ECOS 2 - final clinical notes Flashcards
Rales (crackles)
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
wheezing
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
stridor
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
atelectasis
alveolar collapse - blockage of airflow to a portion of the lung
insertion of Anterior and Middle Scalenes
1st rib - elevate rib and lateral flexion of the neck
insertion of posterior scalene
2nd rib- elevate rib and lateral flexion of the neck
what ribs are involved in increasing the anterior/posterior diameter of the chest?
ribs 3-7 –> pump handle motion (a/p) - moves anteriorly and superiorly
what ribs increase transverse diameter?
Ribs 1-2,8-10 ; bucket handle (move superior and laterally)
what ribs are associated with caliper motion?
Ribs 11 and 12
what is the first rib to treat?
key rib– BITE
inhalation - Bottom
exhalation - Top
what muscles are used in the treatment of Ribs 3-5?
pectoralis minor
what muscles are used in the treatment of Ribs 6-8?
serratus anterior
what muscles are used in the treatment of Ribs 9-10?
Latissimus Dorsi
what muscles are used in the treatment of Ribs 11-12?
quadratus lumborum
decreased or absent fermitus is indicative of?
COPD, pleural effusions, fibrosis, pneumothorax, thickened chest wall
decreased or absent fremitus is indicative of?
COPD, pleural effusions, fibrosis, pneumothorax, thickened chest wall
increased fremitus is indicative of ?
pneumonia- increased transmission through consolidated tissue
bronchophony
“99” test; spoken words become louder and clearer (indicates consolidation)
egophony
“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.
rhonchi
relatively low-pitches, snoring quality
suggests secretions in large airways
egophony
“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.
pulmonary htn signs
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
pulmonary HTN signs
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
C wave on JVP
backflow/backward push by closure of the tricuspid valve during isovolumetric systole
X wave/ slope
represents passive atrial filling and atrial relaxation
steeper descent seen in cardiac tamponade or constrictive pericarditis
y slope
open tricuspid valve and rapid RV filling in RV diastole
very steep if there is severe tricuspid regurgitation
y slope
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)
S1
ventricular systole
- closing of mitral then tricuspid valves
S2
ventricular diastole - filling
closing of aortic and pulmonary valves
S3
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
S3
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
S4
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
a wave
Ra contraction ; TV open
coincides with S1
precedes carotid pulsation
v wave
atrial filling, increased volume and pressure in RA when TV is closed
what is an example of an ejection murmur and where can you hear it best?
aortic stenosis
aortic valve 2nd ICS at RSB
what are examples of early diastolic murmurs and where can you hear them best?
aortic and pulmonic regurgitations
pulmonary valve - 2nd ICS at LSB
where can pulmonic stenosis best be heard?
Erb’s point- 3rd ICS - 2 FB lateral from LSB
what are pansystolic murmurs and where can they best be heard?
tricuspid regurgitations and ventricular septal defects
tricuspid valve - 4th ICS at LSB
what are mid to late diastolic murmurs heard within the tricuspid valve area?
tricuspid stenosis and atrial septal defect
what is a pansystolic murmur within the mitral valve area?
mitral regurgitation
what is a mid-late diastolic murmur within the mitral valve area?
mitral stenosis
which maneuver would increase the intensity of a hypertrophic cardiomyopathy murmur?
standing valsalva
which maneuver would increase the intensity of a murmur caused by aortic stenosis?
squatting Valsalva
what would decrease the intensity of a murmur caused by aortic stenosis?
standing valsalva
what would decrease the intensity of a murmur caused by hypertrophic cardiomyopathy?
squatting valsalva
Left ventricular volume, venous return, vascular tone, arterial blood pressure, peripheral vascular resistance are inversely proportional to what?
mitral valve prolapse (and its onset)
outflow obstruction and the intensity of a murmur caused by hypertrophic cardiomyopathy
what are the murmur effects of squatting valsalva maneuver ?
intensifies murmur - aortic stenosis
decreases intensity of murmur - hypertrophic cardiomyopathy
what are the murmur effects of standing valsalva maneuver?
intensifies murmur- hypertrophic cardiomyopathy
decreases intensity of murmur- hypertrophic cardiomypathy
what happens during isometric hang grip?
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
what are indications of possibly pulmonary emboli? particularly in pregnant women?
murmurs indicating aortic stenosis or pulmonary HTN can be indicative of a pulmonary embolism
Giant A wave
- obstruction between RA and RV (Tricuspid stenosis or RA myxoma)
- increased RV pressure (pulmonary stenosis)
- pulmonary HTN
- recurrent pulmonary emboli
- AV dissociation ( complete heart block, V-tach)
- cannon A waves. RA contracts against closed TV
normal range - RAP
0-8 mmHg
RV pressure
25/6 mmHg
pulmonary arterial pressure (PAP)
Systolic 15-30 mmHg
diastolic 5-12 mmHg
mean 10-20 mmHg
pulmonary wedge pressure (PCWP)
8-15 mmHg
cardiac output
3.5-7 L/min
Cardiac index (CI) CI= CO/BSA
2.5-4 L/min^2
Systolic Vascular Resistance (SVR)
900-1500 dynes/second/cm
what are the exceptions for Increase of preload/afterload –> increases murmur intensity
Hypertrophic obstructive cardiomyopathy (HOCM)
Mitral valve prolapse
both inverse of preload/afterload
inspiration effects on murmurs
louder on right valves (tricuspid and pulmonary)
expiration effects on murmurs (RIN_LEX)
louder on left valves (mitral and aortic)
what is the order of valve closure
systole - S1 : mitral –> tricuspid
diastole- S2: aortic —> pulmonic
when can you observe hyperresonance?
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.
pulmonary vascular resistance (PVR)
155-255 dynes/second/cm
aortic stenosis - sound shape
crescendo -decrescendo
aortic stenosis - key points
systolic
CALCIFIED aortic valve
radiates to CAROTIDS
SAD (syncopal, anginal, dyspnea)
aortic regurgitation - sound shape
decrescendo
aortic regurgitation - key points
early diastolic MARFANS CT disorders Head bobbing water-hammer pulse femoral bruits "blowing'
tricuspid regurgitation - sound shape
plateau/ holosystolic/pansystolic
tricuspid regurgitation- key point
history of IV drug abuse
mitral stenosis - sound shape
OS decrescendo, crescendo S1
mitral stenosis- key point
rheumatoid fever
mitral valve prolapse - sound shape
crescendo
mitral valve prolapse - key points
young female with psychiatric history
myxomatous valvular pathology
mid systolic click
mitral regurgitation- sound shape
slight pause after S1 then plateau/holosystolic/pansystolic
mitral regurgitation - key points
radiates to AXILLA
best heard at apex
loud blowing
valsalva squatting - effect on preload and afterload
increases
valsalva standing - effect on preload and afterload
decreases
if the pulse/heart rate is fast but normal rhythm (over 100bpm), what cardiac effects would be observed?
sinus tachycardia (100-180),
supraventricular (atrial or nodal) tachycardia (150-250)
atrial flutter w/ regular ventricular response (100-175), ventricular tachycardia (110-250)
if the rate and rhythm are normal (60-100bpm), what cardiac effects could be observed?
normal sinus rhythm (60-100)
2nd-degree AV block (60-100)
atrial flutter with a regular ventricular response (75-100)
if the rate is slow (below 60), but rhythm is normal, what cardiac effects could be observed?
sinus bradycardia (below 60)
2nd degree AV block (30-60)
complete heart block (less than 40)
what cardiac effects are seen in irregular sporadic/rhythmic patterns of heart rate?
with early beats, atrial or nodal (supraventricular) premature contraction
ventricular premature contractions (PVCs)
sinus arrhythmia
in a TOTAL irregular pattern heart rate, what cardiac effects are observed?
atrial fibrillation
atrial flutter with varying block
what is the normal respiratory rate for adults?
14/15-20 breaths per minute
how do you properly size blood pressure cuffs?
width of cuff should be ~40% of upper arm circumference (~12-14 cm in the average adult
what is the proper placement of a BP cuff and steps to taking BP?
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
where is heart level roughly when taking blood pressure?
4th ICS
what is the BP range for prehypertension
S/D: 120-139/80-89
what is the BP range for stage 1 HTN
S/D: 140-159/90-99
what is the BP range for diabetic/renal disease pts 18-60 yo?
S/D: 150-159/90-99
what is the BP range for pts 60+yo or have Stage 2 HTN?
S/D: 160+/100+
what temperature is considered a fever?
100.4 F or 38 C
what is something to note about rectal temperature?
0.5-0.7 F HIGHER than oral temperature
what is something to note about axillary temperature?
0.3-0.4 F LOWER
Ear temperature
temperature taken from the ear drum is reflective of body core/internal organ temperature
what is the 5th vital sign?
peripheral arterial oxygen saturation (SpO2)- 95-100% normal
obtain using a pulse oximetry
what are causes bad waveforms when measuring peripheral arterial oxygen saturation?
improper placement, hypo-perfusion, hypothermia, motion artifact
how do you examine the ear canal?
adults: pull up, out and posterior
children: pull down, out and posterior
what characterizes otitis externa?
symptoms: ear pain
PE findings: swollen entrance to ear canal, erythema, discharge
describe cerumen impaction
accumulation of earwax –> hearing loss, feeling of fullness, itching
characterize ear perforation
hearing loss, ear pain, usually due to infection or trauma (foreign objects, pressure or sound)
tends to heal on its own
characterize serous effusion
hearing loss, eustachian tube cannot drain (Upper respiratory infection)
PE findings: similar to normal or fluid level or bubbles
can lead to otitis media
characterize acute otitis media
fever, ear pain, hearing loss
PE findings: bulging membrane (obscured landmarks), erythema, dilated blood vessels
what is the function for tympanostomy tubes?
they are used to prevent fluid build-up behind the ears mostly in children- helps prevent hearing loss and frequent infections
papilledema
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
what is seen in glaucoma
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
cotton wool spots
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
cotton wool spots are mostly seen in what conditions?
HTN, diabetes, HIV
Drusen bodies
- 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
Drusen bodies can be seen in …
- seen in normal aging and age-related macular degeneration
what is the order of PE for cardiac complaint
inspection, palpation, percussion, auscultation
how many listening posts are there in respiratory exams
2 anterior -inferior to clavicle B/L
4 posterior- medial scapular spine, and inferior scapular borders B/L
what structures have a vesicular sound (lung auscultation)?
lesser bronchi, bronchioles, and lobes
what structures have a bronchial sound?
over trachea
what structures have a Bronchovesicular sound?
main bronchi
pneumothorax
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
describe physiologic splitting of S2
it is normal
inspiration because of increased venous return during inspiration and more time for RV to deliver blood to the lung (delayed P2)
what is the order of an abdominal exam?
inspection
auscultation
percussion
palpation
what pathologies are associated with RUQ pain?
cholecystitis pyelonephritis ureteric colic hepatitis pneumonia
what pathologies are associated with RLQ pain?
appendicitis ureteric colic inguinal hernia IBD UTI gynaecological/ testicular torsion
what pathologies are associated with LLQ pain?
diverticulitis ureteric colic inguinal hernia IBD UTI gynaecological/ testicular torsion
what pathologies are associated with LUQ pain?
gastric ulcer
pyelonephritis
ureteric colic
pneumonia
what condition is associated with all 4 abdominal quadrants?
ureteric colic
how many clicks in a normoactive bowel?
5-34/min
hypoactive bowel sounds
decreased motility, none for 1 minute
- listen for at least 2 min
could indicate constipation, ileus, medication side effect
hyperactive bowel sounds
increased motility
due to: diarrhea, early stages of intestinal obstruction, bowel prep
high-pitched bowel sounds
tinkling could suggest intestinal obstruction
what is the pitch for bell and diaphragm
diaphragm- high pitch
bell-low pitch
friction rub
grating sounds with respiratory variation
- inflammation of the peritoneal surface of an organ
- listen over liver and spleen
venous hum
soft humming noise
- increased collateral circulation between portal and systemic venous systems
listen over epigastric and umbilical regions
