Exam 2 Flashcards
Where should you place the stethoscope to hear bronchial sounds?
Above the manubrium, over the trachea
Expected findings for bronchial aucultation
Sounds should be high-pitched, harsh, and loud
Where are bronchiovesicular sounds heard?
Over the main bronchi
Describe bronchiovesicular sounds
Medium in loudness and pitch
Where are vesicular sound heard?
over the lower bronchi, the bronchioles, and the lobes
Describe the vesicular sounds
softest and lowest in pitch
Describe fine crackles
high pitched, discontinuous crackling sounds that occur when inhaled air meets deflated alveoli
Describe course crackles
loud, low-pitched bubbling sounds that are caused when air meets secretions in the airways
Describe rhonchi
continuous, low-pitched snoring sounds caused by airway obstruction from thick secretions, muscular constriction, or masses; coughing may clear sound
Describe wheezes
continuous, high-pitched musical sounds that are created by the narrowing of airways from swelling, secretions, or masses
Describe stridor
a loud, continuous high-pitched crowing sound caused by upper airway obstruction
Why are the superficial lymph nodes important?
They can be palpated and are a gateway to assessing the health of the entire lymphatic system; abnormalities can be some of the earliest clues for infection or malignancy
What would a coarse or gritty sensation when palpating the thyroid gland indicate?
An inflammatory process in the gland
How would a provider characterize nodules on the thyroid gland?
Number, smooth or irregular, soft or hard
What should the provider do if the thyroid is enlarged?
auscultate for vascular sounds with the bell of the stethoscope to assess for bruit (indicates a hypermetabolic state and increased blood flow)
What is the manubriosternal junction (angle of Louis)?
A visible and palpable angle of the sternum at which the second rib articulates with the sternum
Describe assessment findings for barrel chest
Ribs are more horizontal, the spine is somewhat kyphotic, and the sternal angle is more prominent
What are some causes of barrel chest?
chronic asthma, emphysema, or cystic fibrosis
What causes the sound heard on S1?
closing of the mitral and tricuspid valves
What causes the sound of S2?
Closing of the pulmonic and aortic valves
Where would the practitioner auscultate for the aortic area of the heart?
2nd intercostal space at the upper right sternal border
Where would the practitioner auscultate for the pulmonic area of the heart?
2nd intercostal space at the upper left sternal border
Where would the practitioner auscultate for Erb’s point?
the 3rd intercostal space at the medial left sternal border
Where would the practitioner auscultate the tricuspid area?
4th intercostal at the left sternal border
Where would the practitioner auscultate the apical/mitral area?
At the fifth left intercostal space, mid-clavicular line
Describe ventricular gallop
A third heart sound known as S3; occurs after S1/2 from the change in blood flow during diastole when rapid filling ends and slow filling begins
How would the practitioner identify the S3 sound?
The heart beat would sound like “KEN-TUCK-y” with Y being the S3; it is a low frequency and intensity sound and best heard with the bell of the stethoscope
Describe atrial gallop
A fourth heart sound, S4; occurs because of late diastolic filling due to atrial contraction right before S1; can indicate increased resistance in ventricles
How would the practitioner identify an atrial gallop?
Resembles the pronunciation of TEN-es-see; a low frequency sound
Describe a pericardial friction rub and what it can indicate
a sound generated from inflammation of the pericardial sac as it rubs against the linings surrounding the heart; is a sign of pericarditis
How will a practitioner identify a pericardial friction rub?
it is a scratching, grating, high frequency sound that is heard in both systole and diastole; best heard with diaphragm at the left lower sternal border
What is an innocent or functional murmur?
Non-cardiac murmurs related to pregnancy, hyperthyroidism, or exersize; common in children
What is a pathological murmur?
A murmur due to congenital or valvular defects; specific defects can be identified by the timing of the murmur and the auscultation region where it is best heard
Name the organs of the lymphatic system
lymph nodes, spleen, thymus, tonsils, adenoids, and Peyer patches in the small intestine
What are the functions of the lymphatic system?
conservation of fluid and plasma that leak from capillaries, defending the body against disease as part of the immune system, and absorbing lipids from the intestinal tract
Where can lymph vessels be found in the body?
every tissue supplied by blood vessels except the placenta and the brain
How do lymphatic vessels work to fight disease?
maintains fluid balance, filters out substances that could be harmful to the body, initiates phagocytosis, produces lymphocytes, produces antibodies, absorbs fat and fat-soluble substances
Where is the thymus located?
in the superior mediastinum
What does the thymus do?
produces T lymphocytes and controls the immune responses generated by B lymphocytes- atrophies after puberty
Where is the spleen?
In LUQ between the stomach and diaphragm
What are the functions of the spleen?
destroying old RBCs, producing antibodies, storing RBCs, and filtering micro-organisms
What are Peyer patches?
small, raised areas of lymph tissue on the mucosa of the small intestine
Describe the development of the lymphatic system in infants and children
begins developing at 20 weeks gestation but is still immature at birth; large amount of lymphoid tissue in childhood and regression of tissue in adulthood
Describe changes to the lymphatic system in a pregnant patient
a pregnant patient has an altered immune system and is therefore more likely to get sick
Describe changes to the lymphatic system in the elderly
the number of lymph nodes will diminish in size and decrease; more likely to have fibrotic and fatty nodes
HPI for enlarged lymph nodes
Associated local symptoms: pain, edema, redness, warmth
Associated systemic symptoms: malaise, fever, weight loss
Predisposing factors: recent surgery, infection
Medications
Character: onset, location, duration
HPI for swelling of extremity
unilateral or bilateral, intermittent or constant, duration
Predisposing factors: trauma, surgery
Associated symptoms: warmth, redness, ulceration
Efforts to treat: TED hose, elevation
HPI for pregnant woman with lymphatic problems
Weeks gestation
Exposure to infections
Exposure to cat feces or litter
Immunization status
What are three physical signs of lymphatic problems?
enlarged lymph nodes (lymphadenopathy), red streaks (lymphangitis), and lymphedema
How to palpate the superficial lymph nodes
use pads of the second, third, and fourth fingers
Should the superficial nodes be palpable in a healthy individual?
No, they are normally not large or firm enough to be felt
Name some words to describe abnormal lymph nodes
Shotty (small and nontender), fluctuant (wavelike motion felt on palpation), and matted (group of nodules that feel connected)
How to characterize enlarged lymph nodes
location, size, shape, consistency (soft, hard), tenderness, mobility, or fixation to surrounding tissues
What would a hard, fixed, painless node suggest?
Malignancy
What would a very tender node indicate?
an inflammatory process
What would a palpable supraclavicular node indicate?
thoracic or abdominal malignancy
Differential diagnosis for lymph node enlargement
thyroid goiter, graves disease, parotid swelling, hemangioma, brachial cleft cyst
Where are the submandibular nodes located?
halfway between the angle and the tip of the mandible
Where are the parotid and retropharyngeal nodes?
angle of the mandible
Where are the postauricular nodes noted?
superficially over the mastoid process
Where are the posterior cervical nodes located?
along the anterior border of the trapezius muscle
Where are the superficial cervical nodes located?
at the sternocleidomastoid muscle
Are lymph nodes more commonly enlarged in children or adults?
Children
When would lymphadenopathy call for further evaluation?
If localized & persistant (esp in young adults/children with supraclavicular) or without evidence of infection
How do you tell the difference between edema and lymphadema?
Edema- improved with diuretics or elevation of affected area
Lymphedema- not improved with diuretics or elevation; both can be pitting or nonpitting
What is lymphangioma?
a congenital malformation of dilated lymphatics; inadequate development and therefore obstruction of the lymphatic system mostly in the neck
S&S of lymphangioma
S- painless cystic masses during 1st year of life
O- soft, nontender, easily compressible mass without margins; present at birth and apparent early in life; diagnosed through physical exam and imaging
What is lymphatic filariasis (elephantiasis)?
massive accumulation of lymphedema throughout the body; transmitted by mosquitos patient is more susceptible to infection, cellulitis, and fibrosis
S&S of elephantiasis
swelling of limb or body area; travel to Asia, Africa, western pacific, India, or the Phillipines, fever, chronic pulmonary infection
O- lymphedema of entire arm or leg or genital regions
What is non-hodgkin lymphoma?
Malignant neoplasm of the lymphatic system and the reticuloendothelial tissues; occur most often in chest, neck, abdomen, tonsils, and skin lymph nodes
S&S of non-hodgkin
S- painless, enlarged lymph nodes, fever, weight loss, abdominal pain, family history
O- nodes may be localized in the posterior cervical triangle or become matted; nodes well-defined and solid
Hodgkin lymphoma
Starts in a single node (most common in neck area) or chain and spreads to contiguous lymph nodes, spleen, liver, and bone marrow; often occurs in late adolescence and young adulthood; males twice as likely to get
S&S of Hodgkin
S- painless enlarged lymph nodes, abdominal pain, history of mononucleosis
O- most common symptom is painless enlarged cervical lymph nodes, asymmetric and progressive, almost rubbery upon palpation
What is epstein-barr virus mononucleosis?
an infection that targets oral epithelial cells and spreads to other structures such as salivary glands, liver, and spleen
S&S of Epstein-barr virus mononucleosis
S- malaise, fatigue, acute or prolonged, fever, headache, sore throat, nausea, abdominal pain, myalgia
O- generalized lymphadenopathy most commonly in cervical nodes and especially epitrochlear nodes, hepatomegaly, splenomegaly, pharyngitis with tonsillar enlargement, petechiae in hard/soft palate
What is toxoplasmosis?
caused by ingestion or inhalation of oocysts in soil, undercooked meat, or raw eggs, cat feces or litter; infection can persist for life without signs of disease or cause congenital infection if exposed during pregnancy especially in the first trimester
What is roseola infantum?
an infection by human herpes virus 6; common in infancy; present in saliva of most adults and readily transmitted via oral secretions
S&S of roseola infantum
S- fever, mild respiratory illness
O- lymphadenopathy, discrete and non tender, involves the occipital and postauricular chains
What is HSV?
infection by human herpes virus 1 or 2; transmitted by oral secretions, genital secretions, and close contact
S&S of HSV
S- burning, itching lesions, enlarged lymph nodes
O- discrete labial and gingival vesicles or ulcers, enlargement of lymph nodes that are firm, discrete, movable, and tender
What is cat scratch disease?
a disease causing lymphadenitis in children caused by a bite, scratch or injury from a cat
S&S of cat scratch disease
S- scratch or wound with painful enlarged lymph nodes
O- single lymph node, very large, lasting longer than 3 weeks
Name some common life-threatening diseases associated with AIDS
Kaposi sarcoma, pneumonia, pulmonary tuberculosis, invasive cervical cancer, parotid enlargement simulating mumps, anemia, chronic diarrhea, recurrent infections
What is serum sickness (Type III hypersensitivity reaction)?
a hypersensitivity reaction in response to antigens in the blood stream
S&S of Serum sickness
S- enlarged lymph nodes, organ transplant, rashes, pain, pruritus, and erythematous swelling at the injection site, recent administration of antibiotics
O- symptoms present 7-10 days after administration of provoking substance, facial and neck edema, urticaria, purpuric lesions
Latex allergy type IV dermatitis
T-cell mediated hypersensitivity reaction caused by chemicals used in latex products; skin reaction occurs within 48-72 hours after infection
Latex allergy type I reaction
true allergic reaction caused by immunoglobulin E antibodies causes release of histamine, leukotrienes, prostaglandins, and kinins; causes generalized urticaria with angioedema, asthma, GI symptoms, anaphylaxis
Why are an infant’s cranial bones separated?
Because the spaces between the bones permit the expansion of the skull to accomodate brain growth
When does ossification of sutures begin?
At 6 years of age
Why does a pregnant woman need increased iodine intake?
Because the mother is the source of the infant’s thyroid hormone until the second trimester; if pregnant woman’s thyroid is enlarged = iodine deficiency
What are some changes to the thyroid in older adults?
T4 production decreases and thyroid gland becomes more fibrotic
S&S of Cushing’s syndrome
face is moon-shaped with thin, erythematous skin; upper thoracic fat pad present
S&S of myxedema
course, sparse hair, temporal loss of eyebrows, periorbital edema, prominent tongue
S&S of hyperthyroid
Fine, moist skin with fine hair, prominent eyes with lid retraction
S&S of Bell palsy
(CNVII); asymmetry of one side of the face
Facial assessment findings for children with downysndrome
depressed nasal bridge, epicanthal folds, mongoloid slant of eyes, low-set ears
Facial assessment findings for children with Hurler syndrome
enlarged skull with low forehead, corneal clouding, and short neck
Facial assessment findings for children with hydrocephalus
enlarged head, thinning of the scalp with dilated scalp veins, sclera visible above the iris
Facial assessment findings for children with fetal alcohol syndrome
poorly formed philtrum, widespread eyes, with inner epicanthal folds and mild ptosis; short nose, thin upper lip
Neck anatomical landmarks
hyoid bone, thyroid, and cricoid cartilages: should be smooth and nontender and should move when patient swallows
Explain what happens to an infant’s respiratory system when it is born
Infant initially gasps and cries, filling the lungs up with air for the first time; increased blood flow to lungs causes closure of the heart’s foramen ovale and ductus arteriosiswithin minutes
What is patent ductus arteriosis (PDA)?
failure to close of the heart’s foramen ovale and ductus arteriosus; more common in infants under 30 weeks of gestation; if large enough can lead to left ventricular overload and heart failure
Describe anatomical changes to chest during pregnancy
lower ribs flare increasing the lateral diameter; the diaphragm at rest rises as much as 4 cm above its usual resting positioning; minute ventilation increases and increased tidal volume
Changes of chest in older adults
barrel chest is common, increased AP chest diameter, stiffening of chest wall, alveoli become more fibrous , dry mucous membranes
HPI for patient with cough
Onset: sudden or gradual Nature: dry, moist, wet, hacking Sputum production/characteristics Pattern Severity: tired patient, disrupts sleep
HPI for shortness of breath
Onset: sudden or gradual, duration Position most comfortable Related to activities? Harder to inhale or exhale Efforts to treat? oxygen?
What would a Kussmaul breathing pattern indicate?
metabolic acidosis
Describe Cheyne-Stokes respirations
regular periodic pattern of breathing with intervals of apnea followed by crescendo/decrescendo sequences
What would Cheyne-stokes respiratory pattern indicate?
brain damage at the cerebral level or drug associated respiratory compromise
How do chest retractions appear?
the chest wall seems to cave in at or around the bones
What would the prescence of retractions indicate?
an obstruction in the airways
S&S of an obstructed airway
inspiratory stridor, hoarse or barking cough or cry, retractions, difficulty swallowing
Describe crepitus
a crackly or crinkly sensation felt upon palpation of chest; indicates an underlying pathological process
How does one evaluate thoracic expansion?
stand behind the patient and bplace thumbs along the spinal processes at the level of the 10th rib with palms lightly in contact with the posterolateral surfaces
What would decreased or absent fremitus indicate?
excess air in the lungs or emphysema, pleural thickening or effusion, or bronchial obstruction
What would increased fremitus indicate?
fluids or a solid mass within the lungs, heavy bronchial secretions, or a compressed lungs
What can indicate tension pneumothorax?
Displaced trachea to either side depending on where the tension pneumo is; pneumo on the right= trachea displaced to the left and vice versa
Patient positioning for percussion of the chest
1st. examin back- patient sitting with head bent forward and arms folded infront
2nd. Have patient raise the arms overhead while you percuss the lateral and anterior chest
Correct order of percussion of chest
Start with back and then front’ always move from superior to inferior and medial to lateral
What sound is expected on percussion of the chest?
resonance
What would hyperresonance on percussion of chest indicate?
hyperinflation: emphysema, pneumothorax, or asthma
What would dullness or flatness on percussion of the chest indicate?
pneumonia, atelectasis, pleural effusion, or asthma
How to measure the diaphragmatic excursion
Have patient hold breath on inhale, percuss along scapular line until you locate the lower scapular border, mark the point, ask the patient to take several breaths and exhale and hold, percuss from marked point and make another mark at position of the lower scapular border; measure and record distance between marks
What is the normal diaphragmatic excursion distance
3-5 cm
Describe a hyperresonant sound over percussion of the chest
Very loud, low pitch, long duration, booming quality
What can bad breath indicate?
An infection in the nasal or oral cavity or deep in the lung
What can a sweet, fruity breath indicate?
Diabetic ketoacidosis
Describe a pleural friction rub
Dry, rubbing, or grating sound usually caused by inflammation of pleural surfaces; loudest over lower lateral anterior surface
What is Hamman sign?
Also known as mediastinal crunch; found with mediastinal emphysema
Would men or women have greater vocal resonance? Why?
Men; because their voices are lower-pitched
Define bronchophony
Vocal resonance with greater clarity and increased loudness of spoken sounds
Describe whispered pectoriloquy
when a whisper can be heard clearly and intelligibly through the stethoscope on the chest; a sign of consolidation of the lungs
What is a newborns expected respiratory rate?
40-60 respirations per minute
What does stridor indicate?
an obstruction high in the respiratory tree
What is respiratory grunting?
a mechanism by which the infant tries to expel trapped air or fetal lung fluid while trying to retain air and increase oxygen; cause for concern only if persistant
Changes to respiratory system in children
Chest is thinner and more resonant; intrathoracic sounds easier to hear; increased respiratory rate
Trick to have a child complete big expiration
Have them “blow out” the candle/flashlight
Changes to respiratory system during pregnancy
SOB is common, more deep breaths
Changes to respiratory system in older adults
chest expansion decreased, loss of subcutaneous tissue, kyphosis, flattening of lumbar curve
Sample subjective information for respiratory workup
Nonproductive cough for past several days. Persistent, worse when lies down. Feels ill. Chest feels “heavy”. SOB when walking up stairs. Fever up to 101 degrees. Taking cough syrup without relief
Sample objective information for respiratory assessment
Chest without kyphosis or other distortion. Thoracic expansion symmetric. Respirations rapid and somewhat labored, no retractions or stridor. No friction rubs or tenderness over ribs. Tactile fremitus increased over the left base posteriorly. Crackles heard on inspiration and expiration on left base.
Physical findings associated with asthma
Tachypnea, tachycardia, decreased fremitus, wheezing, prolonged expiration, decreased lung sounds, diaphragm level lower with decreased descent
Physical assessment findings with atelactasis
Delayed or diminished chest wall movement, tachypnea, diminished fremitus, apical cardiac impulse and trachea deviated, dullness over affected lung, adventitious lung sounds
Physical findings with bronchiectasis
Respiratory distress, hyperinflation, clubbing, crackles, rhonchi
Physical findings with bronchitis
tachypnea, shallow breathing, diminished fremitus, adventitious lung sounds, prolonged lung sounds
Physical assessment findings of COPD
respiratory distress, cyanosis, distended neck veins, limited mobility of diaphragm, hyperresonance, decreased breath sounds with inspirational crackles
Physical findings with emphysema
pursed lips, barrel chest, underweight, apical impulse decreased, diminished fremitus, hyperresonance
Physical assessment findings with a pleural effusion
diminished and delayed chest movement, PMI & trachea shifted contralaterally, diminished fremitus, bronchophony, whispered pectoriloquy, dull/flat percussion
Assessment findings with pneumonia consolidation
limited chest rise, increased fremitis (unless emphysema or pleural effusion), dullness, bronchial breath sounds, egophony, whispered pectoriloquy
Assessment findings for pneumothorax
Tachycardia, bulging intercostal spaces, contralateral tracheal deviation (if tension), diminished or absent breath sounds, hyperresonance, diminished or absent fremitus
Difference in symptoms between acute and chronic bronchitis
Acute- fever & chest pain; chronic- productive cough
What is pleurisy?
inflammatory process involving the visceral and parietal pleura
Assessment findings for pleurisy
chest pain when taking a breath (sometimes radiating to shoulder), rapid and shallow respirations, pleural friction rub, possible fever
What is a pleural effusion?
excessive nonpurulent fluid in the pleural space
What is an empyema?
purulent exudative fluid collected in the pleural space
S&S of empyema
febrile, tachypneic, cough and chest pain, progressive dyspnea, cough with blood and sputum, absent or distant breath sounds, percussion is dull and absent fremitus
What can be an indication of a small pneumothorax?
unexplained but persistent tachycardia
What is a major clue to a pulmonary embolism?
pleuritic chest pain with or without dyspnea
Objective findings for pulmonary embolism
low-grad fever, isolated tachycardia, hypoxia, possible pleural friction rub
S&S of epiglottitis
begins suddenly and progresses rapidly without cough, panful sore throat, high fever, beefy red epiglottis
Common respiratory problems in infants/children
diaphragmatic hernia, cystic fibrosis, croup, tracheomalacia, bronchiolitis
S&S of cystic fibrosis
cough with sputum, malabsorption, bronchiectasis, barrel chest, pulmonary hypertension, cor pulmonale
What is cystic fibrosis?
autosomal recessive disorder of exocrine glands involving the lungs, pancreas, and sweat glands
S&S of croup
barking cough, labored breathing, retractions, restlessness
What is tracheomalacia?
lack of rigidity or floppiness of the trachea or airway
S&S of tracheomalacia
noisy breathing, wheezing, stridor, respiratory distress
