PCM 1 - Final Exam Flashcards
Is the diaphragm of the stethoscope best for high- or low-pitched sounds?
High Pitched
e.g.,: S1, S2, AR, MR, Friction Rubs
The diaphragm of the stethoscope is best for high pitched sounds, give some examples.
- S1
- S2
- AR (aortic valve regurgitation)
- MR (mitral valve regurgitation)
- Friction Rubs
Is the bell of the stethoscope best for high- or low-pitched sounds?
Low Pitched
e.g., S3, S4, MS, Carotid Bruit
The bell of the stethoscope is best for low pitched sounds, give some examples.
- S3
- S4
- Carotid Bruit
- MS (mitral valve stenosis)
What are the 4 major steps, in order, to the cardiovascular exam?
- Inspection
- Palpation
- Percussion
- Auscultation
List general appearance items to Inspect for during Step 1 of the cardiovascular exam?
- consciousness
- cyanosis
- flushing
- respiratory patterns
- anxiety/distress
- body habitus
- diaphoresis (sweating)
- neck veins (JVD)
What is the common shape upon inspection of a pt with COPD?
Barrel Chested
What is the shape of a pt’s chest with Pectus Carinatum upon inspection?
Pigeon Chest
What is the shape of a pt’s chest with Pectus Excavatum upon inspection?
Funnel Chest
What are the common landmarks used during Inspection (Step 1) of the cardiovascular exam?
- sternal notch
- sternal angle
- sternal border
- mid-clavicular line
- anterior axillary line
- xiphoid process
- nipples
During Palpation (step 2) of the cardiovascular exam what is the Point of Maximal Impulse (PMI)?
PMI –> used to estimate location of apex/left border of the heart.
> can assess supine or left lateral decubitus position
usually palpated near the 4th-5th intercostal space in the mid-clavicular line
may need to have patient lift her breast
PMI may not e readily felt in healthy heart/patient
What does the Point of Maximal Impulse (PMI) estimate?
Location of Apex/Left Border of the Heart
In what position should the pt be in to determine the Point of Maximal Impulse (PMI) during Step 2 (palpation) of the cardiovascular exam?
Supine or Left Lateral Decubitus
In what location is the Point of Maximal Impulse (PMI) typically palpated?
Normally - near the 4th-5th Intercostal Space in the Midclavicular Line
What is typically palpated near the 4th-5th Intercostal Space in the Mid-clavicular Line?
Point of Maximal Impulse (PMI)
True or False:
The PMI (point of maximal impulse) may not be readily felt in healthy heart/patient.
True
True or False:
Palpation of an impulse should be felt through the second heart sound (S2).
False - should NOT be felt through S2
**Impulse should be a small, brisk beat and measure less than 2.5cm. The impulse should last through the first 2/3 of the systolic period (or less).
What location do you auscultate the Aortic Valve?
Right 2nd Intercostal Space @ Sternal Border
What location do you auscultate the Pulmonic Valve?
Left 2nd Intercostal Space @ Sternal Border
What location do you auscultate the Tricuspid Valve?
Left 4th Intercostal Space @ Sternal Border
What location do you auscultate the Mitral Valve?
Left 5th Intercostal Space @ Mid-Clavicular Line
What location do you auscultate Erb’s Point?
Left 3rd Intercostal Space @ Sternal Border
**Erb’s Point –> point at which S1 and S2 is heard equally.
What is Erb’s Point?
The point at which S1 and S2 are heard equally.
Which sound is heard at the Right 2nd ICS @ the SB?
Aortic Valve
Which sound is heard at the Left 2nd ICS @ the SB?
Pulmonic Valve
Which sound is heard at the Left 4th ICS @ the SB
Tricuspid Valve
Which sound is heard at the Left 5th ICS @ the Mid-Clavicular Line?
Mitral Valve
What causes S1?
Closure of the Tricuspid and Mitral Valves
What causes S2?
Closure of the Aortic and Pulmonic Valves
- may split with inspiration (normal)
What is the S3 sound?
Dull, Low Pitch, Best Heard with Bell
Due to high pressure and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of the cardiac cycle.
Physiologic in children/young adults.
Pathologic > 40 y/o (“Ken-Tuck-Y”)
What is the S4 sound?
Dull, Low Pitch, Best Heard with Bell.
Atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle.
Can be normal in trained athletes.
“Ten-Nes-See”
What is systole?
Ventricular Contraction and Ejection
S1 –> S2
What is diastole?
Ventricular Relaxation and Filling
S2 –> S1
Between which two heart sounds is a systolic murmur heard?
S1 and S2
Give 4 examples of pathologies that cause systolic murmurs.
- aortic stenosis
- pulmonic stenosis
- mitral regurgitation
- tricuspid regurgitation
Diastolic murmurs are heard between which two heart sounds?
S2 and S1
Give 4 examples of pathologies that cause diastolic murmurs.
- aortic regurgitation
- pulmonic regurgitation
- mitral stenosis
- tricuspid stenosis
What are the characteristics of a Grade 1 murmur?
very faint
What are the characteristics of a Grade 2 murmur?
quiet, but heard easily with stethoscope
What are the characteristics of a Grade 3 murmur?
moderately loud, NO THRILL
What are the characteristics of a Grade 4 murmur?
loud, with palpable thrill
What are the characteristics of a Grade 5 murmur?
very loud w/thrill - may be heard with stethoscope partly off chest
What are the characteristics of a Grade 6 murmur?
heard with stethoscope entirely off the chest
Rate the grade of murmur:
Murmur heard with stethoscope entirely off the chest.
Grade 6
Rate the grade of murmur:
Murmur is very loud w/thrill, and can be heard with stethoscope partly off the chest.
Grade 5
Rate the grade of murmur:
Murmur is loud with palpable thrill.
Grade 4
Rate the grade of murmur:
Murmur is moderately loud, with no thrill.
Grade 3
Rate the grade of murmur:
Murmur is quiet, but heard easily with stethoscope.
Grade 2
Rate the grade of murmur:
Murmur is very faint.
Grade 1
Is the carotid pulse palpated medial or lateral to the SCM?
Medial
What is the carotid pulse palpated for?
Assess for thrills and bruits
** pressure on the carotid baroreceptors may cause a hypotensive reflex and possible fainting
What are the 4 grades of the peripheral pulse scale?
0: absent, pulse not palpable 1+: pulse diminished, barely palpable 2+: Normal, average intensity, expected 3+ pulse is strong, full, increased 4+: pulse is bounding
Which grade on the peripheral pulse scale of 4 is considered normal?
2+: normal, average intensity, expected
What is the capillary refill test testing?
Test of Digital Perfusion (e.g., arterial occlusion, hypovolemic shock, hypothermia)
**Normal capillary refill time is 2 seconds or less **
When performing an examination for pitting edema, how long is pressure firmly applied with your finger tip?
Examined by pressing firmly for 5 seconds over the:
- dorsum of the foot - anterior tibia - behind medial malleolus
Where are the 3 locations in which you exam for pitting edema?
1) dorsum of the foot
2) anterior tibia
3) behind medial malleolus
What are the grades used in the four point scale for the examination for pitting edema?
Absent
1+: barely detectable, slight pitting (2mm); disappears rapidly
2+: slight indentation (4mm); remains for 10-15 seconds
3+: deeper indentation (6mm); may be >1 minute
4+: very marked indentation (8mm); 2-5 minutes
From where do the anterior and posterior axillary lines drop vertically from?
Anterior and Posterior Axillary Folds
From where does the Mid-Axillary line drop from?
Apex of the Axilla
From where does the mid-sternal line drop from?
suprasternal notch
From where does the mid-clavicular line drop from?
Vertically from the midpoint of the clavicle.
What is the landmark in which the 2nd rib meets with the manubrium and the body of the sternum?
Sternal Angle
At which landmark is a needle decompression performed for an emergent decompression tension pneumothorax?
2nd ICS just superior to the 3rd rib margin at the mid-clavicular line for emergent decompression tension pneumothorax, followed by chest tube placement.
**recall: neurovascular bundle runs inferior to each rib, so needles and tubes should be placed superior to the rib margins
At what ICS (intercostal space) doe you insert a chest tube?
4th ICS at mid or anterior axillary line in the 4th ICS just superior to the margin of the 5th rib
At which vertebral level would the lower margin of an endotracheal tube appear on a chest x-ray?
T4
Which intercostal space is a landmark for thoracentesis?
7th Intercostal Space
List the 4 major things to evaluate during respiration of the patient.
- rate (normal: 14-20x/minute)
- rhythm
- depth
- effort
In what respiratory problems does intercostal retractions occur?
- severe asthma
- COPD
- upper airway obstruction
What are pursed lips during breathing characteristic of?
Obstructive Lung Disease (COPD)
What is a characteristic posture/position of a pt with obstructive lung disorders?
Tend to sit leaning forward with shoulders elevated.
Contraction of which accessory muscles can occur in pts with difficult breathing?
- sternomastoid
- scalenes
- supraclavicular retraction
Which pathology can cause lateral displacement of the trachea?
Tension Pneumothorax (causes deviation of trahea towards countrlateral side)
What is “clubbing” of the fingernails?
- Bulbous swelling of soft tissue at nail base.
- Loss of normal angel between nail and proximal nail fold (>180 degrees) leading to a spongy or floating feeling.
- Involves vasodilation with increased blood flow to the distal potion of the digits, and changes in connective tissue possible due to hypoxia, changes in innervation, or a platelet derived groth factor from fragments of platelet clumps.
In which pathologies is fingernail clubbing seen in?
- congenital heart disease
- interstitial lung disease
- bronchiectasis
- pulmonary fibrosis
- lung abscess
- inflammatory bowel disease
- malignancies (lung cancer)
- cystic fibrosis
What is Tactile fremitus?
Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks.
- perform on anterior and posterior chest
- pt says “ninety-nine” or “one-one-one”
- often more prominent in the interscapular area than in the lower lung fields, and is more prominent on the right than the left.
- disappears below the diaphragm
What is indicitive of decreased/absent fremitus?
- COPD
- pleural effusions
- fibrosis
- pneumothorax
- thick chest wall
- an infiltrating tumor
What is indicitve of increased fremitus?
- pneumonia
increased transmission through consolidated tissue
What is the purpose of percussion of the chest?
To establish whether underlying tissues are:
- air-filled - fluid-filled - solid
Which finger is used during percussion of the chest?
Hyperextended Middle Finger
- have only hyperextended middle finger firmly contact skin
- strike extended middle finger aiming for the DIP with a quick, sharp, but erlaxed wrist motion
- start superiorly percussing obht sides of the chest working toward the base procedding in a “ladder-like” pattern
- also perform on the anterior chest
- percussion penetrates only 5cm to 7cm into chest, so it can miss deep seated lesions
What is the depth that can be accessed by percussion of the chest?
penetrates only 5cm - to - 7cm
** Thus, percussion can miss deep seated lesions. **
In what position should the pt be in while performing percussion on the posterior side?
- Seated, with both arms crossed in front of chest.
During percussion, what are the 5 percussion notes that you should identify?
- Flat (soft intensity; high pitch)
- Dull (medium intensity; medium pitch)
- Resonant (loud intensity; low pitch)
- Hyperresonant (very loud; lower pitch)
- Tympanitic (loud intensity; high pitch - distinguished mainly by its musical timbre
Of the 5 percussion notes, which is expected to be heard in a healthy lung?
Resonant:
- loud intensity
- low pitch
- long duration
True or False:
Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers.
True
True or False:
Generalized resonance may be heard over hyperinflated lungs.
False - HYPERRESONANCE may be heard over hyperinflated lungs.
Give 2 examples of obstructive disorders that can cause generalized hyperresonance heard over hyperinflated lungs during percussion of the chest.
- COPD/Emphysema
- Asthma
During percussion of the chest you hear unilateral hyperresonance. Name 2 pathologies that this finding could suggest.
- large pneumothorax
- large air-filled bulla in lung
Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers. Name two pathologies that would be suggestive of this.
- lobar pneumonia (alveoli filled with fluid and blood cells)
- pleural accumulations
> effusion (serous fluid)
> hemothorax (blood)
> emphyema
> fibrous tissue or tumor
Pleural accumulation of what substance causes an Effusion?
Serous Fluid
Pleural accumulation of what substance causes a Hemothorax?
Blood - treated with chest tube placement.
Pleural accumulation of what substance causes a Empyema?
Pus
What is Diaphragmatic Excursion?
Used to determine the distance between inhale and exhale of the diaphragm.
1) patient exhale completely and hold it
2) percuss level of diaphragm
3) mark with pen
4) patient breathes normally for a few breaths
5) patient inhales completely and holds it
6. percuss for level of diaphragm
7) mark level with pen
8) distance between the two is diaphragmatic excursion
What can cause asymmetry with one side of the diaphragm than another, noticed during diaphragmatic excursion assessment?
- pleural effusion (will have dullness to percussion)
- high diaphragm secondary to:
> atelectasis
> phrenic nerve paralysis
What is the range of normal diaphragmatic excursion?
Normal Excursion = 3-5.5 cm
What would dullness at a level higher than expected during diaphragmatic excursion suggest?
- pleural effusion
- high diaphragm (as in atelectasis, or phrenic nerve paralysis)
Which side of the stethoscope do you use during auscultation of the lungs?
- Diaphragm of the Stethoscope
While listening to auscultations with the diaphragm of your stethoscope, should the patient breath through an open or closed mouth?
Open Mouth
True or False:
Compare auscultation side to side at each level before going to the next level (“ladder-like pattern”).
True
At minimum, how many spots should auscultation be assessed during a lower respiratory exam?
- Listen at Minimum to each lobe of the lungs:
> upper and lower lobe (left lung)
> upper, middle, and lower lobe (right lung)
What are the 4 normal breath sounds?
- vesicular (sound heard over most of lungs (parenchyma))
- bronchovesicular
- bronchial
- tracheal
What is the intensity and pitch of Vesicular Breath Sounds?
Soft and Low Pitched
During which potions of the respiratory cycle are vesicular breath sounds heard?
Heard through inspiration and about 1/3 of expiration.
What is the intensity and pitch of Bronchovesicular breath sounds?
Intermediate Intensity and Pitch
During which portions of the respiratory cycle are bronchovesicular breaths sounds heard?
Heard equally in Inspiration and Expiration
In which location are bronchovesicular breath sounds best heard?
1st and 2nd Interspaces Aneriorly and Between the Scapulae
What is the intensity and pitch of Bronchial Breath Sounds?
Loud Intensity and High Pitched
During which portion of the respiratory cycle are bronchial breath sounds heard?
Expiratory sounds heard longer than inspiratory.
In which location are bronchial breath sounds best heard?
Over Manubrium (larger proximal airways)
What is the intensity and pitch of Tracheal Breath Sounds?
Very Loud Intensity and High Pitched
During which portion of the respiratory cycle are Tracheal Breath Sounds heard?
Equally in Inspiration and Expiration