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Simmons NURP 530 > Exam 2 > Flashcards

Exam 2 Flashcards

HEENT, CV, PV, Thorax and Lungs

1
Q

Headache: concerning for what conditions

A

life-threatening secondary causes such as meningitis, subarachnoid hemorrhage or mass lesion

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2
Q

types of primary headaches

A

migraine, tension, cluster, chronic daily

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3
Q

types of secondary headaches

A

systemic or infectious causes such as meningitis, subarachnoid hemorrhage

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4
Q

signs of subarachnoid hemorrhage

A

thunderclap headaches that reach maximal intensity over several minutes and are preceded by a sentinel leak

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5
Q

Erb’s point

A

3rd ICS on the left sternal border, best heard in the left lateral recumbent position

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6
Q

Mitral area

A

Also apex of the heart, best auscultated on the 5th ICS, at MCL

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7
Q

S3 - other name, best heard

A

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

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8
Q

S4 - other name, best heard

A

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

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9
Q

S1 is louder than S2

A

At the apex (5th ICS at MCL)

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10
Q

S2 is louder than S1

A

At the base

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11
Q

Abnormal JVP

A

> 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.

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12
Q

Where JVP is best assessed

A

From pulsations in the RIJV, which is directly in line with the SVC and RA.

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13
Q

Physical activity recommendations

A

Aerobic: 150 minutes of moderate- intensity activity such as brisk walking, each week.

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14
Q

When to begin screening for cardiovascular risk factors

A

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)

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15
Q

Atypical ACS symptoms in women

A

Particularly in age > 65, upper back, neck or jaw pain, SOB, PND, n/v, and fatigue

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16
Q

Carotid upstroke always occurs in…

A

systole immediately after S1 so sounds or murmurs coinciding with the upstroke are systolic, those that follow are diastolic

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17
Q

Grade 1 murmur

A

Very faint, heard only when listener is tuned in, may not be heard in all positions

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18
Q

Grade 2 murmur

A

Quiet, but heard immediately after placing the stethoscope on the chest

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19
Q

Grade 3 murmur

A

Moderately loud

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20
Q

Grade 4 murmur

A

Loud, with palpable thrill

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21
Q

Grade 5 murmur

A

Very loud, with thrill. May be heard when the stethoscope is partly off the chest

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22
Q

Grade 6 murmur

A

Very loud, with thrill. May be heard with stethoscope entirely off the chest

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23
Q

PMI best palpated…

A

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.

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24
Q

PMI diameter

A

< 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

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25
Q

PMI amplitude

A
  • 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
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26
Q

PMI duration

A
  • Normal: Lasts through 2/3 of systole or less
  • Abnormal: example, sustained high-amplitude impulse may indicate LVH
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27
Q

Stethoscope DIAPHRAGM

A

better for picking up high-pitched sounds of S1 and S2, murmurs of aortic and mitral regurgitations and pericardial friction rubs

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28
Q

Stethoscope BELL

A

more sensitive to low-pitched sounds of S3 and S4 and the murmur of mitral stenosis

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29
Q

Auscultating for MITRAL STENOSIS

A

Pt in left lateral decubitus position, place bell of stethoscope lightly on the apical impulse (may also hear S3 and S4 and mitral murmurs)

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30
Q

Auscultating for AORTIC REGURGITATION

A

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

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31
Q

Split S1

A

Delayed closure of the tricuspid valve, best heard in the lower left sternal border

Is not affected by respiratory cycle

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32
Q

Diastolic murmurs

A

usually represent valvular heart disease

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33
Q

Systolic murmurs

A

may correlate with valvular heart disease but can be physiologic flow murmurs arising from normal heart valves

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34
Q

Murmur of aortic stenosis radiates to

A

neck especially on the right side

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35
Q

Murmur in mitral regurgitation radiates to

A

left axilla

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36
Q

Murmur descriptors

A
  1. 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
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37
Q

Fully described murmur

A

medium-pitched, grade 2/6, blowing decrescendo diastolic murmur, best heard in the 4th left interspace, with radiation to the apex (aortic regurgitation)

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38
Q

Peripheral artery disease defined

A

as atherosclerotic disease distal to the aortic bifurcation, some guidelines also include the abdominal aorta

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39
Q

AAA symptoms

A

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

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40
Q

Prevalence of AAA in first-degree relatives

A

15-28%

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41
Q

Risk factors for AAA

A

older age, male sex, smoking, family history Other potential RF: other vascular aneurysms, taller height, CAD, cerebrovascular disease, atherosclerosis, HTN and HLD

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42
Q

AAA screening

A

USPSTF (grade B rec): one-time u/s screening of men age 65-75 who have smoked > 100 cigarettes in their lifetime

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43
Q

Key components of Peripheral Arterial Exam

A
  1. 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
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44
Q

Signs of heart failure in infants

A

tachypnea, tachycardia and hepatomegaly

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45
Q

Noncardiac Signs of cardiac disease in infants

A
  • Poor feeding
  • FTT
  • Irritability
  • Tachypnea
  • Hepatomegaly
  • Clubbing
  • Poor overall appearance
  • Weakness
  • Fatigue
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46
Q

PAT or PSVT in infants

A

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

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47
Q

Split S2 in neonates

A

Detected in silence or when baby asleep

Its detection eliminates many, but not all, of the more serious congenital cardiac defects

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48
Q

S3 - Third heart sounds in children

A

Represent rapid ventricular filling Normal in children Should be differentiated from third heart sound gallop (pathologic)

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49
Q

Fourth heart sounds in children

A

Not common Suggest HF

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50
Q

Benign murmurs in infants

A

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)

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51
Q

Murmurs in infants

A

Benign if not other non-cardiac signs present, disappear by age 1 year

Pathological with other physical findings

52
Q

Coarctation of the aorta

A

Blood pressure is lower in legs than arms

53
Q

Still’s murmur

A
  • 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
54
Q

Examples of pathological murmurs that appear in infancy and childhood

A

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

55
Q

Benign murmur in adolescents

A

pulmonary flow murmur (chronic anemia or following exercise)

56
Q

Pneumatic otoscope

A

tool that allows to assess mobility of the tympanic membrane

57
Q

Rinne test

A

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

58
Q

hypertensive retinopathy

A

vascularity cross over into cup and disc

59
Q

Recommendations of flu vaccine

A

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

60
Q

left homonymous hemianopsia

A

picture!!!

61
Q

Recommendations of pneumonia vaccine

A

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

62
Q

paroxysmal nocturnal dyspnea

A

cardiac in nature, sob at night which is relieved by sitting up

63
Q

pupillary responses

A

convergence, accomodation, the near reaction and the light reaction

64
Q

LDCT annual for lung CA

A

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

65
Q

pneumonia

A

pain with deep inspiration, purulent sputum, fever

66
Q

weber test

A

Test assesses for lateralization in unilateral hearing loss

Conductive Loss: Lateralizes to bad ear

Sensorineural Loss: Lateralizes to good ear

67
Q

aortic stenosis

A

midsystolic murmur, diminished S2, thrill transmitted to the carotid artery from the 2nd intercostal space

68
Q

papilledema

A

bulging disc, related to high ICP

69
Q

rib fracture

A

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)

70
Q

heart failure: JVP measurement, carotid upstrokes and sound over carotid

A

JVP is 5 cm, carotid upstrokes are brisk, bruit is heard over carotid artery

71
Q

Screening recommended for athletes

A

screening for risk factors and family history, history and physical

72
Q

Heart failure with LVH

A

sustained PMI, elevated JVP, isolated systolic hypertension, widened pulse pressure

73
Q

carotid upstroke/downstroke (or contour of the pulse wave)

A

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

74
Q

croup

A

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

75
Q

epiglottitis

A

child sitting stiffly in tripod position, difficulty swallowing saliva, sore throat, rarely seen thanks to the Hib vaccine

76
Q

mitral valve prolapse

A

often preceded by midsystolic click with late systolic murmur, best heard in mitral area

77
Q

The setting sun sign

A

occurs with hydrocephalus when anterior fontanelles is bulging and eyes are deviated downward revealing upper scleras

78
Q

substernal retractions

A

types of retractions

79
Q

early systolic ejection sounds

A

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.

80
Q

Systolic clicks

A

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

81
Q

Opening snap

A

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

82
Q

AHA CV Risk Categories for Women HIGH

A

>=1 of CHD, CVD, PAD, AAA, DM or ESRD or 10-year predicted risk of > 10%

83
Q

AHA CV Risk Categories for Women AT RISK

A
  • >=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
84
Q

AHA CV Risk Categories for Women IDEAL

A
  • 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
85
Q

Cyanotic heart diseases

A

DANGEROUS Pulmonary artery stenosis Pulmonary atresia Tetralogy of Fallot Tricuspid atresia Trunkus arteriosus Hypoplastic left heart syndrome Transposition of great arteries

86
Q

Acyanotic heart diseases

A

OK PDA Atrial septal defect Ventricular septal defect Coarctation of aorta Aortic stenosis Pulmonary artery stenosis (mild) PFO - may remain open after birth

87
Q

Identify this Eye Picture

A

Papilledema

Swelling of the optic disc and anterior bulging of the physiologic cup

Associated with increased ICP

88
Q

Name this Eye Picture

A

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.

89
Q

Name this Eye Photo

A

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.

90
Q

Name this Eye Photo

A

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

91
Q

Name this Eye Photo

A

Diabetic retinopathy

92
Q

Name this Eye Photo

A

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.

93
Q

Name this Eye Photo

A

Esotropia (intermittent alternating convergent strabismus)

Developmental disorder

Usually appears in early childhood

[Note: exotropia is intermittent alternating DIVERGENT strabismus]

94
Q

Name this visual field defect

A

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

95
Q

Coarctation of aorta

A

Blood pressure of upper extremities is higher than blood pressure in lower extremities

96
Q

Conductive hearing is caused by

“conducting bad behavior”

A

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

97
Q

Sensorineural hearing loss is caused by

A

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)

98
Q

Anxiety with hyperventilation: symptoms and relieving factors

A

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

99
Q

Intermittent claudication

A

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

100
Q

Neurogenic claudication

A

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

101
Q

Carotid upstroke is delayed in…

A

aortic stenosis

102
Q

Carotid pulse is bounding in…

A

aortic regurgitation

103
Q

Carotid pulse is small, thready or weak in…

A

cardiogenic shock

104
Q

Carotid bruit indicates…

A

aortic stenosis, mitral regurgitation, PDA or coarctation of the aorta

105
Q

Rhinosinusitis s/s

A

purulent nasal drainage, facial pain increases with valsalva maneuvers and leaning forward

106
Q

Pupillary light reactions

A

direct light reaction, consensual reaction to light

CN II, CN III

107
Q

Absence of red reflex indicates

A

opacity of the lens (cataract), vitreous, and less commonly, detached retina

or, in children, retinoblastoma

108
Q

Opthalmoscope settings

A

0: to view fundus

+10 or +12: to view anterior structures such as vitreous and lens

109
Q

Leukoplakia

A

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.

110
Q

Diffuse enlargement of the thyroid can be caused by…

A

Graves disease, Hashimoto thyroiditis, and endemic goiter

111
Q

Where is stridor the loudest?

A

over the neck

112
Q

S1 sound indicates…

A

indicates closure of the mitral valve

113
Q

S2 sound indicates…

A

closure of the aortic valve

114
Q

Sudden dyspnea occurs in…

A

PE, spontaneous PTX and anxiety

115
Q

Xiphoid process is most prominent in…

A

newborns and young infants

116
Q

Newborn or child with possible abnormal facies, carefully review…

A
  • family history
  • pregnancy
  • perinatal history
117
Q

Pneumonia in infants s/s

A

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]

118
Q

PDA or patent ductus arteriorosus s/s

A

continuous murmur begin in systole into S2 and/or into part of diastole

due to hole

hyperdynamic precordium and bounding distal pulses

119
Q

In infants/children,

a true gallop rhythm s/s

A

tachycardia plus a loud S3, S4 or both

Pathologic and indicate HF (poor ventricular function)

120
Q

Children: Adenoidal hypertrophy

A

Nasal voice plus snoring

121
Q

Children: hypernasal speech

A

submucosal cleft palate

122
Q

Children: hoarse voice plus cough

A

viral infection (croup)

123
Q

Childhood asthma s/s

A

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.

124
Q

In pediatric population

A

4th heart sounds represent decreased ventricular compliance, suggesting heart failure

125
Q
A

Simmons NURP 530 (4 decks)

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