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FADevisM_FM.qxp 9/12/08 7:46 PM Page 2

NotesClinical Medicine Pocket Guide
Bruce Y. Lee, MD, MBA
Purchase additional copies of this book at
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A Davis’s Notes Book
F.A. DAVIS COMPANY • Philadelphia
Medical
Notes

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Dwinnell, MD; Adam D. Elkin, MD; Sam Ghaffari, DO; Shilpa Grover, MD; Naghmeh
Khodai, MD; Leslie H. Lee, MD; Elizabeth Mack, MD; John Tobias Musser, MD; Diane
E. Nuñez, MS, ANP-C; Manali Indravadan Patel, MD, MPH; Mohammad Qasaymeh,
MD; Susan D. Wolfsthal, MD; Erica Young, PA; and Kevan M. Zipin, MD
As new scientiﬁc information becomes available through basic and clinical research,
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Diseases and Disorders
American Cancer Society Guidelines:
Cancer (CA) Detection
Breast CA (Women)
■ Ն40 y.o.: Mammogram every year
■ Clinical breast exam: 20-39 y.o. ~q3yr and Ն40 y.o. every year
■ Breast self-exam option for Ն20 y.o
■ Ͼ20% lifetime risk: MRI and mammogram every year
■ 15%-20% lifetime risk: discuss w/physician about MRI
Colon and Rectal CA
■ Ն50 y.o. male or female: Do one of following five:
■ Fecal occult blood test (FOBT) or fecal immunochemical
test (FIT) every year
■ Flexible sigmoidoscopy q5yr
■ Yearly FOBT or FIT and flexible sigmoidoscopy q5yr
(preferred)
■ Double-contrast barium enema q5yr
■ Colonoscopy q10yr
■ Start earlier (e.g., Ն40 y.o.) if:
■ Pt history of colorectal CA, adenomatous polyps, or
chronic inflammatory bowel disease
■ Strong family history of colorectal CA or polyps (CA or
polyps first-degree relative Ͻ60 y.o. or two first-degree
relatives any age)
■ Family history of hereditary colorectal CA syndrome
Cervical CA (for Women)
■ ~3 yr after begin vaginal intercourse or Ն21 y.o., whichever
comes first: Regular Papanicolaou (Pap) test every year or
newer liquid-based Pap test q2yr
■ When Ն30 y.o.:
■ May continue every year or change to q3yr HPV DNA test
and either conventional or liquid-based Pap test
■ If 3 normal Pap tests in a row, may change to q2-3yr
■ If risk factors*: Continue every year
1
BASICSBASICS
*Prenatal DES exposure, HIV, or øimmunity
FADavis_Chapter 01.qxd 9/12/08 3:38 PM Page 1

■ Ն70 y.o.: If Ն3 normal Pap tests in row and no abnormal Pap
last 10 years, may stop; if risk factors,* continue every year
■ Total hysterectomy (uterus and cervix): May stop, unless
surgery was for cervical CA or pre-CA
Endometrial (Uterine) CA (for Women)
■ High risk for hereditary nonpolyposis colon CA: Ն35 y.o.:
offer endometrial biopsy every year
Prostate CA (for Men)
■ Ն50 y.o.: Offer prostate-specific antigen and digital rectal
examination every year
■ Ն45 y.o. high-risk (African-American or strong family history
Ն1 first-degree relatives [father, brothers] diagnosis Ͻ65 y.o.):
Every year
■ Ն40 y.o. higher risk (multiple first-degree relatives): Every
year; if negative consider waiting until Ն45 y.o.
Diagnostic and Therapuetic Procedures
Electrocardiogram (ECG)
Rate (Normal: 60–100 bpm)
■ Bradycardia: Ͻ60 bpm; tachycardia: Ͼ100 bpm
P Waves
■ Normal: P upright (positive), uniform, precedes each ORS
■ None: Rhythm junctional or ventricular
■ Right atrial enlargement (RAE): P Ͼ2.5 mm tall in II and/or
Ͼ1.5 mm in V1; better criteria: (RVH or RV displacement
signs) QR, Qr, qR, or qRs in V1 (w/o CAD); QRS in V1 Ͻ5 mm
and ratio V2/V1 voltage Ͼ6
■ Left atrial enlargement (LAE): P duration Ͼ0.12 sec in II;
notched P in limb leads w/interpeak duration Ͼ0.04 sec;
terminal P negativity in V1 duration Ͼ0.04 sec, depth Ͼ1 mm
■ Biatrial enlargement (BAE): RAE and LAE, P in II Ͼ2.5 mm
tall and Ͼ0.12 sec duration; initial and component of P in V1
Ͼ1.5 mm tall and prominent P-terminal force
2
BASICSBASICS

PR Interval (Normal: 0.12–0.20 sec)
■ Short PR (Ͻ0.12 sec) Could be normal variant or:
■ Wolff-Parkinson-White (WPW): Accessory path RA†RV or
LA†LV so early ventricle activation leads to Δ-wave (initial
slurring of QRS), ⁄QRS duration (usu. Ͼ0.10 sec), second-
degree ST-T Δs from altered ventricular activation
■ Lown-Ganong-Levine: AV nodal bypass track into bundle
of His † early ventricle activation w/o Δ-wave
■ AV junctional rhythms w/retrograde atrial activation
(inverted P in II, III, aVF)
■ Ectopic atrial rhythms w/origin near AV node
■ Prolonged PR (:0.20 sec):
■ First-degree AV block (PR interval usu. constant); øconduc-
tion in atria, AV node, bundle of His, or bundle branch
(when contralateral bundle blocked)
■ Second-degree AV block (PR interval normal or ⁄; some P
waves do not conduct): Type I (Wenckebach): increasingly
⁄PR until a P not conducted; type II (Mobitz): fixed PR
intervals and nonconducted Ps
■ AV dissociation (Ps and QRS dissociated): Incomplete
(slow SA node so subsidiary escape pacemaker takes over
or subsidiary pacemaker faster than sinus rhythm) or
complete (third-degree AV block: atria and ventricles each
have separate pacemakers)
QRS Complex
■ Poor R wave progression (PRWP): RՅ3 mm in V1–3, normal
variant, LVH, LBBB, LAFB, anterior or anteroseptal MI, COPD
(R/S ratio in V5–6 Ͻ1) ), diffuse infiltrative/myopathic
processes, WPW pre-excitation, heart rotates clockwise,
misplaced leads
■ Prominent anterior forces: R/S ratio Ͼ1 in V1 or V2; normal
variant, posterior MI, RBBB, WPW pre-excite
QRS Interval (Normal: 0.6–0.10 sec)
■ QRS duration 0.10–0.12 sec: Incomplete RBBB or LBBB
(same as complete RBBB and LBBB except QRS duration),
nonspecific IVCD, LAFB, or LPFB (some)
3
BASICSBASICS

■ QRS duration Ͼ0.12 sec:
■ Complete RBBB: RV depolarizes after LV, second half QRS
oriented right and anterior † terminal R’ in V1, terminal R
in aVR, and downward ST-T in both V1/aVR; terminal S and
upward ST-T in I, aVL, V6
■ Complete LBBB: LV depolarizes after RV, second half QRS
oriented left and posterior † terminal S and upward ST-T
in V1; terminal R and downward ST-T in I, aVL, V6
■ Nonspeciﬁc Intraventricular Conduction Deﬁcit (IVCD):
QRS duration Ͼ0.10 sec but not bundle branch or fascicu-
lar block criteria; causes: ventricular hypertrophy, MI,
drugs (esp. class IA and IC antiarrhythmics), ⁄K+
■ Ventricle-origin ectopic rhythm (e.g., VT)
QT Interval (Normal: Ͻ1
⁄2 R-R interval; normal
QT Ͻ500 msec)
■ Beginning R wave † end of T wave; varies w/HR
■ Bazett’s formula: QTc = QT/͙RR (normal QTcՅ440 msec)
■ QTc Ͼ0.47 sec (male) and Ͼ0.48 sec (female) † long QT syn-
drome (LQTS): (May † torsade de pointes: ventricular tachy-
cardia w/varying QRS morphology): Drugs (e.g.,antiarrhyth-
mics, tricyclics, phenothiazines); abnormal electrolytes (Kϩ
,
Ca2ϩ
, Mg2ϩ
); øthyroid, hypothermia, CNS dz (esp. SAH, CVA,
trauma); hereditary LQTS; CAD (post-MI)
Axis Deviation
■ Left-axis deviation (LAD):
■ LAFB: rS complexes in II, III, aVF; small Qs in I and/or aVL;
R-peak time in aVL Ͼ0.04 sec, often lurred R downstroke;
QRS duration usu. Ͻ0.12 sec unless coexisting RBBB, usu.
see poor R progression in V1–V3 and deeper S in V5 and
V6, may mimic LVH voltage in aVL and mask LVH voltage
in V5 and V6
■ Other causes: LBBB, LVH, inferior MI, ⁄diaphragm
■ Right axis deviation (RAD):
■ LPFB: rS complex in lead I; qR in II, III, aVF, with R in III ϾR
in II; QRS duration usu. Ͻ0.12 sec unless RBBB
■ Other causes: Cor pulmonale, pulmonary heart disease,
pulmonary hypertension
4
BASICSBASICS

ST Segment
■ ST elevation
■ Normal variant “early repolarization” (usu. concave up,
ending w/symmetrical, large, upright T waves)
■ Ischemic heart disease: Acute transmural injury (usu.
convex up or straightened); persistent in post-acute MI
suggests ventricular aneurysm
■ Prinzmetal’s (variant) angina (coronary vasospasm)
■ During exercise testing †⁄⁄⁄tight coronary artery stenosis
or spasm (transmural ischemia)
■ Acute pericarditis: Concave up ⁄ST (not aVR); no reciprocal
øST (except in aVR); unlike “early repolarization”, usu. T
low amplitude and ⁄HR; may see øPR (atrial injury)
■ Other causes: LVH (in right precordial leads w/large S);
LBBB; ⁄K+
; hypothermia
■ ST Depression
■ Normal variants/artifacts: Pseudo ST depression (poor
skin-electrode contact); physiologic J-junctional depression
w/sinus tachycardia; hyperventilation
■ Ischemic heart disease: Subendocardial ischemia, non
Q-wave MI, reciprocal Δs in acute Q-wave MI (e.g., ST
depression in leads I and aVL with acute inferior MI)
■ Nonischemic causes: RVH (right precordial leads) or LVH
(left precordial leads, I, aVL), digoxin, øK+
, MVP (some),
CNS dz, second-degree to IVCD (e.g., WPW, BBB)
T Wave
■ Normal: T same direction as QRS except in V2; asymmetric
w/ﬁrst half moving more slowly than second half; T always
upright in I, II, V3–6, and always inverted in aVR
■ T-wave inversions: Normal variant, myocardial ischemia or
infarction or contusion, pericarditis (subacute or old),
myocarditis, CNS dz †⁄QT (esp. SAH), idiopathic apical
hypertrophy, MVP, abnormal electrolytes, O2, CO2, pH, or
temperature, digoxin, post-tachycardia or -pacing, RVH and
LVH w/”strain”
5
BASICSBASICS

U Waves (Normal: Same Polarity and Usually
Ͻ1/3 Amplitude of T)
■ Normal: Asymmetric w/ascending limb move more rapidly
than descending limb (opposite to normal T)
■ Prominent upright U: Sinus bradycardia, øKϩ
, Quinidine and
other type 1A antiarrhythmics, CNS dz (long QT), LVH, MVP,
øthyroid
■ Negative or “inverted” U: Ischemic heart dz, MI (in leads
with pathologic Q waves), angina, coronary vasospasm
(Prinzmetal’s angina)
■ Nonischemic causes: Some cases of LVH or RVH (usu. in
leads with prominent R waves), LQTS
Myocardial Infarction
■ Q-wave MI: Total coronary occlusion
■ Non Q-wave MI: Subtotal occlusion
■ More leads with MI changes (Q waves and ST elevation) †
larger infarct size and worse prognosis
6
BASICSBASICS
Evolution of Q-Wave MI
Q* T ST
Pre-MI
Hyperacute ⁄Amplitude/width May ⁄
Transmural Injury ⁄⁄⁄
Necrosis ϩ Terminal inversion Less
Necrosis/Fibrosis ϩ Inversion
Fibrosis ϩ Upright
*Pathologic: duration Ͼ0.04 s or Ͼ25% R-amplitude
■ Conditions resembling MI: WPW pre-excitation (negative
Δ-wave ~ pathologic Qs); IHSS (mimic pathologic Qs); LVH
(QS or PRWP in V1-3); RVH (tall R in V1 or V2); LBBB (QS or
PRWP in V1-3); pneumothorax (no right precordial R);
COPD/cor pulmonale (no R V1-3 and/or inferior Q and RAD);
LAFB (Qs anterior chest leads); acute pericarditis (⁄ST); CNS
dz (diffuse ST-T wave Δs)

Atrial Arrythmias
■ Premature atrial complexes: Single or repetitive, unifocal or
multifocal, ectopic P (P’) may hide in preceding ST-T; P’R
interval nl/⁄; P’ may be nonconducted, conducted w/aberration
(e.g., wide QRS), or conducted normal
■ Premature junctional complexes: Retrograde P appears
before (PR usu. Ͻ0.12 sec), during, or after QRS
■ Atrial fibrillation: Poorly defined atrial activity; appearance
may ~old saw; ventricular response = irregularly irregular
unless AV block
■ Atrial flutter: Regular atrial activity w/”clean” sawtooth appear-
ance in II, III, aVF, and usu. discrete ‘P’ in V1; atrial rate = 150-
450/min; AV conduction ratio may vary 2:1, 3:1, etc
■ Ectopic atrial tachycardia and rhythm: Ectopic, discrete,
unifocal P’ w/atrial rate Ͻ250/min (Ͻ100 † rhythm); ectopic
P' waves usu. precede QRS w/P'R interval ϽRP' interval;
ventricular response: 1:1 or varying AV block
■ Multifocal atrial tachycardia and rhythm: ՆThree different P
morphologies in given lead; rate = 100-250/min (Ͻ100 †
rhythm), varying P'R intervals; ventricles: irregularly irregular
(i.e., often confused with atrial fibrillation); may be intermittent
■ Paroxysmal supraventricular tachycardia: Different re-entry
cicuits; sudden onset and stop; usu. narrow QRS (unless BBB
or rate-related aberrant ventricular conduction); types: AV
nodal re-entrant tachycardia, AV reciprocating tachycardia,
sinoatrial re-entrant tachycardia
■ Junctional rhythms and tachycardias:
■ Junctional escape beats: Origin AV jxn; rate: 40-60 bpm
■ Junctional escape rhythm: Ն3 Junctional escapes; rate
40-60 bpm; may be AV dissociation or retrograde † atria
■ Accelerated junctional rhythm: Rate = 60-100 bpm
■ Nonparoxysmal junctional tachycardia: HR Ͼ100 bpm
Ventricular Arrythmias
■ Premature ventricular complexes (PVCs): May be unifocal,
multifocal, or multiformed; may be isolated single events or
couplets, triplets, or salvos (4-6 in row); may occur early in cycle
(R-on-T), after T, or late in cycle (fuse w/next QRS = fusion beat)
7
BASICSBASICS

■ Ventricular tachycardia (VT): Sustained (Ͼ30 sec) vs. nonsus-
tained; monomorphic vs. polymorphic vs. torsade-de-pointes
(polymorphic associated w/LQTS; phasic variations QRS
polarity; rate often Ͼ200 bpm; may † Vfib); AV dissociation
vs. retrograde atrial capture; Consider wide complex
tachycardia is VT if: AV dissociation, ⁄⁄⁄axis deviation, QRS
morphology atypical for BBB, concordance (all precordial
leads in same direction), regular rhythm (RR intervals equal,
irregularly irregular rhythm suggests atrial fibrillation ϩ
aberration or ϩ WPW pre-excitation), QRS morphology ~pre-
vious PVCs, very wide QRS complexes (Ͼ0.16 sec), no RS
V1-V6, beginning of R to nadir S Ͼ0.1 sec in any RS lead
Lumbar Puncture
Indications
■ Dx CNS disease, administer CNS treatment or treat
hydrocephalus
Contraindications
■ ⁄Intracranial pressure (ICP); intracranial mass effect (r/o mass
lesion: head CT when signs of ⁄ICP)
■ Bleeding dysfunction
■ Infection near site
■ Elderly: avoid fast and large volume withdrawals.
Equipment
■ Skin preparation: sterile sponges, povidone-iodine swabs,
and EtOH swabs
■ Mask, sterile field (towels and drapes), and gloves
■ Local anesthetic, usu. lidocaine 1% plain
■ Syringe (3 mL) and needles (22-G ϫ 1.5”, 25-G ϫ 5/8”)
■ Spinal needles (both 18- and 20-G, 3” length)
■ Three-way stopcock, sterile collection tubes, and manometer
■ Gauze dressings and adhesive bandage
Preparation
■ Sterile technique; skin preparation
■ Find L4-5 space (L4 at iliac crest level)
8
BASICSBASICS

■ Local anesthesia: infiltrate skin (25-G needle), then Δ to 22-G
needle and advance † infiltrate deeper tissue
Patient Positioning
■ Lateral decubitus: (preferred): Lateral decubitus position at
edge of bed, while maximally flexing knees (near chest),
hips, and back (opens L3/L4 space) pt. shoulders and hips
perpendicular to bed
■ Sitting: (easier for obese or spinal dz/deformity): Pt. sits at
bed edge, leans over two pillows, flexes head
Technique
■ Insert spinal needle into skin and slowly advance (keep per-
pendicular to skin, hold w/two hands, keep stylet in place);
feel “pop”; perforate ligamentum flavum; withdraw stylet,
and look for CSF drainage
■ If no CSF and needle advanced Ͻ4 cm (in adult), advance 2 mm,
remove stylet, and check for CSF drainage; repeat until get CSF
or needle advanced Ͼ4 cm (then withdraw and redirect needle)
■ Connect three-way stopcock, and attach manometer;
measure opening pressure (normal 70-180 mm CSF)
■ Send fluid for studies; remove needle and dress wound;
pt. remains supine Ն12 h (minimize headaches)
Complications
Brain herniation (⁄ ICP and mass), infection (meningitis or empyema),
subdural hematoma (rapid withdrawal of large volume CSF), bloody
tap, spinal epidural hematoma, headache, dry tap † needle may be
too lateral or deep
■ For CSF interpretation see Labs Tab
Cricothyroidotomy
Indications
■ Emergent need for airway; airway obstruction above cricoid
cartilage level, failed intubation, or laryngeal trauma, mass,
or hematoma
9
BASICSBASICS

Contraindications
■ Subglottic airway obstruction
■ Intubation possible
■ Uncorrectable coagulopathy
Equipment
■ Suction
■ Local anesthesia (e.g., 1% lidocaine and 1:100,000 epinephrine)
■ Scalpel (ideally, No. 15 blade)
■ Retractors (Army-Navy or large vein refractors)
■ Kelly clamps
■ Suture (2-0 or 3-0 silk, 4-0 vicryl)
■ Cuffed tracheostomy tubes (preferable) or No. 4 or 5 small,
flexible endotracheal (ET) tubes.
Preparation
■ Palpate and locate cricothyroid ligament: between cricoid
and thyroid cartilages (~1.5 cm inferior to thyroid cartilage);
neck strap muscles lateral to ligament
Patient Positioning
■ Neck extended (unless cervical injury)
Technique
■ Sterilely prepare and drape skin
■ If enough time, infiltrate entry site with lidocaine
■ Scalpel † 3 cm horizontal (ørisk of thyroid or cricothyroid
cartilage damage) or vertical (better in obese when cannot
palpate cricothyroid membrane) incision over center of
cricothyroid membrane
■ Gently spread subcutaneous tissue w/clamp † expose
cricothyroid membrane; may need retractors to spread neck
strap muscles laterally
■ Avoid blood vessels, use scalpel to cut horizontally through
membrane; may widen incision with clamp
■ Insert tracheostomy tube or endotracheal tube
■ Inflate tube cuff; suture or tie down tube
■ Ventilate w/Ambu bag
■ Δ to formal tracheostomy Յ1 week (or risk stenosis)
Complications
■ Bleeding, subglottic/glottic stenosis, chondritis
10
BASICSBASICS

Endotracheal Intubation
Indications
■ Signiﬁcant ⁄ CO2 or ø O2 from respiration
■ Protect airway or pulmonary toilet
Contraindications
■ Only intubate if necessary
■ Inaccessible/damaged oral cavity/larynx † nasal intubation
(if no coagulopathy, severe intranasal problems, basilar skull
fracture, or CSF leak)
■ Cervical spine instability
Equipment
■ Lubricant: Water-soluble 2% lidocaine jelly
■ Tape and skin adhesive
■ O2 and bag-valve-mask ventilation device (Ambu bag)
■ If available: O2 saturation monitor,in-line CO2 monitor
■ Suction apparatus, suction tubing, tips, catheters
■ Laryngoscope w/straight and/or curved blade
■ Endotracheal tubes; syringe (10 mL) † inﬂate cuff
■ Flexible metal stylet and Magill forceps
■ Anesthesia
Recommended ET Parameters (for nasal:
add 2 cm to each measurement)
Pree- Neo- 1-2 4-6 8-12
Age mie nate 6 mo yr yr yr Adult
ET Tube
Diameter (cm) 2.5 3–3.5 3.5–4 4–5 5–5.5 6–7 7.5–8.5
Blade (cm) 0 0–1 1 1–2 2 2–3 4–5
Insert: Lips to
Mid-Trachea
(cm)† 10 11 11–12 12 ϩ (age/2) ©:~23
ª~21
11
BASICSBASICS

Preparation
■ Rapid-sequence intubation: IV sedative (etomidate) †
sedated, then IV muscle relaxant (succinylcholine); may add
sedative (fentanyl or morphine), lidocaine, and/or ⁄⁄-lasting
paralytic (vecuronium)
■ Awake intubation: Topical anesthetic, mild sedative and
analgesic; stomach should be empty
■ Test laryngoscope; monitor HR, BP, and SaO2
Patient Positioning
■ Extend head and flex neck; if possible (i.e., no cervical spine
problem), place foam material, “doughnut”, or folded towel
under occiput
Technique
■ Ventilate pt. w/bag-valve-mask; assess airway
■ Remove foreign bodies (e.g., dentures)
■ Assistant: Continuously push back anterolateral cricoid carti-
lage rim with first and second fingers until tube is placed
■ Open laryngoscope; use dominant hand to open mouth and
nondominant hand to insert laryngoscope blade into right
(left if left-handed) side of mouth
■ Sweep blade to midline tongue base (sweep tongue to other
side); blade tip should be in valleculae (curved blade) or
below epiglottis (straight blade)
12
BASICSBASICS

■ Lift laryngoscope handle straight upward and forward †
expose vocal cord; avoid lips, teeth, and trap tongue; using
dominant hand pass lubricated ET tube through right (left if
left-handed) corner of mouth and advance tip through vocal
cords (while looking)
■ Remove stylet when proximal cuff ends at cord level
■ Advance tube into trachea; inﬂate cuff (~15 mm Hg); check
placement: symmetric chest expansion, breath sounds both
lungs (no breath in stomach)
■ Attach in-line CO2 monitor: Check for ⁄O2 saturation and CO2
in exhaled air
■ Secure tube w/tape (upper lip and cheek or neck)
■ Check chest x-ray (tip should be 4 cm above carina)
■ Once tube in place, longer-term sedation (aerosol benzocaine
[20%] † tongue and posterior pharynx, midazolam or
thiopental, fentanyl or morphine)
Complications
■ Tube in esophagus or right mainstem bronchus
■ Aspiration (may ørisk w/antacids, H2-blockers,
metoclopramide, head-up positioning)
■ Damage to lips, teeth, tongue, airway
Pericardiocentesis
Indications
■ Cardiac tamponade
■ ⁄ pericardial effusion † øhemodynamics
Contraindications
■ Coagulopathy/bleeding dysfunction
■ Skin infection over needle insertion site
Equipment
■ Skin preparation supplies, sterile gloves, towels/drapes
■ Local anesthetic (1% or 2% lidocaine, 25-G needle, 3-mL syringe)
■ Pulse oximeter, ECG monitoring (V lead)
■ 16- to 18-G spinal needle and No. 11 blade
■ 20-mL syringe and sample tubes
13
BASICSBASICS

Preparation
■ Continuous ECG monitoring (30° semi-Fowler position pre-
ferred); if V lead attached to pericardiocentesis needle † ⁄
sensitivity; an insulated wire with alligator clips at each end
works well
■ Prepare skin; sterile technique; wear sterile gloves, mask,
and gown; drape over xiphoid area
■ Local anesthesia (infiltrate skin 1%-2% lidocaine)
Patient Positioning
■ Supine with thorax (i.e., head of bed) elevated 30-45 degrees
Technique
■ Needle: Insert (2 cm below costal margin to left adjacent to
xiphoid with blade) and direct (upward and posterior) at
45-degree angle for 4-5 cm; aim toward right (preferable) or
left (⁄risk penetrate RV) scapular tip
■ Advance (aspirate continuously) needle until encounter fluid,
check for cardiac pulsations, or ⁄ST on ECG. May feel needle
enter cavity
■ Remove blood: (usu. 5-10 mL because most is clotted); if
Ն20 mL, then probably in RV
■ If hemodynamics do not improve, then may need
thoracotomy or local pericardial window excision
■ Send fluid for appropriate studies
Complications
Myocardial wall injury/penetration, myocardial infarction, pneu-
mothorax, bowel perforation
Arterial Line
Indications
■ Hemodynamic monitoring
■ Arterial blood sampling
■ Frequent blood draws
Contraindications
■ Infection or lesion at insertion point
■ Occlusion or thrombosis of artery
14
BASICSBASICS

■ Systemic infection (use peripheral site)
Equipment
■ Peripheral arterial line (with angiocatheter): Angiocatheter
(20- or 22-G, 2” length) or arterial line kit, sterile scalpel
■ Femoral arterial line (Seldinger technique): Seldinger kit:
needle (16-18 G), 10-mL syringe, guide wire, sterile scalpel,
dilator, catheter
■ Skin preparation supplies
■ Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe)
■ Sterile gloves, towels or drapes, dressing supplies
■ Heparinized saline (pressurized delivery system)
■ Blood gas syringe (for arterial blood sampling)
■ Another 5-mL syringe w/heparinized saline
■ Sutures
■ Arterial pressure monitoring equipment
■ Arm board w/terrycloth roll
Preparation
■ Peripheral (radial): Nondominant hand: perform Allen test
(compress radial and ulnar arteries † palm blanches; release
ulnar artery and check reperfusion of palm; delay Ͼ5 sec =
abnl † choose another site) to confirm collateral circulation
■ Use sterile technique; prepare and drape skin
■ Use lidocaine to infiltrate entry and suture points
Patient Positioning
■ Peripheral: Usu. radial artery but can do dorsalis pedis; pt.
seated and supine; immobilize wrist on arm board w/roll
under wrist in slight dorsiflexion
■ Femoral: Supine
Technique
Peripheral Arterial Line (Angiocatheter)
■ Locate pulse w/index finger of nondominant hand; small
incision w/scalpel over entry site
■ Insert angiocatheter at 30°–45° to artery † bright pulsatile
red blood freely † catheter; slowly advance catheter until
flow stops; withdraw slightly until blood pumps again;
advance catheter over needle into vessel
15
BASICSBASICS

Femoral Arterial Line (Seldinger Technique)
■ Locate pulse and make small incision w/scalpel
■ Connect 10-mL syringe to needle and insert needle at 45° to
artery while aspirating on syringe
■ Insert and withdraw (while aspirating) needle until bright red
blood pumps into syringe † detach syringe and use finger to
block off hub of needle
■ Push guidewire through needle (should be no resistance);
remove needle over wire
■ Cut incision larger so dilator can enter
■ Use dilator over wire to expand hole, then remove
■ Apply gentle pressure if bleeding
■ Push catheter over wire through hole into artery
■ Remove wire; check for bright red pulsatile blood in catheter
hub
For Peripheral or Femoral Arterial Line
■ If no blood, remove catheter and retry insertion; if still no
blood, try flushing needle w/heparinized saline; if not
successful third time, try another site; cap catheter
■ Suture catheter to skin; draw blood samples prn and attach
manometer; sterile dressing
Removal of Arterial Line
■ Wear gloves; remove sutures, then catheter
■ Confirm removed catheter is intact
■ Firm pressure to entry site for 10 min (longer when large
lumen or anticoagulation)
■ After bleeding stopped, apply pressure dressing
■ Next day: check blood flow to extremity
Complications
■ Vessel perforation or thrombosis; limb ischemia*
■ Dislodged or loose connections to line
■ Incorrent placement or malfunction of line
■ Air embolus*
■ Infection, suppurative thrombophlebitis, sepsis*
■ Bleeding (apply pressure/additional sutures)
16
BASICSBASICS
*Remove line immediately

Central Line
Locations
■ Femoral vein: Easy access; far from airways and lungs, but
area can be dirty and prevent pt. from walking
■ Internal jugular (IJ) vein: øBleed risk, but poor landmarks and
can puncture carotid artery
■ Subclavian vein: Comfortable; clear landmarks; but risk of
pneumothorax or bleeding
Indications
■ Hyperalimentation or long-term IV therapy
■ Give medications (e.g., vasoactive/inotropes, phlebitic)
■ Hemodialysis or rapid fluid administration
■ Intracardiac pacing
■ Central venous pressure monitoring
Contraindications
■ Subclavian: øPulmonary function (COPD, asthma), high levels
of PEEP, coagulopathy, superior vena cava thrombosis, upper
thoracic trauma
■ IJ: Tracheostomy, ⁄⁄⁄pulmonary secretions
■ Femoral: Vena caval compromise (clot, extrinsic
compression, IVC filter), local infection, cardiac arrest or low
flow states, requirements for pt. mobility.
Equipment
■ Central line kits are available
■ Skin preparation supplies (iodine, chlorhexidine, or EtOH)
■ Local anesthetic (1%-2% lidocaine, 25-G needle, 3-mL syringe)
■ Sterile gloves, dressings, towels or drapes
■ Supplies for Seldinger technique (or specific intravascular
access kit)
■ Needle (16- to 18-G): For IJ lines, only insert needle 0.5-1.0”
(Ͼ1.5” may † pneumothorax); 10-mL syringe
■ Guidewire, scalpel, dilator, catheter
■ If the Seldinger technique is not used, a catheter-over-needle
system may be used
■ Heparinized saline
17
BASICSBASICS

■ Suture
■ Central venous pressure monitoring device
■ May need ultrasound if difficulty inserting
Preparation
■ For both insertion and removal: Use sterile technique; sterile
gown, hair cover, face mask/shield
■ Skin preparation; sterile drapes
■ Flush catheter w/saline
■ Liberally infuse area w/local anesthetic
Patient Positioning
■ Femoral: Supine; stand on side of your dominant hand (right
side of pt. if you are right-handed)
■ IJ: Supine; turn pt. head 45° away from insertion side;
remove pillow from under pt. head and place pt. in
Trendelenburg position
■ Subclavian: Trendelenburg position, remove pillow, towel
roll between scapulae
Insertion Points
■ Femoral vein: One finger breadth medial to artery and two fin-
ger breadths inferior to inguinal ligament; with bevel up and
at 45°–60° above skin, insert needle parallel to vessel (steeper
angle †ørisk of entering peritoneum; more medial insertion
angle † less chance of needle entering femoral artery)
■ IJ: Lateral to carotid; Landmark: Apex of triangle (clavicle and
two heads of sternocleidomastoid) OR between sternal notch
and mastoid process; insert needle at 70° to skin, and aim for
ipsilateral nipple
■ Subclavian: 2 cm inferior to junction of lateral third and
medial two thirds of clavicle and 2 cm above suprasternal
notch; finder needle may be too short to reach vein
Needle Approach
■ Femoral vein: With bevel up and at 45°-60° above skin, insert
needle parallel to vessel (steeper angle †ørisk of entering
peritoneum; more medial insertion angle †øchance of enter-
ing femoral artery)
■ IJ: Insert needle at 70° to skin and aim for ipsilateral nipple;
aim lateral; if unsuccessful, withdraw and carefully go
18
BASICSBASICS

slightly medial; reassess landmarks; can use long (~3”)
angiocatheter instead of regular needle
■ Subclavian: Insert needle bevel up; guide placement w/
nondominant hand: place index finger at sternal notch and
thumb at clavicle; keep needle parallel to floor and first aim
for clavicle; when hit clavicle, walk needle down (push on
needle tip; do not push on syringe) until just below clavicle;
then advance needle 4-5 cm; once find vein, rotate needle
90° so that bevel faces caudally; if no blood, withdraw and
redirect more cephalad
Technique
■ Make sure you continuously aspirate while advancing or
withdrawing needle
■ Using appropriate insertion point and approach, locate vein
w/finder needle (optional w/femoral vein)
■ Aspirate venous blood w/finder needle, then insert large-bore
needle at same site and at same angle; use nondominant
hand to grab needle hub and lower needle to parallel vein
and aspirate again to reconfirm flow (may use transducer to
confirm venous blood); hold needle in place, remove syringe,
and thread guidewire into needle; check for ectopy
■ Remove needle over guidewire and continue to hold wire
w/gauze; do not let go of guidewire until removed
■ Make incision 3–4 mm (w/scalpel) through skin and fascia; push
dilator 3–4 cm over guidewire to expand subcutaneous tissue
■ Thread catheter over guidewire
■ Advance catheter and remove guidewire
■ Aspirate blood and flush each port
■ Suture line in place and consider spacer in small pt
■ STAT chest x-ray to r/o PTX and check line placement
Removing Central Lines
■ If line tunneled/trapped, may have to remove under
fluoroscopy
■ Place pt. in Trendelenburg position (reverse Trendenlenburg
for femoral lines) and remove any pillows
■ Remove all bandages, gauze, and all suture material
■ Pt. should hum or Valsalva maneuver during line removal
■ Apply sterile dressing (gauze and occlusive dressing)
19
BASICSBASICS

Complications
Nonplacement/misplacement/nonfunction of line, dislodged line,
infection, suppurative thrombophlebitis, catheter-related sepsis,
pneumothorax, catheter/guidewire embolism, air embolism, vessel
thrombosis, central vein thrombosis, hemorrhage, arrhythmias,
myocardial or central vein perforation, pericardial tamponade,
infection, hematoma, subcutaneous emphysema or fluid infiltra-
tion, arterial puncture/laceration, hemorrhage
Swan-Ganz (SG) Catheters
Indications
■ Acute heart failure or severe hypovolemia
■ Hemodynamic instability
■ Severe pulmonary disease
■ Sample blood and determine cardiac output
Contraindications
■ Infection or lesion at entry point
■ Occlusion or thrombosis of desired vessel
■ Caution: systemic infection
Equipment
■ Skin preparation (iodine, chlorhexidine, or EtOH)
■ Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL syringe)
■ Sterile gloves, towels or drapes, dressings
■ Seldinger supplies: Needle (16–18-G), syringe (10 mL), guide
wire, scalpel, dilator, catheter
■ Catheter supplies: SG catheter, monitor, protective sheath,
syringe (3 mL),heparinized saline
■ Sutures
Preparation
■ Prepare and drape skin; sites: subclavian (preferred), internal
jugular (preferred), or femoral veins
■ Local anesthesia: Infiltrate skin entry site
■ SG catheter: Flush each lumen w/heparinized saline; check
balloon (inflate w/1–1.5 mL air); attach pressure monitor and
infusion ports
20
BASICSBASICS

■ Keep catheter in protective plastic container until zeroing pro-
cedure complete; remove catheter from plastic container and
move tip w/wrist flick † appropriate waveform (monitor screen)
Patient Positioning
■ Subclavian or IJ: Supine and 15° Trendelenburg’s position;
turn pt.’s head away from entry site; place roll under spine
between shoulder blades
■ Femoral: Supine and flat
Technique
■ Use sterile technique
■ Connect 10-mL syringe to needle; small incision w/scalpel;
Seldinger technique: cannulate vessel w/needle, pass wire
through needle into vessel (no resistance) and widen passage-
way w/dilator; thread introducer over wire into incision
■ Remove wire and aspirate blood to confirm placement
■ Flush w/normal saline or heparin solution
■ Tightly cap introducer; suture introducer to skin
■ Insert flushed and zeroed SG catheter; another person
needed to inflate/deflate balloon during placement
■ Thread catheter through sheath protector; move protector
out of way to end of catheter
■ Watch pressure monitor while advancing catheter; when
catheter tip clears introducer, inflate balloon † 1-1.5 mL;
balloon floats catheter w/blood flow † RA and through
heart; check for distinctive pressures
■ Further advance catheter † “wedge” balloon in PA
21
BASICSBASICS
Right
atrium
Right
ventricle
Pulmonary
artery
Pulmonary
capillary
wedge
pressure
PressureinmmHg

■ When wedged, deflate balloon and confirm return of
pulsatile pulmonary artery pressures
■ Reinflate balloon and reconfirm wedge position
■ Record appropriate pressures
■ Pull protective sheath over catheter and attach to introducer;
confirm introducer well sutured and caps tight; chest x-ray to
confirm placement
■ Check every day for infection; Δ catheter over wire q3–7d
If Catheter Does Not Place Easily
■ Deflate balloon, then pull catheter back and advance again;
flush catheter w/5-10 mL cold saline to stiffen; occasionally,
fluoroscopy needed
Removal
■ Wear gloves; pt. supine; deflate balloon
■ Slowly remove catheter; may leave introducer for venous
access; clean entry site w/sterile soap
■ Remove sutures; remove IV lines from transducer; pt. holds
breath while remove introducer; check that entire catheter
removed
■ Firm pressure at entry point ϫ Ն10 min; if bleeding stops †
occlusive dressing ϫ 24-48 hrs; culture catheter tip
■ Check site next day for infection or bleeding
Complications
See complications for central venous lines; in addition, may
cause pulmonary artery perforation, pulmonary infarction, car-
diac arrhythmias
Thoracentesis
Indications
■ Diagnostic: Most new effusions, unless clear clinical dx with
no e/o pleural space infection
■ Therapeutic: Dyspnea from large pleural effusion; also may
aid work-up of large effusion
Contraindications
■ No absolute contraindications
■ May need platelets/factor replacement: e.g., platelets
Ͻ50,000, PT/PTT Ͼ 2 ϫ normal
22
BASICSBASICS

■ Relative contraindication: Cellulitis or herpes zoster at needle
puncture site
■ Caution: mechanical or manual ventilation
Equipment
■ Sterile towel, gauze pads, dressing, drape w/fenestration
■ Basin for preparation solution
■ Syringe(s) (10-20 mL)
■ Needles (22- and 25-G) for inﬁltration
■ Povidone iodine
■ Local anesthetic (e.g., 1% lidocaine): 10 mL
■ Heparin: 1 mL
■ Atropine: Available at bedside (for vasovagal reaction)
■ Syringe (50- to 60-mL) for aspiration
■ Sterile drainage tubing
■ Three-way stopcock
■ Needle or needle catheter (depends on technique): Hypodermic
needle (18–22-G, 1.5”–2”), over-the-needle catheter (16–20-G
needle) or through-the-needle catheter (14–18-G needle)
■ Scalpel (needle catheter technique only)
■ Sterile specimen bowl or Vacutainer bottle
■ Analysis containers: Iced blood gas syringe, specimen tubes
(red-top and purple-top), sterile transport media for culture
or 10-mL sterile container, 5 red-top specimen tubes for
cytology or 10- to 50-mL plain bottle
Preparation
■ Start IV; draw serum protein and LDH
■ Pulse-oximetry monitoring; O2 as needed
■ Diagnostic: Premoisten 50– to 60-mL collection syringe with
1 mL heparin (100 U/mL) to prevent clotting
■ Sterile technique, prepare skin with antiseptic; place sterile
towels/drape around site
■ Effusion height: Percussion and tactile fremitus
Patient Positioning
■ Upright (preferred): Pt. sits erect on bed edge and extended
arms rest on bedside table; large effusion † pt. leans
forward slightly; insert needle posterior rib at least one
interspace below top of effusion; midscapular or posterior
axillary line
y
23
BASICSBASICS

■ Lateral decubitus: Effusion side down, back at bed edge;
insert needle posterior axillary line
■ Supine: Head elevated; insert needle midaxillary; needle
should not be lower than 8th intercostal space (ICS)
Technique
■ Needle technique: (Diagnostic † only small volumes) simple
20- or 22-G needle
■ Needle catheter technique: Insert catheter over or through
needle and leave in pleural space
1. Use 25-G needle and syringe w/5–10-mL anesthetic
2. Raise skin wheal at rib upper edge in midscapular or poste-
rior axillary line
3. Δ 25-G † 3.75-cm 22-G needle (on anesthetic syringe)
4. Insert 22-G needle through wheal and infiltrate
subcutaneous tissue, muscle, and rib periosteum
5. Advance needle 1-2 mm † aspirate subcutaneous
tissue/muscle † infiltrate small amount anesthetic
6. Repeating step 5 † “walk” needle above rib’s superior
edge and advance through ICS until † pleural space
7. Hold needle perpendicular to chest † avoid trauma to
neurovascular bundle of adjacent rib
8. When enter pleural space (may feel “pop”), aspirate fluid to
ensure pleural space reached
9. Withdraw needle (grasp with thumb and index finger)
10. No fluid † “dry tap” (i.e., missed area)
11. Air bubbles † enter lung parenchyma (too high)
12. Postprocedure chest x-ray
Terminate Procedure When
■ Diagnostic: Removal 50-100 mL fluid
■ Therapeutic: Dyspnea relief or removal 1000 mL fluid
■ May remove larger volumes if monitor pleural pressures
q200 mL for second liter and then q100 mL; terminate if
pleural pressure Ͼ -20 mm Hg
■ Aspirate air † suggests lung puncture or laceration, unless
needle Ͻ 20-G (making pneumothorax unlikely)
■ Δ Sx: e.g., abdominal pain, ⁄SOB
■ Persistent cough
24
BASICSBASICS

Complications
Pneumothorax, cough, infection, hemothorax, splenic rupture,
abdominal hemorrhage, unilateral pulmonary edema, air
embolism, retained catheter fragment
Light’s Criteria (Pleural Fluid = Exudate)
1) Pleural fluid:serum protein ratio Ͼ0.5; 2) Pleural fluid LDH
Ͼ2/3 upper limit of normal serum LDH; 3) Pleural fluid:serum
LDH ratio Ͼ0.6
25
BASICSBASICS
Special Pleural Fluid Assays
Assay Diagnosis Suspected
Amylase Pancreatitis, esophageal rupture
Triglycerides Chylothorax, intrathoracic total
parenteral nutrition
Glucose Rheumatic effusion
Urea or creatinine Urinothorax
Cytology Malignancy
Pleural Fluid
Parapneumonic
Empyema
TB
Malignant
effusion
PE/infarct
Collagen vas-
cular disease
RA
SLE
Hemothorax
Description
Turbid
Turbid,
purulent
Straw color,
serosanguinous
Turbid, bloody
Straw color,
bloody
Turbid
Green
Yellow
Bloody
WBC
Count
⁄
⁄
Ͻ10,000
Ͻ10,000
⁄
⁄ø
⁄ø
⁄ø
⁄ø
Main
WBC
PMNs
PMNs
Both
Mono’s
Both
Both
Both
Both
PMNs
Glucose
ø
ø
ø
ø
Serum
øø
Serum
Serum
pH
Ͼ7.3
Ͻ7.3
Ͻ7.4
Ͻ7.3
7.4
Ͻ7.3
Ͼ7.3
Ͻ7.3
Diagnostic Features of Pleural Fluid

Nasogastric and Feeding Tubes
Indications
Nasogastric Tubes
■ Diagnostic gastric lavage: Check for GI bleed
■ Decompress stomach: Ileus, GI obstruction, persistent vomit-
ing, preabdominal surgery
■ Removal toxins and pill fragments
■ Heating or cooling (temperature abnormalities)
■ Prevent aspiration (e.g., trauma)
■ Deliver medications, feedings, contrast, or charcoal
Feeding Tubes
■ Enteral feeding or medication delivery
Contraindications
■ Facial fracture: (Use mouth instead)
■ Possible cervical spine injury (use extreme caution)
■ For feeding tube only: Adynamic ileus, malabsorptive
syndromes, intestinal obstruction, gastroenteritis
Equipment
■ 16-18 Fr nasogastric tube or feeding tube
■ Lubricant jelly (K-Y or lidocaine)
■ Topical anesthetic (e.g., Hurricane spray)* and nasal
vasoconstrictors (e.g., phenylephrine)*
■ Emesis basin; cup of water and straw
■ Catheter tip syringe
■ Suction apparatus
■ Gloves and eye protection, stethoscope, tape, benzoin
Preparation
■ Wear gloves and eyewear when place or remove tube
■ Estimate tube length = patient’s ear to umbilicus
■ Premedication: Spray anesthetic † throat back; apply
vasoconstrictor and topical anesthetic † nasal mucosa
■ Liberally apply lubricant along tube/tube tip
26
BASICSBASICS
*Optional

Patient Positioning
■ Upright or decubitus, neck flexed
Technique
■ Turn on suction apparatus (w/tonsil tip attached)
■ Pt. should hold emesis basin and cup of water
■ Insert tube in nostril toward occiput
■ Apply firm, constant pressure to tube while pt. takes small
sips of water and swallows
■ Advance until two black lines on tube visible out of nares
and nose between second and third black lines
■ Hold tube firmly in place close to nostril
■ Check placement in stomach: Attach catheter tip syringe to
tube and inject 30-60 mL air; use stethoscope to hear air
“whoosh” over epigastrium; use syringe to aspirate gastric
fluid (normal pH Ͻ5)
■ Secure tube in two places (nose and second site like
forehead or shoulder) w/benzoin and tape
■ Abdominal x-ray to confirm placement (not necessary if
suction applied)
■ Mark tube near nose to track proper placement
■ Record suction output volume and character
For Feeding Tube
Same procedure as nasogastric tube except:
■ Often need to place tube in duodenum or jejunem so:
■ Advance tube additional 20-40 cm
■ Pt. lays on right side for 8-12 hr
■ Fluid aspirate pH Ͼ7
■ May use metoclopramide or erythromycin to ⁄gastric
motility † enhance tube passage
■ May need fluoroscopy to place
■ Do not use tube (or remove guidewire, if present) until check
abdominal plain film for placement
Tube Removal
■ Disconnect tube from suction; remove tape
■ Pull steadily to remove tube; discard tube
27
BASICSBASICS

Complications
■ ⁄⁄⁄Gagging during placement: spray more topical anesthetic
to back of throat
■ Difficulty passing tube † tube stuck in nose (try other nos-
tril), coils in mouth or esophagus (use ice to chill/stiffen tube)
■ Placement in lung (coughing): Remove immediately
■ Hypovolemia from ⁄⁄⁄nasogastric tube output: IV fluids
0.5–1 mL LR or NS and 30 mEq KCI/L for every mL of output
■ If tube blockage, try any or all of following:
■ Check tube: Inject air into vent port and listen for hissing
(which is normal)
■ Disconnect/reconnect apparatus or reposition tube
■ Irrigate tube w/30–40 mL NS
■ Throat discomfort: Throat lozenges prn
■ Aspiration pneumonia
■ Trauma to nasal mucosa, nares, sinus orifices († sinusitis),
lung, esophagus, gastric mucosa
■ Tube too low (NGT drains drain bile)
■ Tube too high (⁄aspiration risk)
Paracentesis
Indications
■ Therapeutic: Massive ascites †ø respiration, pain
■ Diagnostic: distinguish transudative vs exudative ascites
■ Dx spontaneous bacterial peritonitis, malignant, chylous
Contraindications
■ Coagulopathy
■ Abdominal adhesions
■ Agitation
■ Significantly distended bowel
■ Pregnancy
■ Infection (e.g., cellulitis at insertion site)
Equipment
■ Paracentesis kits available
■ Skin preparation supplies
28
BASICSBASICS

■ Local anesthetic (1%–2% lidocaine, 25-G needle, 3-mL
syringe)
■ Sterile gloves, towels or drapes, and dressing
■ Spinal needle (20-G)
■ Syringe or vacuum bottle
■ Scalpel, #11 blade
■ Butterfly needle (Ն20-G with sterile tubing)
Preparation
■ Decompress bladder (void or urinary catheterization)
■ ID flank region (gas-filled bowel will float to top); avoid
previous incisions
■ Prepare skin; sterile technique; prepare and drape skin
■ Local anesthesia: Infiltrate skin entry site, lower fascial levels
and peritoneum
■ Ultrasound guidance: If previous abdominal surgery or
infection
Patient Positioning
■ Supine or sitting (leaning forward: better w/small amount of
fluid); raise bed so pt. is comfortable
Technique
■ Sterile technique
■ Insert and advance 20-G spinal needle w/stylet until feel
peritoneum “give”
■ Remove stylet; attach syringe and advance needle (5-mm
increments) while aspirate until get fluid
■ If remove large volume: Connect tubing btween spinal needle
and (butterfly needle) vacuum bottle; placing soft catheter
(Seldinger technique) into peritoneal cavity may help
■ Remove needle and sterile dry dressing over site
■ Send fluid for appropriate tests
Complications
■ Perforate organ or blood vesel, bleed/hematoma,
persistent site leakage, infection, leaving catheter in
abdominal cavity, hypotension, dilutional øNaϩ
,
hepatorenal syndrome
29
BASICSBASICS

Diagnostic Peritoneal Lavage (DPL)
Indications
■ Acute abdominal trauma with coincident major nonabdominal
injury (head injury, major fracture)
■ Critically ill pt. in whom an intra-abdominal source of fever
or sepsis is suspected
Contraindications
■ Multiple previous abdominal operations
■ Recent abdominal surgery, known abdominal adhesions, or
obliteration of abdominal space from infection
■ Pregnancy
■ Caution: Dilated viscera (e.g., bowel loops)
30
BASICSBASICS
Peritoneal Fluid Assays
Assay Diagnosis Suspected
Amylase Pancreatitic
Triglycerides Chylous
RBC count Ͼ50.000/␮L Hemorrhagic ascites (malignancy,
TB, or trauma)
WBC Ͼ350/␮L Infection (spontaneous bacterial
peritonitis)
PMNs Bacterial
Mononuclear cells TB or fungal
pHϽ7 Infection
Serum-Ascitic Albumin Gradient (SAAG)
=AlbuminSerum–AlbuminAscites from same day
High (Ն1.1 g/dL) Portal hypertension (transudative): CHF,
cirrhosis, EtOH hepatitis, fulminant
hepatic failure, portal-vein thrombosis
Low (Ͻ1.1 g/dL) Exudative: Peritoneal carcinomatosis,
pancreatic/biliary ascites, peritoneal TB,
nephrotic syndrome, serositis, bowel
obstruction/infarction

Equipment
■ Skin preparation supplies (povidone-iodine solution)
■ Mask, sterile sponges, towels and drapes, gown, gloves
■ Local anesthetic, preferably 1% lidocaine w/1:100,000
epinephrine
■ Syringe (5- or 10-mL)
■ Needles (21-G ϫ 1.5” and 25-G ϫ 1/8”)
■ Sterile surgical tray, include scalpels (Nos. 11 and 15),
scissors, Kelly clamps, pickups, needle holders
■ Sutures (0 silk, 2-0 silk, #1 and 4-0 vicryl, and 4-0 nylon)
■ Peritoneal catheter and connection tubing
■ Normal saline
■ Dressing supplies
Preparation
■ Decompress stomach (nasogastric or orogastric tube)
■ Empty urinary bladder (void or Foley catheter)
■ Prepare and drape skin
■ Entry site: usu. just caudal to umbilicus; if pelvic fracture,
supraumbilical
■ If not unconscious/sedated, local anesthesia to skin entry
site, lower fascial levels, and peritoneum
Patient Positioning
■ Supine or (if therapeutic) sitting
Technique
■ Use sterile technique
■ Open technique described here. [Alternative: Seldinger
technique (insert needle † abdomen, pass wire over needle,
dilate, and pass catheter through tract)]
■ 5-mm vertical incision (No. 11 blade) down to linea alba
fascia; do not enter abdominal cavity
■ Expose linea alba and place stay suture on each side of
fascia (0 silk); hemostat † “tag” each suture
■ Make 1 cm vertical incision in linea alba; enter peritoneal
cavity using blunt dissection; retract abdominal wall w/blunt
end of Senn retractor
■ Insert and direct catheter (always keep perpendicular to
abdominal wall) † right or left iliac region
31
BASICSBASICS

■ Never force catheter against resistance
■ Gently aspirate fluid into syringe through catheter
■ Attach 1-L sterile saline bag to catheter and empty bag into
peritoneal cavity by gravity
■ Drop bag to ground and allow fluid to siphon out
■ Send all fluid to laboratory; remove catheter
■ Suture incision closed (deep fascia: stay sutures of 0 silk;
skin: 4-0 vicryl for subcuticular dermal closure and 4-0 nylon
for skin closure)
Complications
øSensitivity to retroperitoneal injury, ⁄sensitivity to minor intraperi-
toneal injuries, false negative (poor technique or diaphragmatic
injuries), wound infection, false positive (bleeding from incision),
øsensitivity from prior DPL (introduce gas/fluid into abdomen),
bleeding, viscous perforation
Transurethral Catheterization
Indications
■ Urinary retention (e.g., neurogenic bladder)
■ Urinary sampling
■ Monitor urinary output
■ Bladder irrigation or tests (e.g., cystogram)
Contraindications
■ Ureteral stricture or disruption
■ Acute urethral or prostatic infection
■ Relative: Anticoagulated pt. (use ⁄⁄⁄lubricants and
nontraumatic technique)
Equipment
■ Sterile gloves, gauze, sponges, towels
■ Water-soluble lubricant (may use lidocaine 2% jelly)
■ Syringe (10-mL); sterile water or saline (5 mL)
■ Adhesive tape
■ Urinary drainage system w/tubing and collection bag
■ Urinary catheter (usually 16- or 18-Fr Foley):
32
BASICSBASICS

■ Foley: Double-lumen (larger † urine, smaller † balloon
inflation): Usu. used to drain bladder
■ Straight (red Robinson): Straight catheterization
■ Coude: Difficult cases; narrow, curved, firmer tip
■ 3-way irrigation: Retrograde bladder irrigation
Preparation
■ Pretest balloon inflation w/saline
■ Skin preparation: Sterile technique; retract foreskin (if pres-
ent) or spread labia (urethral meatus anterior to vagina and
posterior to clitoris); prepare entire penis or periurethral area
(including urethral meatus) w/Ն3 povidone-iodine applica-
tions; keep one hand sterile while other holds penile shaft
■ Always lubricate catheter tip and shaft
■ May inject lidocaine 2% into urethra preinsertion
Patient Positioning
■ Supine; male: penis straight upward; female: frog-leg position
Technique
■ Always use sterile technique; insert and slowly advance
catheter through urethral meatus (male: maintain continuous
upward penile traction; retract penis caudally may help pass
prostatic urethra)
Straight
catheter
Foley
catheter
3-way
irrigation
catheter
Coude
catheter
33
BASICSBASICS

■ Urine drains † inflate balloon (5 mL of saline); no urine †
push on bladder; never inflate balloon w/o urinary return
(† damaged urethra)
■ Do not attempt multiple passes; if cannot avoid multiple
passes, use smaller or Coude catheter placement
■ Gently pull back catheter until mild resistance
■ Tape catheter to thigh w/slight catheter slack
■ Return foreskin to back over penis head
Complications
Difficulty passing catheter (from any lower GU structure/disruption
or prostatic enlargement); Traumatic catheterization † hematuria,
transurethral tear/false passage; infection
Suprapubic Catheterization
Indications
■ Pelvic trauma causing urethral tear or disruption
■ Need for bladder drainage in the presence of urethral or
prostate infection
■ Acute urinary retention when transurethral catheterization
not possible
Contraindications
■ Nonpalpable bladder
■ Uncorrectable bleeding diatheses
Equipment
■ Local anesthetic (1% lidocaine Ϯ epinephrine; 22-G, 1.5”
needle, 10-mL syringe)
■ Razor
■ Sterile gloves, mask, gauze sponges, towels and sheets
■ No. 11 scalpel
■ Syringe (60-mL)
■ Suprapubic catheter (usu. 14-G, 12”); intracatheter needle;
needle holder, scissors, and pickups
■ Suture (2-0 silk or nylon)
■ Adhesive tape
■ Urinary drainage system w/bag and tubing
■ Sterile dressings
34
BASICSBASICS

Preparation
■ Local anesthetic agent Ϯ IV sedation
■ Bladder must be distended and palpable
■ Shave umbilicus to pubis
■ Locate puncture site (midline, 4 cm above pubis)
■ Prepare skin w/alcohol solution
■ Infiltrate skin, subcutaneous, abdominal wall, bladder wall
w/local anesthetic
■ Prepare skin w/providone-iodine; sterile towels/drapes
Patient Positioning
■ Supine w/roll under hips † extend abdomen and pelvis
Technique
■ Always use sterile technique
■ Avoid multiple needle passes
■ Catheter-through-needle or sterile Seldinger technique
■ Shallow skin incision (No. 11 blade)
■ While aspirating, advance needle w/syringe through incision
(at 60° to abdominal skin) until get urine flow † syringe;
remove syringe from needle
■ Thread intracath catheter through needle † bladder
■ Urine flow in catheter † remove needle over catheter
■ Free flow urine through catheter † suture catheter in place;
attach urine collection device to catheter
■ Sterile dressing
Complications
Difficulty passing the suprapubic catheter, infection, traumatic
placement, bowel perforation
Arthrocentesis
Indications
■ Dx septic joint or crystal-induced arthritis
■ Traumatic (blood in joint) vs inflammatory effusion
■ Dx intra-articular fracture (blood and fat globules)
■ Sx relief: Pain (hemarthrosis or tense effusion)
■ Give anti-inflammatory or local anesthetic medications
35
BASICSBASICS

Contraindications
■ Infection in tissue overlying puncture site
■ Bacteremia
■ Bleeding diatheses
■ Joint prosthesis
Equipment
■ Skin preparation supplies and sterile gloves, drapes, basin,
cup, test tubes, gauze, dressings, saline hemostat
■ Local anesthetic
■ Syringes (2, 10, and 20 mL); needles (18, 20, 22, and 25G)
■ Three-way stopcock
■ Green-top tube w/liquid anticoagulant, microscope slides
w/coverslips, culture media (for infection)
Preparation
■ Carefully identify landmarks and choose puncture site (avoid
nerves, tendons, major vessels)
■ Sterile technique; prepare skin (allow betadine solution to
dry btween applications); remove betadine w/EtOH to
prevent betadine † joint space
■ Δ gloves after skin preparation; apply sterile towels/drape
■ Infiltrate skin w/local anesthetic (22-/25-G needle)
Patient Positioning
■ For knee lateral approach: Supine on examination table, feet
at right angle, knee slightly flexed (15°–20°), rolled towel
under popliteal space
■ For knee patella tendon approach: Pt. sits upright with foot
perpendicular to floor
Technique
■ Attach (18- to 22-G) needle to syringe and insert through
skin, subcutaneous tissue, and into joint space
■ Knee lateral approach: Insert needle 1 cm superior/lateral to
superior lateral patella; may use hand to grasp and elevate
patella slightly; needle † under patella at 45° to midjoint
area; should be no resistance
■ Other approaches: Enter through patella tendon or medially
or laterally directly above joint line
36
BASICSBASICS

■ Aspiration of synovial fluid confirms joint space placement
■ If Δ syringe: Use hemostat to hold needle hub
■ Aspirate all joint space contents/fluid
■ Remove needle and dress wound; send fluid for tests
■ Larger effusions: Use larger syringe and consider using
three-way stopcock (do not have to Δ syringe)
Complications
Infection, bleeding, anesthetic hypersensitivity.
Fluid stops flowing (joint space drained, needle tip dislodged, or
debris/clot obstruct tip), needle dislodged (slightly advance/retract
needle, rotate bevel, or use ø pressure to aspirate), cartilage dam-
age (from bouncing needle off bone)
Abscess Incision and Drainage
Indications
■ Palpable skin abscess (usu. Ͼ5 mm) that does not resolve
with conservative measures (warm soaks)
37
BASICSBASICS
Monosodium urate
(gout)
Ca2ϩ
pyrophosphate
dihydrate (CPPD)
Pseudogout
Ca2ϩ
phosphate
(hydroxyapatite)
Cholesterol
Corticosteroids
Strong negative birefringence, needle-
shaped, long*
Uricase digestion X-ray diffraction
Weak and birefringence, rhomboid or
small rods, pleomorphic*
X-ray diffraction
Not easily visualized*
Electron microscopy X-ray diffraction
Rhombic or platelike, notched corners,
multicolor, occasionally small, needle-
like*
Chemical determination
Pleomorphic; variable birefringence*
Postintra-articular steroid Rx
Joint Fluid Crystal Characteristics‡
Crystal Diagnosis
*On polarizing microscope

Contraindications
■ Very large abscesses (may need operating room)
■ Deep abscesses in very sensitive areas (supralevator,
ischiorectal, perirectal)
■ Locations: Palmar space, deep plantar spaces, nasolabial
folds (may drain to sphenoid sinus)
Equipment
■ Universal precautions materials
■ Local anesthesia: 1% or 2% lidocaine with epinephrine, 10-cc
syringe and 25-G needle
38
BASICSBASICS
Joint Fluid Characteristics‡
WBC Mucin Δ Glucose*
Dx Appears /mL3
PMNs Clot (mg/dL)
Normal Clear, pale 0–200 Ͻ10% Good ~0
yellow
Group I (noninflammatory)
DJD; Clear to 50–4K Ͻ30% Good ~0
traumatic slight turbid
arthritis
Group II (noninfectious, mildly inflammatory)
SLE; Clear to 0–9K Ͻ20% Good ~0
scleroderma slightly (occasion-
turbid ally fair)
Group III (noninfectious severe inflammatory)
Gout Turbid 100–160K ~70% Poor 10
Pseudogout Turbid 50–75K ~70% Fair/poor ?
RA Turbid 250–80K ~70% Poor 30
Group IV (infectious inflammatory effusions)
Acute Very turbid 150–250K ~90% Poor 90
bacterial
TB TB 2500–100K ~60% Poor 70
*Mean difference between synovial fluid and blood glucose
‡Adapted from Cohen, AS. Cecil’s Tectbook of Medicine

39
BASICSBASICS
■ Skin preparation solution and sterile drapes
■ No. 11 scalpel blade with handle
■ Sterile gauze and tape
■ Hemostat, scissors
■ Packing strip (plain or iodoform, 1/2”)
■ Culture swab
Preparation
■ Universal precautions; prepare skin and sterile drapes
■ Inﬁltrate local anesthetic, allow 2–3 minutes for anesthetic to
take effect
Patient Positioning
■ Depends on abscess location
Technique
■ Cut through skin into abscess w/wide incision (No. 11 blade);
incision should follow skin fold lines
■ Allow pus to drain; soak up w/gauzes
■ Swab inside abscess cavity (culture swab)
■ Gently explore cavity w/hemostat, break up loculations
■ Pack abscess cavity; dress wound w/gauze and tape
■ May send pus for Gram stain and culture (commonly strepto-
coccus, staphylococcus, or enterics (perianal), or anaerobic
and gram-negatives.
Complications
Abscess actually sebaceous cyst or hematoma, no drainage,
bleeding

40
H&P
Cranial Nerve Major Functions How to Test
I Olfactory Smell Odor
II Optic Vision Vision chart
III Oculomotor Most eye muscles Follow ﬁnger
IV Trochlear Superior oblique Look down at
(eye ø and out) nose
V Trigeminal Face sensation Touch face
Chewing muscles Clench teeth
VI Abducens Lateral rectus Look to side
(eye lateral)
VII Facial Face expressions Smile
Tears/saliva ⁄øEyebrows
Taste (anterior 2/3 Sugar or salt
tongue)
VIII Vestibuloco- Hearing Tuning fork
chlear Equillibrium ? Vertigo
(auditory)
IX Glossopharyn- Taste (posterior Gag reﬂex
geal 1/3 tongue) Swallow
Sense carotid BP Uvula position
X Vagus Larynx/pharynx ? Hoarseness
Parasympathetic Open wide, say
Taste “AH”
XI Spinal Trapezius/ Shoulder
Accessory sternocleidomastoid shrug/raise
Turn head
XII Hypoglossal Move tongue Tongue out

41
H&P
Distinguishing
Causes Upper Lower
of Motor Motor Motor Extra-
Defects Neuron Neuron Muscle Cerebellar pyramidal
øStrength ϩ ϩ ϩ Ϫ Ϫ
Atrophy Ϫ ⁄⁄⁄ ⁄ Ϫ Ϫ
Fasciculations Ϫ ϩ Ϫ Ϫ Ϫ
Babinski’s ϩ Ϫ Ϫ Ϫ Ϫ
⁄Tone ϩ Ϫ Ϫ Ϫ Ϫ
øTone Ϫ ϩ ϩ/Ϫ Ϫ Ϫ
Hyperreflexia ϩ Ϫ Ϫ Ϫ Ϫ
Hyporeflexia Ϫ ϩ ϩ/Ϫ Ϫ Ϫ
Clasp knife ϩ Ϫ Ϫ Ϫ Ϫ
Ataxia Ϫ Ϫ Ϫ ϩ Ϫ
Distinguishing Vestibular (peripheral VIII
nerve), Cerebellar, and Sensory (afferent
pathway: peripheral nerve to thalamus/
parietal lobe) Lesions
Finding Vestibular Cerebellar Sensory
Vertigo ϩ Ϯ Ϫ
Nystagmus ϩ Often ϩ Ϫ
Dysarthria Ϫ Ϯ Ϫ
Limb ataxia Ϫ Usual ϩ ϩ
Stand feet together; ϩ Ϫ ϩ
eyes open
Stand feet together; ø Ϫ Ϫ
eyes closed
Vibratory and position sense ϩ ϩ ø
Ankle reflexes ϩ ϩ ø
(continued)

Lower Extremities
Cannot toe walk when Ն50% loss S1 † gastrocnemius and anterior
tibialis; cannot heel walk when Ն50% loss L4, L5 † tibialis anterior
Sciatic Nerve Compression
■ Cross-leg (well leg) straight-raising test: Pt. lies supine and
lifts uninvolved leg up with knee extended; positive: pain
radiates posterior leg † foot
■ Straight leg-raising test: Like cross-leg but pt. lifts involved
leg; positive: pain radiates back † below knee; hamstring
problem: only posterior thigh pain
Femoral Nerve Compression
■ Reverse leg-raising test: Pt. lies prone and extends involved
leg with knee extended; if pain radiates anterior leg † foot,
then femoral nerve compression
Intrathecal Pathology
■ Milgram’s test: Pt. lies supine and raises legs ~5 cm and
holds for 30 sec † stretches iliopsoas and anterior
42
H&P
Distinguishing
Causes Upper Lower
of Motor Motor Motor Extra-
Defects Neuron Neuron Muscle Cerebellar pyramidal
Akinesia Ϫ Ϫ Ϫ Ϫ ϩ/Ϫ
Chorea or Ϫ Ϫ Ϫ Ϫ ϩ/Ϫ
athetosis
Intention Ϫ Ϫ Ϫ ϩ/Ϫ Ϫ
tremor
Resting tremor Ϫ Ϫ Ϫ Ϫ ϩ/Ϫ

43
H&P
abdominal muscles and ⁄ intrathecal pressure; if no leg pain,
no intrathecal pathology
Reflexes
Nerve
Reflex Root Nerve Testing
Jaw Pons Mandibular
branch,
trigeminal
Tap mandible at down-
ward angle w/mouth
slightly open
Biceps C5–6 Musculocu-
taneous
Tap biceps tendon
w/arm flexed partially
at elbow
Brachiora-
dialis
C5–6 Radial Strike radius lower end
just above wrist
Normal: Elbow flexion
Triceps C7–8 Radial Tap triceps tendon;
support upper arm; let
forearm hang
Finger C8, T1 Median Either tap palm or hold
pt.’s middle finger
loosely and flick
fingernail down †
normal: finger slightly
extends; abnormal:
Hoffman’s sign (thumb
flexes, adducts)
Upper
abdomen
T7–10 Use blunt object to
stroke abdomen lightly
in and down
Normal: Umbilicus
deviates toward
stimulus
Lower
abdomen
T11–L1
(continued)

44
H&P
Patellar L3–4 Femoral Strike patellar tendon
Ankle
(Achilles)
S1–2 Tibial Tap Achilles tendon
when pt. dorsiflexes
foot at ankle
Normal: Plantar flexion
Anal wink S2–4 Touch perianal skin
Normal: Anus contracts
Cremasteric
reflex
T12 Genital
branch (gen-
itofemoral)
Stroke inner thigh
Normal: Ipsilateral
scrotal sac move ⁄
Reflexes
Nerve
Reflex Root Nerve Testing

45
H&P
Anterior thoracic rami
Lateral thoracic rami
Iliohypo-
gastric
Ilio-
inguinal
Obturator
Lateral femoral cutaneous
Anterior femoral cutaneous
Medial femoral cutaneous
Superficial peroneal
Saphenous
Sural
Sural
Tibial
Lateral
plantar
Medial
plantar Deep
peroneal
C2
C3
C4 C5
C6T1T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4 L5
C7
C8
S2
S3
Trigeminal
Anterior cutaneous
nerve neck
Supraclavicular
Axillary
Lateral cutaneous
nerve arm
Median cutaneous
nerve arm
Lateral cutaneous
nerve forearm
Median
cutaneous
nerve
forearm
Radial
Median
Ulnar
Saphenous
Sole of foot
Peripheral Nerves

46
H&P
Sural Tibial
Lateral
plantar
Medial
plantar
Saphenous
Sole of foot
Great occipital
Lesser occipital
Greater auricular
Posterior rami of cervical nerves
Axillary
Supraclavicular
Posterior cutaneous
nerve forearm
Lateral cutaneous
nerve forearm
Median cutaneous
nerve arm
Lateral thoracic rami
Median cutaneous
nerve forearm
Radial
Median
Ulnar
Posterior thoracic rami
Posterior
lumbar
rami
Posterior sacral rami
Lateral femoral cutaneous
Lateral femoral nerve of calf
Superficial peroneal
Sural
Medial femoral cutaneous
Calcaneal
Saphenous
Obturator
C2
C3
C4
C5
C6
C7C8
T10
T12
L1
L2
L3
L4
L5
S3
S4
S5
S3
S4
S5
S1
S2
L2
L3
L4 L5
Peripheral Nerves

47
H&P
Right Shoulder
Liver
Gallbladder
Diaphragm
Pancreas
Cardiac
Left Shoulder
Lung
Diaphragm
(Kehr’s sign)
Pancreas
Cardiac
Arm
Cardiac
Periumbilical
Duodenum
Appendix
Suprapubic
Bladder
Uterus
Groin/
Inner thigh
Ureters
Kidneys
Jaw
Cardiac
Epigastric
Duodenum
Appendix
Hiatal hernia
Gallbladder
and bile ducts
Pancreas
Referred Pain

Brain Circulation
48
H&P
Anterior
communicating
artery
Communicating artery
Middle cerebral artery
Anterior cerebral artery
Posterior cerebral
artery
Basilar artery
Internal carotid
Vertebral artery
Superior cerebellar
Anterior inferior
cerebellar
Posterior inferior cerebellar
Anterior spinal

Posterior cerebral Medial occipital and temporal cortex
Posterior corpus callosum
Upper midbrain
Thalamus
Superior cerebellar Upper cerebellum
Upper pons
Low midbrain
Anterior inferior Upper cerebellum
cerebellar Upper pons
Low midbrain
Posterior inferior Lower cerebellum
cerebellar Medulla
Anterior spinal (ASA) Anterior (ventral) spinal cord
49
H&P
Main Artery Region of Brain Sustained
Anterior cerebral Medial frontal and parietal
Anterior corpus callosum
Middle cerebral Lateral frontal, parietal, occipital,
temporal cortex
Lenticulostriate branches †
caudate nucleus, putamen,
upper internal capsule

50
H&P
Frontal lobe
problem solving,
planning, apathy,
inattention, aphasia,
contralateral weakness,
labile affect,
Broca’s area
Temporal lobe
memory problems,
aggressive sexual behavior
Dominant:
Wernicke’s aphasia
Cerebellum
ataxia, dysarthria,
dysmetria, intention
tremor, nystagmus,
scanning speech
Occipital lobe
vision problems
Parietal lobe
contralateral sensation
Dominant:
reading, writing,
or math ability
Non-dominant:
neglect, difficulty dressing
Midbrain, Pons,
Medulla
CN 3–12

51
H&P
Macula
Fovea
Optic
nerve
Vitreous
humor
Optic
disk
Retina
Sclera
Conjuctiva
Anterior
chamber
Cornea
Pupil
Iris
Ciliary body
Choroid
Lens
Zonule
Optic nerve
Left eye
Left eye
visual
field
Right eye
visual
field
Right eye
Optic chiasm
Optic tract
Optic
radiation
Striate cortex
Lateral
geniculate
nucleus
1
1
3
3
2
2
4
4
5
5
Eye Examination

52
H&P
Superior
rectus
CN3 Superior
oblique
CN4
Medial
rectus
CN3
Lateral
rectus
CN6
Inferior
rectus
CN3
Inferior oblique
CN3
Optic nerve
Macula
Fovea
Optic nerve
(“blind spot”)
Optic
disk
Blood
vesselsOptic
cup

53
H&P
Weber’s test Rinne’s test
Fork at midline forehead Bone conduction: Put fork on
mastoid
Normal: Sound ϭ both ears Air conduction: Put fork near
ear
Abnormal: Sound lateralizes † Normal: Air conduction
one ear † øipsilateral conductive Ͼ bone
hearing or øcontralateral Abnormal: Bone conduction
sensorineural hearing Ͼ air conduction, which
results in øconductive
hearing
Ear Examination
Tuning Fork Tests
Vertigo
Dix-Hallpike test (Nylen-Barany test): Pt. sits on examination table
and extends legs; turn pt.’s head 30°–45° to one side, and pt. quickly
lies back so head hangs over table end; look for nystagmus; repeat
whole procedure with head turned in opposite direction
Positive: Nystagmus † benign paroxysmal positional vertigo

54
H&P
Cardiac Manuevers
Mechanism Maneuvers
Right-
Sided
Murmurs
Aortic
Stenosis
(AS)
Mitral
Regurgi-
tation
(MR) IHSS*
Preload
Venous
return
Inspiration,
squatting,
raise ⁄legs
⁄⁄ ⁄⁄ øø øø
Expiration,
Valsalva’s,
standing,
nitrates,
diuretics
øø øø øø ⁄⁄
Afterload Isometric
hand grip
⁄⁄ øø
⁄⁄
øø
⁄⁄
Valsalva’s,
vasodila-
tors
øø øø øø ⁄⁄øø
*IHSS ϭ idiopathic hypertrophic subaortic stenosis

55
H&P
Comments
Diastole
Early Mid Late
Systole
AS
Heard best @ R base
(radiate R carotid)
AI
Heard best @ 3rd/4th L ICS
(if radiate R sternal border
aortic root dilate, e.g., Marfan)
MS
MI
TI
VSD
PDA
MVP
PS
PI
TS
Early Mid Late
Harsh
Low
Opening snap
Rumble
Opening snap
Rumble
Opening snap
Systolic click
Systolic click
Blowing
Blowing
Second degree
Machinery
All MV murmurs heard best@ apex , S1.
Can be confused with Austin Flint
(AI: mid-diastolic murmur @ MV
when blood enters from aorta &
L atrium simultaneously; No OS)
If LV volume (stand, Valsalva) earlier
clicks, duration, intensity; if LV volume
(squat, legs, hand grip) delay clicks,
duration, intensity
Radiate L axilla/back;
severe MR S3; with isometric
handgrip & stand squat
Heard best @ 4th L sternal border;
wide split S1; may with inspiration
(Carvallo’s sign);TS often occurs with MS
Heard best @ 4th L sternal border; may
with inspiration (Carvallo’s sign); 1st degree
rare; usually 2nd degree to pulm HTN
Heard best @ L base; confused with
venous hum; if pulmonary HTN,
may disappear systolic murmur,
pulmonic ejection sound
Heard best @ L 3rd/4th ICS and along
sternal border; NI S2
Heard best @ L 2nd ICS (radiate to
L neck) + palpable thrill; wide split S2
Heard best @ L 2nd/3rd ICS;
may during inspiration

56
H&P
Heart Sound Causes
S1 Soft: øCardiac output, tachycardia, ⁄⁄⁄MR
Loud: Hyperdynamic (fever, exercise),
mitral stenosis, atrial myxoma
S2 (Aortic) Soft: Calciﬁc AS
Loud: Systemic hypertension (HTN),
dilated aortic root
S2 (Pulmonic) Loud: Pulmonary HTN
S3 (Low frequency, ⁄Atrial pressure †⁄ﬂow rates (congestive
early diastole) heart failure [CHF] most common, valvular
regurge, left † right shunts)
Normal in age Ͻ40 yr
Jugular Venous Pressure (JVP)
S1
S2
A APP
S1
S2
Type Causes
Inspiration Expiration
Normal or physiologic
Wide, fixed, splitting
Wide split, varies with
inspiration
Paradoxical splitting
Intrathoracic
pressure
Atrial septal defect
Pulmonary stenosis
RBBB
Hypertrophic
cardiomyopathy
A P A P
A P
P A
A P
PA
Adapted from University of Washington Advanced Physical Diagnosis
Learning and Teaching at the Bedside, Edition 1.
S4 (Low-frequency Stiffened LV (HTN, AS, ischemic or
presystolic portion hypertrophic cardiomyopathy, acute MR
of diastole) from chorda tendinea rupture)

57
H&P
45°
Right atrium
Sternum
Jugular vein
a
c
v
x
y
Maximal
atrial filling
Small and usually
not visible
TV opening and
atrial emptying
RV contraction
and TV closure
R atrial
contraction
• Fluid overload
• Blockage before heart (SVC obstruction)
• CO (e.g., HR, constrictive pericarditis,
R heart failure pericardial effusion, TS or TI,
cardial tamponade)
• Hyperdynamic circulation
JVP

58
H&P
Sign Causes
Kussmaul’s (during inspiration, Constrictive pericarditis
JVP ⁄distention; øin normal pt.) (negative in cardiac tamponade)
Severe right heart failure
Hepatojugular reflux (push Right ventricular failure if
liver † ⁄venous return to right JVP remains elevated
atrium) (transient only in normal pt.)
Absent A waves Atrial fibrillation
Sinus tachycardia
Dominant A waves Pulmonary HTN
Pulmonary stenosis
Tricuspid stenosis
Right atrial myxoma
Cannon A wave (very large Ventricular tachycardia
A waves) Complete heart block
Paroxysmal nodal tachycardia
Dominant V wave Tricuspid regurgitation
Absent X descent Atrial fibrillation
Exaggerated X descent Cardiac tamponade
Constrictive pericarditis
Large CV waves Tricuspid regurgitation
Constrictive percarditis
Sharp Y descent Constrictive pericarditis
Tricuspid regurgitation
Slow Y descent Right atrial myxoma
Tricuspid stenosis
Absent Y waves Cardiac tamponade
Abdominal Examination

59
H&P
RUQ
Biliary colic
Cholecystitis
Duodenal ulcer
Hepatitis
RLL pneumonia
LUQ
Gastritis
LLL pneumonia
Pancreatitis
Splenic problems
Periumbilical
Appendicitis
Gastroenteritis
Mesenteric
lymphadenitis
Myocardial
ischemia or
infarction
Pancreatitis
Back
Acute pancreatitis
Posterior
duodenal ulcer
Retrocecal
appendicitis
Ruptured AAA
LLQ
Diverticulitis
Ectopic pregnancy
Ovarian cyst
Ovarian torsion
Tubo-ovarian
abscess
RLQ
Appendicitis
Cecal diverticulitis
Ectopic pregnancy
Ovarian cyst
Ovarian torsion
Tubo-ovarian
abscess
Flank
Abdominal aortic
aneurysm
Pylelonephritis
Renal colic
Suprapubic
Ectopic pregnancy
Endometriosis
Mittelschmerz
PID
Ovarian cyst
Uterine leiomyoma
UTI
McBurney’s point

60
H&P
Abdominal Physical Examination Findings
Appendicitis
■ Psoas’ sign: Place hand above pt.’s right knee; ask pt. to flex
right hip against resistance † pain
■ Obturator sign: Raise the pt.’s right leg with the knee flexed;
rotate leg internally at hip
■ McBurney’s sign: Tenderness right abdomen two-thirds
distance from anterior iliac spine to umbilicus
■ Rovsing’s sign: Palpate LLQ † RLQ pain
Gallbladder Disorders
■ Murphy’s sign: In cholecystitis; pt. breathes out; palpate
below right costal margin at midclavicular line; pt. inspires †
gallbladder moves down, hits your hands; if gallbladder ten-
der then pt. will stop inspiration † ϩ test; negative in chole-
docholithiasis and ascending cholangitis
■ Charcot’s triad: In cholangitis; RUQ pain, fever, chills,
jaundice
Retroperitoneal Hemorrhage
■ Cullen’s sign: Bluish periumbilical discoloration
■ Grey Turner’s sign: Flank discoloration
Vaginitis
Candida Vulvovaginitis
■ Discharge: Dry cottage cheese–like
■ Symptoms: Vaginal/vulvar pruritus, irritation, burning, sore
■ Examination: Vulva: red, edema, and adherent white clumps
Bacterial Vaginosis
Amsel’s criteria (3 of 4 needed for diagnosis):
■ Discharge: Gray-white, thin, homogenous, adherent
■ Vaginal pH Ͼ4.5 (normal pH: 3.8–4.5)
■ Clue cells: Bacteria-coated vaginal epithelial cells
■ ϩ Whiff (amine) test: KOH ϩ discharge † fishy odor
Trichomonas Vaginitis
■ Discharge: ⁄⁄⁄, grayish-green, frothy (CO2 bubbles)
■ Symptoms: Vulvar/vaginal pruritus, irritation, edema

■ Examination: strawberry cervix (punctate hemorrhage),
pH Ͼ5.0, ϩ whiff test, wet preparation (vaginal vault, not
endocervix): Motile, ﬂagellated trichomonads
Atrophic Vaginitis
■ Discharge: Thin or clear
■ Symptoms: Vaginal irritation
■ Examination: Vagina/vulva: pale, dry, thin, øørugae, pH 5–7
Scrotal Complaints
Epididymitis ϭ Chlamydia, Gonorrhea, or E. coli
■ Insidious onset; dysuria, frequency, urethral discharge;
swollen/tender upper posterior testicle
■ Rx: Antibiotics
Torsion ϭ Testis Twists on Spermatic Cord Axis
■ Surgical emergency: Sudden onset; abnormal testis elevation/
axis; “bell clapper” deformity (congenital unanchored
swinging testis); absent cremasteric reﬂex and Prehn’s sign
61
H&P
Spermatic
cord
Testicular
veins
Testicular
artery
Vas deferens
Epididymis
Testicle
Hydrocele
Torsion
Varicocele
Spermatocele
Epididymitis

Appendage Torsion ϭ Twists on Testicular
Appendage
■ Subacute symptoms, firm tender nodule upper pole
epididymis; “blue dot sign” (blue/black spot visible beneath
skin on testis/epididymis cranial aspect)
■ Rx: Bedrest and scrotal elevation
Traumatic Injury ϭ Epididymitis, Hematoma, or
Rupture
■ Trauma history, ecchymosis, edema
■ Rx: Surgery if: uncertain diagnosis, ?testicle injury, disruption
of tunica albuginea, or no flow Doppler ultrasound
Hydrocele ϭ Fluid-Filled Sac Around Testis
■ Painless, ⁄size/tenseness from morning waking to later in
day; transillumination: translucent fluid
■ Rx: Most resolve spontaneously; surgery if discomfort or
tense hydrocele † testicle atrophy
Varicocele ϭ Abnormal Tortuous/Dilated Veins
■ Swelling, dull heaviness, ⁄ with exercise; no scrotal skin
change; palpable “bag of worms”
■ Rx: May † infertility; scrotal support or surgery; ?obstructing
mass if sudden onset in older pt.
Spermatocele ϭ Benign Cystic Sperm
Accumulation
■ Asymptomatic: Painless, freely movable nodule superior to
and separate from testis; transilluminates easily
■ Rx: None, unless bothersome
62
H&P

Tanner Stages
IIIIIIIVV
Ͻ10y.o.10–11y.o.12–14y.o.13–15y.o.16ϩy.o.
NoneSmallamount;Dark,coarse,Adultquality;Adult(extends
long,downy,startstocurlnotedistributiontomedial
slightlyandextend(sparemedialthigh)
pigmentedlaterallythighs)
MalePubicHair
(continued)
63
H&P

64
H&P
IIIIIIIVV
Ͻ10y.o.10–11y.o.12–14y.o.13–15y.o.16ϩy.o.
NoAreolawidens;⁄Elevated,extends⁄Size,⁄elevation;Adult;areola
buddingbudding,smallbeyondareolarareolaϩpapillabacktobreast
glandulartissueborders;areolaformsecondarycontour;
surroundswidensmoundpapillaprojects
Testicle1.6–6mL;skin6–12mL;12–20mL,Ͼ20mL,
volumethins,reddens,penis⁄⁄Scrotumadult
Ͻ1.5mL;enlarges;penis:lengthens(anddarkens);
penisnochangepenis:⁄length,
small⁄circumference
Breast Female Testicles

Stages of Labor
65
H&P
Cervical
Comments Duration Dilation
Contractions ⁄ frequency, Most 0–4 cm
strength,and regularity; variable
cervical thinning or hours to
effacement days
Most rapid cervical Average 4–10 cm
dilation nulliparous:
5 hr;
multiparous:
2 hr
1st
Stage
ActiveLatent
May blend into active 15 min–3 hr 7–10 cm;
phase; more rapid descent; slower
baby passes lower into pace
pelvis and deeper into
birth canal; when no
anesthesia, often vomiting
and shaking
Female actively pushes Nulliparous: Complete
out baby 2–3 hr
Nulliparous: Ͼ1 cm/hr Multiparous:
Multiparous: Ͼ2 cm/hr Ͻ1 hr
Accelerated by Ͻ1–30 min
breastfeeding (release
oxytocin) or pitocin
2ndStage
(birth)
Transition
(Deceleration)
3rdStage
(placenta
delivery)

66
H&P
Placenta
Umbilical
cord
Uterus
Cervix
Blood
Placenta abruptia
More common when mother has high
blood pressure or uses cocaine
Placenta previa
Usually in multiparous women or
uterine structural abnormalities (e.g., fibroids)
Placenta prematurely detaches
(incompletely or completely)
Placenta implants
over or near cervix

67
H&P
x
The cephalic or vertex
presentation (normal)
Usually normal vaginal delivery
Seated or full breech position
Usually normal vaginal delivery
The transverse
position (rare)
Usually shoulder first to
present; usually cesarean
section required
Frank breech
position
• Vertical or longitudinal lie
• Vertical or
longitudinal lie
• Vertical or
longitudinal lie
• Legs pointed
straight
upward
• Limbs to chest
• Neck flexed
Front
Front
Back
Back

68
H&P
Frontal
bone
Frontal
bone
Parietal
bone
Parietal
bone
Occipital bone
Lambdoidal
suture
Sagittal
suture
Coronal
suture
Metopic
suture
Anterior fontanelle
(closes at age 18–24
months, may bulge
with crying or ICP)
Posterior fontanelle
(closes at 2 months)
Back
Front
Obstetric Visits and Testing Timeline

69
H&P
010
162428323537
203040
HgB/HCT,bloodtype,Rhantibody
screen,RPR/VDRL,rubellaAb,hep
BsAg,UA,urineC&S,Pap(thin
prep),wetprep,PPD,HIV,TSH,
gonorrhea,chlamydia
Sicklecell,Tay-Sachs,cysticfibrosis,VZV,geneticscreen,andurinetoxscreens
4regularcontractionsin20minutesor8regularcontractionsin60minuteswithPROM
withprogressiveeffacement>80%andcervicaldilation>1cm
Gonorrhea,chlamydia,
groupBstrepcx
InitialVisitLabs
Uterussize
Ultrasound
Pretermlabor
Biophysical
profile
Pregnancy-
associated
plasmaprotein
TripleScreen:
␤-HCG,AFP,
estradiol
One-hour
glucolatest
Non-stresstest
RhoGAM
OBVisits
Weeks
Every4weeks
Fetalhearttone
withDoppler
Fetal
heart
tone
Fundalheight
&toxemia
signs
Q2–4wksQ0.5–1wkQ1–2
General
SymphysispubisMidpointSpubis/umbilicusUmbilicusSize(cm)=Weekofgestation
IfRh(–)
Optional
GestationalageFetalsurveyprn
If>140&3hrwnl,thenrepeat
@32wks
Fetalmovement

Skin Examination
Lesion Descriptions
■ Macule: Flat; different color; can be seen, not felt
■ Excoriation: Mechanical skin erosion or destruction
■ Lichenification: Chronic irritation † leathery skin thickening
with induration and hyperkeratosis
■ Onycholysis: Nail substance loosening or loss
■ Plaque: Flat, elevated, usu. Ͼ5 mm
■ Solid raised, discrete: Papule (Յ5 mm), nodule (Ͼ5 mm),
pustule (pus-filled)
■ Blister: Fluid-filled vesicle (Յ5 mm), bulla (Ͼ5 mm)
Shoulder Examination
Range of Motion (ROM)
■ Adhesive capsulitis (frozen shoulder): Stiffness, pain, and
ørange of movement; scar tissue forms post surgery or
injury; develops when stop using joint from pain, injury, or
chronic health condition (e.g., diabetes or arthritis)
■ Labral tears: Labrum ϭ cartilage disk on glenoid; pain at back
or in front on top of shoulder; feels deep inside; palpation
does not duplicate pain; pain or “clunking” sound with
overhead motion; causes: fall on outstretched arm, forceful
lifting, or repetitive throwing
Abduction/external rotation: Pt. places hand behind head and
reaches as far down spine as possible; extent of reach should be
at least ~C7 level;
Forward flexion: Pt. traces out arc while reaching forward (elbow
straight); should be able to move hand to a position over head;
normal range 0–180°
Extension: Ask pt. to reverse direction and trace an arc backward
(elbow straight); pt. should be able to position hand behind back
Appley scratch test (adduction and internal rotation): Ask pt. to
place hand behind back and reach as high up spine as possible;
note extent of reach relative to scapula/thoracic spine (should be
at least T7); see figure for additional parts of examination
70
H&P

71
H&P

72
H&P
Impingement (of Rotator Cuff Tendons)
Inflammation (tendonitis, bursitis), bone spurs, or ⁄fluid † squeez-
ing rotator cuff (supraspinatus) tendon against bone (acromion);
tendon may have tiny tears † scar tissue † further damage; night-
time shoulder pain
Neers’ test: Place your hand on pt. scapula; use other hand to
hold pt. forearm; internally rotate pt. arm so that pt. thumb points
downward; flex pt. arm forward to position hand over head; pos-
itive: pain
Hawkin’s (for more subtle impingement): Raise pt. arm to 90° for-
ward flexion; rotate it internally (i.e., thumb pointed down); puts
humerus greater tubercle position to further compromise space
beneath acromion; positive: pain

73
H&P
-
Biceps
Yergason’s test: Flex pt. elbow 90°; pt. resists while externally
rotate arm; if pain in biceps tendon † positive test † biceps
tendon injury
Rotator Cuff Tear
■ “Rotator cuff” ϭ four tendons ϭ supraspinatus (most
common injured), infraspinatus, subscapularis, teres minor;
muscles originate from scapula † single tendon unit insert-
ing on humerus greater tuberosity
■ Repetitive overhead work or sports activity (e.g., painting,
swimmers)
■ Gradual or acute onset; pain, stiffness; difﬁculty reaching
overhead or behind back; may be snapping sensation
Gerber’s liftoff test (check subscapularis function): Pt. places
hand behind back, with palm facing out; pt. lifts hand away from
back; partial tear will limit movement or cause pain; complete
tears prevent movement
Drop arm test for supraspinatus tears: Fully abduct pt.’s arm so
that hand is over head; have pt. slowly lower arm to side; if
suprapinatus torn, at ~90° arm will seem to drop suddenly toward
body
“Empty can” test for supraspinatus weakness: With elbows
extended, thumbs pointing downward, and arms abducted to 90°
in forward ﬂexion, pt. attempts to elevate arms against examiner
resistance
Acromioclavicular Joint Dysfunction
Cross-arm test: Pt. raises arm to 90°, then actively abducts,
attempting to touch opposite shoulder; pain suggests problem

74
H&P
Glenohumeral Joint Instability
“Giving way” feeling or periodic shoulder dislocation; cannot keep
humeral head centered in glenoid socket; shoulder pain in throw-
ing athletes; anterior glenohumeral joint pain and impingement
Sulcus test: With arm extened and at rest at pt.’s side, exert
downward traction on humerus, and watch for sulcus or depres-
sion lateral/inferior to acromion
■ Apprehension tests: Put humeral head in imminent
subluxation or dislocation † pt. shows fear
■ Crank (pt. sitting or standing) or fulcrum (pt. supine) test:
Place arm in extreme abduction and external rotation, which
may cause apprehension
■ Relocation test: Pt. supine.
■ First part (fulcrum test): Push humeral head forward
■ Second part: Push humeral head posteriorly † prevents
anterior subluxation † negative apprehension test
■ Inferior apprehension test: Hold upper limb in abduction,
with pt.’s forearm resting on your shoulder; exert downward
pressure over humeral neck; if shoulder unstable, head will
be pushed down and groove appears
Knee Examination
Anterior Cruciate Ligament (ACL)
Anterior drawer: Flex knee ~80°; relax hamstrings; stabilize foot;
leg in neutral rotation; pull proximal tibia forward to see anterior

75
H&P
displacement; quantify displacement (mm), and grade end point:
hard (anterior cruciate ligament [ACL] halts forward motion) or
soft (no ACL)
Lachman’s: Anterior drawer variant; flex (15°–20°) and externally
rotate (relax iliotibial [IT] band) knee; one hand holds inner calf,
and other hand holds outer aspect distal thigh; pull tibia anteriorly
Pivot shift: Slight distal traction on leg; apply valgus and internal
rotation force to extended knee; (no ACL † tibia anteriorly sub-
luxes on distal femur); flex knee Ͼ30° (IT band † extendor †
flexor of knee and tibial anterolateral subluxation reduces)
Posterior Cruciate Ligament (PCL)
Tibial drop back test: Flex knee 80°; compare proximal tibial
prominence to femoral condyles; PCL-deficient knee † gravity
subluxes knee posteriorly; normal knee: tibial plateau located
approximately 1 cm anterior to femoral condyles
Quadriceps active test: Starting position: flex knee 80°, neutral
rotation; apply counterpressure against ankle while pt. fires
quadriceps muscle (i.e., tries to straighten leg); quadriceps pulls
anteriorly through the tibial tubercle to reduce any posterior

translation in the knee; if PCL injured, then will see reduction of
a posteriorly subluxed tibia with quadriceps contraction
Posterior drawer test: Flex knee 80°, palpate hamstrings to ensure
they are relaxed; stabilize foot and keep in neutral rotation; push
tibia posteriorly; if PCL-deficient knee
Meniscus
MacMurray’s test: Place thumb and finger on joint line; watch
face for pain; flex leg, externally rotate foot, abduct and extend
leg to test medial meniscal “clicks”; flex leg, internally rotate and
adduct for lateral meniscal “clicks”
Squat test: During full squat, check joint line tenderness and
rotate each leg internally (test lateral meniscus) and externally
(test medial mensiscus)
76
H&P

77
H&P
Patella
Bulge test: Check for effusion; press down patella † empty
suprapatellar pouch; wipe hand along medial side to displace
fluid laterally; compress lateral side, and watch for bulge medially
Effusion: tap test: Push sharply on patella; if effusion, patella will
bounce off femur
Patellar tilt test: With knee flexed 20°, use thumb to flip up
lateral edge of patella; normally can tilt patella up above hori-
zontal; excessively tight lateral retinaculum † no upward
movement
Soloman’s test: Lift patella away from femur; synovial thickening
† patella hard to grasp
Patellar compression test: Attempts to correlate anterior knee
pain w/articular degeneration; compress patella down into
trochlear groove as pt. flexes and extends knee
Lateral patellar apprehension test: Flex knee 45°; keep knee
relaxed; use one hand to stabilize leg while using other hand to
apply lateral pressure to patella
Medial patellar apprehension test: Fully extend knee; apply
medial translation force; medial subluxation, which most often
occurs in a pt. after a lateral release, occurs in the initial flexion
arc of 0°–30°; after this point, the patella reduces into the bony
confines of the trochlear groove when the knee is flexed
Patellar displacement (Sage sign): Normally can displace patella
medially and laterally 25%–50% of patellar width; ⁄movement †
loose patellar restraints (frequent in adolescent females)
Suprapatellar plica snap test: Palpate medial suprapatellar plica
midway between medial patellar border and adductor tubercle;
roll plica under your fingers while assessing pain/inflammation

78
H&P
Upper and Lower Extremity Muscles
Part Action Muscle Root Nerve
Arm Externally Infraspinatus C5 Suprascapular
rotate
Abduct Supraspinatus
Deltoid C5 Axillary
Elbow Flex Biceps C5–6 Musculocuta-
neous
Brachioradialis Radial
Extend Triceps C8 Radial
Wrist Extend Extensor carpi C6–7 Radial
radialis longus
Extensor carpi C7
ulnaris
Flexor carpi ulnaris C8 Ulnar
Flex Flexor carpi radialis C6–7 Median
Finger Extend Extensor digitorum C7 Radial
5th Abduct 1st dorsal T1 Ulnar
Finger interosseous
Abduct digiti minimi
Thumb Abduct Abductor pollicis T1 Median
brevis
Oppose Opponens pollicis Median
Hip Extend Gluteus maximus L5–S2 Inferior gluteal
Flex Iliopsoas L2,L3 Femoral
Abduct Gluteus medius and L4–S1 Superior
minimus, tensor gluteal
fasciae latae
Thigh Abduct Abductors L2–4 Obturator

79
H&P
Part Action Muscle Root Nerve
Knee Extend Quadriceps femoris L3–4 Femoral
Flex Hamstrings L5–S1 Sciatic
Ankle Dorsi Tibialis anterior L4–5 Peroneal
(ﬂex)
Plantar Gastrocnemius S1–2 Tibial
Soleus
Foot Evert Peronei L5–S1 Peroneal
Invert Tibialis posterior L4 Tibial
Toes Dorsiﬂex Extensor digitorum L5–S1 Peroneal
longus
Extensor digitorum S1
brevis

80
ALGOR
Algorithms
Hyperprolactinemia (Ͻ100 ng/mL)
■ Ectopic production
■ Breast stimulation (e.g., breastfeeding)
■ Δ metabolism (liver failure, renal failure)
■ Hypothyroidism
■ Medications (e.g., oral contraceptives, antipsychotics, antide-
pressants, antihypertensives, H2-receptor blockers, opiates)
Hyperprolactinemia (Ͼ100 ng/mL)
■ Prolactin
■ Empty sella syndrome
■ Pituitary adenoma
Normogonadotropic Hypogonadism (⁄⁄Androgens)
■ Polycystic ovary syndrome
■ Androgen-secreting tumor (ovarian or adrenal)
■ Cushing’s disease
■ Nonclassic congenital adrenal hyperplasia
■ Exogenous androgens
■ Thyroid disease
■ Acromegaly
Uterine Outﬂow Obstruction
■ Asherman’s syndrome
■ Cervical stenosis
Hypergonadotropic Hypogonadism
(Ovarian Failure)
■ Postmenopausal
■ Premature failure: e.g., autoimmune, chemotherapy,
galactosemia, genetic, 17-hydroxylase deﬁciency syndrome,
mumps, pelvic radiation
FADavis_Chapter 03 .qxd 9/12/08 3:48 PM Page 80

81
ALGOR
Breastdevelopment&
femaleTannerstage
Pelvic
ultrasound
Uterineoutflow
obstruction?
Mullerian
dysgenesis
Pituitary
defect
GnRH
deficiency
Buccal
smear
Puregonadal
dysgenesis
Male
pseudohermaphrodite
Polycysticovary
syndrome
Adrenalor
ovariantumor
Second-Degree
Amenorrhea
Imperforate
hymen
Transverse
vaginalseptum
Hyperandrogenism?Karyotype
Karyotype
Height
LH
FSH
Turner’s
PrimaryAmenorrhea
NormalAbnormal
Uterus
Nouterus
46XX
Yes
No
NoYes
46XY
46XX46X0
Abnormal
Normal
<5
ng/mL
<5
ng/mL
>40
ng/mL
>40
ng/mL
Short
Normal

82
ALGOR
SecondaryAmenorrhea
Uterineoutflow
obstruction?
Hyperprolactinemia
Pregnancytest
FSH
LH
Prolactin
TSH
Pregnancy
Thyroid
disease
Normogonadotropichypogonadism
Hypogonadotropic
hypogonadism
Hypergonadotropic
hypogonadism
(ovarianfailure)
Estrogen/progestogenchallenge
Abnormal
Normal
–
+
Nobleeding
Nobleeding
Vaginalbleeding
<7days
Vaginalbleeding<7days
Vaginalbleeding
<5ng/mL>40ng/mL
<5ng/mL>20ng/mL
Progestin
challenge

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