27-36 rweeks rof rgestation rregardless rof rprior rimmunization rhistory • Influenza rvaccine rat rany rtrimester rduring rinfluenza rseason • Pneumococcal, rmeningococcal, rHepatitis rB • MMR, rpolio rand rvaricella rNOT rDURING rPREGNANCY o Rubella rtiters rdrawn rduring rpregnancy rand rimmunized rafter rbirth rif rnonimmune • Check rRH(D) rand rantibody rtype rduring rfirst rprenatal rvisit, rat r28 rweeks rand rdelivery o Anti-D rimmunoglobulin rshould rbe rgiven rto rall rRh-negative rwomen rat r28 rweeks and ragain rwithin r3 rdays rof rdelivery rto rprevent rsensitization rif rthe rinfant ris rRh-D rpositive Know rwhat rto rbe rconcerned rabout rif ryou rnote ran rirregular rrectal rmass rPg. r618 • Any rmasses rwith rirregular rborders rsuspicious rfor rrectal rcancer A rtender rpurulent rreddened rmass rwith rfever ror rchills rsuggests ran ranal rabscess. rAbscesses rtunneling rto rthe rskin rsurface rfrom rthe ranus ror rrectum rmay rform ra rclogged ror rdraining rano-rectal rfistula. rFistulas rmay rooze rblood, rpus, ror rfeculent rmucus. rConsider ranoscopy ror rsigmoidoscopy rfor rbetter rvisualization. (epithelial rcells rwith rstippled rborders); rsniff rfor rfishy rodor rafter rapplying rKOH r(“whiff rtest”); rtest rthe rvaginal rsecretions rfor rpH r>4.5. Know rwhat rmiliaria rrubra r(pg. r819) Scattered rvesicles ron ran rerythematous rbase, rusually ron rthe rface rand rtrunk, rresult rfrom robstruction rof rthe rsweat rgland rducts; rdisappears rspontaneously rwithin rweeks r(refer rto rpic ron rpg. r819) Know rthe rcharacteristics rof ra rbreast rcyst r(pg. r423) Usually rsoft rto rfirm, rround, rmobile rand roften rtender. rMost rcommon rbetween rthe rages rof r25-50 Know rthe rsigns rof rperitonitis r(pg. r486) When rtender rarea ris rpalpated rfor rguarding, rearly rvoluntary rguarding rmay rbe rreplaced rby rinvoluntary rmuscular rrigidity rand rsigns rof rperitoneal rinflammation. rThere rmay ralso rbe rRLQ rpain ron rquick rwithdrawal ror rdeferred rrebound rtenderness. rSee rfindings rsuggestive rof rperitonitis rsecondary rto rpossible rappendicitis rpg. r485-486) Know rwhere rpain ris rwith rdiverticulitis r(p. r488-489) Left rlower rquadrant Know rwhat rposition rto rhave rpt rin rto rlisten rfor rmitral rstenosis r(pg. r382 r& r383) Left rlateral rdecubitus Know rwhat rto rask rin rregards rto rcardiovascular rreview rof rsystems r(pick rthe rone rthat rbelongs) r(pg. r357) Ask rquestions rrelated rto: rchest rpain, rpalpitations, rshortness rof rbreath, rswelling r(edema), rsyncope. rReview rinfo ron rpages r355-358 rof rtext Know rhow ra rbartholin’s rgland rinfection rpresents r(pg. r597) Acutely, rthe rgland rappears ras ra rtense, rhot, rvery rtender rabscess. rPossible rlabial rswelling. rLook rfor rpus remerging rfrom rthe rduct ror rerythema raround rthe rduct ropening. rChronically, ra rnontender rcyst ris rfelt rthat rmay rbe rlarge ror rsmall. Know rwhere rpain ris rwith rappendicitis r(pg. r457, r488) RLQ rpain ror rpain rthat rmigrates rfrom rthe rperiumbilical rregion, rcombined rwith rabdominal rwall r igidity ron rpalpation ris rsuspicious rfor rappendicitis. Know rhow rsyphilis rpresents rgenitally r(pg. r291, rpg. r597, rpg. r557) Female: rsyphilitic rchancre- rfirm, rpainless rulcer rfrom rprimary rsyphilis, rforms rapprox. r21 rdays rafter rexposure rto rTreponema rpallidum. rIt rmay rremain rhidden rand rundetected rin rthe rvagina rand rheals rregardless rof rtreatment rin r3-6 rweeks. Secondary rsyphilis r(Condyloma rlantum)- rlarge rraised, rround ror roval, rflat-topped rgray ror rwhite rlesions rpoint rto rcondylomata rlata. rThese rare rcontagious rand, ralong rwith rrash rand rmucus rmembrane rsores rin rthe rmouth, rvagina, ror ranus rare rmanifestations rof rsecondary rsyphilis. Male: rPrimary rsyphilis: rsmall rred rpapule rthat rbecomes ra rchancre, ra rpainless rerosion rup rto r2 rcm rin rdiameter. rBase rof rchancre ris rclean, rred, rsmooth, rand rglistening; rborders rare rraised rand rindurated. rChancre rheals rwithin r3-8 rweeks. Know rthe rsigns rof rproctitis r(pg. r609) Anorectal rpain, ritching, rtenesmus, ror rdischarge ror rbleeding rfrom rinfection ror rrectal rabscess rsuggest rproctitis. Know rwhat rcauses rdark, rbloody remesis r(pg. r458) Hematemesis rmay raccompany resophageal ror rgastric rvarices, rMallory-Weiss rtears, ror rpeptic rulcer rdisease. Know rwhat rcauses ran rS3 rheart rsound r(know rthe rmechanics rof rthe rdisease) r(pg. r348) In rchildren rand ryoung radults, ra rthird rheart rsound r(S3) rmay rarise rfrom r apid rdeceleration rof rthe rcolumn rof rblood ragainst rthe rventricular rwall. rIn ran rolder radult, ran rS3 rusually rindicates ra rpathologic rchange rin rventricular rcompliance. Know rthe rsigns rof rthrombophlebitis r(pg. r525) Local rswelling, rredness, rwarmth, rand ra rsubcutaneous rcord rsignal rsuperficial rthrombophlebitis r(an remerging rrisk rfactor rfor rDVT). Know rwhat rchalazion ris r(pg. r275) A rsubacute rnontender, rusually rpainless rnodule rcaused rby ra rblocked rmeibomian rgland. rMay rbecome racutely rinflamed, rbut runlike ra rstye, rusually rpoints rinside rthe rlid rrather rthan ron rthe rlid rmargin. rPic ron rpg r275. Know rwhat rthe rlungs rdo rwith rage r(pg. r960) Chest rwall rbecomes rstiffer rand rharder rto rmove r(decrease rin rchest rwall rcompliance), rrespiratory rmuscles rmay rweaken, rand rthe rlungs rlose rsome rof rtheir relastic rrecoil. rLung rmass rand rthe rsurface rarea rfor rgas rexchange rdecline, rand rresidual rvolume rincreases ras rthe ralveoli renlarge. rAn rincrease rin rclosing rvolumes rof rsmall rairways rpredisposes rto ratelectasis rand rrisk rof rpneumonia. Diaphragmatic rstrength rdeclines. Know rwhat rdiastasis rrecti ris r(pg. r930) As rtension ron rthe rabdominal rwall rincreases rwith radvancing rpregnancy, rthe rrectus rabdominus rmuscles rmay rseparate rat rthe rmidline, rcalled rdiastasis rrecti. rIf rdiastasis ris rsevere, respecially rin rmultiparous rwomen, ronly ra rlayer rof rskin, rfascia, rand rperitoneum rmay rcover rthe ranterior ruterine rwall, rand rfetal rparts rmay rbe rpalpable rthrough rthis rmuscular rgap. Identify rmacula rin rthe reye r(pg. r228) Refer rto rpicture ron rpg r228 Know rthe rsequence rof rthe rabdomen r(pg. r22) Inspect, rauscultate, rpercuss, rpalpate r(first rpalpate rlightly, rthen rdeeply). rAssess rthe rliver rand rspleen rby rpercussion rthen rpalpation. rTry rto rpalpate rthe rkidneys. rPalpate rthe raorta rand rits rpulsations. rIf ryou rsuspect rkidney rinfection, rpercuss rposteriorly rover rthe rcostovertebral rangles. Senile r(Actinic) rPupura r(pic) rpg. r990 Know rthe rsigns rof repididymitis r(pg. r560) Acute repididymitis: ran racutely rinflamed repididymis ris rindurated, rswollen, rand rnotably rtender, rmaking rit rdifficult rto rdistinguish rfrom rthe rtestis. rThe rscrotum rmay rbe rreddened rand rthe rvas rdeferens rinflamed. r(pic ron rpg. r560) Know rwhat rto rdo rif ryou rcannot rfeel ra rtesticle rin rthe rscrotum rof ra rnewborn r(pg. r840) rIf ryou rfeel ra rtestis rup rin rthe ringuinal rcanal, rgently rmilk rit rdownward rinto rthe rscrotum. rNeed rto rdifferentiate rbetween rundescended rtestes r(in rthe ringuinal rcanals) rand rhighly rretractile rtestes. Know rthe rsign rfactors rof rprostate rcancer r(pg. r610) Risk rfactors: rage: rrare rin rages rbelow r40 rbut rincidence rrates rbegin rincreasing rrapidly rafter rage r50. rMedian rage rat rdiagnosis ris r66. Ethnicity: rAfrican rAmerican rmen rhave rthe rhighest rincidence rand rmortality rrates. Compared rto rwhite rmen, ra rhigher rpercentage rof rAfrican rAmerican rmen rare rdiagnosed rwith rprostate rcancer rbefore rage r50. rThey rare ralso rmore rlikely rto rpresent rwith radvanced-stage rcancer. Family rhistory: rGenetics rappear rto rplay ran rimportant rrole rin rprostate rcancer rrisk. rFor rmen rwith rone raffected rfirst rdegree rrelative r(father, rbrother) rrisk rof rdeveloping rprostate rcancer rincreases rtwo rfold. rFor rmen rwith r2 ror r3 raffected rfirst rdegree rrelatives, rrisk rincreases r5-11 rfold. The rBRCA1 rand rBRCA2 rmutations ralso rappear rto rconfer rincreased rrisk rof rprostate rcancer. Other rrisk rfactors: rAgent rOrange rexposure ramong rVietnam rveterans, rdiets rhigh rin ranimal rfat, robesity, rand rcigarette rsmoking. rBPH ris rNOT ra rrisk rfactor. Know rwhat rchicken rpox rlooks rlike r(will rbe ra rdescription) r(pg. r923) Picture rlocated ron rpg r923, rbut rno rdescription rincluded Know rthe rsigns rof rcandida rvaginitis r(pg. r598) Discharge rthat ris rwhite rand rcurdy, rmay rbe rthin rbut rtypically rthick, rnot rmalodorous. rOften raccompanied rby rpruritis, rvaginal rsoreness, rpain ron rurination r(from rskin rinflammation) rand rdyspareunia. rVulva rand rsurrounding rskin rare roften rinflamed rand rsometimes rswollen rto ra rvariable rextent. rThe rvaginal rmucosa ris roften rreddened rwith rtenacious rpatches rof rwhite rdischarge. Know rwhat rto rdo rif ra rpatient rhas rvague rcomplaints rwith rnegative rwork-up rscreen rfor rdepression r(pg. r150) Know rto rscreen rfor rdepression rwith rvague rcomplaints rand rnegative rwork-up Know rwhen rto rorder rABI r(pg. r519)????? Risk rfactors rfor r LE rPeripheral rArtery rDisease: 1. Age rgreater rthan ror requal rto r50 rwith ra rhx rof rDM ror rsmoking 2. Leg rsymptoms rwith rexertion 3. Nonhealing rwounds Know rwhich rlymph rnode rgroup ris rmost rcommonly rinvolved rin rbreast rcancer r(pg. r441) Central rnodes r(axillary) Personal rhx rof rearly ronset rbreast rcancer r(<40 ryears) Two ror rmore r1st rdegree rrelatives rdiagnosed rwith rbreast rcancer rat ran rearly rage rAge rof rfirst rfull rterm rpregnancy Late rmenopause rBreast rtissue rdensity Modifiable r isk rfactors: rbreastfeeding rfor rless rthan r1 ryear, rpostmenopausal robesity, ruse rof rHRT, rcigarette rsmoking, ralcohol ringestion, rphysical rinactivity, rand rtype rof rcontraception. Know rthe rsigns rof rBPH r(pg. r623) Symptoms rarise rfrom rboth rsmooth rmuscle rcontraction rin rthe rprostate rand rbladder rneck rand rfrom rcompression rof rthe rurethra. rThey rmay rbe rirritative r(urgency, rfrequency, rnocturia), robstructive r(decreased rstream, rincomplete remptying, rstraining), ror rboth rand rare rseen rin rmore rthan r1/3 rof rmen rby rage r65. rThe raffected rgland rmay rbe rnormal rin rsize, ror rmay rfeel rsymmetrically renlarged, rsmooth, rand rfirm, rthough rslightly relastic; rthere rmay rbe robliteration rof rthe rmedian rsulcus rand rmore rnotable rprotrusion rinto rthe rrectal rlumen. Know rthe rsigns rof relder rabuse r(pg. r985) Elder rmistreatment rincludes rabuse, rneglect, rexploitation, ror rabandonment. rPrevalence ris rhighest rin radults rwith rdementia rand rdepression. rCOULD rNOT rFIND rSPECIFIC rLIST rOF rSIGNS Know rthe rsigns rof rrectal rprolapse r(pg. r621) On rstraining rfor ra rbowel rmovement, rthe rrectal rmucosa, rwith ror rwithout rits rmuscular rwall, rmay rprolapse rthrough rthe ranus, rappearing ras ra rdoughnut ror rrosette rof rtissue. rA rprolapse rinvolving ronly rmucosa ris rrelatively rsmall rand rshows rradiating rfolds r(pic ron rpg. r621). rWhen rthe rentire rbowel ris rinvolved, rthe rprolapse ris rlarger rand rcovered rby rconcentrically rcircular rfolds. Know rwhat ra ronychomycosis rlooks rlike r(pg. r212) See rpic rat rthe rtop rof rpg. r212 Know rthe rsigns rof rgestational rHTN r(pg. r942) Gestational ris rsystolic rblood rpressure r(SBP) r>140 rmm rHg ror rdiastolic rblood rpressure r(DBP) r> r90 rmm rHg rfirst rdocumented rafter r20 rweeks, rwithout rproteinuria ror rpreeclampsia, rthat rresolves rby r12 rweeks rpostpartum. Know rthat rage ris ra rbig rrisk rfactor rfor rbreast rcancer r(425) *Included ron rthe ranswer rabove Know rwhat rto rdo rif ryou rfeel ran rabdominal rmass r(pg. r487) Occasionally rthere rare rmasses rin rthe rabdominal rwall rrather rthan rinside rthe rabdominal rcavity. rAsk rthe rpatient reither rto rraise rthe rhead rand rshoulders ror rto rstrain rdown, rthus rtightening rthe rabdominal rmuscles. rFeel rfor rthe rmass ragain. Know rthe rbest rway rto rexamine rthe rlateral rportion rof rthe rbreast r(pg. r437) Ask rthe rpatient rto rroll ronto rthe ropposite rhip, rplacing rher rhand ron rher rforehead rbut rkeeping rthe rshoulders rpressed ragainst rthe rbed ror rexamining rtable. rThis rflattens rthe rlateral rbreast rtissue. rBegin palpation rin rthe raxilla, rmoving rin ra rstraight rline rdown rto rthe rbra rline, rthen rmove rthe rfingers rmedially rand rpalpate rin ra rvertical rstrip rup rthe rchest rto rthe rclavicle. rContinue rin rvertical roverlapping rstrips runtil ryou rreach rthe rnipple, rthen rreposition rthe rpatient rto rflatten rthe rmedial rportion rof rthe rbreast. Know rwhat rfunctional rsyndrome ris r(pg. r150) The rterm rfunctional rsomatic rsyndrome rhas rbeen rapplied rto rseveral rrelated rsyndromes rcharacterized rmore rby rsymptoms, rsuffering, rand rdisability, rthan rby rconsistently rdemonstrable rtissue rabnormality. rExamples rinclude rIBS, rfibromyalgia, rchronic rfatigue, rTMJ rdisorder, rand rmultiple rchemical rsensitivity. rFunctional rsyndromes rhave rbeen rshown rto r“frequently rco-occur rand rshare rkey rsymptoms rand rselected robjective rabnormalities.” rThe rco-occurrence rrates rfor rcommon rfunctional rsyndromes rsuch ras rIBS, rfibromyalgia, rchronic rfatigue, rTMJ rdisorder, rand rmultiple rchemical rsensitivity rreach r30-90%, rdepending ron rthe rdisorders rcompared. rThe rprevalence rof rsymptom roverlap ris rhigh rin rthe rcommon rfunctional rsyndromes, rname rcomplaints rof rfatigue, rsleep rdisturbance, rmusculoskeletal rpain, rHA, rand rGI rproblems. rThe rcommon rfunctional rsyndromes ralso roverlap rin rrates rof rfunctional rimpairment, rpsychiatric rcomorbidity, rand rresponse rto rcognitive rand rantidepressant rtherapy. Know rhemorrhoid rvs rpolyp rvs rcancer r(pg. r621) Internal rhemorrhoids: renlargements rof rthe rnormal rvascular rcushions rlocated rabove rthe rpectinate rline, rusually rnot rpalpable. rMay rcause rbright rred rbleeding, respecially rduring rdefecation. rThey rmay ralso rprolapse rthrough rthe ranal rcanal rand rappear ras rreddish, rmoist, rprotruding rmasses. rPic ron rpg. r621 Polyps rof rthe rrectum: rfairly rcommon rand rvariable rin rsize rand rnumber, rthey rcan rdevelop ron ra rstalk r(pedunculated) ror rlie ron rthe rmucosal rsurface r(sessile). rThey rare rsoft rand rmay rbe rdifficult ror rimpossible rto rfeel reven rwhen rin rreach rof rthe rexamining rfinger. rEndoscopy rand rbiopsy rare rneeded rfor rdifferentiation rof rbenign rfrom rmalignant rlesions. rPic ron rpg. r622 Cancer rof rthe rrectum: rusually rfirm, rnodular, rrolled redge. rPic ron rpg. r622 Know rwhat rcauses ra rsplit rS2 r(what ris rgoing ron rin rthe rheart) r(pg. r349) During rinspiration rthe rright rheart rfilling rtime ris rincreased, rwhich rincreases rright rventricular rstroke rvolume rand rthe rduration rof rright rventricular rejection rcompared rwith rthe rneighboring rleft rventricle. rThis rdelays rthe rclosure rof rthe rpulmonic rvalve, rP2, rsplitting rS2 rinto rits rtwo raudible rcomponents. rCan rbe rheard rat rthe r2nd rand r3rd rleft rintercostal rspaces rclose rto rthe rsternum. Know rthat rthe rBuerger rtest ris rfor rchronic rarterial rinsufficiency r(pg. r530) rPostural rcolor rchanges rof rchronic rarterial rinsufficiency: rif rpain ror rdiminished rpulses rsuggest rarterial rinsufficiency, rconsider rlooking rfor rpostural rcolor rchanges rusing rthe rBuerger rtest. rRaise rboth rlegs rto rabout r90 rdegrees rfor rup rto r2 rmin runtil rthere ris rmaximal rpallor rof rthe rfeet. rThen rask the rpatient rto rsit rup rwith rlegs rdangling rdown, rcompare rboth rfeeting rnoting rthe rtime rrequired rfor: rReturn rof rpinkness rof rthe rskin, rnormally rabout r10 rsec ror rless Filling rof rthe rveins rof rthe rfeet rand rankles, rnormally rabout r15 Know rthe rcauses rof rincreased rjugular rvenous rpressure r(pg. r377) Elevated rJVP ris rhighly rcorrelated rwith rboth racute rand rchronic rheart rfailure. rIt ris ralso rseen rin rtricuspid rstenosis, rchronic rpulmonary rhypertension, rSVC robstruction, rcardia rtamponade, rand rconstrictive rpericarditis