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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
X wave/ slope
represents passive atrial filling and atrial relaxation steeper descent seen in cardiac tamponade or constrictive pericarditis
26
y slope
open tricuspid valve and rapid RV filling in RV diastole very steep if there is severe tricuspid regurgitation
27
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)
28
S1
ventricular systole | - closing of mitral then tricuspid valves
29
S2
ventricular diastole - filling | closing of aortic and pulmonary valves
30
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
31
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
32
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
33
a wave
Ra contraction ; TV open coincides with S1 precedes carotid pulsation
34
v wave
atrial filling, increased volume and pressure in RA when TV is closed
35
what is an example of an ejection murmur and where can you hear it best?
aortic stenosis aortic valve 2nd ICS at RSB
36
what are examples of early diastolic murmurs and where can you hear them best?
aortic and pulmonic regurgitations pulmonary valve - 2nd ICS at LSB
37
where can pulmonic stenosis best be heard?
Erb's point- 3rd ICS - 2 FB lateral from LSB
38
what are pansystolic murmurs and where can they best be heard?
tricuspid regurgitations and ventricular septal defects tricuspid valve - 4th ICS at LSB
39
what are mid to late diastolic murmurs heard within the tricuspid valve area?
tricuspid stenosis and atrial septal defect
40
what is a pansystolic murmur within the mitral valve area?
mitral regurgitation
41
what is a mid-late diastolic murmur within the mitral valve area?
mitral stenosis
42
which maneuver would increase the intensity of a hypertrophic cardiomyopathy murmur?
standing valsalva
43
which maneuver would increase the intensity of a murmur caused by aortic stenosis?
squatting Valsalva
44
what would decrease the intensity of a murmur caused by aortic stenosis?
standing valsalva
45
what would decrease the intensity of a murmur caused by hypertrophic cardiomyopathy?
squatting valsalva
46
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
47
what are the murmur effects of squatting valsalva maneuver ?
intensifies murmur - aortic stenosis | decreases intensity of murmur - hypertrophic cardiomyopathy
48
what are the murmur effects of standing valsalva maneuver?
intensifies murmur- hypertrophic cardiomyopathy | decreases intensity of murmur- hypertrophic cardiomypathy
49
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
50
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
51
Giant A wave
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
52
normal range - RAP
0-8 mmHg
53
RV pressure
25/6 mmHg
54
pulmonary arterial pressure (PAP)
Systolic 15-30 mmHg diastolic 5-12 mmHg mean 10-20 mmHg
55
pulmonary wedge pressure (PCWP)
8-15 mmHg
56
cardiac output
3.5-7 L/min
57
``` Cardiac index (CI) CI= CO/BSA ```
2.5-4 L/min^2
58
Systolic Vascular Resistance (SVR)
900-1500 dynes/second/cm
59
what are the exceptions for Increase of preload/afterload --> increases murmur intensity
Hypertrophic obstructive cardiomyopathy (HOCM) Mitral valve prolapse both inverse of preload/afterload
60
inspiration effects on murmurs
louder on right valves (tricuspid and pulmonary)
61
expiration effects on murmurs (RIN_LEX)
louder on left valves (mitral and aortic)
62
what is the order of valve closure
systole - S1 : mitral --> tricuspid | diastole- S2: aortic ---> pulmonic
63
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.
64
pulmonary vascular resistance (PVR)
155-255 dynes/second/cm
65
aortic stenosis - sound shape
crescendo -decrescendo
66
aortic stenosis - key points
systolic CALCIFIED aortic valve radiates to CAROTIDS SAD (syncopal, anginal, dyspnea)
67
aortic regurgitation - sound shape
decrescendo
68
aortic regurgitation - key points
``` early diastolic MARFANS CT disorders Head bobbing water-hammer pulse femoral bruits "blowing' ```
69
tricuspid regurgitation - sound shape
plateau/ holosystolic/pansystolic
70
tricuspid regurgitation- key point
history of IV drug abuse
71
mitral stenosis - sound shape
OS decrescendo, crescendo S1
72
mitral stenosis- key point
rheumatoid fever
73
mitral valve prolapse - sound shape
crescendo
74
mitral valve prolapse - key points
young female with psychiatric history myxomatous valvular pathology mid systolic click
75
mitral regurgitation- sound shape
slight pause after S1 then plateau/holosystolic/pansystolic
76
mitral regurgitation - key points
radiates to AXILLA best heard at apex loud blowing
77
valsalva squatting - effect on preload and afterload
increases
78
valsalva standing - effect on preload and afterload
decreases
79
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)
80
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)
81
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)
82
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
83
in a TOTAL irregular pattern heart rate, what cardiac effects are observed?
atrial fibrillation | atrial flutter with varying block
84
what is the normal respiratory rate for adults?
14/15-20 breaths per minute
85
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
86
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
87
where is heart level roughly when taking blood pressure?
4th ICS
88
what is the BP range for prehypertension
S/D: 120-139/80-89
89
what is the BP range for stage 1 HTN
S/D: 140-159/90-99
90
what is the BP range for diabetic/renal disease pts 18-60 yo?
S/D: 150-159/90-99
91
what is the BP range for pts 60+yo or have Stage 2 HTN?
S/D: 160+/100+
92
what temperature is considered a fever?
100.4 F or 38 C
93
what is something to note about rectal temperature?
0.5-0.7 F HIGHER than oral temperature
94
what is something to note about axillary temperature?
0.3-0.4 F LOWER
95
Ear temperature
temperature taken from the ear drum is reflective of body core/internal organ temperature
96
what is the 5th vital sign?
peripheral arterial oxygen saturation (SpO2)- 95-100% normal | obtain using a pulse oximetry
97
what are causes bad waveforms when measuring peripheral arterial oxygen saturation?
improper placement, hypo-perfusion, hypothermia, motion artifact
98
how do you examine the ear canal?
adults: pull up, out and posterior children: pull down, out and posterior
99
what characterizes otitis externa?
symptoms: ear pain PE findings: swollen entrance to ear canal, erythema, discharge
100
describe cerumen impaction
accumulation of earwax --> hearing loss, feeling of fullness, itching
101
characterize ear perforation
hearing loss, ear pain, usually due to infection or trauma (foreign objects, pressure or sound) tends to heal on its own
102
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
103
characterize acute otitis media
fever, ear pain, hearing loss PE findings: bulging membrane (obscured landmarks), erythema, dilated blood vessels
104
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
105
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
106
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
107
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
108
cotton wool spots are mostly seen in what conditions?
HTN, diabetes, HIV
109
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
110
Drusen bodies can be seen in ...
- seen in normal aging and age-related macular degeneration
111
what is the order of PE for cardiac complaint
inspection, palpation, percussion, auscultation
112
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
113
what structures have a vesicular sound (lung auscultation)?
lesser bronchi, bronchioles, and lobes
114
what structures have a bronchial sound?
over trachea
115
what structures have a Bronchovesicular sound?
main bronchi
116
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
117
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)
118
what is the order of an abdominal exam?
inspection auscultation percussion palpation
119
what pathologies are associated with RUQ pain?
``` cholecystitis pyelonephritis ureteric colic hepatitis pneumonia ```
120
what pathologies are associated with RLQ pain?
``` appendicitis ureteric colic inguinal hernia IBD UTI gynaecological/ testicular torsion ```
121
what pathologies are associated with LLQ pain?
``` diverticulitis ureteric colic inguinal hernia IBD UTI gynaecological/ testicular torsion ```
122
what pathologies are associated with LUQ pain?
gastric ulcer pyelonephritis ureteric colic pneumonia
123
what condition is associated with all 4 abdominal quadrants?
ureteric colic
124
how many clicks in a normoactive bowel?
5-34/min
125
hypoactive bowel sounds
decreased motility, none for 1 minute - listen for at least 2 min could indicate constipation, ileus, medication side effect
126
hyperactive bowel sounds
increased motility | due to: diarrhea, early stages of intestinal obstruction, bowel prep
127
high-pitched bowel sounds
tinkling could suggest intestinal obstruction
128
what is the pitch for bell and diaphragm
diaphragm- high pitch | bell-low pitch
129
friction rub
grating sounds with respiratory variation - inflammation of the peritoneal surface of an organ - listen over liver and spleen
130
venous hum
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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