Health Assessment Test 2 Flashcards
Common presenting symptoms of Ears, Nose & Throat
Ear pain
Hearing loss
Vertigo
Nasal discharge
Nosebleed
Snoring
Sinus pain
Dental problem
Mouth lesions
Sore throat
Dysphagia
Obtaining the history with ear pain
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
When is an otoscopic exam done?
The otoscopic exam is done in a routine screening and with complaint to inspect the external auditory canal and middle ear.
The auditory canal is inspected from…
The auditory canal is inspected from the meatus to the tympanic membrane.
How do you perform an ear exam in an adult?
To examine the ear in an adult grasp the auricle and lift up and back.
How do you perform an ear exam in an child?
To examine the ear in a child up to 3-4 years old you pull the auricle down and back.
During an exam you inspect the tympanic membrane for?
Inspect the TM for:
- landmarks (cone of light)
- color
- contour
- perforation.
Rinne test
Air conduction
Weber test
Bone conduction
Whisper test
Auditory function
How to perform a Rinne test
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.
How to perform a Weber test
(Bone conduction)
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.
When do you test for a Gag reflex?
Gag reflex is only tested in patients with suspected brainstem pathology, impaired consciousness, or impaired swallowing.
Tests CN IX and X
If palate elevation is impaired what CN might be the source?
CN X
If the gag reflex is impaired what CN might be the source?
CN IX or X
Normal age and condition variations of the EARS of an INFANT
- 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
Normal age and condition variations of the NOSE of an INFANT
- <3 no frontal or sphenoid sinuses. Frontal sinuses don’t fully develop until teen years
Normal age and condition variations of the MOUTH of an INFANT
- Avoid depressing the tongue because this stimulates a strong reflex and protrusion of the tongue, making visualizing of the mouth difficult
Normal age and condition variations of the EARS of a CHILD
- 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
Normal age and condition variations of the NOSE of a CHILD
- 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)
Normal age and condition variations of the MOUTH of an CHILD
- Inspect teeth for grinding, decay, and brown spots
Normal age and condition variations of the EARS of an OLDER ADULT
- 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
Normal age and condition variations of the NOSE of an OLDER ADULT
- Dry mucosa
- Increased hairs in vestibule
Normal age and condition variations of the MOUTH of an OLDER ADULT
- Reduced salivary flow
- Thinning buccal mucosa
- Tongue for fissure and varicose veins
- Inspect dental occlusion
How do you measure the symmetry of the ears?
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.
Grading the tonsils
Mouth/Throat Anatomy
Otitis Media with effusion
Inflammation of the middle ear resulting in the collection of serous, mucoid, or purulent fluid (effusion) when the tympanic membrane is intact
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
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
Malignant Otitis Externa Fulgurant
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.
Conductive hearing loss
- Hearing loss resulting from the reduced transmission of sound to the middle ear
Sensorineural hearing loss
- 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
Ménière disease
- 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
Vertigo
- 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
Viral rhinosinusitis
Viral rhinosinusitis
- Most common URI
- Associated with a sore throat, nasal congestion, rhinorrhea, sneezing, cough, and mild malaise
Bacterial rhinosinusitis
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
Acute pharyngitis
- 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
Peritonsillar abscess
- Deep infection in the space between the soft palate and tonsil – MED EMERGENCY
CENTOR Criteria Pneumonic
CAFE-O
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
Ask the patient to extend the tongue to inspect for :
- Ask the patient to extend the tongue while you inspect for:
- Deviation
- Tremor
- Limitation of movement
- CN XII
When would you perform transillumination of the sinuses?
- Transillumination of the frontal and maxillary sinuses may be performed if sinus tenderness is present or infection is suspected
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
Mouth and throat Documentation of SOAP note for ENT
- 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.
Stensen duct
Major duct to the salivary glands that opens into the mouth cavity
Fordyce spots
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
Normal Finding of Head & Neck
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
Normal Finding of Lymphatics
No edema, erythema, enlargement (adenopathy) or tenderness of nodes
Normal Finding of Eyes
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
Normal Finding of Ears, Nose, & Throat
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
Normal ear & teeth development in infants
- 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
Normal hearing in older adult
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)
Conductive hearing loss may result from:
- Excess deposition of bone cells along the ossicle chain, causing fixation of the staples in the oval window
- Cerumen impaction
- Sclerotic tympanic membrane
External Otitis
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
Acute Otitis Media (AOM)
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
Serous Otitis
(conductive hearing loss)
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
Cholesteatoma
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
Mastoiditis
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
Foreign Body or cerumen impaction
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
Barotrauma
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
TMJ disorder
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
HOARSENESS
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
Acute laryngitis
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
Chronic laryngitis
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)
Neoplasm
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
GERD
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
SORE THROAT
Most often result of an inflammation of the mucosa of the oropharynx, secondary to an infectious cause (viral, bacterial, fungal)
Viral Pharyngitis
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
GABHS pharyngitis
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
Mononucleosis
(Epstein-Barr virus)
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
Candidiasis
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
Epiglottitis
(d/t H. influenza type b)
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
Primary muscle of respiration
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
The tubular system provides a pathway along which air is:
Filtered
Humidified
Warmed
Respiratory System in Infants
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
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…
“O” observation, because I caused that pain
COPD CHEST
Flat diaphragm causes barrel chest with 1:1 ratio
Two ways to look at the lungs
Verticle axis - invisible line to make vertical locations, count the ribs and interspaces; sternal angle is the best guide and horizontal
Chest circumference of infant
Chest circumference at birth is 1:1 then goes to 1:2 at 2 years old
Chages in the chest wall in Pregnant women
Rib cage relaxes increased chest expansion, the diaphragm goes up. Respirations rate remains the same with deeper breathing
Chest Changes in the Older Adults
- 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.
What happens with people with Barrel Chest
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
Ace Inhibitor Cough
Chronic dry cough continuous
What is considered a acute cough vs. a chronic cough
Acute cough is < 3 weeks
Chronic cough is > 8 weeks
Subacute and chronic cough red flags
- 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
Anemia can cause what in relation to the heart?
Systolic murmur
Albumin is a excellent marker for…
Nutrition
Conjunctiva with a hint of pink indicates what level of hemoglobin?
Hemoglobin of at least an 8
Five A’s in smoking cessation
Smoking is the leading cause
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
Example of personal and social history
- 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
Causes of dyspnea in infants and children
- 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
Order to complete exam
Inspect
Palpate
Percuss
Auscultate
What should you inspect the chest for?
- 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
Expected findings in a normal chest?
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
Pectus Excavatum
Congenital posterior displacement of lower aspect of sternum. “hollowed-out” appearance.
Concave appearance of the lower sternum
NO SYMPTOMS - DOES NOT INVOLVE OTHER CONDITIONS
Pectus Carinatum
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
Paradoxic breathing
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.
Retractions
- 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
Breathing Patterns
Kussmaul’s - sweet breath from DKA body trying to get rid of acidity
Palpation for masses vs. tactile fremitus
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”
Palpate the anterior and lateral chest for:
- Masses
- Tenderness
- Crepitus
- Tactile fremitus
Tactile Fremitus
What is its purpose and how is it performed
- 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
What does increased or decreased tactile fremitus indicate?
- Increased: Presence of consolidation, fluids or solids
- Decreased: Excess air in lungs (pleural effusion, pneumothorax, COPD)
Percussion Expected finding vs. Unexpected findings
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
During Auscultation of Anterior and Axillary Lung fields how can the sounds be characterized
•All sounds can be characterized in the same manner as the percussion notes:
- Intensity
- Pitch
- Quality
- Duration
Listen with the diaphragm of the stethoscope
Vesicular Breath Sounds
Vesicular: Normal - soft and low pitched; usually heard over most of both lungs
Bronchial Breath Sounds:
Bronchial: Normal - louder and higher in pitch; usually heard over the manubrium
Bronchovesicular Breath Sounds:
Bronchovesicular: Normal - intermediate intensity and pitch; usually heard over the 1st and 2nd interspaces
Tracheal Breath Sounds:
Tracheal: Normal - over the trachea and neck, very loud
Abnormal findings during auscultation:
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
Normal lung findings:
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.
Crackles aka Rales
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.
Rhonchi
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.
Wheezes
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.
Stridor
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
Bronchial sound over peripheral lung field
Abnormal indicates: Consolidation such as pneumonia, pulmonary edema
When is there Absent or Attenuated Sounds during auscultation?
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
Friction rub
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
What is Diaphragmatic Excursion?
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.
What sounds are normal with Percussion
Resonance over lung fields
Flat over spinous process, scapula
Diaphragmatic excursion measures between 3 to 6 cm
Bronchophony
- Bronchophony: patient repeat 99 in normal voice while NP auscultates
- Negative (normal) findings: Muffled sounds
- Positive: Voice become clearer and distinct
Whispered Pectoriloquy
- 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
•Egophony
- 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)
Sounds on auscultation
Chest circumference in infants is…
2-3 cm smaller than head circumference
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
True
•Respiratory grunting in Infants
Respiratory System in Infants
- 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
By what age do children use the thoracic (intercostal) musculature for respiration
6 or 7
Normal breath sounds in a child
Breath sounds
- More resonant
- Hyperresonance common
- Easy to miss dullness
- Bronchovesicular sounds may predominate
Respiratory changes in the pregnant woman
increases her ventilation by breathing more deeply, not more frequently
Respiratory changes in the older adult
•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
Sample Normal Respiratory ROS note
Lungs: Chest: CTA/P B/L all lobes; (–) W/R/R.
Detailed: used if presenting with a lung/thoracic issue
AP diameter
Acute Bronchitis
- Inflammation of the large airways
- Viral origin (Most often)
Acute Bronchitis History
- 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
Influenza
- Viral acute onset infection
- Can affect nose, throat and sometimes lungs
Patients look and feel like hell
S/S Pneumonia
- 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.
Complications from the flu
- Otitis media
- Sinusitis
- Acute myositis
- Pneumonia
- Exacerbation of chronic illness (asthma, COPD)
Pneumonia S/S
•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
Pneumonia Physical Exam Findings:
- 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
Pertussis AKA Whooping Cough
- Contagious bacterial infection caused by Bordetella pertussis
- 3 stages disease
Pertussis AKA Whooping Cough
3 stages
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.
Pertussis AKA Whooping Cough
Differential Diagnosis
Differential diagnosis
- Pneumonia
- Asthma
- Bronchiolitis (Children)
- Croup (children)
Other causes of chronic cough.
- •Postnasal drip
- •GERD
- •TB
Bronchiolitis
- Inflammation of bronchial airways from various diseases
- RSV (Respiratory syncytial virus) 70 to 85% of cases
Bronchiolitis
History or S/S
- Irritability
- Anorexia
- Fever
- Noisy breathing (due to rhinorrhea)
- Cough
- Grunting
- Cyanosis
- Apnea
- Vomiting
Bronchiolitis
Physical Exam
- Tachypnea
- Retractions (increased work of breathing), nasal flaring, grunting
- Rhinorrhea
- Wheezing
- Upper respiratory findings: pharyngitis, conjunctivitis, otitis
Bronchiolitis
Differential Diagnosis
- Other pulmonary infections such as pertussis, croup, or bacterial pneumonia
- Aspiration
- Vascular ring
- Foreign body
- Asthma
- Heart failure
- Gastroesophageal reflux
- Cystic fibrosis
COPD in older adults loss of alveolar sac so decreased gas exchange
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.
What would a COPD pt present with?
- 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)
Obstructive Sleep Apnea
•Syndromes: episodic reduction or cessation of airflow during sleep
Obstructive Sleep Apnea commonly associated sx
•Common associated conditions:
Obesity, Adenotonsillar hypertrophy,GERD, Allergic rhinitis, medications (Sedatives, seizures)
Obstructive Sleep Apnea
Nocturnal Symptoms
Nocturnal symptoms:
- Loud snoring
- Witnessed apneic episodes
- Frequent arousal
- Disruptive sleep
Obstructive Sleep Apnea
Daytime Sx
Day time symptoms:
- Sleepiness, fatigue
- Lack of concentration
- Frequent URI/Ear infections
- Hyponasal voice
Common Physical Finding in a patient with OSA
- High BMI
- Short neck, enlarged tongue, soft palate edema, Enlarged tonsils, deviated nasal septum
- In severe cases: Failure to thrive s/s.
D/D for OSA
Differential diagnosis:
- Narcolepsy, Depression, Asthma, COPD, CHF, GERD
Asthma
Features
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
Asthma
Physical Examination
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
Classification of Asthma
Intermittent = all 2’s
Mild = all 2’s except 3-4 nighttime awakenings
Persistent Moderate = Daily
Persistent Severe = Through the day
Ankle - Brachial Index
Calf Pain / Claudication
Angina of the legs
Ankle-Brachial Index
Anything over a 0.91 is good.
Quick reference is that the ankle should be higher than the arm
ANKLE
BRACHIAL
How do you access for peripheral perfusion?
Edema
Color
Clubbing
Palpate the arterial pulses in distal extremities, comparing characteristics bilaterally for the following:
- Rate
- Rhythm
- Contour
- Amplitude
•Inspect the extremities for sufficiency of arteries and veins through the following:
- Color, skin texture, and nail changes
- Presence of hair
- Muscular atrophy
- Edema or swelling
- Varicose veins
What peripheral arteries do you palpate?
(7)
Carotid
Brachial
Radial
Femoral
Popliteal
Dorsalis pedis
Posterior tibial
Palpate for artery characteristics
Rate and rhythm
Pulse contour (waveform)
Amplitude (force)
Symmetry
Obstructions
Variations
How would you describe the amplitude of a pulse on a scale of 0-4
4: Bounding, aneurysmal
3: Full, increased
2: Expected
1: Diminished, barely palpable
0: Absent, not palpable
Which arteries would you use the bell of your stethoscope to auscultate?
- Temporal
- Carotid
- Abdominal aorta
- Renal
- Iliac
- Femoral
Bruit types
- Radiation of murmurs
- First noted during the cardiac examination
- Aortic stenosis murmur
- Obstructive arterial disease
- Evidence of local obstruction
Claudication
Angina of the legs
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
Jugular venous pressure
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)
Hepatojugular Reflux
- 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
How do you assess for venous obstruction and insufficiency?
- Thrombosis
- Homan sign
- Calf pain with passive dorsiflexion of the foot
- Peripheral Edema
- Grading 1+ through 4+
- Varicose veins
Peripheral Vascular changes in Pregnant Women
Increased cardiac output in first trimester
Increasing blood volume in second semester
JVP remains normal
What s/s are identified with venous obstruction, insufficiency and PVD?
- 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
Changes in the peripheral vascular system in older adults
- Dorsalis pedis and posterior tibial pulses may be more difficult to find
- Superficial vessels are more apt to appear tortuous and distended
Temporal arteritis (giant cell arteritis)
•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
Peripheral arterial disease
Stenosis of the blood supply to the extremities by atherosclerotic plaques
Raynaud phenomenon
Exaggerated spasm of the digital arterioles (occasionally in the nose and ears) usually in response to cold exposure and anxiety
Arterial embolic disease
Atrial fibrillation can lead to clot formation within the atrium, which may be dispersed throughout the arterial system
Venous thrombosis
- Sudden or gradual with varying severity of symptoms
- Can be the result of trauma or prolonged immobilization
Arterial Ulcer vs Venous Ulcer
Arterial ulcers
Venous Ulcers
Normal position of the heart
- 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
Dextrocardia aka Right Mirror Image
- 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
- Right and left atria ¾upper chambers
- Right and left ventricles¾lower chambers
- Right and left atria ¾upper chambers
- Right and left ventricles¾lower chambers
Coronary Artery
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
Atrioventricular (AV) valves:
- 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
Semilunar Valves
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
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
Electrical conductivity of the heart
RHF
Pressure build up toward the systemic system
liver, spleen, peripheral
LHF
Lungs - coughing, Ruddy - coughing
SA node
Mother
Pacemaker of the heart keeping it 60-100
Atrial kick
Accounts for 25% of EF and disappears with Afib
Wide QRS
Hypertrophic heart
When does a child’s heart reach adult position?
7 yo
Less that 7yo listen at the 4th intercoastal space
Changes in the heart at birth
- Ductus arteriosus and interatrial foramen ovale close
- Right ventricle assumes pulmonary circulation
- Left ventricle assumes systemic circulation
Changes in the heart of a older adult
- 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
CHEST PAIN
The proper order of a cardiac exam is?
- Inspecting
- Palpating
- Percussing the chest (rare)
- Auscultating the heart
Remember to auscultate last
Apical Pulse
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
What grade of a murmur is considered pathological with a thrill?
3,4,5
Where is Left Ventricular size better judged?
By the location of the apical pulse
Right ventricle tends to enlarge in the ________ _________ rather than laterally
Anteriorposterior
Auscultate the diaphragm with the ____ of the stethoscope
Bell
Auscultate heart sounds for
•Location:
- Aortic, pulmonic, triscupid and mitral
- Identify S1 and S2 (lup dup)
- Assess overall rate and rhythm
- Intensity
- Pitch
- Pathologies
S1
“Lub”’ = Closure of the AV valves
Beginning of Systole
Radial & Carotid pulse coincides with S1
Low pitch sound (S1) heard best at apex
S2
“DUB” = Closure of the Semilunar
Diastole
High Pitch Sound (Diaphram) heard best at base
S2 increases with inspiration
S1 Split
Mitral valve and Tricuspid valves closing
S1 split – Hard to hear- Most often occurs during deep inspiration (best heard tricuspid area)
S2 Split
Aortic closes faster than pulmonic
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.
After listening to S1, S2 and for a S1/S2 split you then listen for:
Listen for abnormal sounds: S3, S4, murmurs, pericardial friction rubs
Auscultation of heart sounds:
- 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
What position is best for auscultation of S3 and murmurs b/c of low pitch?
Left Lateral Decubitus
S3 aka Ventricular Gallop
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
S4 Atrial Gallop
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
Murmurs
When chambers contract and the valves are not patent or blood is not flowing through valves well. Abnormal turbulent blood flow.
Where does the sound created by aortic stenosis radiate to
Carotid
Where does the sound from mitral regurgitation radiate to?
The axilla
Describe the timing of a Systolic Murmur
Systolic: occurring at or after S1 but finishing before S2
Innocent or physiologic grade 1,2,3
Describe the timing of a Diastolic Murmur
Diastolic: occurring at or after S2 but finishing before S1
ALWAYS PATHOLOGIC
HEART MURMUR MNEMONICS
Systolic vs. Diastolic
MR PASS
HEART MURMUR MNEMONICS
Diastolic
MS ARD
Classification of Heart Murmurs
How to determine if a murmur is systolic or diastolic
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
Grading Heart Murmurs
- 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
All DIASTOLIC murmurs regardless of thrill or no thrill are:
Pathological
(AORTIC STENOSIS and MITRAL REGURGITATION)
All benign murmurs occur during
Systole
Thrill starts at:
Grade IV
Any systolc murmur grade 1/2/3 (meaning without a thrill) are considered
benign
Name three Systolic heart murmurs
Mitral Regurgitation
Aortic Stenosis
Mitral Valve Prolapse
All benign if Grade 1,2,3 (NO THRILL)
Name Diastolic Murmurs
Mitral Stenosis
Aortic Regurgitation
Aortic Stenosis
ALWAYS PATHOLOGICAL
Changes in heart sounds of pregnant women?
Audible splitting of S1 and S2
If the person is <40 a S3 can be
Benign
A S4 is 99.99% always
Pathological b/c it has to do with a stiff heart which is more common in older adults indicating decreased left ventricular compliance
Angina
The heart cannot supply the coronary arteries for the increased demand on the heart.
Stable Angina
Predictable with exertion and improves with rest
Unstable Angina
Aka Acute Coronary Syndrom
New-onset
Increase in frequency, duration or lower threshold for symptoms
Chest pain at rest
The typical presentation of MI
Substernal pressure
Abdominal pain
Heaviness
SOB
Radiates to jaw or arm
If you make them move and increase metabolic demand it exacerbates pain
Right Sided Heart Failure
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
Left sided Heart Failure
Back up in pulmonary circulation b/c heart is not propelling blood forward with its usual force.
Ruddy cough, Productive cough
Reduced Ejections Fraction
AKA
Systolic Heart Failure
(HFrEF)
EF <40%
Inotropic abnormality due to MI or dilated cardiomyopathy
Results in diminished systolic emptying (EF<40%)
Diastolic HF
HF with preserved EF
(HFpEF)
A compliance abnormality, due to HTN, cardiomyopathy.
Ventricular relaxation is impaired (EF>50%)
How do you treat diastolic heart failure AKA HRpEF
Treat comorbidity: HTN, diabetes
Cor pulmonale
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
Which physical findings is most suggestive of systolic heart failure?
S3
History of Heart Failure
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)
Physical S/S of HF
S3 gallop
Hepatomegaly
Jugular venous distension
Hepatojugular reflux
Ascites
Displaced PMI
Poor cardiac output
Hypotension
Pulsus alternans
Narrow pulse pressure
cook extremities
Cardiac Tamponade
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
Cardiac Tamponade Findings
Pulses paradoxus
Tachycardia
JVD
Hypotension
Beck’s Triad
Distant heart sounds hypotension, distended neck veins
Diagnostic criteria for Pericarditis
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
What will you see patients with Pericarditis do to relieve pain
Leaning forward and sitting up
Pain is NOT relieved with nitrates
Afib
paroxysmal or continuous supraventricular tachyarrhythmia characterized by rapid, uncoordinated atrial electrical activity and an irregularly irregular ventricular response.
Symptoms of AFib
- 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
While palpating the precordium, a heave is identified with lateral displacement of the apical pulse. Such findings may indicate
Left ventricular hypertrophy
