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ecos > ECOS 2 - final clinical notes > Flashcards

ECOS 2 - final clinical notes Flashcards

1
Q

Rales (crackles)

A

discontinuous, intermittent, nonmusical and brief. Can be heard during INSPIRATORY or expiratory phases or mid-phases.
small airway closed during expiration, “popping” open during INSPIRATION

Fine rales: soft, high-pitched, very brief (5-10 msec)- sounds like velcro

coarse crackles: louder, lower in pitch, brief (20-30 msec)

congestive heart failure, pleural effusion, pulmonary edema, pulmonary fibrosis, atelectasis, bronchiectasis, PNEUMONIA, COPD, asthma

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2
Q

wheezing

A

generally EXPIRATORY, but can be inspiratory of biphasic

continuous musical quality, relatively high-pitched, prolonged, hissing or shrill quality

narrowed airways (asthma, COPD, bronchitis, heart failure), reactive airway disease

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3
Q

stridor

A

high-pitched wheeze, entirely/predominantly INSPIRATORY in nature
but can be expiratory or biphasic

often louder in the neck than in the chest wall
airway (larynx/trachea) obstruction - toys (EMERGENCY)
other causes: croup, epiglottitis, anaphylaxis

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4
Q

atelectasis

A

alveolar collapse - blockage of airflow to a portion of the lung

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5
Q

insertion of Anterior and Middle Scalenes

A

1st rib - elevate rib and lateral flexion of the neck

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6
Q

insertion of posterior scalene

A

2nd rib- elevate rib and lateral flexion of the neck

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7
Q

what ribs are involved in increasing the anterior/posterior diameter of the chest?

A

ribs 3-7 –> pump handle motion (a/p) - moves anteriorly and superiorly

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8
Q

what ribs increase transverse diameter?

A

Ribs 1-2,8-10 ; bucket handle (move superior and laterally)

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9
Q

what ribs are associated with caliper motion?

A

Ribs 11 and 12

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10
Q

what is the first rib to treat?

A

key rib– BITE
inhalation - Bottom
exhalation - Top

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11
Q

what muscles are used in the treatment of Ribs 3-5?

A

pectoralis minor

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12
Q

what muscles are used in the treatment of Ribs 6-8?

A

serratus anterior

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13
Q

what muscles are used in the treatment of Ribs 9-10?

A

Latissimus Dorsi

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14
Q

what muscles are used in the treatment of Ribs 11-12?

A

quadratus lumborum

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15
Q

decreased or absent fermitus is indicative of?

A

COPD, pleural effusions, fibrosis, pneumothorax, thickened chest wall

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16
Q

decreased or absent fremitus is indicative of?

A

COPD, pleural effusions, fibrosis, pneumothorax, thickened chest wall

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17
Q

increased fremitus is indicative of ?

A

pneumonia- increased transmission through consolidated tissue

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18
Q

bronchophony

A

“99” test; spoken words become louder and clearer (indicates consolidation)

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19
Q

egophony

A

“ee” sounds like and “ah”; has a nasal bleating qualitu and should be localized. in patients with fever and cough, the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia.

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20
Q

rhonchi

A

relatively low-pitches, snoring quality

suggests secretions in large airways

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21
Q

egophony

A

“ee” sounds like and “ah”; has a nasal bleating quality and should be localized. in patients with fever and cough, the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia.

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22
Q

pulmonary htn signs

A

chest pain, dyspnea, exertion intolerance, barrel chest (COPD), edema, cyanosis

increased JVP

all can cause an increase in Right Atrial Contraction, volume and pressure when the Tricuspid valve is closed —> prominent “ A wave” and “ v wave” respectively

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23
Q

pulmonary HTN signs

A

chest pain, dyspnea, exertion intolerance, barrel chest (COPD), edema, cyanosis

increased JVP

all can cause an increase in Right Atrial Contraction, volume and pressure when the Tricuspid valve is closed —> prominent “ A wave” and “ v wave” respectively

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24
Q

C wave on JVP

A

backflow/backward push by closure of the tricuspid valve during isovolumetric systole

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25
Q

X wave/ slope

A

represents passive atrial filling and atrial relaxation

steeper descent seen in cardiac tamponade or constrictive pericarditis

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26
Q

y slope

A

open tricuspid valve and rapid RV filling in RV diastole

very steep if there is severe tricuspid regurgitation

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27
Q

y slope

A

open tricuspid valve and rapid RV filling in RV diastole

very steep if there is severe tricuspid regurgitation

slow y descent - obstruction RV fillling (TS or RA myxoma)

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28
Q

S1

A

ventricular systole

- closing of mitral then tricuspid valves

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29
Q

S2

A

ventricular diastole - filling

closing of aortic and pulmonary valves

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30
Q

S3

A

due to high pressures and abnormal deceleration of inflow across the mitral valve at the end of rapid filling phase; heard immediately after S2

physiologically normal in children
pathologic for adults especially over 40 - HF

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31
Q

S3

A

due to high pressures and abnormal deceleration of inflow across the mitral valve at the end of rapid filling phase; heard immediately after S2

when left atria fills the stiff non compliant left ventricle under high pressure

physiologically normal in children
pathologic for adults especially over 40 - HF

Ken-tucky

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32
Q

S4

A

Before S1- represents an atrial gallop from forceful contraction of atria against a stiffened ventricle.

S4 immediately precedes S1 and can be normal in trained athletes. a low resting HR is also normal in trained athletes.

atrial filling sound due to high pressure from SVC/IVC and pulmonary venous return
Ten- nes - see

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33
Q

a wave

A

Ra contraction ; TV open
coincides with S1
precedes carotid pulsation

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34
Q

v wave

A

atrial filling, increased volume and pressure in RA when TV is closed

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35
Q

what is an example of an ejection murmur and where can you hear it best?

A

aortic stenosis

aortic valve 2nd ICS at RSB

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36
Q

what are examples of early diastolic murmurs and where can you hear them best?

A

aortic and pulmonic regurgitations

pulmonary valve - 2nd ICS at LSB

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37
Q

where can pulmonic stenosis best be heard?

A

Erb’s point- 3rd ICS - 2 FB lateral from LSB

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38
Q

what are pansystolic murmurs and where can they best be heard?

A

tricuspid regurgitations and ventricular septal defects

tricuspid valve - 4th ICS at LSB

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39
Q

what are mid to late diastolic murmurs heard within the tricuspid valve area?

A

tricuspid stenosis and atrial septal defect

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40
Q

what is a pansystolic murmur within the mitral valve area?

A

mitral regurgitation

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41
Q

what is a mid-late diastolic murmur within the mitral valve area?

A

mitral stenosis

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42
Q

which maneuver would increase the intensity of a hypertrophic cardiomyopathy murmur?

A

standing valsalva

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43
Q

which maneuver would increase the intensity of a murmur caused by aortic stenosis?

A

squatting Valsalva

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44
Q

what would decrease the intensity of a murmur caused by aortic stenosis?

A

standing valsalva

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45
Q

what would decrease the intensity of a murmur caused by hypertrophic cardiomyopathy?

A

squatting valsalva

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46
Q

Left ventricular volume, venous return, vascular tone, arterial blood pressure, peripheral vascular resistance are inversely proportional to what?

A

mitral valve prolapse (and its onset)

outflow obstruction and the intensity of a murmur caused by hypertrophic cardiomyopathy

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47
Q

what are the murmur effects of squatting valsalva maneuver ?

A

intensifies murmur - aortic stenosis

decreases intensity of murmur - hypertrophic cardiomyopathy

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48
Q

what are the murmur effects of standing valsalva maneuver?

A

intensifies murmur- hypertrophic cardiomyopathy

decreases intensity of murmur- hypertrophic cardiomypathy

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49
Q

what happens during isometric hang grip?

A

increase peripheral vascular resistance, arterial BP, vascular tone

makes LV work harder to get blood out of aorta, back up pressure against left ventricle –> systolic murmurs

  • mitral regurgitation
  • pulmonary stenosis
  • can worsen ventricular septal defects
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50
Q

what are indications of possibly pulmonary emboli? particularly in pregnant women?

A

murmurs indicating aortic stenosis or pulmonary HTN can be indicative of a pulmonary embolism

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51
Q

Giant A wave

A
  1. obstruction between RA and RV (Tricuspid stenosis or RA myxoma)
  2. increased RV pressure (pulmonary stenosis)
  3. pulmonary HTN
  4. recurrent pulmonary emboli
  5. AV dissociation ( complete heart block, V-tach)
    - cannon A waves. RA contracts against closed TV
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52
Q

normal range - RAP

A

0-8 mmHg

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53
Q

RV pressure

A

25/6 mmHg

54
Q

pulmonary arterial pressure (PAP)

A

Systolic 15-30 mmHg
diastolic 5-12 mmHg
mean 10-20 mmHg

55
Q

pulmonary wedge pressure (PCWP)

A

8-15 mmHg

56
Q

cardiac output

A

3.5-7 L/min

57
Q 
Cardiac index (CI)
CI= CO/BSA
A

2.5-4 L/min^2

58
Q

Systolic Vascular Resistance (SVR)

A

900-1500 dynes/second/cm

59
Q

what are the exceptions for Increase of preload/afterload –> increases murmur intensity

A

Hypertrophic obstructive cardiomyopathy (HOCM)
Mitral valve prolapse
both inverse of preload/afterload

60
Q

inspiration effects on murmurs

A

louder on right valves (tricuspid and pulmonary)

61
Q

expiration effects on murmurs (RIN_LEX)

A

louder on left valves (mitral and aortic)

62
Q

what is the order of valve closure

A

systole - S1 : mitral –> tricuspid

diastole- S2: aortic —> pulmonic

63
Q

when can you observe hyperresonance?

A

when percussing lungs hyperinflated with AIR (COPD, acute asthmatic attack)

An area of hyperresonance on one side of the chest may indicate a pneumothorax.

Tympanic sounds are hollow, high, drumlike sounds.

64
Q

pulmonary vascular resistance (PVR)

A

155-255 dynes/second/cm

65
Q

aortic stenosis - sound shape

A

crescendo -decrescendo

66
Q

aortic stenosis - key points

A

systolic
CALCIFIED aortic valve
radiates to CAROTIDS
SAD (syncopal, anginal, dyspnea)

67
Q

aortic regurgitation - sound shape

A

decrescendo

68
Q

aortic regurgitation - key points

A 
early diastolic
MARFANS
CT disorders
Head bobbing
water-hammer pulse
femoral bruits
"blowing'
69
Q

tricuspid regurgitation - sound shape

A

plateau/ holosystolic/pansystolic

70
Q

tricuspid regurgitation- key point

A

history of IV drug abuse

71
Q

mitral stenosis - sound shape

A

OS decrescendo, crescendo S1

72
Q

mitral stenosis- key point

A

rheumatoid fever

73
Q

mitral valve prolapse - sound shape

A

crescendo

74
Q

mitral valve prolapse - key points

A

young female with psychiatric history
myxomatous valvular pathology
mid systolic click

75
Q

mitral regurgitation- sound shape

A

slight pause after S1 then plateau/holosystolic/pansystolic

76
Q

mitral regurgitation - key points

A

radiates to AXILLA
best heard at apex
loud blowing

77
Q

valsalva squatting - effect on preload and afterload

A

increases

78
Q

valsalva standing - effect on preload and afterload

A

decreases

79
Q

if the pulse/heart rate is fast but normal rhythm (over 100bpm), what cardiac effects would be observed?

A

sinus tachycardia (100-180),
supraventricular (atrial or nodal) tachycardia (150-250)
atrial flutter w/ regular ventricular response (100-175), ventricular tachycardia (110-250)

80
Q

if the rate and rhythm are normal (60-100bpm), what cardiac effects could be observed?

A

normal sinus rhythm (60-100)
2nd-degree AV block (60-100)
atrial flutter with a regular ventricular response (75-100)

81
Q

if the rate is slow (below 60), but rhythm is normal, what cardiac effects could be observed?

A

sinus bradycardia (below 60)
2nd degree AV block (30-60)
complete heart block (less than 40)

82
Q

what cardiac effects are seen in irregular sporadic/rhythmic patterns of heart rate?

A

with early beats, atrial or nodal (supraventricular) premature contraction
ventricular premature contractions (PVCs)
sinus arrhythmia

83
Q

in a TOTAL irregular pattern heart rate, what cardiac effects are observed?

A

atrial fibrillation

atrial flutter with varying block

84
Q

what is the normal respiratory rate for adults?

A

14/15-20 breaths per minute

85
Q

how do you properly size blood pressure cuffs?

A

width of cuff should be ~40% of upper arm circumference (~12-14 cm in the average adult

86
Q

what is the proper placement of a BP cuff and steps to taking BP?

A

arm is supported at heart level
palpate brachial A. and place cuff ~2.5cm above antecubital fossa

estimate systolic BP by palpating radial A., inflate until it is not palpable, then add ~30 mmHg

measure by auscultation

87
Q

where is heart level roughly when taking blood pressure?

A

4th ICS

88
Q

what is the BP range for prehypertension

A

S/D: 120-139/80-89

89
Q

what is the BP range for stage 1 HTN

A

S/D: 140-159/90-99

90
Q

what is the BP range for diabetic/renal disease pts 18-60 yo?

A

S/D: 150-159/90-99

91
Q

what is the BP range for pts 60+yo or have Stage 2 HTN?

A

S/D: 160+/100+

92
Q

what temperature is considered a fever?

A

100.4 F or 38 C

93
Q

what is something to note about rectal temperature?

A

0.5-0.7 F HIGHER than oral temperature

94
Q

what is something to note about axillary temperature?

A

0.3-0.4 F LOWER

95
Q

Ear temperature

A

temperature taken from the ear drum is reflective of body core/internal organ temperature

96
Q

what is the 5th vital sign?

A

peripheral arterial oxygen saturation (SpO2)- 95-100% normal

obtain using a pulse oximetry

97
Q

what are causes bad waveforms when measuring peripheral arterial oxygen saturation?

A

improper placement, hypo-perfusion, hypothermia, motion artifact

98
Q

how do you examine the ear canal?

A

adults: pull up, out and posterior
children: pull down, out and posterior

99
Q

what characterizes otitis externa?

A

symptoms: ear pain

PE findings: swollen entrance to ear canal, erythema, discharge

100
Q

describe cerumen impaction

A

accumulation of earwax –> hearing loss, feeling of fullness, itching

101
Q

characterize ear perforation

A

hearing loss, ear pain, usually due to infection or trauma (foreign objects, pressure or sound)

tends to heal on its own

102
Q

characterize serous effusion

A

hearing loss, eustachian tube cannot drain (Upper respiratory infection)

PE findings: similar to normal or fluid level or bubbles

can lead to otitis media

103
Q

characterize acute otitis media

A

fever, ear pain, hearing loss

PE findings: bulging membrane (obscured landmarks), erythema, dilated blood vessels

104
Q

what is the function for tympanostomy tubes?

A

they are used to prevent fluid build-up behind the ears mostly in children- helps prevent hearing loss and frequent infections

105
Q

papilledema

A

indicates increased intracranial pressure that results in intra-axonal edema along the optic nerve –> swelling and engorgement of the optic disc (irregular blurred disc margins)

think: intracranial hemorrhage, meningitis, trauma, mass lesion

106
Q

what is seen in glaucoma

A

disc cupping- due to increased intraocular pressure (backward depression of the disc and atrophy)

base of the enlarged cup is pale
normal cup to disc ratio is 0.4
glaucoma is around 0.7

107
Q

cotton wool spots

A

white/grayish ovoid lesions with irregular soft borders.
moderate size but smaller than disk
result from extruded axoplasm from retinal ganglion cells caused by microinfarcts of the retinal nerve fiber layer.

HTN, DM, HIV

108
Q

cotton wool spots are mostly seen in what conditions?

A

HTN, diabetes, HIV

109
Q

Drusen bodies

A
  • small yellow spots, edges may be soft or hard
  • distribution varies but may concentrate at the posterior pole between the optic disc and the macula
  • consists of dead pigment epithelial cells
  • seen in normal aging and age-related macular degeneration
110
Q

Drusen bodies can be seen in …

A
  • seen in normal aging and age-related macular degeneration
111
Q

what is the order of PE for cardiac complaint

A

inspection, palpation, percussion, auscultation

112
Q

how many listening posts are there in respiratory exams

A

2 anterior -inferior to clavicle B/L

4 posterior- medial scapular spine, and inferior scapular borders B/L

113
Q

what structures have a vesicular sound (lung auscultation)?

A

lesser bronchi, bronchioles, and lobes

114
Q

what structures have a bronchial sound?

A

over trachea

115
Q

what structures have a Bronchovesicular sound?

A

main bronchi

116
Q

pneumothorax

A

collapse of the lung caused by gas/air going into the space between the chest wall and lungs.

unilateral absence of breath sound in the area of pneumothorax

117
Q

describe physiologic splitting of S2

A

it is normal
inspiration because of increased venous return during inspiration and more time for RV to deliver blood to the lung (delayed P2)

118
Q

what is the order of an abdominal exam?

A

inspection
auscultation
percussion
palpation

119
Q

what pathologies are associated with RUQ pain?

A 
cholecystitis
pyelonephritis
ureteric colic
hepatitis
pneumonia
120
Q

what pathologies are associated with RLQ pain?

A 
appendicitis
ureteric colic
inguinal hernia
IBD
UTI
gynaecological/ testicular torsion
121
Q

what pathologies are associated with LLQ pain?

A 
diverticulitis
ureteric colic
inguinal hernia
IBD
UTI
gynaecological/ testicular torsion
122
Q

what pathologies are associated with LUQ pain?

A

gastric ulcer
pyelonephritis
ureteric colic
pneumonia

123
Q

what condition is associated with all 4 abdominal quadrants?

A

ureteric colic

124
Q

how many clicks in a normoactive bowel?

A

5-34/min

125
Q

hypoactive bowel sounds

A

decreased motility, none for 1 minute
- listen for at least 2 min
could indicate constipation, ileus, medication side effect

126
Q

hyperactive bowel sounds

A

increased motility

due to: diarrhea, early stages of intestinal obstruction, bowel prep

127
Q

high-pitched bowel sounds

A

tinkling could suggest intestinal obstruction

128
Q

what is the pitch for bell and diaphragm

A

diaphragm- high pitch

bell-low pitch

129
Q

friction rub

A

grating sounds with respiratory variation

  • inflammation of the peritoneal surface of an organ
  • listen over liver and spleen
130
Q

venous hum

A

soft humming noise
- increased collateral circulation between portal and systemic venous systems
listen over epigastric and umbilical regions

ecos (11 decks)

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