PCM Newer Material Flashcards
How does measuring JVP work?
Place the pt supine and allow veins to engorge, then put the pt up to 30-45 degrees. have them turn their head to the left and look at their right JV. take a ruler with CM markings and place it at the angle of louie and go horizontally to the halfway point of the JV. Add 5 because the heart is 5 below the sternum
What is a normal range to JVP (including the +5)?
0-8
What 2 things could cause an increase of JVD/JVP?
SVC obstruction , severe heart failure
What does it mean to have a higher A wave
Trouble getting out of the atria.. so Tricuspid/pulmonary stenosis, pulmonary embolism
What does it mean to have a higher V wave?
Tricuspid Regurgitation.
What does the JVP waveforms measure side wise?
What’s going on on the RIGHT side of the heart
What are the 2 heart sounds and where can you best hear them?
First sound = Lub –> closure of the mitral and tricuspid. Best heard at the APEX of the heart
second sound = dub –> closure of aortic and pulmonic valves. Best heard at the BASE of the heart
What is the reason for a systolic murmur + diastolic murmur.
Where are these sounds from?
Systolic = between S1 and S2
Flow sucks across the valve or regurgitation so Mitral / Tricuspid regurgitation or aortic/pulmonic stenosis
Diastolic = between S2 and the next S1
Flow sucks across the mitral valve / tricuspid (stenosis) or pulmonic/aortic regurgitation (insufficiency)
What are the grades for a murmur?
1 = very faint
2 = quiet but heard with stethoscope
3 = moderately loud but no thrill
4-6 have thrill
4 is loud with thrill
5 is loud with stethoscope partially off chest
6 you can hear it without the stethoscope on it.
What’s the difference between HPI and H&P?
H&P is a new patient. it includes HPI and also includes a huge review of systems. it WILL have a CC because that’s how you get into the hospital
it could be a annual checkup, and that won’t have a CC.
HPI is history of present illness. Usually when they present to the hospital and have a chief complaint you’re doing an HPI
What’s included in the HPI and the ROS?
HPI has associated symptoms vs ROS is review of systems which talks about symptoms asking about bodily changes that may not be related to the symptoms.
What are the different things we look at for general appearance of the pt?
Position Activity Posture Affect Skin color Diaphoretic
What activity would you see someone with a kidney stone? appendicitis?
restless
still
what posture is not normal?
slumped, fetal position
what affect would you see in someone that is sick?
grimace, worried, frightened.
furrowed brows
what skin color is considered”sick”?
anemic or washed out
What is diaphoretic
sweating
may be hot or cold.
the cold is associated with really bad problems.
What are the two problems of urinary origin that we talked about?
Cystitis or pyelonephritis
cystitis is bladder localized
pyelonephritis is kidney localized infection
What are the three GI things we talked about?
where are two of them localized?
Appendicitis, Collitis, Diverticulitis
appendicitis is localized to lower right. diverticulitis is lower left
What are the 2 things we talked about in the female reproductive system?
what’s the one thing for the male reproductive system?
Cyst, Ovarian Cyst Rupture
Prostatitis
What is a possible sign of urinary tract cancer? What are the different categories for this?
Hematuria
Gross - can see with naked eye
Microscopic = urinalysis
What are the majority of renal cel carcinomas?
clear cell type
What do you want to label your PLAN with?
you want to determine the most cost effective with the highest yield and least potential complications first, and go from there on down.
Why is it good to go through a FH?
a few types of benign or familial hematuria that could cause it could include other symptoms. blood in the urine sometimes can be associated with something else that they have as a disorder.
like an autoimmune disorder
What is..
hypopnea?
Bradypnea?
Hyperpnea?
Decreased depth and rate of respiration
regular rhythm but slower than normal rate (less than 14)
deeper breathing and higher rate (happens during exercise)
What is.. Tachypnea Dyspnea Hypoxia Hypoxemia
rapid breathing (20-25/min)
feeling SOB
deficiency in amount of O2 reaching tissues
oxygen deficiency in arterial blood
What is.. Apnea Atelectasis Pleximeter finger Plexor finger
no breathing
collapse of lung tissue that affects alveoli from normal O2 absorption
hyperextended middle finger on skin
thing that’s hitting the pleximeter finger
Where is a needle thoracentesis placed?
2nd intercostal space, midclavicular line
Where is a chest tube inserted?
where is it going if you want to put it in the 5th intercostal space for males and females?
4th and 5th, just anterior to mid axillary line
males = just below the nipple
females = inframammary fold
Where is the neurovascular bundle and why do we care?
runs along the inferior margins of each rib
chest tubes and needles need to be placed over the superior margin of the rib to avoid the bundle
What are the 5 lines we learned in lab?
midsternal line midclavicular line anterior axillary line midaxillary line posterior axillary line
What is pulse oximetry?
what can cause a bad wave form? (4)
measures peripheral arterial oxygen saturation (SpO2)
improper placement
hypo perfusion, hypothermia, motion artifact
What is End Tidal CO2?
concentration of CO2 in exhaled air at the end of respiration.
Because CO2 is only a trace gas in the air, the CO2 detected in exhaled air is produced by the body and delivered to the lungs by the blood correlates with PaCO2
normal PETCO2 35-40, normal PaCO2 35-45
How does an incentive spirometer work?
what does it help with?
completely exhale, put over mouthpiece, breathe in as much as possible, moving the piston. get to the point of the piston that the Dr. recommends, hold for 2-5 seconds
atelectasis, treatment and prevention
What is a PFT?
shows how well the lungs are working and diagnose obstructive vs. restrictive.
there’s expensive ones or spirometry
spirometry measures lung functions, amount and speed of air inhaled and exhaled
What would you inspect for breathing problems with someones skin color?
blue face, nail beds blue, hypoxia
What if the trachea isn’t midline?
pneumothorax, pleura effusion, atelectasis, mass
What are the different accessory muscles used?
sternomastoids, scalene, trapezius, and another one in the abdominal region
What causes clubbing of the nails
congenital heart disease, interstitial lung disease, pulmonary fibrosis, CF, cancer, IBD, etc.
What are the different shapes of the chest that are considered a deformity
Barrel chest pigeon chest funnel chest kyphoscoliosis flail chest
What is a flail chest?
multiple rib fractures result in weird movements.
the injured part moves inward during inhalation and pushes outward during exhlaation
If you have asymmetrical expansion of the ribcage what is one reason why?
pleural effusion
If you have retraction, what could cause that?
they tighten at the wrong time, severe asthma, COPD, upper airway obstruction
What is tactile fremitus?
decreased vibration?
increased vibration?
balls of your hands or ulnar surface –> 99 or 1-1-1
COPD, pleural changes (effusions, fibrosis, air, infiltrating tumor)
pneumonia
What are the 5 percussion sounds?
Flat, dull, resonant, hyper resonant, tympanic
What can cause dullness?
fluid or solid tissue replaces air.
lobar pneumonia, pneumothorax, hemothorax, empyema, fibrous tissue, etc.
What can cause hyperresonance
COPD, asthma, chronic bronchitis
How do you do diaphragmatic excursion and what can happen if it’s abnormal?
exhales completely, percuss the diaphragm (spot where resonant and dullness meet), mark with pen, inhale as much as can, mark diaphragm
normal is 3-5.5
Asymmetry one side over the other is pleural effusion
high diaphragm could be atelectasis or phrenic nerve paralysis
What are the 4 breath sounds?
what do they sound like? Best heard?
Which ones, if heard more distal, would you suspect air-filled lungs has been replaced by fluid filled or solid lung tissue?
When might you have decreased breath sounds?
bronchial: Loud and high pitched. best heard over manubrium
bronchovesicular Intermediate in intensity and pitch. best heard in 1st and 2nd interspaces between scapulae
tracheal: Very loud and high pitched, heard over trachea
vesicular: Soft and low pitched. heard over most of lungs
Bronchovesicular or bronchial
decreased air flow or poor transmission of sound.
What are crackles?
caused by small airway closed during inspiration, “popping” open during inspiration.
sounds like velcro
pneumonia, CHF, atelectasis, fibrosis, COPD, asthma, etc.
What causes wheezing?
rapid airflow through a narrowed bronchial airway
what causes stridor?
narrowing of the upper airway. this is emergent
What is rhonchi?
What is pleural friction rub?
Suggest secretions in large airways
sounds like a creaking door. Inflamed and roughened pleural surface grate each other.
What is bronchophany?
Egophany?
whisper pectoriloquy?
spoken words get louder to auscultation
E sounds like A
whispering words are louder and clearer during auscultation
Wha are the ABCs to reading a chest X-ray?
Adequate/Assessment, Airway Bones and soft tissues Cardiac size/valves Diaphragms Effusion/ET tube, EKG leads Fields/fissures, foreign body Great vessels, gastric bubble Hilar Masses Impression
What are the main things to do for an ear evaluation?
include hearing and looking
Check the external ear, check for drainage and redness, tenderness of the tragus,
can use a puffer to look at the TM
normal TM you should see a cone of light and seeing the bony structures.
whisper test first, then do weber ring
What is the whisper test?
primary test you do for checking hearing loss
softly whisper into each ear and ask the pt what was whispered (combination of numbers and letters)
normal: patient can repeat sequences after 2 sequences, can identify 3 of the 6.
abnormal: incorrectly identifies 4/6
ALSO rub fingers next to one ear as well and ask pt what one it was at
What is the Rinne/Weber tests?
Start with weber. if it goes to the affected ear, then go to rinne
if to the other side, then it’s sensorineural
when doing Rinne, if BC>AC, it’s conductive hearing loss
If AC>BC, normal.
What can cause conductive hearing loss? What part of the ear is it associated with?
sensorineural causes? What part of the ear is it associated with?
too much wax.. external or middle
head trauma, age, ototoxic drugs.. inner ear, cochlear nerve, central brain
What are the signs of problems with the tonsils?
what’s to note about kids?
redness, exudate on them.
Kids have huge tonsils
What is cobblestoning?
flex colored bumpy. indicative of post nasal drainage.
fluid is coming down from the nose and irritating the skin.
usually this is caused by allergic rhinitis
When do kids get their frontal sinuses?
age 7
What swells in the nose and what colors determine what it is?
turbinates.
if bluish tint = allergic rhinitis
if clear = viral rhinorrhea
What are the different lymph node spots that we were taught
Preauricular Postauricular Submental Submandibular Tonsillar Anterior Cervical posterior Cervical Supraclavicular
What are the three main signs of streptococcal pharyngitis?
what is it caused by?
biggest is little red bumps on the prepalatine surface
exudate on the tonsils, and erythematous in nature.
Group A beta-hemolytic streptococcus
Why can someone have nausea with strep?
pharynx is next to abdominal organs for the homunculus
You’re more likely to have GABHS if… (6)
children 5-15 winter and early months absence of. cough tender ANTERIOR cervical lymphadenopathy Tonsillar exudate Fever
What do you do if the Centor score is 2 or 3?
4+?
rapid strep in office
Treat them regardless
What do you use for dx strep? 2 things
what about for mono?
what do you give for tmt of strep?
Rapid strep = detects presence of group A
Throat Culture
Monospot test
penicillin
What does pharyngitis mean?
What are the common symptoms for viral pharyngitis?
inflammation of the pharynx with resulting sore throat.
it can be viral or bacterial
Inflamed mucous membrane, conjunctivitis, fatigue, hoarseness, low grade fever
What is Acute otitis labyrinthitis?
inner ear, feeling like vertigo, dizzy
What is Acute Otitis Media?
what are the different types?
what about chronic OM?
inflammation of middle ear caused by bacteria or virus
Acute suppurative OM is OM with purulent material in middle ear
Serous OM is fluid build up in the middle ear WITHOUT bacterial or viral infection.
Chronic OM with effusion happens when fluid remains in the middle ear and continues to return without bacterial or viral infection… they give kids ear tubes to prevent this.
Chronic Suppurative OM is persistent ear infection that results in tearing or perforating the eardrum
What is Acute Otitis Externa?
Outer ear infection –> swimmer’s ear
Pt reports drainage from the ear.
pain upon touching external ear structures.
What is otosclerosis
abnormal bone growth around stapes bone.
progressing hearing loss at age 10-30, marked loss occurring during middle age.
Conductive / Sensory loss and otosclerosis?
Conductive = Ossicle Sclerosis into a single immovable mass
Sensory = otic capsule sclerosis
affects males more than females
What is Acute Rhinosinusitis
What is it caused by sometimes?
What are the symptoms?
mucosal lining becomes inflamed by viral or bacterial infections.
dental infections
thick nasal discharge
cough
sneezing
facial pressure
“does it hurt to lean forward”?
What is a hallmark for bacterial sinusitis?
Double sickening!
What is Croup?
caused by?
Bark like cough.
Swelling of the larynx, trachea, bronchi causing stridor.
caused by parainfluenza, influenza, etc.
What is epiglottis?
caused by?
symptoms?
swelling of epiglottis, caused by type 2 flu or group A strep.
toxic appearance, tripod, high grade fever, sore throat, muffled voice
this is an emergency
What is BPPV?
most common cause of vertigo caused by Canalithiasis (stone preventing endolymph from moving)
feeling like you’re spinning or that your head is spinning
What 2 maneuvers are associated with this?
Dix-hallpike maneuver
Epley maneuver
What is the general cause of vertigo
eustachaian tube dysfunction, causes by flu, sinus infection, allergies
What is Vestibular Neuritis?
Inflammation of the nerve affects branch associated with balance. results in dizziness or vertigo but NO CHANGE IN HEARING.
What is Labyrinthitis?
affects BOTH branches of the vestibulocochlear nerve, HEARING DOES CHANGE as well as dizziness or vertigo.
What is Meniere’s disease?
disorder in inner ear that causes episodes of vertigo and fluctuating hearing loss ending in permanent hearing, tinnitus, fullness/pressure in ear.. usually only affects one ear.
What is the CENTOR mnemonic?
C = absence of Cough E = Exudate N = Anterior Cervical Lymph Nodes T = Temp >100.4 3-14 OR old 45+
if 3-14 +1, if 45+ -1
What are the two normal heart sounds and where do they come from?
(LUB) S1 = Systolic blood pressure –> closure of the AV valves
(DUB) S2 = Diastolic blood pressure –> Closure of the semilunar valves
What are the abnormal heart sounds?
S3 = Ken-tuckee
normal in children and young adults
Vibratory sound that occurs form blood filling the relaxed ventricle. Occurs after S2
S4: Tenness-ee (atrial filling from high pressure from SVC/IVC and pulmonary venous return. Occurs before S1 NORMAL IN ATHLETES
What are the listening posts?
All Physicians Take Money
2nd, 2nd, 3rd (erbs), 4th, 5th + midclavicular line
What makes murmurs louder or softer (excluding the exceptions)
Louder = RINspiration LEXpiration Higher Preload Higher Afterload
Softer =
Lower Preload
Lower Afterload
during breathing, which parts become louder or softer?
what intercostal space would you listen to?
RINspiration = Inspiration the right side is louder, so Tricuspid + Pulmonic murmurs are louder
This would be 2nd and 4th
LEXpiration = Expiration the left side is louder. Mitral and Aortic louder
This would be 5th and 2nd
What is HOCM and how does preload and after load affect its loudness?
HOCM is a hypertrophied septum.
Increased preload and after load fixes the problem, so sounds quieter
What is MVP, how does preload and after load affect it, and what’s the mnemonic to know?
mitral valve prolapse. increasing the preload and after load makes it better so sounds quieter.
You’ll see Myxomatous Valvular Disease with it.
See the MVP, be the MVP and everything will CLICK
Aortic Stenosis is caused from what?
What is a common sound of this?
does it radiate anywhere?
Mnemonic
getting old causes calcium deposits inside the valves.
Crescendo decrescendo
radiates up to Carotid arteries
OLD –> SAD
Syncope, angina, dyspnea
What is the mnemonic for diastolic / systolic murmurs?
Diastolic: Ms. PrArTs
Systolic: Mr. TrAsPs
Mitral Regurgitation:
Phrase to use?
Radiation?
Best heard where?
What kind of sound?
“Rheu-mitral”
to the axilla
5th intercostal space and it radiates to axilla
holosystolic (TV sound)
Tricuspid regurg
sound type
who usually has it? mnemonic
holosystolic
history of ivda
Want to TRI some drugs?
Aortic Regurg
Mnemonic?
What does it sound like?
What is it presented with usually?
AR thar she BLOWS
early blowing diastolic murmur
connective tissue disorders, marfan, HEAD BOBBING, femoral bruits
Mitral Stenosis
phrase to use?
Mnemonic?
Opening “Snap”
“Rheu-mitral”
The OS is MS
Opening Snap is Mitral Stenosis
What’s the order of heart sounds?
S4, S1, S2, S3
Umbo?
Where the eardrum meets the tip of the males. from here the cone of light fans downward and anteriorly.
What’s the handle of the malleus?
Manubrium
When can you have a septal perforation?
Meth, cocaine, trauma, surgery
How many sets of turbinates are there?
3, inferior, middle, superior
What are the 4 types of sinuses?
how do you palpate the maxillary ones?
Frontal, Maxillary, Ethmoid, Sphenoid
press up on the location
What is Aphthous Ulcers?
Cheilitis?
Gingivitis?
Torus Palatinus?
canker sores
B12 or iron deficiency, red cracks at corners of mouth
swelling or ulcerations gums
Benign lump on hard palate
Where is an endotracheal tube seen on an Xray?
T4
What are the different retraction sites?
Supraclavicular
Substernal
Intercostal
What’s the steps to a cardiovascular exam?
this is not what you expect
Inspection
Palpation
Percussion
Auscultation
How do you inspect for carotid bruits?
use bell of diaphragm, check for bruits AFTER palpating pulse.
ask the pt to inhale and hold breath when listening
What is Systole and Diastole?
Systole = Ventricular contraction and ejection
Diastole = Ventricular relaxation and filling
What’s the average pulse?
which is bounding?
2/4. 4/4 is bounding
Allen Test? What does it indicate if there’s a problem?
occlude both arteries while pt makes a fist, have the pt open and close fist, palm should be pale.
release pressure on ulnar artery and observe color return to hand within 5-10 seconds. Repeat with radial artery
INDICATION: lack of dual blood supply to the hand (negative indication for radial catheterization)
2,4,6,8 edemas, what is the grade an the times
1,2,3,4
rapidly gone, 10-15 sec, 1 minute, 2-5 minutes
