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ADV Health Assessment & Clinical Reasoning > Health Assessment Test 2 > Flashcards

Health Assessment Test 2 Flashcards

1
Q

Common presenting symptoms of Ears, Nose & Throat

A

Ear pain
Hearing loss
Vertigo
Nasal discharge
Nosebleed
Snoring
Sinus pain
Dental problem
Mouth lesions
Sore throat
Dysphagia

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2
Q

Obtaining the history with ear pain

A

Patient: 2 year-old AA female. Her mother states “Michele is having intense left ear pain” X 2days
Potential common etiologies of Ear pain
Infections, allergic conditions, Trauma, foreign body, referred pain.
Clinical presentations of the various etiologies?
Role Play: HPI? (OLDCARTS)
Address symptomatology (attributes of the symptom)
What direct questions might you ask?

Address
• Past medical history
• Pertinent Past surgical history
• Current medications and allergies
• Pertinent Family history
• Pertinent social history
• Always address Smoking, ETOH, drugs, and Occupation, living conditions, education, safety, exercise habits, diet and exercise only if pertinent.
• ROS: What are the systems pertinent to Cc and HPI?
• What are your potential differential diagnoses and working diagnosis at the end of subjective data collection

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3
Q

When is an otoscopic exam done?

A

The otoscopic exam is done in a routine screening and with complaint to inspect the external auditory canal and middle ear.

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4
Q

The auditory canal is inspected from…

A

The auditory canal is inspected from the meatus to the tympanic membrane.

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5
Q

How do you perform an ear exam in an adult?

A

To examine the ear in an adult grasp the auricle and lift up and back.

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6
Q

How do you perform an ear exam in an child?

A

To examine the ear in a child up to 3-4 years old you pull the auricle down and back.

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7
Q

During an exam you inspect the tympanic membrane for?

A

Inspect the TM for:

  • landmarks (cone of light)
  • color
  • contour
  • perforation.
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8
Q

Rinne test

A

Air conduction

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9
Q

Weber test

A

Bone conduction

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10
Q

Whisper test

A

Auditory function

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11
Q

How to perform a Rinne test

A

Rinne test (Air conduction) – comparing sound through the bone compared to sound through the air (should be 2x as long). Strike fork and place end on mastoid with tuning fork facing backward so the pt doesn’t hear the air conduction. Have pt tell you when the vibration stops then place sound 1-2” from the patients ear. Should be 2x as long heard. If so this is a + Rinne test indicating a healthy state.

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12
Q

How to perform a Weber test

(Bone conduction)

A

Weber test (Bone conduction) – After striking fork place handle on top of pts forehead midline and ask if they can hear it = it is considered “no lateralization” if heard more on the right or left it is said to “lateralize to that ear”.

If Weber test is negative it is abnormal and the sound lateralized to the right or left ear

If the hearing loss is conductive, the sound will be heard best in the affected ear. If the loss is sensorineural, the sound will be heard best in the normal ear.

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13
Q

When do you test for a Gag reflex?

A

Gag reflex is only tested in patients with suspected brainstem pathology, impaired consciousness, or impaired swallowing.

Tests CN IX and X

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14
Q

If palate elevation is impaired what CN might be the source?

A

CN X

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15
Q

If the gag reflex is impaired what CN might be the source?

A

CN IX or X

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16
Q

Normal age and condition variations of the EARS of an INFANT

A
  • Ears
    • Inspect auricle for full formation and flexibility
    • Auditory canals should be examined in first few weeks of life
    • Tympanic membrane becomes conical after first few months of life
    • Evaluate infant hearing using sound stimuli, observe that kids are following your voice
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17
Q

Normal age and condition variations of the NOSE of an INFANT

A
  • <3 no frontal or sphenoid sinuses. Frontal sinuses don’t fully develop until teen years
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18
Q

Normal age and condition variations of the MOUTH of an INFANT

A
  • Avoid depressing the tongue because this stimulates a strong reflex and protrusion of the tongue, making visualizing of the mouth difficult
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19
Q

Normal age and condition variations of the EARS of a CHILD

A
  • Otoscopic exam, pull auricle down to view TM
    • Observe that kids are following your voice
    • Audiometric eval should be performed on all young children at reg intervals
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20
Q

Normal age and condition variations of the NOSE of a CHILD

A
  • Palpate the paranasal sinuses after they have developed (maxillary sinuses by 4 years of age and frontal sinuses by 7 to 8 years of age BUT will not fully develop until teens)
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21
Q

Normal age and condition variations of the MOUTH of an CHILD

A
  • Inspect teeth for grinding, decay, and brown spots
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22
Q

Normal age and condition variations of the EARS of an OLDER ADULT

A
  • Irritation in auditory canal if hearing aide is worn
  • Course hair on the auricle
  • TM for sclerotic changes
  • Note presence of sensorineural (presbycusis) or conductive hearing loss
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23
Q

Normal age and condition variations of the NOSE of an OLDER ADULT

A
  • Dry mucosa
  • Increased hairs in vestibule
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24
Q

Normal age and condition variations of the MOUTH of an OLDER ADULT

A
  • Reduced salivary flow
  • Thinning buccal mucosa
  • Tongue for fissure and varicose veins
  • Inspect dental occlusion
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25
Q

How do you measure the symmetry of the ears?

A

The auricle of the ear should be an imaginary line extending from the inner eye canthus to the occiput. The consistency of auricle should be firm and mobile without nodules.

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26
Q

Grading the tonsils

A

Mouth/Throat Anatomy

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27
Q

Otitis Media with effusion

A

Inflammation of the middle ear resulting in the collection of serous, mucoid, or purulent fluid (effusion) when the tympanic membrane is intact

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28
Q

Healthy tympanic membrane. B, Tympanic membrane partially obscured by cerumen. C, Bulging tympanic membrane with loss of bony landmarks. D, Perforated tympanic membrane. E, Perforated tympanic membrane that has healed. F, Tympanostomy tube protruding from the right tympanic membrane

A

Otitis media with effusion. A, The middle ear filled with serous fluid; note the bulging appearance and distorted light reflex. B, Air-fluid levels in upper middle ear. C, Acute otitis media. Note the red bulging tympanic membrane with obscured bony landmarks and distorted light reflex

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29
Q

Malignant Otitis Externa Fulgurant

A

Peri auricular cellulitis due to decreased vascularity pts will need IV abx at hospital. The inflammation in the auditory canal often extends with inflammation of the pinna. Serious.

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30
Q

Conductive hearing loss

A
  • Hearing loss resulting from the reduced transmission of sound to the middle ear
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31
Q

Sensorineural hearing loss

A
  • Hearing loss resulting from a disorder of the inner ear, damage to cranial nerve VIII, genetic disorders, systemic disease, ototoxic medication, trauma, tumors, or prolonged exposure to loud noise
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32
Q

Ménière disease

A
  • Disorder of progressive hearing loss that in some cases has a genetic mode of transmission
  • S/S: Imbalance, fullness in ears, motion sickness, tinnitus, nystagmus
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33
Q

Vertigo

A
  • Illusion of rotational movement by a patient, often due to a disorder of the inner ear (anything involving the inner ear can lead to vertigo)
    • Ménière disease
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34
Q

Viral rhinosinusitis

A

Viral rhinosinusitis

  • Most common URI
  • Associated with a sore throat, nasal congestion, rhinorrhea, sneezing, cough, and mild malaise
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35
Q

Bacterial rhinosinusitis

A

Bacterial rhinosinusitis

  • Bacterial infection of one or more of the paranasal sinuses
  • Often complications of viral infection
  • Associated similar symptoms as viral plus potential unilateral sinus pain, maxillary toothaches sensation that worsened when bending forward.
  • Double sickening – get better than sx starts again
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36
Q

Acute pharyngitis

A
  • Infection of tonsils or posterior pharynx by microorganisms such as group A β-hemolytic streptococci or other streptococcal species, Neisseria gonorrhea, Mycoplasma pneumoniae

Tonsillitis and Pharyngitis – notice erythema and exudate in crypts of the tonsils

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37
Q

Peritonsillar abscess

A
  • Deep infection in the space between the soft palate and tonsil – MED EMERGENCY
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38
Q

CENTOR Criteria Pneumonic

CAFE-O

A

Centor Criteria Pneumonic -

C - Cough (absent) or Can’t Cough (+1)

A - Adenopathy Swollen Anterior Cervical Lymph Nodes (+1)

F – Fever > 100.4 (+1)

E – Exudate or Enlarged Tonsils (+1)

O - <15 (+1), 15 – 44 = 0, >45 (-1)

Centor Criteria - CDC Recommendations for Adults with Acute Pharyngitis

1 Criteria – No abx, symptomatic trmt

2- 3 Criteria – Rapid test: abx for positives, Symptomatic trmt

4 Criteria – Empiric abx, Symptomatic trmt

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39
Q

Ask the patient to extend the tongue to inspect for :

A
  • Ask the patient to extend the tongue while you inspect for:
    • Deviation
    • Tremor
    • Limitation of movement
    • CN XII
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40
Q

When would you perform transillumination of the sinuses?

A
  • Transillumination of the frontal and maxillary sinuses may be performed if sinus tenderness is present or infection is suspected
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41
Q

Case study conductive or sensory hearing loss

  • The patient fails his whispers test, he states” I can hear your voice better with my right ear”
  • Perform the Weber and Rinne test
    • Weber test: Lateralization to the right ear.
    • so either conductive or sensorineural hearing loss
      • Either conductive hearing loss in the right ear
      • Or sensorineural hearing loss in the left ear.
    • Which is it? Need to perform the Rinne test to both ears.
    • So when performing the Rinne test
      • Right ear AC>BC normal
      • Left ear is AC>BC normal

Result??? Sensory neural HL to left ear.

Causes: wax build up, infection, perforation

A
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42
Q

Mouth and throat Documentation of SOAP note for ENT

A
  • Lips symmetrical, pink without cracking, lesions or maceration. Buccal mucosa, palate, tonsillar pillar pink, moist without lesions. Gingiva without hypertrophy, retraction, or bleeding. Teeth in good repair. Tongue pink, smooth without lesions, midline. CNXII intact. Tonsils grade 2 bilaterally, without exudate or erythema. Uvula elevates midline with phonation, Posterior pharynx without erythema, exudate, postnasal drip or lesions.
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43
Q

Stensen duct

A

Major duct to the salivary glands that opens into the mouth cavity

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44
Q

Fordyce spots

A

Visible sebaceous (sweat) glands can be found in genitals and in the mouth. They appear as small, painless, raised, pale, red or white spots or bumps 1-3mm. Normal occurrence. Also appear on the male and female genitials

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45
Q

Normal Finding of Head & Neck

A

Full and controlled range of motion. Trachea midline, smooth, non-tender, and movable. Thyroid nonpalpable, and/or free of nodules

May describe carotids and jugulars here or with CV system

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46
Q

Normal Finding of Lymphatics

A

No edema, erythema, enlargement (adenopathy) or tenderness of nodes

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47
Q

Normal Finding of Eyes

A

20/20 on Snellen bilaterally. EOMs intact without nystagmus, conjunctiva pink, sclerae white, cornea clear with corneal reflex intact. Visual fields full by confrontation. PERRLA, red reflex present. Optic discs cream colored, borders well defined. 3:5 a:v ratio, no nicking, hemorrhage, or exudate noted

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48
Q

Normal Finding of Ears, Nose, & Throat

A

Pinna non-tender to palpation, the external canal is free of cerumen, foreign bodies, without erythema, TM pearly gray; landmarks and cone of light apparent, mobile. Nasal mucosa pink, without discharge, inferior turbinates visible, no septal deviation, nares patent.

Frontal and maxillary sinuses nontender to palpation, percussion

Lips, tongue, and gums pink and smooth with good dentition noted. Uvula rises equilaterally in the midline. Oral cavity absent of lesions, masses, non-tender to palpation

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49
Q

Normal ear & teeth development in infants

A
  • External auditory canal in infants shorter than in adults
  • Eustachian tube in infants wider, shorter, more horizontal than in adults
  • Salivation increased by 3 months
  • 22 deciduous teeth by 6 and 24 months, permanent teeth in jaw 6 months, eruption of permanent teeth 6 years old and done by 14 – 15 years old
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50
Q

Normal hearing in older adult

A

1/3 of adults > 65 years old have hearing loss (presbycusis) as a result

  • Degeneration of hair cells in the organ of Corti
  • Degeneration of the cochlear conductive membrane
  • Decreased vascularization of the cochlea
  • Loss of cortical and organ of Corti auditory neurons

Sensory hearing loss first occurs with high frequency sounds and then progresses to lower frequency (presbycusis)

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51
Q

Conductive hearing loss may result from:

A
  • Excess deposition of bone cells along the ossicle chain, causing fixation of the staples in the oval window
  • Cerumen impaction
  • Sclerotic tympanic membrane
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52
Q

External Otitis

A

CONDITION External Otitis

HISTORY

More common in adults, especially with DM, swimmers, and “ear pickers”

CC: bilateral itching, pain

PHYSICAL FINDINGS

Discharge, inflamed swollen external canal, pain with movement of the pinna

TM normal or not visible

DIAGNOSTIC STUDIES

NONE

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53
Q

Acute Otitis Media (AOM)

A

CONDITION

Acute otitis media (AOM)

HISTORY

More common in children <6

Hx of smoke exposure, recent URI

PHYSICAL FINDINGS

CC: severe or deep pain, unilateral sensation of fullness

Red, bulging TM, decreased or loss of light reflex, opaque TM, decreased TM mobility

DIAGNOSTIC STUDIES

None initially

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54
Q

Serous Otitis

(conductive hearing loss)

A

CONDITION - Serous Otitis

HISTORY - More common in children, but will occur in adults with recent URI.

PHYSICAL FINDINGS - CC: unilateral pain, sensation of crackling, or decreased hearing, Decreased TM mobility. Fluid line or air observed behind TM. Conductive hearing loss

DIAGNOSTIC STUDIES - None initially

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55
Q

Cholesteatoma

A

CONDITION

Cholesteatoma (epidermal cyst in middle ear)

HISTORY

PHYSICAL FINDINGS

CC: hearing loss

Pearly white lesion on or behind TM, commonly located in superior anterior quadrant of TM

DIAGNOSTIC STUDIES

Immediate referral to ENT

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56
Q

Mastoiditis

A

CONDITION - Mastoiditis

HISTORY - Recent OM: chronic otitis

PHYSICAL FINDINGS - CC: pain behind ear

DIAGNOSTIC STUDIES - Swelling and tenderness over mastoid process. Fever, erythema

X-ray of mastoid sinus reveals cloudiness

Referral

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57
Q

Foreign Body or cerumen impaction

A

CONDITION - Foreign Body or cerumen impaction

HISTORYVague sensation of discomfort, decreased hearing

PHYSICAL FINDINGS - Visualize foreign body or cerumen, may detect foul odor, conductive hearing loss

DIAGNOSTIC STUDIES - NONE

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58
Q

Barotrauma

A

CONDITION - Barotrauma

HISTORY - History of flying, diving

PHYSICAL FINDINGS - CC: severe pain, hearing loss, sensation of fullness

Retraction or bulging of TM, perforation of TM, fluid in canal

DIAGNOSTIC STUDIES - Tympanogram – indirectly measures pressure in middle ear

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59
Q

TMJ disorder

A

CONDITION - TMJ disorder

HISTORY - CC: discomfort to severe pain, typically worse in AM. Usually unilateral

PHYSICAL FINDINGS - Maloccclusion, bruxism, normal external and middle ear structures and function.

Jaw click

DIAGNOSTIC STUDIES- NONE

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60
Q

HOARSENESS

A

Disturbance of the normal pitch by processes that affect the structure or function of the vocal cords. Describes rough, harsh, or deep voice. May be an early sign of local disease or a manifestation of systemic illness. It is a cardinal symptom for laryngeal disease

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61
Q

Acute laryngitis

A

CONDITION - Acute laryngitis

HISTORY - Voice overuse, exposure to environmental irritants, recent URI

PHYSICAL FINDINGS - Voice quality, aphonia, cervical lympadenopathy, erythema of pharynx, edema and redness of vocal cords

DIAGNOSTIC STUDIES - None, if duration of hoarseness is less than 3 weeks

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62
Q

Chronic laryngitis

A

CONDITION - Chronic laryngitis

HISTORY - Chronic history of smoking, ETOH use, exposure to environmental irritants, duration of hoarseness more than 3 weeks

PHYSICAL FINDINGS - Edema of vocal cords, nodules may be present

DIAGNOSTIC STUDIES - Lateral and AP views of the neck, laryngoscopy

(ENT referral)

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63
Q

Neoplasm

A

CONDITION - Neoplasm

HISTORY - Smoking, airborne exposure, chronic ETOH use, history of chronic cough, hoarseness for more than 3 weeks

PHYSICAL FINDINGS - Tracheal deviation, pain with advanced tumor, hoarseness may be only sign

DIAGNOSTIC STUDIES - ENT referral for biopsy

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64
Q

GERD

A

CONDITION - GERD

HISTORY

PHYSICAL FINDINGS - History of UGI burning and cough, especially at night, chronic use of ETOH, NSAIDS, or aspirin, history of ulcer disease, smoker, frequent clearing of throat. May have epigastric tenderness on palpation, vocal cord inflammation or ulcers

DIAGNOSTIC STUDIES - Referral for endoscopy if symptoms not relieved by medications and dietary alterations

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65
Q

SORE THROAT

A

Most often result of an inflammation of the mucosa of the oropharynx, secondary to an infectious cause (viral, bacterial, fungal)

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66
Q

Viral Pharyngitis

A

CONDITION - Viral Pharyngitis

HISTORY - Scratchy, sore throat, malaise, myalgias, headache, chills, cough, rhinitis

PHYSICAL FINDINGS - Erythema, edema of the throat, tender posterior cervical nodes

DIAGNOSTIC STUDIES - NONE

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67
Q

GABHS pharyngitis

A

CONDITION - GABHS pharyngitis

HISTORY - Most common in 5-15 year old, check for known exposure, fall/winter season, sudden onset of fever, severe sore throat, malaise, absence of cough and URI symptoms

PHYSICAL FINDINGS - Fever > 38.5 (101.5), exudate, anterior cervical lymphadenopathy

DIAGNOSTIC STUDIES - Positive rapid strep, strep culture

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68
Q

Mononucleosis

(Epstein-Barr virus)

A

CONDITION - Mononucleosis

HISTORY - (Epstein-Barr virus)

PHYSICAL FINDINGS - Young Adults, slow onset of malaise, low-grade temperature, mild sore throat

DIAGNOSTIC STUDIES​ - + pharyngeal exudate, palatine petechiae, posterior cervical lymphadenopathy, splenomegaly

Positive monospot, CBC with differential: > 50 % leukocytes

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69
Q

Candidiasis

A

CONDITION - Candidiasis

HISTORY - Immunosuppressed, person tx’ed with antibiotics, diabetes, HIV

PHYSICAL FINDINGS - CC sore mouth, throat, difficulty swallowing

Curdy, white plaques that bleed when scraped off

DIAGNOSTIC STUDIES - KOH smear shows hyphae

Culture

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70
Q

Epiglottitis

(d/t H. influenza type b)

A

CONDITION - Epiglottitis

HISTORY - d/t (H. influenza type b)

PHYSICAL FINDINGS - Sore throat, difficulty with secretions, unable to lie flat, can’t talk

Respiratory distress, drooling, toxic appearance. Do not examine pharynx

DIAGNOSTIC STUDIES - Immediate referral to ENT

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71
Q

Primary muscle of respiration

A

Diaphram

External intercostal muscles increase the anteroposterior chest diameter and create negative pressure during inspiration.

Expiration is a passive process where the thoracic muscles relax leading to a decrease in thoracic pressure. healthy lungs recoil.

Accessory muscles are the sternocleidomastoid, trapezius, scalenes, pectoralis, and serratus

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72
Q

The tubular system provides a pathway along which air is:

A

Filtered

Humidified

Warmed

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73
Q

Respiratory System in Infants

A

Ribs are flexible to support lungs. Higher rate of 02 consumption. More likely to use accessory muscles in time of distress and high metabolic demand.

Nasal flaring

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74
Q

Pt comes in with c/o pain in the chest. Their complaint is “S” subjective. When I press on their chest and they react with pain, that is…

A

“O” observation, because I caused that pain

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75
Q

COPD CHEST

A

Flat diaphragm causes barrel chest with 1:1 ratio

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76
Q

Two ways to look at the lungs

A

Verticle axis - invisible line to make vertical locations, count the ribs and interspaces; sternal angle is the best guide and horizontal

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77
Q

Chest circumference of infant

A

Chest circumference at birth is 1:1 then goes to 1:2 at 2 years old

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78
Q

Chages in the chest wall in Pregnant women

A

Rib cage relaxes increased chest expansion, the diaphragm goes up. Respirations rate remains the same with deeper breathing

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79
Q

Chest Changes in the Older Adults

A
  • Barrel chest from loss of muscle strength in thorax and diaphragm and loss of lung resiliency
  • Skeletal changes emphasizing dorsal curve of thoracic spine (Kyphosis)
  • Alveoli less elastic, higher risk for fatigue and dyspnea on exertion

Muscles are not as strong.

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80
Q

What happens with people with Barrel Chest

A

When there is a barrel chest there is more dead space. In this dead space oxygen fills it up but the oxygen does not move in and out it is referred to as residual volume. Residual volume increased and vital capacity decreases

Increase in the Anteroposterior diameter 1:1

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81
Q

Ace Inhibitor Cough

A

Chronic dry cough continuous

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82
Q

What is considered a acute cough vs. a chronic cough

A

Acute cough is < 3 weeks

Chronic cough is > 8 weeks

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83
Q

Subacute and chronic cough red flags

A
  • Hemoptysis
  • Smoker age >45 with new cough, change in cough or coexisting voice disturbance
  • Adults age 55–80 with a 30-pack year history or who have quit less than 15 y ago
  • Dyspnea, especially at rest or at night
  • Hoarseness
  • Systemic symptoms: continuous fever, unintentional weight loss, peripheral edema with weight gain
  • Dysphagia
  • Vomiting
  • Recurrent pneumonia
  • Abnormal physical exam or chest x-ray
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84
Q

Anemia can cause what in relation to the heart?

A

Systolic murmur

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85
Q

Albumin is a excellent marker for…

A

Nutrition

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86
Q

Conjunctiva with a hint of pink indicates what level of hemoglobin?

A

Hemoglobin of at least an 8

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87
Q

Five A’s in smoking cessation

Smoking is the leading cause

A

Ask about smoking at each visit

Advise patients regularly to stop smoking using a clear, personalized message

Assess patient readiness to quit

Assist patients to set stop dates and provide educational materials for self-help

Arrange for follow-up visits to monitor and support patient progress

Ask, Advise, Assess, Assist, Arrange

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88
Q

Example of personal and social history

A
  • Tobacco use
  • Use of alcohol/drugs
  • Employment
  • Home environment
  • Exposure to respiratory infections, influenza, TB
  • Nutritional status
  • Use of complementary and alternative therapies
  • Regional/travel exposures
  • Hobbies
  • Exercise tolerance
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89
Q

Causes of dyspnea in infants and children

A
  • Low birth weight and prematurity
  • Coughing and sudden-onset shortness of breath
  • Possible ingestion of kerosene, antifreeze, or hydrocarbons in household cleaners
  • Apneic episodes; use of apnea monitor
  • Swallowing dysfunction
  • Gastroesophageal reflux
  • History of pneumococcal and influenza vaccination
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90
Q

Order to complete exam

A

Inspect

Palpate

Percuss

Auscultate

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91
Q

What should you inspect the chest for?

A
  • Shape and symmetry
  • Chest wall movement
  • Superficial venous patterns

Inspect the chest for:

  • Prominence of ribs
  • Sternal protrusion
  • Spinal deviation
  • Anteroposterior vs. transverse diameter
  • Expected: 1:2
  • Barrel chest: 1:1
  • Observe respiration
  • Estimate costal angle
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92
Q

Expected findings in a normal chest?

A

Expected findings:

  • Symmetricaland elliptical without lesions, scars or deformities
  • Symmetrical rise and fall of chest wall
  • AP is 1:2 in adult
  • Respiration between 12 to 20, even quiet and unlabored
  • Costal angle is less than 90 degree
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93
Q

Pectus Excavatum

A

Congenital posterior displacement of lower aspect of sternum. “hollowed-out” appearance.

Concave appearance of the lower sternum

NO SYMPTOMS - DOES NOT INVOLVE OTHER CONDITIONS

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94
Q

Pectus Carinatum

A

At birth or Post CABG

Mid childhood and 11-14 year old pubertal males undergoing a growth spurt. Some parents report that their child’s pectus seemingly popped up ‘overnight‘.

Convex deformity

Associated with comorbidities - MVP, scoliosis, asthma

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95
Q

Paradoxic breathing

A

On inspiration, the lower thorax is drawn in, and on expiration, the opposite occurs

The paradoxical chest movement occurs when, instead of moving downward on the inhale and upward on the exhale (as is the case in normal diaphragmatic breathing), the diaphragm moves upward on the inhale and downward on the exhale.

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96
Q

Retractions

A
  • When the chest wall seems to cave in at the sternum, between the ribs, at the suprasternal notch, above the clavicles, and at the lowest costal margins
  • Suggests an obstruction to inspiration at any point in the respiratory tract
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97
Q

Breathing Patterns

Kussmaul’s - sweet breath from DKA body trying to get rid of acidity

A
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98
Q

Palpation for masses vs. tactile fremitus

A

Techniques

  • For masses, tenderness crepitus use the pads of 4 fingers.
  • For tactile fremitus Palms of your open hands or the ulnar portion of your hand over the left superior anterior lung

“99”

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99
Q

Palpate the anterior and lateral chest for:

A
  • Masses
  • Tenderness
  • Crepitus
  • Tactile fremitus
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100
Q

Tactile Fremitus

What is its purpose and how is it performed

A
  • Tactile fremitus : tactile fremitus is palpable vibration of the chest wall produce by speech.
  • Ask patient to say 99 while palpating.
  • Compare the vibration symmetrically
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101
Q

What does increased or decreased tactile fremitus indicate?

A
  • Increased: Presence of consolidation, fluids or solids
  • Decreased: Excess air in lungs (pleural effusion, pneumothorax, COPD)
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102
Q

Percussion Expected finding vs. Unexpected findings

A

Expected report

Resonance to percussion

  • Throughout the anterior and axillary chest
  • Dullness over liver and precordium

Unexpected findings:

Dullness: tumor, fluids so cancer,

  • Pneumonia, pleural effusion

Hyper-resonance: excess air (COPD, Asthma, pneumothorax)

Tympany: Pneumothorax

103
Q

During Auscultation of Anterior and Axillary Lung fields how can the sounds be characterized

A

•All sounds can be characterized in the same manner as the percussion notes:

  • Intensity
  • Pitch
  • Quality
  • Duration

Listen with the diaphragm of the stethoscope

104
Q

Vesicular Breath Sounds

A

Vesicular: Normal - soft and low pitched; usually heard over most of both lungs

105
Q

Bronchial Breath Sounds:

A

Bronchial: Normal - louder and higher in pitch; usually heard over the manubrium

106
Q

Bronchovesicular Breath Sounds:

A

Bronchovesicular: Normal - intermediate intensity and pitch; usually heard over the 1st and 2nd interspaces

107
Q

Tracheal Breath Sounds:

A

Tracheal: Normal - over the trachea and neck, very loud

108
Q

Abnormal findings during auscultation:

A

Bronchial sound over peripheral lung field

Consolidation such as pneumonia, pulmonary edema

-Rhonchi are low-pitched snore-like sounds, often characterized by secretions within the large airways

Sometimes cleared with a cough

  • Wheezes are continuous, high-pitched, musical, sounds that are produced by air flowing through narrowed bronchi. Predominantly expiratory
  • Rales: A crackling sound, may indicate pneumonia
  • Stridor is a loud, rough, continuous, high-pitched sound that is pronounced during inspiration. Indicates proximal airway obstruction
109
Q

Normal lung findings:

A

Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

110
Q

Crackles aka Rales

A

Produced by air passing over airway secretions. A crackle is a discontinuous sound, as opposed to a wheeze, which is continuous. The popping sounds produced are created when air is forced through respiratory passages that are narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation or infection of the small bronchi, bronchioles, and alveoli. Crackles that don’t clear after a cough may indicate pulmonary edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome (ARDS).May indicate pneumonia, fluid overload

Crackles are often described as fine, medium, and coarse.

Fine crackles are soft, high-pitched, and very brief. You can simulate this sound by rolling a strand of hair between your fingers near your ear, or by moistening your thumb and index finger and separating them near your ear.

Coarse crackles are somewhat louder, lower in pitch, and last longer than fine crackles. They have been described as sounding like opening a Velcro fastener.

111
Q

Rhonchi

A

Rhonchi are low-pitched snore-like sounds, often characterized by secretions within the large airways

Sometimes cleared with a cough

Rhonchi are continuous, best heard during expiration but may also be heard during inspiration and expiration.

112
Q

Wheezes

A

Wheezes are continuous, high-pitched, musical, sounds that are produced by air flowing through narrowed bronchi. Predominantly expiratory

These wheezes occur when airways are narrowed, such as may occur during an acute asthmatic attack.

113
Q

Stridor

A

Stridor is a loud, rough, continuous, high-pitched sound that is pronounced during inspiration. Indicates proximal airway obstruction

Stridor is caused by obstruction of the upper airway, is a sign of respiratory distress and thus requires immediate attention

114
Q

Bronchial sound over peripheral lung field

A

Abnormal indicates: Consolidation such as pneumonia, pulmonary edema

115
Q

When is there Absent or Attenuated Sounds during auscultation?

A

when there is no airflow to the region being auscultated

This can occur in a pneumothorax, hemothorax, pleural effusion, or parenchymal consolidation, which includes the feeding airway

116
Q

Friction rub

A

Occurs outside the respiratory tree

Dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration

Caused by inflamed, roughened surfaces rubbing together

117
Q

What is Diaphragmatic Excursion?

A

Not a reliable method

  • Diaphragmatic excursion: Not a reliable methods.
  • Pt takes a deep breath in
  • Percuss downward from beneath the right scapula
  • Listen for change in sound from resonant to dullness.
  • Ask patient to take anPt takes a deep breath in
  • Percuss downward from beneath the right scapula
  • Listen for change in sound from resonant to dullness.
  • Ask patient to take another deep breath and blow out all the way out and hold it.
  • Begin at the first mark and Percuss again upward on the scapular line
  • other deep breath and blow out all the way out and hold it.
  • Begin at the first mark and Percuss again upward on the scapular line
  • Measure the distance between two line: normal 3 to 6 cm.
118
Q

What sounds are normal with Percussion

A

Resonance over lung fields

Flat over spinous process, scapula

Diaphragmatic excursion measures between 3 to 6 cm

119
Q

Bronchophony

A
  • Bronchophony: patient repeat 99 in normal voice while NP auscultates
  • Negative (normal) findings: Muffled sounds
  • Positive: Voice become clearer and distinct
120
Q

Whispered Pectoriloquy

A
  • Whispered Pectoriloquy:patient repeats 99 in a whisper while NP auscultates
  • If Bronchophony is negative so will whispered pectoriloquy
  • Positive: Extreme bronchophony where even a whisper can be heard clearly through the stethoscope
121
Q

•Egophony

A
  • Egophony: patient repeats “eeee” in normal voice while NP auscultates
  • Negative: Hear the sound eeeeeee’s
  • Positive: Intensity of the spoken voice is increased and there is a nasal quality. eeeee’s become stuffy broad ayyy’s ( like sheep sounds)
122
Q

Sounds on auscultation

A
123
Q

Chest circumference in infants is…

A

2-3 cm smaller than head circumference

124
Q

True or False

Periodic breathing, a sequence of relatively vigorous respiratory efforts followed by apnea of as long as 10 to 15 seconds, is common

A

True

125
Q

•Respiratory grunting in Infants

A
126
Q

Respiratory System in Infants

A
  • Coughing is rare; sneezing is frequent
  • Hiccups are also frequent
  • At first, breathing is primarily diaphragmatic; use of intercostal muscles is gradual
  • Paradoxic breathing (the chest wall collapses as the abdomen distends on inspiration) is common, particularly during sleep
127
Q

By what age do children use the thoracic (intercostal) musculature for respiration

A

6 or 7

128
Q

Normal breath sounds in a child

A

Breath sounds

  • More resonant
  • Hyperresonance common
  • Easy to miss dullness
  • Bronchovesicular sounds may predominate
129
Q

Respiratory changes in the pregnant woman

A

increases her ventilation by breathing more deeply, not more frequently

130
Q

Respiratory changes in the older adult

A

•Chest expansion decreased

Respiratory muscle weakness

General physical disability

Sedentary lifestyle

Calcification of rib articulations

Bony prominences marked

Kyphosis with flattening of lumbar curve

Increased anteroposterior diameter

Hyperresonance common

131
Q

Sample Normal Respiratory ROS note

A

Lungs: Chest: CTA/P B/L all lobes; (–) W/R/R.

Detailed: used if presenting with a lung/thoracic issue

AP diameter

132
Q

Acute Bronchitis

A
  • Inflammation of the large airways
  • Viral origin (Most often)
133
Q

Acute Bronchitis History

A
  • History:
  • Headache, nasal congestion
  • Cough for >5 days and no evidence of pneumonia, asthma, exacerbation of COPD
  • Cough is initially dry and nonproductive, then productive; later, mucopurulent sputum, which may indicate secondary infection.
  • Dyspnea (especially on exertion), wheeze, and fatigue may occur.
  • Possible contact with others who have respiratory infections (1) it is an infection and will spread
  • Fever: None or low grade, high grade fever may suggest pneumonia or influenza infection
  • Substernal chest pain with cough, have them take a deep breath and cough out to hear wheeze
  • Cough may last up to 6 weeks

Key history and PE:

  • Mildly ill appearance
  • Pharynx injected, Lung exam may be normal or Rhonchi, wheezes with deep breath, clear with cough.
  • No evidence of lung consolidations.

During history: you need to make sure you r/o pneumonia, influenza

134
Q

Influenza

A
  • Viral acute onset infection
  • Can affect nose, throat and sometimes lungs

Patients look and feel like hell

135
Q

S/S Pneumonia

A
  • Signal symptoms:
  • Systemic symptoms:
  • Myalgias
  • Malaise
  • Fatigue, anorexia
  • Fever above 100. F
  • Elderly may present with low grade fever or no fever but increase confusion, fatigue
  • Headache (scalp pain)
  • Sore throat
  • Cough

PE:

  • Physical exam is not specific for influenza.
  • Physical examination should exclude complications such as otitis media, pneumonia, sinusitis, and tracheobronchitis.
136
Q

Complications from the flu

A
  • Otitis media
  • Sinusitis
  • Acute myositis
  • Pneumonia
  • Exacerbation of chronic illness (asthma, COPD)
137
Q

Pneumonia S/S

A

•Bacterial but can be viral infection

Signal symptoms:

  • Myalgias, anorexia, malaise
  • Headache
  • Cough: productive Clear/yellow/reddish.
  • If red think strept pneumonia
  • Chills, Fever above 100F
  • Elderly may present with low grade fever or no fever but increase confusion, fatigue
  • Pleural pain
138
Q

Pneumonia Physical Exam Findings:

A
  • High fever, tachycardia, tachypnea (fast respirations)
  • Ill appearing
  • Claminess
  • Accessory muscle use, increased tactile fremitus, Crackles, Positive bronchophony, egophony

CANNOT DIAGNOSE A PNEUMONIA WITHOUT A CHECK XRAY SHOWING INFILTRATES OR CONSOLIDATION

LRI, GENERAL MALAISE CAN BE USED

139
Q

Pertussis AKA Whooping Cough

A
  • Contagious bacterial infection caused by Bordetella pertussis
  • 3 stages disease
140
Q

Pertussis AKA Whooping Cough

3 stages

A

Classic pertussis has three phases, which occur over 6 to 10 weeks:

•Catarrhal phase: rhinorrhea, mild cough, low-grade fever

  • •Apnea and cyanosis: Infants
  • Paroxysmal phase: Severe Cough occurs in bursts, with increased intensity and frequency, often followed by an inspiratory whoop and/or posttussive vomiting.
  • Convalescent phase: Coughing paroxysms decrease in frequency and intensity.
  • In the absence of paroxysms or complications, the physical exam may be normal.
141
Q

Pertussis AKA Whooping Cough

Differential Diagnosis

A

Differential diagnosis

  • Pneumonia
  • Asthma
  • Bronchiolitis (Children)
  • Croup (children)

Other causes of chronic cough.

  • •Postnasal drip
  • •GERD
  • •TB
142
Q

Bronchiolitis

A
  • Inflammation of bronchial airways from various diseases
  • RSV (Respiratory syncytial virus) 70 to 85% of cases
143
Q

Bronchiolitis

History or S/S

A
  • Irritability
  • Anorexia
  • Fever
  • Noisy breathing (due to rhinorrhea)
  • Cough
  • Grunting
  • Cyanosis
  • Apnea
  • Vomiting
144
Q

Bronchiolitis

Physical Exam

A
  • Tachypnea
  • Retractions (increased work of breathing), nasal flaring, grunting
  • Rhinorrhea
  • Wheezing
  • Upper respiratory findings: pharyngitis, conjunctivitis, otitis
145
Q

Bronchiolitis

Differential Diagnosis

A
  • Other pulmonary infections such as pertussis, croup, or bacterial pneumonia
  • Aspiration
  • Vascular ring
  • Foreign body
  • Asthma
  • Heart failure
  • Gastroesophageal reflux
  • Cystic fibrosis
146
Q

COPD in older adults loss of alveolar sac so decreased gas exchange

A

Emphysema

•Condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function

Chronic bronchitis

  • Large airway inflammation, usually a result of chronic irritant exposure; more commonly, a problem for patients older than 40
  • Productive cough most days for 3 months duration, 2 successive years.
147
Q

What would a COPD pt present with?

A
  • SH: History of smoke exposure
  • Symptoms

Slow and progressive with occasional exacerbation:

  • Fatigue
  • Dyspnea
  • Exercise intolerance
  • Cough
  • Sputum production

Xray: Indicative of COPD

Trapped air, blunted costophrenic angle->

Flat diaphragm

End stage-> Core pulmonale (right sided Heart failure-> Enlarged heart

Definite diagnosis:

  • Spirometry measurement: FEV1 (amount able to exhale)/FVC (total amt of air in lungs)<0.70 (if over 70% there isn’t COPD)
148
Q

Obstructive Sleep Apnea

A

•Syndromes: episodic reduction or cessation of airflow during sleep

149
Q

Obstructive Sleep Apnea commonly associated sx

A

•Common associated conditions:

Obesity, Adenotonsillar hypertrophy,GERD, Allergic rhinitis, medications (Sedatives, seizures)

150
Q

Obstructive Sleep Apnea

Nocturnal Symptoms

A

Nocturnal symptoms:

  • Loud snoring
  • Witnessed apneic episodes
  • Frequent arousal
  • Disruptive sleep
151
Q

Obstructive Sleep Apnea

Daytime Sx

A

Day time symptoms:

  • Sleepiness, fatigue
  • Lack of concentration
  • Frequent URI/Ear infections
  • Hyponasal voice
152
Q

Common Physical Finding in a patient with OSA

A
  • High BMI
  • Short neck, enlarged tongue, soft palate edema, Enlarged tonsils, deviated nasal septum
  • In severe cases: Failure to thrive s/s.
153
Q

D/D for OSA

A

Differential diagnosis:

  • Narcolepsy, Depression, Asthma, COPD, CHF, GERD
154
Q

Asthma

Features

A

Chronic airway inflammation

with two key features:

  • History of respiratory sx
    • Wheezing
    • Dyspnea
    • Cough
    • Chest tightness
  • Variable airways limitation

Sx worsened at night

Triggered by exertion or exposure

155
Q

Asthma

Physical Examination

A

May be unremarkable

HEENT: S/S of seasonal allergies

Skin: May have s/s of eczema

Lungs: During exacerbation

  • Use of accessory muscles, expiratory wheezing. S/S of trapped air. Decreased tactile fremitus
  • Long term asthma; positive clubbing
156
Q

Classification of Asthma

A

Intermittent = all 2’s

Mild = all 2’s except 3-4 nighttime awakenings

Persistent Moderate = Daily

Persistent Severe = Through the day

157
Q
A
158
Q

Ankle - Brachial Index

A
159
Q

Calf Pain / Claudication

A

Angina of the legs

160
Q

Ankle-Brachial Index

A

Anything over a 0.91 is good.

Quick reference is that the ankle should be higher than the arm

ANKLE

BRACHIAL

161
Q

How do you access for peripheral perfusion?

A

Edema

Color

Clubbing

Palpate the arterial pulses in distal extremities, comparing characteristics bilaterally for the following:

  • Rate
  • Rhythm
  • Contour
  • Amplitude
162
Q

•Inspect the extremities for sufficiency of arteries and veins through the following:

A
  • Color, skin texture, and nail changes
  • Presence of hair
  • Muscular atrophy
  • Edema or swelling
  • Varicose veins
163
Q

What peripheral arteries do you palpate?

A

(7)

Carotid

Brachial

Radial

Femoral

Popliteal

Dorsalis pedis

Posterior tibial

164
Q

Palpate for artery characteristics

A

Rate and rhythm

Pulse contour (waveform)

Amplitude (force)

Symmetry

Obstructions

Variations

165
Q

How would you describe the amplitude of a pulse on a scale of 0-4

A

4: Bounding, aneurysmal
3: Full, increased
2: Expected
1: Diminished, barely palpable
0: Absent, not palpable

166
Q

Which arteries would you use the bell of your stethoscope to auscultate?

A
  • Temporal
  • Carotid
  • Abdominal aorta
  • Renal
  • Iliac
  • Femoral
167
Q

Bruit types

A
  • Radiation of murmurs
  • First noted during the cardiac examination
  • Aortic stenosis murmur
  • Obstructive arterial disease
  • Evidence of local obstruction
168
Q

Claudication

Angina of the legs

A

Pain that results from muscle ischemia

  • Dull ache
  • Muscle fatigue and cramps
  • Usually appears during sustained exercise, such as walking a distance or climbing several flights of stairs
  • A few minutes of rest will ordinarily relieve it
  • It recurs again with the same amount of activity
  • Continued activity causes worsening pain
169
Q

Jugular venous pressure

A

NO PULSE, venous, looking at waves

Increased in CHF

Cutoff point is 4cm above the sternal angle

Central venous pressure is the JVP +5cm b/c the atrium is 5cm away

If JVP is + (more than 4 have to do HJR)

170
Q

Hepatojugular Reflux

A
  • If JVP is elevated conduct a hepatojugular reflux
  • Apply 10 to 15 seconds of pressure over liver
  • The hepatojugular reflux is exaggerated is highly indicative of right atrium increased pressure and heart failure and right-sided if it is a choice.

WILL SEE A 1 CM RISE IN HEALTHY THAT DISAPPEARS AFTER COMPRESSION OF THE LIVER STOPS

171
Q

How do you assess for venous obstruction and insufficiency?

A
  • Thrombosis
  • Homan sign
  • Calf pain with passive dorsiflexion of the foot
  • Peripheral Edema
    • Grading 1+ through 4+
  • Varicose veins
172
Q

Peripheral Vascular changes in Pregnant Women

A

Increased cardiac output in first trimester

Increasing blood volume in second semester

JVP remains normal

173
Q

What s/s are identified with venous obstruction, insufficiency and PVD?

A
  • Swelling and tenderness over the muscles
  • Pain worsened while standing and improve with leg elevation
  • Peripheral edema
  • Engorgement of superficial veins while standing
  • Erythema and/or cyanosis
  • Thickening of the skin
174
Q

Changes in the peripheral vascular system in older adults

A
  • Dorsalis pedis and posterior tibial pulses may be more difficult to find
  • Superficial vessels are more apt to appear tortuous and distended
175
Q

Temporal arteritis (giant cell arteritis)

A

•An inflammatory disease of the branches of the aortic arch including the temporal arteries. Inflammation of the arteries that supply the eye

Painful, red, inflamed, refer to ENT for steroids

176
Q

Peripheral arterial disease

A

Stenosis of the blood supply to the extremities by atherosclerotic plaques

177
Q

Raynaud phenomenon

A

Exaggerated spasm of the digital arterioles (occasionally in the nose and ears) usually in response to cold exposure and anxiety

178
Q

Arterial embolic disease

A

Atrial fibrillation can lead to clot formation within the atrium, which may be dispersed throughout the arterial system

179
Q

Venous thrombosis

A
  • Sudden or gradual with varying severity of symptoms
  • Can be the result of trauma or prolonged immobilization
180
Q

Arterial Ulcer vs Venous Ulcer

A
181
Q

Arterial ulcers

A

Venous Ulcers

182
Q

Normal position of the heart

A
  • In mediastinum
  • Left of midline
  • Above diaphragm
  • Between medial/lower borders of lungs
  • Behind sternum
  • 3rd to 6th intercostal cartilage

More horizontal in pregnant women

183
Q

Dextrocardia aka Right Mirror Image

A
  • Heart positioned to the right, either rotated or displaced, or as a mirror image
  • If the heart and stomach are placed to the right and the liver to the left, this habitus is termed situs inversus
184
Q
  • Right and left atria ¾upper chambers
  • Right and left ventricles¾lower chambers
A
  • Right and left atria ¾upper chambers
  • Right and left ventricles¾lower chambers
185
Q

Coronary Artery

A

Blood Supply to the Heart Muscle

Blood Supply to the Conduction System

Right coronary artery supplies Right atrium, right ventricle, inferior portion of the left ventricle,

Left anterior descending Anterior: (the widow maker infarction)

  • Supplies left ventricle
186
Q

Atrioventricular (AV) valves:

A
  • Tricuspid valve, which has three cusps (or leaflets), separates the right atrium from the right ventricle
  • Mitral valve, which has two cusps, separates the left atrium from the left ventricle
187
Q

Semilunar Valves

A

Two semilunar valves, each has three cusps

Pulmonic valve separates the right ventricle from the pulmonary artery

Aortic valve lies between the left ventricle and the aorta

188
Q

S1 / S2

Lub (louder at the bottom) A/V - Mitral and Tricuspid Valves

Dub (louder at the top) Aorta/Pulmonic valves

Lub is beginning of systolic

Dub is beginning of diastolic

A

Electrical conductivity of the heart

189
Q

RHF

A

Pressure build up toward the systemic system

liver, spleen, peripheral

190
Q

LHF

A

Lungs - coughing, Ruddy - coughing

191
Q

SA node

A

Mother

Pacemaker of the heart keeping it 60-100

192
Q

Atrial kick

A

Accounts for 25% of EF and disappears with Afib

193
Q

Wide QRS

A

Hypertrophic heart

194
Q

When does a child’s heart reach adult position?

A

7 yo

Less that 7yo listen at the 4th intercoastal space

195
Q

Changes in the heart at birth

A
  • Ductus arteriosus and interatrial foramen ovale close
  • Right ventricle assumes pulmonary circulation
  • Left ventricle assumes systemic circulation
196
Q

Changes in the heart of a older adult

A
  • Stiffness and decreased compliance
  • Isolated systolic hypertension 170/60 BP
  • Heart size may decrease
  • Left ventricular wall thickens
  • Valves fibrose and calcify
  • Heart rate slows
  • Stroke volume decreases
  • Cardiac output during exercise declines by 30% to 40% (decreased cardiac Reserve)
  • Endocardium thickens
  • Myocardium becomes less elastic
  • Electrical irritability may be enhanced
197
Q

CHEST PAIN

A
198
Q

The proper order of a cardiac exam is?

A
  • Inspecting
  • Palpating
  • Percussing the chest (rare)
  • Auscultating the heart

Remember to auscultate last

199
Q

Apical Pulse

A

Point of maximal impulse (PMI): Point at which the apical impulse is most readily seen or felt.

If it is more vigorus than expected it is a heave (forceful) or lift (less forcefull).

Thrill: a fine, palpable, rushing vibration; a palpable murmur

Should be visible at about the midclavicular line in the fifth left intercostal space

  • In some patients, it may be visible in the fourth left intercostal space
  • It should not be seen in more than one space if the heart is healthy
  • Obscured by obesity, large breasts, or muscularity
200
Q

What grade of a murmur is considered pathological with a thrill?

A

3,4,5

201
Q

Where is Left Ventricular size better judged?

A

By the location of the apical pulse

202
Q

Right ventricle tends to enlarge in the ________ _________ rather than laterally

A

Anteriorposterior

203
Q

Auscultate the diaphragm with the ____ of the stethoscope

A

Bell

204
Q

Auscultate heart sounds for

A

•Location:

  • Aortic, pulmonic, triscupid and mitral
  • Identify S1 and S2 (lup dup)
  • Assess overall rate and rhythm
  • Intensity
  • Pitch
  • Pathologies
205
Q

S1

A

“Lub”’ = Closure of the AV valves

Beginning of Systole

Radial & Carotid pulse coincides with S1

Low pitch sound (S1) heard best at apex

206
Q

S2

A

“DUB” = Closure of the Semilunar

Diastole

High Pitch Sound (Diaphram) heard best at base

S2 increases with inspiration

207
Q

S1 Split

Mitral valve and Tricuspid valves closing

A

S1 split – Hard to hear- Most often occurs during deep inspiration (best heard tricuspid area)

208
Q

S2 Split

Aortic closes faster than pulmonic

A

Split increases with inspiration and decreases or disappear on expiration. If split remains throughout expiration: Fixed split possibly indicating valvular diseases. Best heart at the base of the heart: especially at the pulmonic area.

209
Q

After listening to S1, S2 and for a S1/S2 split you then listen for:

A

Listen for abnormal sounds: S3, S4, murmurs, pericardial friction rubs

210
Q

Auscultation of heart sounds:

A
  • Aortic valve area
    • Second right intercostal space at the right sternal border
    • S2>S1
  • Pulmonic valve area
    • Second left intercostal space at the left sternal border
    • S2>S1
  • Erb’s point
    • Third intercostal space at the left sternal border
    • S2=S1
  • Tricuspid area
    • Fourth left intercostal space along the lower left sternal border
    • S1>S2
  • Mitral (or apical) area
    • Apex of the heart in the fifth left intercostal space at the midclavicular line
    • S1>S2
211
Q

What position is best for auscultation of S3 and murmurs b/c of low pitch?

A

Left Lateral Decubitus

212
Q

S3 aka Ventricular Gallop

A

Ventricular gallop

Low pitched sound (Bell) very faint best heard with EXPIRATION

Left lateral position listen with bell over apex, ask pt to suspend respirations

Compliant heart. Sound of blood hitting a flexible or compliant heart.

Sign of systolic heart failure or floppy heart. Heart failure (mostly systolic), acute valve regurgitation, cardiomyopathy, high output state such as anemia, hyperthyroidism, renal failure

Myocardial ischemia without ventricular dysfunction or volume overload is not a cause of an S3.

You may hear a S3 in children, pregnant and young olympian athlete

>40 a S3 is pathological

213
Q

S4 Atrial Gallop

A

Low pitched sound heard before S1

The sound made by a non-compliant thick left ventricle

Diastolic Heart Failure maintaining EF

Best heard Left Lateral with Bell over apex and ask pt to suspend respirations.

Always Pathologic: Diastolic HF

214
Q

Murmurs

A

When chambers contract and the valves are not patent or blood is not flowing through valves well. Abnormal turbulent blood flow.

215
Q

Where does the sound created by aortic stenosis radiate to

A

Carotid

216
Q

Where does the sound from mitral regurgitation radiate to?

A

The axilla

217
Q

Describe the timing of a Systolic Murmur

A

Systolic: occurring at or after S1 but finishing before S2

Innocent or physiologic grade 1,2,3

218
Q

Describe the timing of a Diastolic Murmur

A

Diastolic: occurring at or after S2 but finishing before S1

ALWAYS PATHOLOGIC

219
Q

HEART MURMUR MNEMONICS

Systolic vs. Diastolic

MR PASS

A

HEART MURMUR MNEMONICS

Diastolic

MS ARD

220
Q

Classification of Heart Murmurs

A
221
Q

How to determine if a murmur is systolic or diastolic

A

When it occurs in the cardiac cycle

If a murmur occurs with the radial pulse its SYSTOLIC if you don’t feel a thrill then can only be grade 1,2,3 and its benign

As soon as you feel a THRILL its no longer benign its pathological

THE ONLY MURMUR THAT IS NOT PATHOLOGICAL AND IS BENIGN IS A SYSTOLIC GRADE 1,2,3

222
Q

Grading Heart Murmurs

A
  • I – Very faint, may not be heard in all positions
  • II – Quiet, but heard upon placing stethoscope on the chest
  • III – Moderately heard without thrill
  • IV – Loud with thrill
  • V – Very loud with stethoscope partly off the chest with thrill
  • VI – Heard without stethoscope/ palpable thrill and heave
  • Harsh – Well heard with bell/diaphragm
  • Rumble – Low, best heard with bell
  • Blowing – High, best heard with diaphragm
  • Musical – Vibratory quality
223
Q

All DIASTOLIC murmurs regardless of thrill or no thrill are:

A

Pathological

(AORTIC STENOSIS and MITRAL REGURGITATION)

224
Q

All benign murmurs occur during

A

Systole

225
Q

Thrill starts at:

A

Grade IV

226
Q

Any systolc murmur grade 1/2/3 (meaning without a thrill) are considered

A

benign

227
Q

Name three Systolic heart murmurs

A

Mitral Regurgitation

Aortic Stenosis

Mitral Valve Prolapse

All benign if Grade 1,2,3 (NO THRILL)

228
Q

Name Diastolic Murmurs

A

Mitral Stenosis

Aortic Regurgitation

Aortic Stenosis

ALWAYS PATHOLOGICAL

229
Q

Changes in heart sounds of pregnant women?

A

Audible splitting of S1 and S2

230
Q

If the person is <40 a S3 can be

A

Benign

231
Q

A S4 is 99.99% always

A

Pathological b/c it has to do with a stiff heart which is more common in older adults indicating decreased left ventricular compliance

232
Q

Angina

A

The heart cannot supply the coronary arteries for the increased demand on the heart.

233
Q

Stable Angina

A

Predictable with exertion and improves with rest

234
Q

Unstable Angina

A

Aka Acute Coronary Syndrom

New-onset

Increase in frequency, duration or lower threshold for symptoms

Chest pain at rest

235
Q

The typical presentation of MI

A

Substernal pressure

Abdominal pain

Heaviness

SOB

Radiates to jaw or arm

If you make them move and increase metabolic demand it exacerbates pain

236
Q

Right Sided Heart Failure

A

Back up into systemic circulation. Heart fails to propel blood forward with its usual force resulting in congestion in the pulmonary circulation

Blood in liver spleen

237
Q

Left sided Heart Failure

A

Back up in pulmonary circulation b/c heart is not propelling blood forward with its usual force.

Ruddy cough, Productive cough

238
Q

Reduced Ejections Fraction

AKA

Systolic Heart Failure

(HFrEF)

A

EF <40%

Inotropic abnormality due to MI or dilated cardiomyopathy

Results in diminished systolic emptying (EF<40%)

239
Q

Diastolic HF

HF with preserved EF

(HFpEF)

A

A compliance abnormality, due to HTN, cardiomyopathy.

Ventricular relaxation is impaired (EF>50%)

240
Q

How do you treat diastolic heart failure AKA HRpEF

A

Treat comorbidity: HTN, diabetes

241
Q

Cor pulmonale

A

Right sided HF

Right side of heart has to push harder to get blood into heart so right ventricle enlarges

Results from high pressure in the lungs from COPD

242
Q
A
243
Q

Which physical findings is most suggestive of systolic heart failure?

A

S3

244
Q

History of Heart Failure

A

Dyspnea on exertion, cannot exercise. Easily fatigued.

Nocturnal nonproductive cough, orthopnea, paroxysmal nocturnal dyspnea, frothy pink sputum.

Wheezing (esp nocturnal) without hx of asthma

Cheyne-Stokes respirations

Pain in URQ (Hepatic congestion)

Nausea - poor appetite (advanced)

245
Q

Physical S/S of HF

A

S3 gallop

Hepatomegaly

Jugular venous distension

Hepatojugular reflux

Ascites

Displaced PMI

Poor cardiac output

Hypotension

Pulsus alternans

Narrow pulse pressure

cook extremities

246
Q

Cardiac Tamponade

A

Squeezing of the heart from excessive accumulation between the outer later of the heart

Causes Dyspnea, Syncope/Dizzyness, Altered mentation, N/V from hepatic engorgement

247
Q

Cardiac Tamponade Findings

A

Pulses paradoxus

Tachycardia

JVD

Hypotension

248
Q

Beck’s Triad

A

Distant heart sounds hypotension, distended neck veins

249
Q

Diagnostic criteria for Pericarditis

A

Acute pericarditis (at least two of four criteria)

  • Typical (pleuritic) chest pain
  • Pericardial friction rub
  • ECG changes with widespread ST elevation
  • New/ increasing pericardial effusion
250
Q

What will you see patients with Pericarditis do to relieve pain

A

Leaning forward and sitting up

Pain is NOT relieved with nitrates

251
Q

Afib

A

paroxysmal or continuous supraventricular tachyarrhythmia characterized by rapid, uncoordinated atrial electrical activity and an irregularly irregular ventricular response.

252
Q

Symptoms of AFib

A
  • Symptoms vary from none to mild (palpitations, light-headedness, fatigue, poor exercise capacity) to severe (angina, dyspnea, syncope).
  • AFib: irregularly irregular heart rate and pulse, frequently tachycardiac, pulse deficit

Lose atrial kick and 25% of cardiac output, blood pools there and a clot can develop

253
Q

While palpating the precordium, a heave is identified with lateral displacement of the apical pulse. Such findings may indicate

A

Left ventricular hypertrophy

ADV Health Assessment & Clinical Reasoning (4 decks)

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