Exam 2: Respiratory, Cardiac, Immunizations Flashcards
Cardiac: What do you listen for with the client in LLD?
mitral stenosis, S3, S4 - with bell
Cardiac: What do you listen for with the client leaning forward?
Aortic regurgitation murmurs - with diaphragm. “breathe in, breathe out, hold”
What heart sounds do you hear with the diaphragm?
high pitched: S1, S2, murmurs of AR and MR, AS, friction rubs, VSD
What heart sounds do you hear with the bell?
low pitched: S3, S4, diastolic murmurs (e.g. MS)
Cardio: what are the characteristics of sounds to be described?
Frequency (pitch) Intensity (loudness) Duration Timing (systole, diastole)
What are the valves of the heart?
Atrioventricular: tricuspid & mitral/bicuspid Semilunar: pulmonic & aortic
Name the areas of the heart
RV is most of anterior chest
Base is superior aspect of heart at R & L 2nd IS
Xiphoid process is good landmark for RV.
Tell me about a normal PMI
4th or 5th interspace, 7-9cm lateral to midsternal (at or just medial to midclavicular)
Supine diameter: 1-2.5 (about a quarter)
Tell me about an abnormal PMI
Larger than 2.5cm (evidence of LVH, or enlargement, as seen in HTN and AS)
Lateral to midclavicular or >10cm lateral to midsternal (LVH)
Xiphoid/epigastric area (COPD)
Sinus arrhythmia
varies with respiration
normal HSs, though S1 may vary with the HR
Atrial or nodal premature contractions
Rhythm: atrial/nodal beat before next expected heart beat. Pause. Rhythm resumes
Heart Sounds: S1 may differ in intensity from normal S1. S2 may be decreased.
PVC (sporadic or regularly irregular)
Rhythm: ventricular beat comes before next expected beat. Pause. Rhythm resumes.
Heart Sounds: S1 may differ from normal, S2 may be decreased. Both likely split.
Afib & Aflutter w/varying AV block (Irregularly irregular)
Rhythm: ventricular rhythm is totally irregular, though possible short runs of regular-seeming
Heart Sounds: S1 varies in intensity
Paradoxical Pulse
decrease in pulse’s amplitude on quiety inspiration (st palpable, but possibly need BP cuff)
Systolic pressure decreases >10mmHg during inspiration
Causes: pericardial tamponade, exacerbatins asthma & COPD, st in constrictive pericarditis
pulsus alternans
pulse alternates in amplitude beat to beat even though rhythm is basically regular (must be).
Indicates LV failure, usually accompanied by S3
Normal Pulse Pressure
~30-40 mmHg pulse pressure
small, weak pulse
Pulse pressure diminished, upstroke may feel slowed, peak prolonged
causes: decreased SV (HF, hypovolemia, severe AS); increased peripheral resistance (exposure to cold and severe HF)
Large, bounding pulse
pulse pressure increased, rise and fall may feel rapid, peak brief
Causes: increased stroke volume, decreased peripheral resistance, or both (fever, anemia, hyperthyroidism, AR, AV fistulas, PDA); increased stroke volume d/t slow HRs (bradycardia, complete heart block); decreased compliance/increased stiffness of aortic walls (aging, atherosclerosis)
Systolic click
Usually MVP (systolic ballooning into LA from both leaflet redundancy & elongations of chordae tendineae)
Mid to late systolic
High pitched, often followed by MR murmur
several positions recommended: supine, seated, squatting, standing (squatting delays click & murmur, standing moves them closer to S1)
Opening snap
very early diastolic sound
stenotic mitral valve
listen with diaphragm medial to apex along lower left sternal border
intermittently irregular beats
e.g., ectopic beats - PAC, PVC
Continuously irregular beats
a.k.a. “regularly irregular”
Afib: palpittions that warrant ECG
Superior view of heart valves
What happens during diastole (+atrial kick)
AV valves open, passive flow (about 75% of volume) move into relaxed ventricles, then atria contract & active flow accounts for about 25% into ventricles (atrial kick)
isovolumic phase of ventricular systole
interval between closing of AV valves and opening of semilunar valves
ECG: define p, qrs, t, u
p: atrial depolarization
qrs: ventricular depolarization
t: ventricular repolarization
u: ventricular diastole
ECG leads
6 limb leads, 6 precordial leads
CAD risk factors for women
DM, smoking, HTN, obesity
questions you ask if chest pain
O: when did pain start? having pain now?
L: where is pain located? Does it radiate?
D: how long have you had pain?
C: what does it feel like? Pressure, tightness, heaviness, stabbing? Associated symptoms?
A: aggravates/alleviates? rest? Nitro?
R: travel to any part of your body?
T: when did you notice? Intermittent or persistent?
characteristics: squeezing, discomfort, burning, stabbing
Associated symptoms: cough
Relieved by: rest or nitrogylcerin
Special considerations on pediatric cardiac exam
Listen in at least 2 positions
S3 heard through thin chest walls
S4 indicates poorly compliant ventricles - always abnormal
murmurs: should disappear when supine, be systolic, not be assoc w/clicks, rubs, or other sx
school age: may disappear w/sitting
What causes S3?
passive flow of blood from atria
slight resistance to filling d/t ventricular overload and/or systolic dysfunction
What causes S4?
vigorous atrial ejection of blood d/t resistance to filling at end of diastole (presystole): decreased ventricular compliance
Normal vs abnormal S3
Normal: young adults, children, increased HR, late pregnancy
abnormal: older adult, HTN, volume overload (CHF), MR, high output states (thyroid, anemia)
Listening for S3
“Kentucky”
Hooked on back of S2 (after opening snap)
low pitch - apex, LLD, bell
does not vary w/respiration, persists when sitting upright, increases w/isotonic exercise (e.g., sit-ups)
Normal vs abnormal S4
Normal: trained athletes, elderly (ventricles become stiff)
Abnormal: systemic or pulmonary HTN, CAD/ischemia, AS/cardiomyopathy, delayed conduction
Listening for S4
“Tennessee”
Hooked on front of S1
Low pitch: LLD, bell
What is Split S2?
widening of normal interval beween aortic and pulmonic components of S2 - A valve closes before P valve
Normal vs Abnormal S2 - who and on exam
Physiologic: who - athletes, <40yo; on exam - pulmonic area, on inspiration, louder on reclining, disappears during slow breathing or holding breath
Pathologic: who - >40; on exam - appears or persists during expiration. May indicate pulmonary stenosis, ASD, RT BBB
Squatting valsalva and its effect on murmurs
Increases LV volume & increased vascular tone
MVP: delays click, murmur shortens (dec prolapse, harder to hear)
hypertrophic cardiomyopathy: Decreases intensity of murmur (dec outflow obstruction)
Aortic stenosis: increases intensity (inc blood volume ejected into aorta)
Standing valsalva and its effect on murmurs
decreseased LV volume, decreased vascular tone
MVP: click earlier, murmur longer (inc prolapse)
hypertrophic cardiomyopathy: increased intensity of murmur (inc outflow obstruction)
Aortic stenosis: decreased intensity of murmur (dec blood volume into aorta)
Physiologic murmurs: example causes
exercise, fever, hyperthyroidism, pregnancy, children, anemia
Grading of Heart Murmurs
- Very faint
- Quiet but heard immediately w/stethoscope on chest
- Moderately loud
- Loud, w/palpable thrill
- Very loud, w/thrill. May be heard w/stethoscope partly off chest
- Very loud, w/thrill. May be heard w/stethoscope off chest
What type of murmur might you hear in each area of the heart?
Systolic murmurs: mid, holo, and late
Midsystolic: AS, PS, ASD, HOCM*
Holosystolic: MR, TR, VSD
Late systolic: MVP
*Hypertrophic obstructive cardiomyopathy - most common cause of MIs in pediatric population
Diastolic murmurs: early, mid/late, other
Early diastolic: AR, PR, Austin-flint
Mid/late diastolic: MS, TS
Other/rare: PDA
Murmurs in infants and children
S3 common - be concerned if increased intensity
Murmurs common in newborns until 48h of age - if <grade></grade>
<p>Most common cause: CHD. Acquired - rheumatic fever</p>
<p></p>
</grade>
Benign pediatric murmurs
Still’s murmur: vibratory, groaning, musical. Heard best btwn LLSB and apex. 3-7yo.
Pulmonary: harsh systolic ejection at 2nd/3rd left IS
Venous Hum: continuous humming. Heard best at upper right sternal border in sitting position. Decreases/disappears supine.
Vesicular breath sounds
inspiratory longer than expiratory
Soft intensity of expiratory
Relatively low pitch
covers most of both lungs
Bronchovesicular breath sounds
inspiratory & expiratory about equal
intermediate intensity of expiratory
intermediate pitch
located 1st & 2nd ICS anteriorly & between scapulae
Bronchial
Expiratory longer than inspiratory
loud intensity of expiratory
relatively high pitch
heard over manubrium, larger proximal airways
Tracheal breath sounds
Inspiratory & expiratory about equal
very loud expiratory intensity
relatively high pitch
heard over trachea
At what gestational age do alveolar cells secrete surfactant?
24-26 weeks
Newborns/Infants & respiration
Newborns: Thorax barrel shaped (shaped like adult at 6yo)
chest & head circumference match
obligate nose-breathers x4 weeks
irregular breathing patterns (apnea 10-15sec)
crackles may be normal
**Newborns & infants: **thin chest wall, little musculature, ribs soft & pliant, some abd breathing (if increased - possible pulm dz). Chest circumference 30-36cm; Respiratory tree - bifurcation of distal trachea at T3 (adults T4-5)
Pregnant women & Respiration
Dyspnea: breathes more deeply but not more frequently
asthma - worse or unaffected
Functional residual capacity decreases
Types of immunity
Active Natural: had the dz. Life long immunity
Active Artificial: immunization via altered dz antigen against which body made antigens (most IZs)
Passive Natural: maternal - infant. Short lifespan - infant unprotected at about 2-3mths.
**Passive Artificial: **Preformed Abs - immune globulins or dz specific globulins. Human or animal products - protect 1-2mths.
Types of Vaccines
Live Attenuated: live weakened strain injected. Stimulates memory B and T cells. Immunity typically long-term. E.g., MMR, Varicella
Inactivated: bacteria or virus isolated & inactivated using heat or chemicals. Can’t cause infection , buts stimulates B cells to produce Abs. Usually need several doses or booster shots. E.g., polio, hep A
**Subunit/conjugate: **also inactivated. Use only part of pathogen that evokes immune response. E.g., HIB, pertussis
Vaccines for Health Care Workers
**HEp B: **3 doses (1 now, 2 in one month, 3 approx 5 months after dose 2)
Tdap: single dose + booster q10y
Influenza: annually
MMR: 1-2 doses if born after 1957
Varicella: 2 doses, 4w apart
Meningococcal: if routinely exposed to N. meningitidis
Required record keeping for IZs
Edition & date of VIS
Date VIS is provided (date of IZ)
Office address & name of person who administers
Date vaccine administered
Vaccine manufacturer & lot #
Diptheria
Transmitted respiratory droplets (or on objects)
Sx: weakness, sore throat, fever, swollen glands in neck
Thick coating builds up on throat or nose in 2-3 days (pseudomembrane - formed from dead tissue) making it hard to breath
Prognosis: may cause damage to heart, kidneys, and nerves, paralysis. 1 in 10 w/Tx die. W/o 1 in 2 die.
**Diagnosis: **throat swab or skin lesion
Tx: isolation 48hrs, antitoxin & antibiotics (erythromycin), respiratory support & airway mgmt
*give diptheria toxoid booster to all close contacts
Tetanus
**Transmission: **not person-person. Bacteria found in soil, dust, manure, enters body through break in skin
Sx: HA, jaw cramping, sudden involuntary muscle tightening, trouble swallowing, seizures, fever
Dx: clinical exam
Tx: medical emergency - hospitalization, immediate human tetanus immune globulin or equine antitoxin, tetanus vaccine, drugs to control muscle spasm, aggressive wound care, Abx, supportive care (possible intubation)
Pertussis
“Whooping cough”
**Transmission: **air droplets, most contagious up to 2 weeks after cough starts
S/s: w/in 5-10 days post exposure, runny nose, low grade fever, violent rapid cough, vomiting, exhaustion, apnea
**Prognosis: **most sever in infants/children. May last 10+weeks
**Dx: **swab secretions at back of throat or nasopharyngeal flush
Tx: strongly recommended before test results. Antibiotics if >1 yo w/in 3weeks cough onset. <1 y and pregnant w/in 6 weeks of cough onset. Azithromycin, clarithromycin, erythromycin, trimethoprim-sulfamethoxasole; vaporizer, suctioning. cough syrup will NOT help
Haemophilus Influenza Type B (HIB)
Types: bacteremia, meningitis, cellulitis
Transmission: droplets, cough
Risk: sickle cell, asplenia, HIV, chemo, radiation, post transplant
S/s: fever, cough, SOB, chills, sweating, HA, muscle pain, excessive tiredness, anxiety, alt MS
**Dx: **one or more lab tests: blood, spinal fluid
**Tx: **Antbx 10 days
**Prognosis: **even w/tx, 3-6% chldren w/meningitis die
Measles
“Rubeola”
**Transmission: **droplet 4 days before & 4 days after rash; incubation 7-21 days, lives on objects 2 hours
S/s: classic prodrome of fever (up to 105F), malaise, three Cs - cough, coryza (inflammation mucous membranes & loss of smell), conjunctivitis, & pathognomonic enanthema (koplic spots - white sposts in mouth) followed by maculopapular rash
complications: pneumonia, hearing loss, enchepalitis
Dx: serology lab confirmation, throat, nasopharyngeal swab
**Tx: **isolation, supportive care
*post exposure prophylaxis: vaccine w/in 72hrs, IG w/in 6 days
*hcp must report to health dept w/in 24 hours
Mumps
**Transmission: **droplet. Incubation 12-25 days
S/s: fever, HA, muscle aches, tiredness, loss of appetite, swelling of salivary glands
**complications: **encephalitis/meningitis, oophoritis and mastitis
**Dx: **serologic testing
**Tx: **isolation for 5 days after glands swell, supportive care
Rubella
“german measles”
**Transmission: **droplet
**S/s: **rash starting on face, spreads to body, low fever, lasting 2-3 days; older persons swollen glands
Complications: birth defects: deafness, heart defects, mental retardation
Hep B
**Transmission: **body fluids
S/S: fever, fatigue, loss of appetite, nausea, emesis, abdominal pain, dark urine, clasy-colred stool, joint pain and jaundice. Appear 90 days after exposure, but can occur 6 weeks to 6 months, lasting 6 months
**Dx: **serologic testing (HBsAg, anti-HBs, etc)
**Tx: **acute: supportive; chronic: close surveillance (infx dz f/u, hepatologist, VA clinics)
Prognosis: can cause lifelong infxn, cirrhosis, liver cancer, liver failure, death
Hep A
Transmission: fecal matter- even microscopic
S/s: jaundice, tiredness, stomach ache, loss of appetite, nausea, joint pain
**Dx: **serologic testing
**Tx: **supportive, fluids, rest
Polio vaccine
**Transmission: **person to person
**S/s: **72% have none. Some have fever, nausea, HA, stiffness in back. <1% permanent paralysis of limbs, of those 5-10% die
Pneumococcal
**Transmission: **air droplets
**S/s: **fever, chills, cough, rapid breathing, chest pain, stiff neck
**Complications: **meningitis, bacteremia, pneumonia
**Dx: **serum, spinal fluid
**Tx: **based on severity. Antibx, caution w/resistance
*immunocompromised, chronic illness, cochlear implants are high risk - should get 23 (can’t get 23 until 2y - get 13
Influenza vaccines
Shot: inactivated
Nasal spray: live attenuated (5-49yo, healthy immune system)
Who should not get certain flu shots
Anyone not feeling well
Inactivated: anyone with Guillai-Barre syndrome
Nasal: long term health problems, received other vaccines w/in 4weeks, age <2, >50, long term aspirin tx, people who care for immunocompromised pts, allergy to eggs
Meningococcal Dz
Risks: community settings (e.g., college dorms)
Transmission: close contact w/throat secretions, spit, kissing; sx present 3-7 days after exposure
S/s: N/V, photophobia, altered MS, neck pain, HA
**Dx: **serum testing, blood or lumbar puncture, CSF
**Tx: **antibx (before test results)
**Prognosis: **10-15% die even w/tx; 11-19% of survivorshave long term disabilities, loss of limbs, deafness, brain damage
Herpes Zoster
“Shingles”
Transmission: can spread by direct contact. caused by virus reactivation - greater risk w/dec immune function
S/s: blistering clear rash in dermatome, pain. Lesions usually crust over/heal in 2-4 weeks
Complications: postherpetic neuralgia (PHN), ophthalmic involvement (medical emergency!), bacterial superinfection, cranial nerve palsy
Rabies
Transmission: saliva or brain/nervous system tissue
S/s: flu-like, fever, HA, cerebral dysfunction, delirium, confusion, agitation
**Onset: **acute 2-10 days, once signs of rabies appear, nearly always fatal
Dx: locate animal & euthanize, examine brain tissue; in humans ante-mortem - serum, spinal fliud, need more than one. Post-mortem - brain biopsy
**Tx: **wash wounds immediately. Give passive Ab & vaccine
Rotovirus
**Transmission: **fecal-oral
S/s: severe acute gastroenteritis, watery diarrhea, vomiting, abdominal pain, dehydration, lasts several days
**Tx: **supportive care
do not give vaccine to severe combined immunodeficiency or intususseption
Pregnancy Vaccinations
Hep A
Hep B
HPV
Influenza IIV, LAIV (live)
MMR (live)
Meningococcal (polysaccharide, conjugate)
Pneumococcal (polysaccharide)
Tdap (toxoid/inact)
Tetanus/diptheria TD (toxoid)
Varicella (live)
Pregnancy vaccinations - BEFORE
Influenza IIV
Influenza LAIV (live)
If indicated: the rest
*Avoid conception 4 weeks for all LIVE
Pregnancy Vaccinations - DURING
Influenza IIV
Tdap 27-36 weeks gest, each pregnancy
(or Tetanus/diptheria Td, but prefer Tdap)
If indicated: meningococcal, pneumococcal, Hep A/B
Contraindicated: Influenza LAIV, HPV, MMR, Varicella, Zoster
Pregnancy Vaccinations - AFTER
Influenza IIV & LAIV
If indicated: the rest (avoid conception 4 weeks for all live)
Special Considerations: MMR immediately PP if not rubella immune; Tdap immediately PP if not given before, Varicella immediately PP if not immune
Adult Vaccinations - GENERAL
Influenza annually
Tdap: one time Tdap then booster Q10y
Varicella: 2 doses
Adult Vaccinations 19-21 yo
HPV 3 doses M &F
MMR 1 or 2 doses
Adult Vaccinations 22-26 yo
HPV 3 doses, females
MMR 1 or 2 doses
Adult Vaccinations 27-49 yo
MMR 1 or 2 doses
Adult Vaccinations 50-59yo
MMR 1 or 2 doses (to about 55yo)
Adult Vaccinations 60-64yo
Zoster 1 dose
Adult vaccinations >= 65yo
Zoster (1 dose)
Pneumococcal polysaccharide (PPSV23) 1 dose
Vaccinations immunocompromised (except HIV)
Influenza IIV
HPV Males & Females through 26yo
Pneumo 12 or 23
*Hib if post-HSCT
C/I’d: varicella, zoster, MMR
Vaccinations HIV
CD4 count <200
Influenza IIV
HPV through 26yo (M & F)
Pneumo 13 or 23
Hep B
C/I’d: varicella, zoster, MMR
Vaccinations HIV
CD4 >200
Influenza IIV
Varicella
HPV through 26yo (M & F)
MMR
Pneumo 13 or 23
Hep B
No C/I
Vaccinations MSM
HPV through 26 yo
Hep A/B
Vaccinations: Kidney Failure
Influenza IIV
Zoster
MMR
Pneumo 13 or 23
Hep B
Vaccinations: Heart Dz, Chronic Lung Dz, Chronic ETOH
Influenza IIV
Zoster
MMR
Pneumo 23
Vaccinations asplenia
Influenza IIV
Zoster
MMR
Pneumo 13 or 23
Meningococcal
Hib
Vaccinations Chronic Liver Dz
Influenza IIV
Zoster
MMR
Pneumo 23
Hep A/B
Vaccinations: Diabetes
Influenza IIV
Zoster
MMR
Pneumo 23
Hep B
Vaccinations: Birth
Hep B 1
Vaccinations: 1 mth
Hep B2 (1-2mo)
Vaccinations: 2 mo
Hep B2 (1-2mo)
Rotavirus 1
DTaP 1
Hib 1
PCV13 1
IPV 1
Vaccinations 4 mo
Rotavirus 2
DTaP 2
Hib 2
PCV13 2
IPV 2
Vaccinations: 6mo
Hep B3 (6-18mo)
Rotavirus 3 (if necessary)
DTaP 3
Hib 3 (depending)
PCV13 3
IPV 3 (6-18mo)
Influenza IIV
Vaccinations: 9mo
Hep B3 (6-18 mo)
IPV 3 (6-18mo)
Influenza IIV
Vaccinations: 12 mo
Hep B3 (6-18 mo)
Hib 3/4 (12 - 15)
PCV13 4 (12 - 15)
IPV 3 (6-18mo)
Influenza IIV
Varicella (12-15)
MMR (12-15)
Hep A 2 doses (12-23mo)
Vaccinations: 15 mo
Hep B3 (6-18 mo)
DTaP 4 (15-18mo)
Hib 3/4 (12 to 15)
PCV13 4 (12 to 15)
IPV 3 (6-18mo)
Influenza IIV
Varicella (12-15)
MMR (12-15)
Hep A 2 doses (12-23mo)
Vaccinations: 18mo
Hep B3 (6-18 mo)
DTaP 4 (15-18mo)
IPV 3 (6-18mo)
Influenza IIV
Hep A 2 doses (12-23mo)
Vaccinations: 19-23 mo
Influenza IIV
Hep A 2 doses (12-23mo)
Vaccinations: 2-3yo
Influenza IIV or LAIV
Vaccinations: 4-6yo
Influenza IIV or LAIV
DTaP 5
IPV 4
MMR 2
Varicella 2
Vaccinations: 7-10
Influenza IIV or LAIV
Vaccinations: 11-12
Influenza IIV or LAIV
Tdap
HPV (3 doses)
Meningococcal 1
Vaccinations: 13-15
Influenza IIV or LAIV
Vaccinations: 16-18
Influenza IIV or LAIV
Meningococcal booster at 16yo
