Exam 2 Flashcards
HEENT, CV, PV, Thorax and Lungs
Headache: concerning for what conditions
life-threatening secondary causes such as meningitis, subarachnoid hemorrhage or mass lesion
types of primary headaches
migraine, tension, cluster, chronic daily
types of secondary headaches
systemic or infectious causes such as meningitis, subarachnoid hemorrhage
signs of subarachnoid hemorrhage
thunderclap headaches that reach maximal intensity over several minutes and are preceded by a sentinel leak
Erb’s point
3rd ICS on the left sternal border, best heard in the left lateral recumbent position
Mitral area
Also apex of the heart, best auscultated on the 5th ICS, at MCL
S3 - other name, best heard
Best heard with bell of stethoscope in the mitral/apical area, in early diastole, with person in left lateral decubitus position When rapid filling ends and slow filling starts
A PHYSIOLOGIC S3 is common in young people (to age 35-40), last trimester of pregnancy, and athletes In older people, may be associated with volume overload
A PATHOLOGIC S3, or ventricular gallop, is abnormal in people over age 40 (high ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of rapid filling phase of diastole)
Causes include decreased myocardial contractility, HF and ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts.
KENTUCKY
S4 - other name, best heard
Atrial gallop
Occurs in late diastole, due to atrial contraction, right before S1, due to pressure overload
Heard in mitral/apical area, in left lateral recumbent position, with bell
May sometimes occur in people over 40 after exercise
However, almost always pathological including hypertensive heart disease, aortic stenosis, and ischemic and hypertrophic CMY.
TENNESSEE
S1 is louder than S2
At the apex (5th ICS at MCL)
S2 is louder than S1
At the base
Abnormal JVP
> 3 cm above the sternal angle or more than 8 cm in total distance above the right atrium
May correlate with both acute and chronic HF, and tricuspid stenosis, chronic pulmonary htn, SVC obstruction, cardiac tamponade and constrictive pericarditis.
Where JVP is best assessed
From pulsations in the RIJV, which is directly in line with the SVC and RA.
Physical activity recommendations
Aerobic: 150 minutes of moderate- intensity activity such as brisk walking, each week.
When to begin screening for cardiovascular risk factors
Age 20 for individual risk factors or “global” risk of CVD and for any family history of premature heart disease (age < 55 in first-degree male relatives and age < 65 in first-degree female relatives)
Atypical ACS symptoms in women
Particularly in age > 65, upper back, neck or jaw pain, SOB, PND, n/v, and fatigue
Carotid upstroke always occurs in…
systole immediately after S1 so sounds or murmurs coinciding with the upstroke are systolic, those that follow are diastolic
Grade 1 murmur
Very faint, heard only when listener is tuned in, may not be heard in all positions
Grade 2 murmur
Quiet, but heard immediately after placing the stethoscope on the chest
Grade 3 murmur
Moderately loud
Grade 4 murmur
Loud, with palpable thrill
Grade 5 murmur
Very loud, with thrill. May be heard when the stethoscope is partly off the chest
Grade 6 murmur
Very loud, with thrill. May be heard with stethoscope entirely off the chest
PMI best palpated…
when patient is in the left lateral decubitus position if not found in supine position, may help if s/he stops breathing while you check location, diameter, amplitude and duration
Lateral displacement toward the axillary line from ventricular dilatation is seen in HF, CMY and ischemic heart disease.
PMI diameter
< 3 cm or size of a quarter, occupies one interspace May feel larger in left decubitus position A diffuse PMI of > 3 cm may singal LV enlargement, > 4 cm LV overload 5 x more likely
PMI amplitude
- Brisk, tapping, diffuse or sustained?
- Normal: small in diameter and brisk and tapping
- Abnormal: one example - hyperkinetic high-amplitude impulse occurs in hyperthyroid, severe anemia, pressure overload of LV from HTN or AS, or volume overload of the LV from AR
PMI duration
- Normal: Lasts through 2/3 of systole or less
- Abnormal: example, sustained high-amplitude impulse may indicate LVH
Stethoscope DIAPHRAGM
better for picking up high-pitched sounds of S1 and S2, murmurs of aortic and mitral regurgitations and pericardial friction rubs
Stethoscope BELL
more sensitive to low-pitched sounds of S3 and S4 and the murmur of mitral stenosis
Auscultating for MITRAL STENOSIS
Pt in left lateral decubitus position, place bell of stethoscope lightly on the apical impulse (may also hear S3 and S4 and mitral murmurs)
Auscultating for AORTIC REGURGITATION
Pt sits up, leans forward, exhales completely and stop breathing after exhalation. Place diaphragm on the left sternal border and at the apex, pausing so that patient can breathe
Split S1
Delayed closure of the tricuspid valve, best heard in the lower left sternal border
Is not affected by respiratory cycle
Diastolic murmurs
usually represent valvular heart disease
Systolic murmurs
may correlate with valvular heart disease but can be physiologic flow murmurs arising from normal heart valves
Murmur of aortic stenosis radiates to
neck especially on the right side
Murmur in mitral regurgitation radiates to
left axilla
Murmur descriptors
- Timing: systolic, diastolic 2. Shape: Crescendo, descrescendo, crescendo-decrescendo, plateau 3. Location of maximal intensity 4. Radiation 5. Intensity (grades) 1-6, 4-6 require presence of thrill 6. Pitch: high, medium, low 7. Quality: blowing, harsh, rumbling, musical
Fully described murmur
medium-pitched, grade 2/6, blowing decrescendo diastolic murmur, best heard in the 4th left interspace, with radiation to the apex (aortic regurgitation)
Peripheral artery disease defined
as atherosclerotic disease distal to the aortic bifurcation, some guidelines also include the abdominal aorta
AAA symptoms
abdominal, flank, back pain, unusual constipation or distention, urinary retention, difficulty voiding or renal colic (an expanding hematoma may cause symptoms by compressing bowel, aortic branch arteries, or the ureters
Prevalence of AAA in first-degree relatives
15-28%
Risk factors for AAA
older age, male sex, smoking, family history Other potential RF: other vascular aneurysms, taller height, CAD, cerebrovascular disease, atherosclerosis, HTN and HLD
AAA screening
USPSTF (grade B rec): one-time u/s screening of men age 65-75 who have smoked > 100 cigarettes in their lifetime
Key components of Peripheral Arterial Exam
- measure BP in both arms 2. palpate carotid upstroke, auscultate for bruits 3. auscultate for aortic, renal and femoral bruits, palpate the aorta and assess its maximal diameter 4. Palpate the pulses of brachial, radial, ulnar, femoral, popliteal, DP, and PT arteries 5. Inspect ankles and feet for color, temp, skin integrity
Signs of heart failure in infants
tachypnea, tachycardia and hepatomegaly
Noncardiac Signs of cardiac disease in infants
- Poor feeding
- FTT
- Irritability
- Tachypnea
- Hepatomegaly
- Clubbing
- Poor overall appearance
- Weakness
- Fatigue
PAT or PSVT in infants
May be normal (tolerated) in utero and in younger infants Child may look healthy or pale with tachypnea HR sustained at 240 beats/minute Dysrhythmia in older children is likely to be true
Split S2 in neonates
Detected in silence or when baby asleep
Its detection eliminates many, but not all, of the more serious congenital cardiac defects
S3 - Third heart sounds in children
Represent rapid ventricular filling Normal in children Should be differentiated from third heart sound gallop (pathologic)
Fourth heart sounds in children
Not common Suggest HF
Benign murmurs in infants
Newborn - Closing Ductus - Transient, soft, ejection, systolic (Upper left sternal border) Newborn - 1 yr - peripheral pulmonary flow murmur - Soft, slightly ejectile, systolic (Upper left sternal border, radiating to lung fields and axillae)
Murmurs in infants
Benign if not other non-cardiac signs present, disappear by age 1 year
Pathological with other physical findings
Coarctation of the aorta
Blood pressure is lower in legs than arms
Still’s murmur
- Grade 1-2/6
- Benign murmur present in pre-school or school age children -
- musical, vibratory, early and midsystolic murmur with multiple overtones located over mid or lower LSB; carotic artery compression will usually cause the precordial murmur to disappear.
- Extremely variable; accentuated with exercise
- May be heard with a carotid bruit which may be eradicated with carotid artery compression
Examples of pathological murmurs that appear in infancy and childhood
Aortic stenosis (systolic, crescendo-decrescendo, aortic area),
and Mitral Valve Disease e.g. MR, MVP, MS
MR - systolic, pansystolic, mitral area
MV prolapse - systolic, midsystolic click with late systolic murmur, mitral area
MS - diastolic, opening snap plus mid-diastolic rumble, mitral area
Benign murmur in adolescents
pulmonary flow murmur (chronic anemia or following exercise)
Pneumatic otoscope
tool that allows to assess mobility of the tympanic membrane
Rinne test
Compares bone conduction and air conduction and determines whether hearing loss is conductive vs. sensorineural
Normal: Air conduction > bone conduction
Conductive loss: Bone conduction >= to air conduction in bad ear
Sensorineural loss: AC > BC in both good and bad ears
hypertensive retinopathy
vascularity cross over into cup and disc
Recommendations of flu vaccine
Should be prioritized for pregnant and postpartum women, residents of nursing homes and LTC facilities, American Indians and Alaska natives, healthcare personnel, and household contacts less than/equal to 5 and greater than/equal to 50
left homonymous hemianopsia
picture!!!
Recommendations of pneumonia vaccine
65 and older, 19-64 smoker or asthma, 2+ who are immunocompromised, residents of nursing homes or LTC facilities, adults 2-64 years with SCD, CV and pulmonary disease, DM, ETOH, cirrhosis, cochlear implants and leaks of CSF
paroxysmal nocturnal dyspnea
cardiac in nature, sob at night which is relieved by sitting up
pupillary responses
convergence, accomodation, the near reaction and the light reaction
LDCT annual for lung CA
Per ACS, adults age 55-74 years in relative good health with at least 30 pack year smoking history who currently smoke or have quit within 15 years
pneumonia
pain with deep inspiration, purulent sputum, fever
weber test
Test assesses for lateralization in unilateral hearing loss
Conductive Loss: Lateralizes to bad ear
Sensorineural Loss: Lateralizes to good ear
aortic stenosis
midsystolic murmur, diminished S2, thrill transmitted to the carotid artery from the 2nd intercostal space
papilledema
bulging disc, related to high ICP
rib fracture
Upon examination, with one hand on the sternum and the other on the thoracic spine, the FNP squeezes the chest. This results in the patient’s local pain (distant from your hands)
heart failure: JVP measurement, carotid upstrokes and sound over carotid
JVP is 5 cm, carotid upstrokes are brisk, bruit is heard over carotid artery
Screening recommended for athletes
screening for risk factors and family history, history and physical
Heart failure with LVH
sustained PMI, elevated JVP, isolated systolic hypertension, widened pulse pressure
carotid upstroke/downstroke (or contour of the pulse wave)
Pressing inside the medial border of a relaxed SCM muscle, at the level of the cricoid cartilage while slowly increasing pressure until you feel a maximal pulsation; then slowly decrease pressure until you best sense the arterial pressure and contour will allow to assess this
croup
2 day history mild rhinorrhea, low grade fever, cough worse early in AM, inspiratory stridor, positive Hoover’s sign (indrawing of the chest wall)
Also known as laryngotracheal bronchitis usually due to viral cause
epiglottitis
child sitting stiffly in tripod position, difficulty swallowing saliva, sore throat, rarely seen thanks to the Hib vaccine
mitral valve prolapse
often preceded by midsystolic click with late systolic murmur, best heard in mitral area
The setting sun sign
occurs with hydrocephalus when anterior fontanelles is bulging and eyes are deviated downward revealing upper scleras
substernal retractions
types of retractions
early systolic ejection sounds
Occur shortly after S1 Relatively high in pitch - best heard with diaphragm
Aortic ejection sound - heard at base and apex (louder), does not vary with respiration - indicative of dilated aortic, aortic valve disease or a bicuspid aortic valve
Pulmonic ejection sound - heard best in LEFT 2nd and 3rd ICS - intensity decreases with inspiration - indicative of dilatation of PA, pulm HTN, and pulmonic stenosis.
Systolic clicks
usually caused by MVP
Clicks are usually mid- to late-systolic
Heard medial to apex or at the left sternal border - heard best with diaphragm - may be followed by late systolic murmur from mitral regurg that crescendos up to S2
Squatting delays the click and murmur due to increased venous return.
Standing moves them closer to S1
Opening snap
MITRAL STENOSIS
Heard very early diastolic sound caused by abrupt deceleration during opening of a stenotic MV
Best heard medial to apex and along lower LSB
High pitch and snapping quality
Heard best with diaphragm
AHA CV Risk Categories for Women HIGH
>=1 of CHD, CVD, PAD, AAA, DM or ESRD or 10-year predicted risk of > 10%
AHA CV Risk Categories for Women AT RISK
- >=1 major risk factor incl smoking, bp >=120/>=80 or treated HTN, total cholesterol >= 200, HDL < 50 or treated dyslipidemia obesity, poor diet, physical inactivity or family hx of premature CVD
- evidence of advance subclinical atherosclerosis, metabolic syndrome or poor exercise capacity on a treadmill test
- systemic autoimmune collagen vascular disease e.g. lupus or rheumatoid arthritis
- history of preeclampsia, GD, pregnancy-induced HTN
AHA CV Risk Categories for Women IDEAL
- Total (untreated) cholesterol < 200 - (untreated) BP < 120/80 - (untreated) FBG < 100 - BMI < 25 - Non-smoking - Physical activity: 150 minutes per week moderate intensity or 75 minutes/week vigorous intensity or combo - Healthy diet
Cyanotic heart diseases
DANGEROUS Pulmonary artery stenosis Pulmonary atresia Tetralogy of Fallot Tricuspid atresia Trunkus arteriosus Hypoplastic left heart syndrome Transposition of great arteries
Acyanotic heart diseases
OK PDA Atrial septal defect Ventricular septal defect Coarctation of aorta Aortic stenosis Pulmonary artery stenosis (mild) PFO - may remain open after birth
Identify this Eye Picture
Papilledema
Swelling of the optic disc and anterior bulging of the physiologic cup
Associated with increased ICP
Name this Eye Picture
Glaucomatous cupping
Death of optic nerve fiblers leads to loss of the tiny disc vessels
Increased intraocular pressure within eye leads to increased cupping (backward depression of the disc) and atrophy.
The base of the enlarged cup is pale.
Name this Eye Photo
Normal
Color yellowish orange to creamy pink
Disc vessels tiny
Disc margins sharp (except perhaps nasally)
Physiologic cup is located centrally or somewhat temporally. It may be conspicuous or absent. Its diambeter from side to side is usually less than half that of the disc.
Name this Eye Photo
Hypertensive retinopathy
Marked arterial-venous crossing changes are seen, especially along the inferior vessels. Copper wiring of the arterioles is present.
Other possible characteristics are Concealment or AV nicking, banking, and tapering
Name this Eye Photo
Diabetic retinopathy
Name this Eye Photo
Drusen
Yellowish round spots that vary from tiny to small.
Edges may be soft or hard.
They are haphazardly distributed.
Seen in normal aging and age-related macular degeneration.
Name this Eye Photo
Esotropia (intermittent alternating convergent strabismus)
Developmental disorder
Usually appears in early childhood
[Note: exotropia is intermittent alternating DIVERGENT strabismus]
Name this visual field defect
Left homonymous hemianopsia
A complete interruption of fibers in the optic radiation, produces a visual defect similar to that produced by a lesion of the optic tract
Coarctation of aorta
Blood pressure of upper extremities is higher than blood pressure in lower extremities
Conductive hearing is caused by
“conducting bad behavior”
Hearing disorders of external and middle ear such as:
Cerumen impaction, infection (otitis externa), trauma, SCC and benign bony growths such as exostoses or osteomas.
Middle ear disorders include otitis media, congenital conditions, cholesteatomas and otosclerosis, tumors and perforation of the TM.
Weber: Lateralizes to bad ear
Rinne: bone conduction is equal or longer than air conduction
Sensorineural hearing loss is caused by
disorders of the inner ear from congenital and hereditary conditions such as
presbycusis, viral infections such as rubella and cytomegalovirus, Meniere disease, noise exposure, ototoxic drug exposure and acoustic neuroma.
Weber test: sound lateralizes to good ear
Rinne test: sound is heard longer through air (AC > BC)
Anxiety with hyperventilation: symptoms and relieving factors
Sighing, lightheadedness, numbness or tingling of the hands and feet, palpitations, chest pain
Other possible manifestations: chest pain, diaphoresis, palpitations
Relieving factors: breathing in and out of a paper or plastic bag may help
Intermittent claudication
Pain or cramping in legs during exertion that is relieved by rest within 10 minutes
Caused by narrowing or blockage in the main artery taking blood to your leg due to hardening of the arteries (atherosclerosis).
Usually in age 50+, with higher incidence in smokers, those who have diabetes, heart diease or elevated cholesterol.
Tx: Modification of risk factors, exercise, e.g. structured walking program, medications, angioplasty, bypass surgery
Neurogenic claudication
Pain with walking or prolonged standing
Radiating from the spinal area into the buttocks, thighs, lower legs or feet
Is a type of intermittent claudication
Carotid upstroke is delayed in…
aortic stenosis
Carotid pulse is bounding in…
aortic regurgitation
Carotid pulse is small, thready or weak in…
cardiogenic shock
Carotid bruit indicates…
aortic stenosis, mitral regurgitation, PDA or coarctation of the aorta
Rhinosinusitis s/s
purulent nasal drainage, facial pain increases with valsalva maneuvers and leaning forward
Pupillary light reactions
direct light reaction, consensual reaction to light
CN II, CN III
Absence of red reflex indicates
opacity of the lens (cataract), vitreous, and less commonly, detached retina
or, in children, retinoblastoma
Opthalmoscope settings
0: to view fundus
+10 or +12: to view anterior structures such as vitreous and lens
Leukoplakia
A thickened white patch occurring anywhere in oral mucosa. This benigh reactive process of the squamous epithelium may lead to cancer and should be biopsied.
Diffuse enlargement of the thyroid can be caused by…
Graves disease, Hashimoto thyroiditis, and endemic goiter
Where is stridor the loudest?
over the neck
S1 sound indicates…
indicates closure of the mitral valve
S2 sound indicates…
closure of the aortic valve
Sudden dyspnea occurs in…
PE, spontaneous PTX and anxiety
Xiphoid process is most prominent in…
newborns and young infants
Newborn or child with possible abnormal facies, carefully review…
- family history
- pregnancy
- perinatal history
Pneumonia in infants s/s
abnormal work of breathing (nasal flaring, grunting, retractions), fever, tachypnea, dyspnea, plus abnormal findings on auscultation such as crackles rule in PNA
Best symptom in ruling OUT pneumonia: absence of tachypnea
[Note: rhonchi indicate upper respiratory infections and wheezing occur normally in asthma or bronchiolitis]
PDA or patent ductus arteriorosus s/s
continuous murmur begin in systole into S2 and/or into part of diastole
due to hole
hyperdynamic precordium and bounding distal pulses
In infants/children,
a true gallop rhythm s/s
tachycardia plus a loud S3, S4 or both
Pathologic and indicate HF (poor ventricular function)
Children: Adenoidal hypertrophy
Nasal voice plus snoring
Children: hypernasal speech
submucosal cleft palate
Children: hoarse voice plus cough
viral infection (croup)
Childhood asthma s/s
Increased work of breathing, expiratory wheezing and a prolonged expiratory phase.
Wheezes are often accompanied by inspiratory rhonchi.
Asthma flares often occur with viral infections.
In pediatric population
4th heart sounds represent decreased ventricular compliance, suggesting heart failure
