Exam 2 Flashcards
The diaphragm of the stethoscope is better for:
Higher pitched sounds. Murmurs of aortic and mitral regurgitation. Pericardial friction rubs.
The bell of the stethoscope is more sensitive to:
Low pitched sounds. S3 and S4. Murmur of mitral stenosis.
Splitting of S2 is usually heard on ____ (Inspiration or expiration) in the ______ area.
Inspiration Pulmonic
S2 is louder than S1 in what areas?
Aortic and pulmonic areas
S2 diminishes, S1 gets louder in what areas?
Through third interspace. Into tricuspid area. Into mitral area.
Attributes of murmurs
TIMING SHAPE LOCATION OF MAXIMAL INTENSITY (Determined by site of origin, explore where murmur is loudest- position relative to sternum, Apex, midsternal, midclavicular, axillary lines) RADIATION (transmission from the point of maximal intensity, reflects site of origin, intensity of murmur, and direction of blood flow) INTENSITY (Graded on a six point scale, expressed as a ratio. Numerator=intensity, denominator =6) PITCH QUALITY (Harsh, blowing, musical, rumbling)
Rubor
Dusky redness May appear gradually Suggests poor arterial circulation
Ventricular gallop S3
A ventricular gallop is the third heart sound, S3. This low frequency vibration occurs after S1 and S2 and seem to result from the change in blood flow in diastole when rapid filling ends and slow filling starts. When listening for S3, the heart sounds resemble the pronunciation of the word Kentucky, with the Y representing S3. S3 has been described as testing the Costco Tori skills of the examiner because of its low frequency and intensity as well as interference of the normal sounds in the chest from the lungs and abdomen. It is best heard with the bell of the stethoscope. Sometimes it is normally heard in those under the age of 40 and trained athletes.
Atrial gallop S4
And atrial Gallup is the fourth heart sound, Asfoor. It is a low frequency sound that occurs in late diastolic filling due to atrial contraction. This causes vibrations in the ventricular walls and happens just before S1, making it difficult to hear. If loud, it can indicate pathology, and it resembles the pronunciation of the word Tennessee, where the 10 is S4. When it is clearly heard it can indicate an increased resistance to ventricular filling. Sometimes S4 can occur normally in people older than 40, especially after exercise.
Pericardial friction rub
Is a sound generated from inflammation of the pericardial sac as it rubs against the linings surrounding the heart, and not really a heart sound. Pericarditis is an inflammatory disease of the pericardium, which causes the membranes to become sticky, producing friction when the heart beats or when the patient breathe. This friction produces the sound known as a pericardial friction rub. It is a scratching, grading, high frequency sound that is heard in both systole and diastole. It seems to be heard with the diaphragm of the stethoscope at the left lower sternal border.
Innocent (or functional) murmurs
Are non-cardiac murmur’s related to pregnancy, hyperthyroidism, exercise, and anemia. It is most often heard and children. This type of murmur is normally heard with systole in the pulmonic precordial area.
Pathological murmurs
Are due to congenital or valvular defects. Specific valvular defects can be identified by their timing during (S, systolic, S, diastolic) and the auscultation region where they are heard.
The presence of a thrill changes the grading of the murmur? True or False
True
What position would you put the patient into for palpating or auscultating the PMI?
Left lateral decubitis position
Where would you palpate and auscultate the PMI?
5th intercostal space, midclavicular line or 7-9 from midsternal line
What is the normal diameter of the PMI?
1-2.5 cms
Rare congenital transposition of heart, heart situated in the right chest cavity and generates right sided apical pulse
Dextrocardia
JVP measured at 3cm above sternal angle, or >8cm above the right atrium is normal. True or False
False
Where could you put the HOB for hypovolemic patients to see point of oscillation best?
You can put the HOB sometimes as low as 0.
In volume overload, where would might the HOB go, to best assess the point of oscillation?
HOB 60 degrees or even 90 degrees.
What maneuver would you perform to assess for mitral stenosis?
Left lateral decubitis position, listen lightly with the bell on the apical pulse.
What maneuver would you perform to assess aortic regurgitation?
Have patient sit up and lean forward, breathe deeply and exhale completely, and have patient briefly stop breathing.
How would you identify systole and diastole?
Auscultate the chest and palpate the right carotid artery in the lower 3rd of the neck with your left index and middle fingers.
What position can the patient be in to auscultate mitral valve prolapse?
Squatting, supine, standing and seated.
You auscultate loud and soft kortkoff sounds or sudden doubling of the HR as the cuff pressure declines.
Pulsus Alternans
What does pulsus alternans indicate?
left ventricular dysfunction
Greater than normal drop in systolic BP during inspiration
Paradoxical Pulse
What murmur is often not heard until adulthood and is heard at the 2nd interspace, and radiates to the carotids, is harsh and has a midsystolic crescendo decrescendo and is heard best with the patient sitting and leaning forward?
Aortic Stenosis
Which part of the stethoscope is aortic stenosis best detected with?
The diaphragm
Vesicular lung sounds
Soft Low pitched Heard during inspiration Heard during 1st third of expiration Heard over most of lung fields
Bronchial lung sounds
Harsher, louder, higher in pitch Heard over trachea Heard over mainstem bronchi Expiratory sound last longer than inspiratory sound Silent gap may separate sounds
Bronchovesicular lung sounds
Heard in 1st and 2nd interspaces anteriorly Heard between the scapulae posteriorly Have intermediate pitch and intensity Inspiratory and expiratory sounds equal induration and sounds separated by silent interval
Crackles
Intermittent Non-musical Brief Heard in abnormalities of the lung parenchyma: pneumonia, pulmonary fibrosis, interstitial lung disease, atelectasis, and early heart failure; or of the airways: bronchitis, bronchiectasis
Fine crackles
Soft High-pitched and very brief Location: usually bases of lower lobes Often accompany congestive heart failure Tip: sounds like rolling a strand of hair between thumb and index finger
Coarse crackles
Louder Lower-pitched Longer Location: trachea and large bronchi Tip: sounds like separating a bel Velcro fastener
Wheezes
High-pitched, continuous, musical Have hissing or shrill quality Created by narrowing of airways from swelling, secretions, or masses— Often suggest asthma, COPD, and bronchitis Location: all lung fields
Rhonchi
Lower-pitched, continuous, snoring quality Arise from obstruction from thick secretions, muscular construction, or masses, secretions in large airways (bronchitis) Location: bronchi Tip: sounds like snoring or moaning
Stridor
Loud, continuous, high-pitched crowing sound that is caused by upper airway obstruction. This is the most serious of the adventitious sounds and it requires immediate attention. Long crowing sounds. High-pitched. Location: trachea. Tip: usually audible without a stethoscope.
External or middle ear disorder that impairs sound conduction to inner ear.
Conductive hearing loss
Hearing improves in noisy environments
Conductive hearing loss
Hearing worsens in loud environment
Sensorineural Hearing Loss
Causes of Senosrineural Hearing Loss
Loud noise exposure, inner ear infections, trauma, acoustic neuroma, congenital/familial and aging
Patient has trouble understanding speech, often complains other mumble.
Sensorineural hearing loss
What test detects unilateral conductive hearing loss, sound lateralized to impaired ear
Weber test
The weber test is being used, and sound lateralizes to impaired ear, what kind of hearing loss is detected?
Unilateral conductive hearing loss
The weber test is being used and the sound lateralizes to the good ear, what kind of hearing loss is detected?
Unilateral sensorineural hearing loss
Testing of bone conduction, comparing air conduction to bone conduction?
Rinne Test
Which test determines whether hearing loss is conductive or sensorineural?
Rinne Test
BC=AC or BC>AC
Conductive hearing loss
Elongated tube, dull retracted & white tympanic membrane, sensorineural hearing loss.
Normal aging process
Chronic inflammatory lesion turns to an ulcer (biopsy to rule out carcinoma) (Add pic)
Chondrodermatitis Helicis
Deposit of uric acid crystals (characteristic of chronic gout) (add pic)
Tophi
Hole in eardrum with thin transparent membranes covering the perforation. Indication of chronic infection
Perforation of tympanic membrane
Scarring process of the middle ear from otitis media
Tympanosclerosis
Caused by bacterial infection (S. pneumonia or H. influenzae). Symptoms: earache, fever, or hearing loss. Eardrum reddens, loses its landmarks, and bulges laterally. Erythematous bulging tympanic membrane w/ yellow mucoid effusion & absent light reflex, may have diminished movement.
Acute Otitis Media (AOM)
Caused by viral upper respiratory infection (otitis media w/ serous effusion) or sudden changes in atomspheric pressure (flying or diving). Amber fluid behind the eardrum is characteristic. Fullness and popping sensation in the ear.
Serous effusion
Swollen, narrow, moist, pale and tender canal (may be reddened)
Acute Otitis Externa (AOE) or swimmer’s ear
Preauricular anomalies (tag or pit). check for what?
Renal issues
painful hemorrhagic vessels on tympanic membrane and/or ear canal. Blood tinged discharge & conductive hearing loss. Caused by mycoplasma, viral & bacterial otitis media
Bullous Myringitis
When nasal mucosa is pale, bluish, and boggy
Allergic rhinitis
When nasal mucusa is red and swollen.
Viral rhinitis
pale sac-like growths that can obstruct air passages. seen in allergic rhinitis, chronic sinusitis, asthma, and CF
polyps
AAP recommends screening for?
All children under 4. Hearing screening also at birth.
Pneumatic Scope
if tympanic membrane fails to move- likely a middle ear effusion.
When we inhale our diaphragm ______ and when we exhale our diaphragm ______?
inspiration- contracts and flattens
expiration - relaxes
Pulmonary reasons for an acute cough and how long must cough be present to be considered acute?
VIral URI, acute bronchitis, foreign body, smoking, ACEI
acute: <3 wks
Pulmonary reasons for a subacute cough how long must cough be present to be considered subacute?
post infectious, pertussis, reflux, bacterial sinusitis, asthma
subacute: 3 - 8 wks
Pulmonary reasons for a chronic cough and how long must cough be present to be considered chronic?
Paroxysmal nocturnal dyspnea, asthma, GERD, chronic bronchitis, bronchiectasis
Chronic: >8 wks
Pt has a positive bronchophony in the LLL. What does this mean?
consolidation in LLL; indicative of PNA.
When performing bronchophony, pt will say 99 during auscultation and if there is consolidation we will hear 99 through the stethescope…IT WILL NOT BE MUFFLED.
Pt has a positive egophony in RLL. What does this mean?
consolidation in RLL.
when auscultating the lungs while the pt says “e” if we hear in the stethoscope what seems like the pt say “a”…this is a positive egophony (or egophony is present in the RLL).
Prolonged inspiration or squeakiness is associated with what in the pedi population?
Croup
Prolonged expiration is associated with what in the pedi population?
ashtma
infants are obligant nose breathers until what age?
4 months old
What is a hoover’s sign and what does it mean?
seesaw breathing and it’s abnormal
