Examination Flashcards by Lauren Wolfe

(1) interview

History
Risk factor assessment
Description of usual activity (NYHA classification)
Medications and side effects
Pain/PMH/family hx/diet/MD/stress

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(2) cardiac examination

Supine:
Vital signs
- ECG identification/interpretation
- HR
- RR
- SpO2 (check pleth and radial pulse!)
Surgical incisions
Lines and tubes
Pulse rate and quality
Blood pressure
Explain RPE scale to pt.

Seated:
Blood pressure
Pulse ox
Heart sounds
Other (pain, angina, JVD, breathing pattern)

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Risk factor assessment

Modifiable vs. non-modifiable

Exposures
- What do you do for work?

Smoking history
- How much/when/still?
- positive reinforcement

Activity/exercise history
- Do you exercise?
- What activities do you participate in?

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Modifiable risk factors

HTN
hypercholesterolemia
smoking
diabetes
physical inactivity
obesity
diet
other (stress, personality type, inflammation)

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Non-modifiable risk factors

Age, sex, genetics, family history

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NYHA Classification - Class 1

Limitation: mild

CVD present
No physical activity limitations
Ordinary activity does not cause undue fatigue, palpitation, dyspnea, or angina

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NYHA Classification - Class 2

Limitation: mild

CVD present
Slight limitation of PA
Comfortable at rest
Ordinary PA results in fatigue, palpitation, dyspnea, or angina

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NYHA Classification - Class 3

Limitation: moderate

CVD present
Marked limitation of PA
Comfortable at rest
Less than ordinary activity causes fatigue, palpitation, dyspnea, or angina

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NYHA Classification - Class 4

Limitation: severe

CVD present
Inability to carry on any PA w/o discomfort
Symptoms of HF or angina present at rest
Discomfort increases w/ PA

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MRC Breathlessness Scale - Grade 0

I only get breathless with strenuous exercise

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MRC Breathlessness Scale - Grade 1

I get short of breath when hurrying on level ground or walking up a slight hill

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MRC Breathlessness Scale - Grade 2

On level ground, I walk slower than people of the same age because of breathlessness, or I have to stop for breath when walking at my own pace on level ground

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MRC Breathlessness Scale - Grade 3

I stop for breath after walking about 100 yards or after a few minutes on level ground

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MRC Breathlessness Scale - Grade 4

I am too breathless to leave the house or I am breathless when dressing

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Pulse rate and quality

Indicates efficacy of circulation
Distinguish b/t pulse and HR
Can confirm accuracy of technology (pulse ox)

Quality
- 3+ = full, bounding
- 2+ = normal
- 1+ = weak, thready
- 0 = absent

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Blood pressure

Normal: less than 120 and less than 80

Elevated: 120-129 and less than 80

HTN stage 1: 130-139 or 80-89

HTN stage 2: >/= 140 or >/=90

HTN crisis: higher than 180 and/or higher than 120

Avoid lines and tubes

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MAP

MAP = DBP + 1/3 (SBP-DBP)
- normal: 70-110 mmHg
- prolonged <60 mmHg may result in organ ischemia

Aortic heart sounds

2nd ICS; right sternal border

Pulmonic heart sounds

2nd ICS; left sternal border

Mitral heart sounds

5th ICS; left midclavicular line
Two steps up from xyphoid process; lateral

Tricuspid heart sounds

4th or 5th ICS; left sternal border
Two steps up from xyphoid process; directly off of sternum

Abnormal heart sounds

S3: HF (decompensated)
S4: MI; HTN

Pulse oximetry

SpO2 > 89%

Inaccurate if weak or non-pulsatile or irregular pulse
- palpate pulse to confirm
- review pleth

Do not provide oxygen if SpO2 > 89%

Modified Borg Scale

1 = very easy
3 = moderate
5 = hard
7 = very hard
10 = very, very hard

(2) pulmonary examination

Supine: ECG Vitals (HR, BP) Respiratory rate/I:E ratio Pulse ox Observe breathing pattern Lines and tubes Percussion Seated: BP Pulse ox Breath sounds Palpation (including chest excursion and tactile fremitus) MRC breathlessness scale

I:E ratio

Normal: 1:2 Obstructive disease: >/= 1:3 Restrictive disease: 1:1

Observe and describe breathing pattern

Comfortable vs distressed Rapid, shallow Abdominal paradox Cheyne-Stokes (oscillation b/t apnea and tachypnea) Kussmaul's breathing (consistent very deep breathing at normal or increased rate)

Areas of auscultation: breath sounds

3 anterior, 3 posterior, 1 lateral Anterior: RUL RML --> below rib 4 RLL --> lateral LUL LLL --> below rib 6, lateral Posterior: Spine of scapula divides upper and lower R/L lobes

Normal breath sounds: bronchial

Loud, high pitched, harsh Heard over and around trachea E > I

Normal breath sounds: bronchovesicular

Heard around sternum, b/t scapula, anterior RUL

Normal breath sounds: vesicular

Medium pitch and loudness Heard over the majority lung periphery I > E

Abnormal breath sounds

Bronchial: - Normal sound in abnormal place - Indicates fluid filled areas Diminished Crackles - air bubbling through fluid or secretions - collapsed alveoli popping open Wheezes - difficulty forcing air out

Audible breath sounds (no stethoscope)

Stridor Grunting Gurgling Wheezing

Palpation

Trachea position Areas of chest pain Hypertrophy/tenderness of accessory mm. Chest wall shape and movement Tactile fremitus

Tactile fremitus

Caused by partial airway obstruction - secretions in airway - bronchoconstriction - tumors

SOB - Modified Borg Dyspnea Scale

1 = very slight 3 = moderate 5 = severe 7 = very severe 10 = maximal

Endurance testing

6MWT Step tests (seated) Incremental shuttle walk test

ABG normal values: pH

7.35-7.45 Changes due to increases/decreases in CO2/HCO3

ABG normal values: PaCO2

35-45 Increases w/ hypoventilation

ABG normal values: PaO2

80-100

ABG normal values: HCO3

22-28 Balances CO2 to maintain ideal pH