Final A Flashcards
What are the fissures on the left lung? How many lobes are there?
Oblique fissure splits the left lung into 2 lobes
What is visceral pleura?
The serous membrane that covers the outer surface of each lung
What is parietal pleura?
The membrane that lines the inner rib cage and upper surface of the diaphragm
What is the primary muscle of inspiration?
Diaphragm
How does the intrathoracic pressure change during inspiration?
It decreases below atmospheric pressure, drawing air in
When the work of breathing is increased, which accessory muscles are most important for respiratory effort?
Sternocleidomastoids
What is hemoptysis?
Blood-streaked sputum
Pain in conditions such as pneumonia, pneumothorax, and PE arise from what area of the thoracic cavity?
The parietal pleura
What measurement can predict 5 year survival in patients with COPD better than FEV1 can?
Degree of dyspnea
What conditions cause wheezing?
Asthma, emphysema - partial airway obstructions from secretions, inflammation, or other airway obstruction
How long does an acute cough last?
Less than 3 weeks
How long does a subacute cough last?
3-8 weeks
How long does a chronic cough last?
More than 8 weeks
What is the leading cause of preventable death in the U.S.?
Smoking
What is tactile fremitus?
Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patient speaks
What does chest percussion during a pulmonary exam help you determine?
Whether the underlying tissues are air-filled, fluid-filled, or solid
What are vesicular breath sounds?
Normal soft-intensity, low-pitched gentle sighing sounds created by air moving through the smaller airways (bronchioles and alveoli)
When are vesicular breath sounds best heard?
On inspiration
What are bronchovesicular breath sounds?
Moderate-intensity and moderate-pitched blowing sounds created by air moving through the larger airways (bronchi)
When are bronchovesicular breath sounds best heard?
Either inspiration or expiration
What are bronchial/tubular breath sounds?
High-pitched, loud, harsh sounds created by air moving through the trachea
When are bronchial/tubular breath sounds best heard
Expiration
What do crackles/rales sound like?
Fine, short, interrupted crackling, high pitched
What causes crackles/rales?
Air passing through fluid or mucus in any airway
When are crackles/rales best heard?
On inspiration
Where are crackles/rales most commonly heard?
At the base of the lower lung lobes
What do gurgles/rhonchi sound like?
Continuous, low-pitched, coarse, harsh - a moaning/snoring quality
When are gurgles/rhonchi best heard?
On expiration
Which adventitious/abnormal breath sounds can be altered by coughing?
Gurgles (rhonchi)
What causes gurgles/rhonchi?
Air passing through narrowed air passages as a result or secretions, swelling, or tumors
Where are gurgles/rhonchi heard?
Can be heard at most lung areas but best heard over the trachea and bronchi
What does a friction rub sound like?
Superficial grating or creaking sounds
When are friction rubs heard?
During both inspiration and expiration
What causes friction rub sounds?
Rubbing together of inflamed pleural surfaces
Where are friction rubs heard the best?
In areas with the greatest thoracic expansion like the lower anterior and lateral chest
What is stridor?
Wheeze-like sounds in the trachea heard when a person breaths
What causes stridor?
Blockage of airflow in the trachea or back of throat
What is whispered pectoriloquy?
When listening with a stethoscope, there is increased loudness of words that a patient whispers in areas of tissue abnormality
What is bronchophony?
When words that a patient says in a normal voice are heard clearly with a stethoscope
What is egophony?
When the patient says the vowel “e”, it sounds more like a nasal “a” when listening with a stethoscope
What causes egophony?
Consolidated lung tissue
What is the most common congenital deformity of the anterior chest wall?
Pectus excavatum
What is pectus excavatum?
When several ribs and the sternum grow abnormally and produce a caved in or sunken appearance of the chest wall
What is pectus carinatum?
A deformity of the chest characterized by protrusion of sternum and ribs
What is pectus carinatum also called?
Pigeon chest
What is the normal ratio of anteroposterior to transverse diameter of an adult chest?
1:2
What is the chest diameter ratio in patients with barrel chest?
1:1
What is flail chest?
A portion of the chest caves in - normally due to a blunt chest injury
What type of breathing is caused by flail chest?
Paradoxical - the chest wall collapses in during inhalation and moves out during exhalation (opposite in normal breathing)
What is the definition of functional residual capacity?
The volume of air left in the lungs after a passive exhalation - 30mL/kg
What does spirometry measure?
The volume and/or flow of air that can be inhaled and exhaled
What lung diseases can be diagnosed using spirometry?
- Asthma
- Bronchitis
- Emphysema
Which common complaint can be investigated using a spirometry test?
Shortness of breath
Which test of respiration can measure whether exposure to chemicals at work affects lung function?
Spirometry
Which test of respiratory checks lung function before someone has surgery?
Spirometry
What lung volumes cannot be measured using spirometry?
FRC and RV
Average tidal volume
500mL
Average residual volume (RV)
1200mL
Average volume for Total Lung Capacity (TLC)
6000mL
Average volume for Vital Capacity (VC)
4800mL
Average volume for Functional Residual Capacity
2400mL
What is FEV1?
Forced expiratory volume - the volume of gas exhaled in 1 second by a force expiration after a full inspiratory
What is the most commonly used parameter to predict survival in COPD patients?
FEV1
What is FVC?
Forced vital capacity - vital capacity measured with a forced expiration
What is a normal FEV1/FVC ratio?
80%
What does the FEV1/FVC ratio measure?
The percent of forced vital capacity that is exhaled in the first second
What is the issue in obstructive lung disease?
There is difficulty exhaling all the air from the lungs because of damage to the lungs or narrowing of the airways inside the lungs
What is the issue in restrictive lung disease?
There is an underlying condition that causes stiffness in the lungs and a restriction with lung expansion
How is FEV1 changed in patients with obstructive lung diseases?
Decreased
How is the FEV1/FVC ratio changed in patients with obstructive lung disease?
Decreased
The diagnosis of COPD is made with the FEV1/FVC ratio is less than __%
70
How is the FEV1/FVC ratio changed in patients with restrictive lung disease?
It remains the same or may even be increased because both FEV1 and FVC are equally reduced. FVC may decline more - causing the ratio to increase
What test is used to determine gas exchange?
Arterial blood gas
Supplemental oxygen should be administered at a PaO2 less than __mmHg
60
A patient is at risk of death with a PaO2 less than __mmHg
26
Normal ABG pH range
7.35-7.45
Normal ABG pCO2 range
35-45
Normal ABG pO2 range
80-100
Normal ABG HCO3 range
22-26
List materials found in an X-ray in order of most radiodense (white) to least radiodense (black)
Metal, bone, soft tissue, fat, air
What instrument used for lung testing is contraindicated in cases of severe bronchospasm and bleeding?
Flexible bronchoscopy
What procedure is done under general anesthesia and is used to remove large tissue samples for biopsy or when severe airway bleeding is present?
Rigid bronchoscopy
What is the purpose of a VQ scan?
To evaluate the circulation of air and blood within a patient’s lungs in order to determine the ventilation/perfusion ratio
A VQ scan is commonly done to check for the presence of what abnormalities in the airways?
Blood clots or abnormal blood flow due to a pulmonary embolism
What layer of the skin is supplied with blood and contains sweat glands and hair follicles?
Dermis
Skin color depends on what 4 pigments?
- Deoxyhemoglobin
- Oxyhemoglobin
- Carotene
- Melanin
An increase in which skin pigment causes cyanosis?
Deoxyhemoglobin
What are the 2 types of hair found on the skin?
- Vellus (short, fine)
- Terminal (scalp, eyebrows)
What are the only skin surfaces where sebaceous glands are not present?
Palms and soles
What are the 2 types of sweat glands?
- Eccrine: widely distributed and open onto surface, control body temp
- Apocrine: axillary and genital regions, stimulated by stress
What are the ABCDEs when screening moles for melanoma?
A - asymmetry B - irregular borders C - color change and variation D - diameter E - elevation or enlargement
Moles greater than or equal to __mm are indicative of possible melanoma
6
6 or more cafe-au-lait spots with diameters greater than 1.5 cm suggests what underlying condition?
Neurofibromatosis
What skin disease is characterized by depigmented macules on face, hands, or feet?
Vitiligo
What is Tetralogy of Fallot?
A birth defect of the heart consisting of four abnormalities that results in insufficiently oxygenated blood pumped to the body
Cyanosis visible peripherally in the fingertips can be indicative of what underlying diseases?
- CHF
- Raynaud’s disease
Central cyanosis can be present in the case of what underlying condition?
Congenital heart disease
What causes jaundice?
Liver disease or hemolysis of RBCs
What is erythema?
A red hue on the skin caused by increased blood flow to the area
What skin disease occurs when the immune system mistakes skin cells as a pathogen?
Psoriasis
What is the most common form of psoriasis?
Plaque psoriasis
What allergic skin disease is associated with asthma?
Atopic eczema
What skin rash presents in the shape of a butterfly and involves with bridge of the nose?
Lupus-Malar rash
What name is given to a patch of closely grouped skin papules more than 1 cm across
Plaque
What is a cyst?
A nodule filled with expressible material, either liquid or semisolid
What is a wheal?
A skin elevation caused by swelling that can itch - associated with an allergic reaction
What is angioedema?
A vascular reaction representing localized edema caused by dilation and increased permeability of capillaries
What skin rash is defined as a raised lesion less than 5mm across and filled with clear fluid - seen in herpes or chicken pox?
Vesicles
What are vesicles more than 5mm across called?
Bulla
What is erythema multiforme?
A skin condition possibly mediated by deposition of immune complex (mostly IgM) on microvasculature of the skin and oral membranes
What are 2 forms of erythema multiforme?
- Stevens-Johnson syndrome
- Toxic epidermal necrolysis
What is lichenification?
Rough, thick epidermis with exaggerated skin lines
What is a keloid?
Hypertrophic scarring that extends beyond the borders of the initiating injury
What term is given to a nonscarring loss of superficial epidermis - usually found with chickenpox?
Erosion
What is excoriation?
Linear or punctate erosions caused by scratching or picking at a primary lesion
What are the 4 stages of pressure ulcers?
1) Skin not broken but is discolored
2) Epidermis is broken, creating a shallow open sore
3) Break in skin extends through dermis into subQ and fat
4) Breakdown extends into muscle
What is cellulitis?
Localized or diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin
In what patients is cellulitis common?
Diabetes and immunocompromised
What vascular lesions are associated with liver disease, pregnancy, and vitamin B deficiency?
Spider angioma
What are 1st degree burns?
The least serious burns that cover only the outer layer of skin but not all the way through
What are 2nd degree burns?
When the first layer of skin has been burned through and the second layer of skin is also burned
What are 3rd degree burns?
The most serious burns involving all 3 layers of the skin that causes permanent tissue damage
Where does the spinal cord begin and end?
From the medulla in the brain to the 1st or 2nd lumbar vertebra
What is the cauda equina?
The region where the nerve roots fan out like a horses tail at the end of the spinal cord (L1-L2)
What is cauda equina sydrome?
When damage to the cauda equina causes loss of function to the lumbar plexus - can lead to severe back pain, bowel/bladder dysfunction, sexual dysfunction, etc
What part of the peripheral nervous system coordinates involuntary operations of the GI tract?
Enteric nervous system
Name and function of cranial nerve I
Olfactory - sensory - smell
Name and function of cranial nerve II
Optic - sensory - vision
Name and function of cranial nerve III
Olfactory - motor - pupillary reactions, extraocular movements and eyelid movement
What can be caused by damage to cranial nerve III?
- Strabismus (lazy eye)
- Ptosis (drooping)
- Diplopia (double vision)
Name and function of cranial nerve IV
Trochlear - motor - downward movement of eye
What can be caused by damage to cranial nerve IV?
- Diplopia
- Strabismus
Name and function of cranial nerve V
Trigeminal - mixed - sensory for eye area, motor for temporal and masseter area
Name and function of cranial nerve VI
Abducens - motor - proprioception and lateral movement of eyeball
Name and function of cranial nerve VII
Facial - mixed - sensory for taste on anterior 2/3 of tongue, motor for facial expression, closing eyes and mouth
What can be caused by injuries to cranial nerve VII?
- Bell’s palsy
- Loss of taste
- Decreased salivation
- Loss of ability to close eyes
Name and function of cranial nerve VIII
Vestibulocochlear - sensory - equilibrium/balance, hearing
What can be caused by injuries to cranial nerve VIII?
- Vertigo
- Atasia
- Nystagmus
- Tinnitus
- Deafness
Name and function of cranial nerve IX
Glossopharyngeal - mixed - sensory for posterior 1/3 of tongue and breathing rate and gag reflex, motor for swallowing and speech
Name and function of cranial nerve X
Vagus - mixed - sensory for taste/breathing rate/visceral sensations/gag reflex, motor for swallowing, coughing, speaking
Name and function of cranial nerve XI
Accessory - motor - swallowing, head and shoulder movement
Name and function of cranial nerve XII
Hypoglossal - motor - movement of tongue during speech and swallowing
Spinal nerves involved in upper abdominal reflex
T7-T9
Spinal nerves involved in lower abdominal reflex
T10-T11
Spinal nerves involved in cremaster reflex
T12-L2
What is the cremaster reflex?
Testicle and scrotum rise when inner thigh of male is stroked
Spinal nerves involved in plantar reflex
L4-S2
What is the plantar reflex?
Toes should flex with stroking of lateral aspect of the foot
What sign are you looking for when testing the plantar reflex?
Babinski sign - a dorsiflexion of big toe when testing the plantar reflex
Spinal nerves involved in biceps reflex
C5-C6
Spinal nerves involved in brachioradialis reflex
C5-C6
Spinal nerves involved in triceps reflex
C6-C8
Spinal nerves involved in patellar reflex
L2-L4
Spinal nerves involved in achilles reflex
S1-S2
What level of consciousness (LOC) does a patient have if they are only aroused with painful stimuli?
Stupor
What LOC does a patient have if they are aroused with gentle shaking?
Obtundation
What LOC does a patient have if they will recognize you when you speak with a loud voice?
Lethargy
What things should you be assessing during a mental status exam?
- Attention
- Language
- Memory
- Higher cognitive abilities
- Cortical functions
What cranial nerves are you testing by observing pupil size, shape, and reaction to light?
3, 4, 6
How can you test function of cranial nerve V?
Palpate the strength of muscle contractions over temporal and masseter areas while patient clenches teeth
How can you test function of cranial nerve VII?
Inspect symmetry of facial expression
How can you test function of cranial nerve XI?
Inspect for atrophy or fasciculations in trapezius muscles
How can you test function of cranial nerve XII?
Inspect for tongue midline with protrusion, strength of tongue, quality of speech
What does a grade of 0 on a muscle strength test indicate?
No muscular contraction
What does a grade of 3 on a muscle strength test indicate?
Active movement against gravity
What does a grade of 5 on a muscle strength test indicate?
Active movement against resistance
How can you test stereognosis?
Have patient identify familiar objects in their hands with their eyes closed
How can you test graphesthesia?
Write on a patient’s hand with something blunt and have them identify number or letter you wrote
How can you test two-point localization?
Find the minimal distance on a patient’s finger or thumb that they are able to discriminate between two points
What does a 4+ grade for a deep tendon reflex represent?
Very brisk, hyperactive, with clonus
What does a 3+ grade for a deep tendon reflex represent?
Brisker than average, possibly but not necessarily indicative of disease
What does a 2+ grade for a deep tendon reflex represent?
Average, normal
What does a 1+ grade for a deep tendon reflex represent?
Somewhat diminished, low normal
What is Brudzinski’s sign? What does it suggest?
Pain with flexion of hips and knees while patient is supine, suggests meningeal inflammation
What is Kernig’s sign?
Pain and increased resistance with straightening the knee while supine
What are the s/s of a CVA?
Brain - confusion, trouble talking, dizziness, loss of balance Eyes - trouble seeing Face/arms/legs - numbness or weakness Stomach - throwing up Body - feeling tired Legs - trouble walking
What is a focal seizure?
A seizure that starts in one area of the brain
What is a generalized seizure?
A seizure that involves both hemispheres of the brain
What are the symptoms of a seizure?
- Blackout
- Involuntary movement of limbs
- Hallucinations
- Odd sounds and sensations
- Episodes of staring
What seizure drug is a first line treatment for all seizure types?
Lamotrigine
What type of seizures is Topiramate used for?
Tonic-clonic and focal
What type of seizure is Oxcarbazepine used for?
Focal
What branch of the vagus nerve is stimulated by a vagus nerve stimulator?
Left
What is multiple sclerosis?
The body’s immune system attacks myelin covering the nerves which interrupts nerve impulses traveling to and from the brain
What are the anesthetic considerations for a patient with multiple sclerosis?
- Local anesthetics can exacerbate symptoms
- NDMBs can be used in normal doses
- Temperature maintenance is important, demyelinated axons are more sensitive to heat
What is Parkinson’s disease?
Slow loss of dopamine-producing neurons
What are the clinical features of Parkinson’s?
Tremors, rigidity, bradykinesia, dementia
What are the anesthetic concerns associated with ALS?
- General anesthesia can cause ventilatory depression post op
- Regional contraindicated in patients with motor neuron disease for fear of exacerbating disease
What is myasthenia gravis?
Autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatiguability
What is the first noticeable symptom of myasthenia gravis?
Weakness of the eye muscles
What are the anesthetic considerations in patients with myasthenia gravis?
- Resistance to depolarizing NMB drugs, may need to increase dose
- Sensitivity to non-depolarizing NMB drugs, need only 10% normal dose
- Avoid cholinesterase inhibitors
What is a cholinergic crisis?
Muscles stop responding to bombardment of Ach leading to flaccid paralysis, respiratory failure, and SLUDGE
What are the anesthetic considerations for patients with muscular dystrophy?
- Avoid sux and volatiles due to risk of hyperkalemic cardiac arrest and rhabdomyolysis
- A general must be a TIVA
- Avoid shivering and increased O2 demand
Where is mitral valve best heard
Apex
Where is tricuspid valve best heard
Lower left sternal border
Where is pulmonic valve best heard
2nd/3rd interspaces left of sternum
Where is aortic valve best heard
2nd interspace right of sternum
Normal PR interval
0.12-0.2 seconds
What pressure is reflected by jugular venous pressure?
Right atrial pressure
What are thrills
Humming vibration felt during palpation carotid
What are bruits
Murmur sound of vascular origin heard with diaphragm of stethoscope
What sounds are heard with diaphragm of stethoscope
High pitched S1 and S2, regurgitation
What sounds are heard with bell of stethoscope
Low pitched S3 and S4, stenosis
What causes S1 sounds
Closure of mitral and tricuspid valves
What causes S2 sounds
Closure of aortic and pulmonic valves
What causes S3 sounds
Rapid movement of blood against ventricular walls
What conditions could cause S3 heart sounds
- Anemia
- Fever
- Pregnancy
- Thyrotoxicosis
Grade I murmur
Very faint
Grade II murmur
Quiet but heard immediately
Grade III murmur
Moderately loud
Grade IV murmur
Loud with palpable thrill
Grade V murmur
Very loud, thrill, heard w/ stethoscope partly off chest
Grade VI
Very loud, thrill, heard with stethoscope entirely off chest
Common systolic murmurs
- Aortic stenosis
- Mitral valve prolapse
- Mitral regurg
- Tricuspid regurg
Common diastolic murmurs
- Aortic regurgitation
- Mitral stenosis
What is skin mobility
Ease with which skin lifts up
What is skin turgor
Speed with which skin returns into place
Discharge rate for junctional pacemakers
40-60bpm
Heart rhythm that results in sudden death
Ventricular fibrillation
Most common cause of sinus arrhythmia
Inspiration and expiration
Murmur shape of aortic stenosis
Crescendo/decrescendo
Murmur shape of mitral regurgitation
Plateau
Murmur shape of aortic regurgitation
Decrescendo
Murmur shape of mitral stenosis
Crescendo
Which murmurs are pansystolic
Mitral and tricuspid regurg
