PCMI Final Flashcards
What are the four sinuses?
Frontal sinus, ethmoid sinuses, sphenoid sinus, maxillary sinus
What is special about the frontal sinus?
It does not develop until 8 to 10 years of age
What is the whisper test?
Doctor stands behind pt
Pt occludes one ear
Doctor whispers a series of 3 letters/numbers (2,K,4)
Pt repeats the sequence back
A second sequence is whispered and the pt repeats it back
Abnormal: Pt incorrectly identifies 4 of 6 letters/numbers
How should you pulling on the ear of your pt when using an otoscope (adult vs children)?
Adult: up, out, and posterior
Children: down, out, and posterior
What are the two types of hearing loss?
Conduction Hearing Loss: external/middle ear problem (conductive phase)
Sensorineural hearing loss: Inner ear, cochlear nerve, or central brain connections problem (sensorineural phase)
What is the Weber test?
Place a vibrating tuning fork on pt’s forehead
Normal: Sound lateralizes to both ears equally
Abnormal: Sound lateralizes to one ear or laterailzation is louder in one ear more than the other.
- If sound is louder in affected ear, this indicates a conduction hearing loss
- If sound is louder in normal ear, this indicates affected ear has a sensorineural hearing loss
What is the Rinne Test?
Compares air and bone conduction
What is Normal Breathing rate?
14-20 breaths/min
What is hypopnea?
shallow breaths with slow respiration rate (<14/min)
What is bradypnea?
Regular breathing rhythm with slow respiration rate (<14/min)
What is hyperpnea?
Deep breaths with fast respiration rate (>20-25/min; normal in exercise)
What is tachypnea?
rapid respiration rate (>20-25/min)
What is dyspnea?
When you feel short of breath
What is hypoxia?
Deficiency in O2 reaching tissues
What is hypoxemia?
O2 deficiency in arterial blood
What is Apnea?
No breathing
What is Atelectasis?
Collapse of lung tissue that affects alveoli from normal O2 absorption
What is the Pleximeter finger?
Hyperextended middle finger of non-dominant hand in percussion
What is the plexor finger?
The “tapping” finger used for percussion on the dominant hand
Where would you insert a needle thoracentesis for emergency decompression during a tension pneumothorax?
In the 2nd intercostal space (between the second and third rib) at the midclavicular line
Where would you insert a chest tube?
4th and 5th intercostal spaces just anterior to mid-axillary line
Where on the rib are the neurovascular bundles located and, knowing this, where in relation to the rib should chest tubes be inserted to avoid damage?
Neurovascular bundle found on inferior margins of each rib, therefore chest tubes should be inserted at the superior margin of the rib to avoid damage.
How does pulse oximetry work?
Light emits red and infrared light through finger. Receptor detects how much of both are transmitted through the finger. Oxygenated hemoglobin absorbs more infrared light than red; deoxygenated blood absorbs more red than infrared light. Comparison of transmission of both frequencies gives the oxygen saturation.
What is PETCO2 and what is its normal value?
Pressure End Tidal CO2. Messurespressure of CO2 in exhaled air at the end of respiration.
PaCO2 and PETCO2 are correlated
Normal PaCO2/PETCO2 = 35-40 mmHg
What is an incentive spriometer?
IS is a a device that has a little ball that rises in a chamber when you inhale through it. Doctor will tell you to inhale at a rate that maintains the ball at a certain height in the chamber.
Helps treat and prevent Atelectasis
What are the two Pulmonary Function Tests?
The two PFTs are Plethysmography (pt sits in an enclosed chamber breathing through a tube) and Spriometry (pt inhales to full capacity and exhales through a tube as rapidly and fully as possible.
Both are used to diagnose Obstructive/Restrictive pulmonary disorders.
What is tracheal deviation a sign of?
Pneumothroax
What does accessory muscle use in breathing indicate?
Same as Retraction
Sign of respiratory distress
Asthma, COPD, Airway obstruction, viral illness
What does retraction (skin retracts in thorax exposing ribs) indicate?
Same as use of accessory muscle
Severe asthma, COPD, Airway obstruction
What are the causes of clubbing fingers?
Congenital Heart disease interstitial lung disease bronchiectasis pulmonary fibrosis cystic fibrosis lung abcess malgnancy (lung cancer) Inflammatory bowel disease
What is funnel chest?
Depression of the lower portion of the sternum. Can cause compression of heart and great vessels resulting in murmurs
What is Pectus Carinatum?
AKA pigeon chest
Sternum displaced anteriorly (increasing the A-P diameter)
What is barrel chest?
Increased diameter of chest resembling a barrel, seen in COPD
What are the signs of Chronic Bronchitis?
“Blue Bloater” - Chronic Bronchitis is one form of COPD
Daily productive cough for 3 months or more in at least 2 consecutive years
Overweight and cyanotic
Elevated hemoglobin
Peripheral edema
Ronchi and wheezing
What are the signs of Emphysema?
“Pink Puffer” - form of COPD
Permanent enlargement and destruction of air spaces distal to terminal bronchiole
Older and thin
Severe dyspnea
Quiet chest
X-ray shows hyperinflation with flattened diaphragm
What is traumatic flail chest?
When pt has multiple rib fractures, paradoxical movements of the thorax occur during breathing.
Injured areas cave inward on inspiration, and move outward on expiration
What is tactile fremitis and what does it tell us?
Palpation test where you place ulnar surface of hands to sense vibration when pt says “ninety-nine”.
Decreased/absent vibration:
- Pt too quiet
- COPD
- Pleural changes (effusion, fibrosis, pneumothorax, infiltrating tumor)
Increased vibration:
-Pneumonia (consolidation)
How deep do percussion tones penetrate?
5-7 cm (can’t detect deep structures)
What does unilateral hyperresonance indicate on percussion test?
Pneumothorax
What does generalized hyperesonance indicate on percussion test?
COPD/asthma
What does dullness replacing resonance indicate on a percussion test indicate?
Fluid/solid tissue replaces air
Pneumonia
Pleural accumulations
What is diaphragmatic excursion?
Distance between diaphragms position at full exhalation and full inhalation.
Detected using percussion to find transition point between resonance and dullness
Normal Diaphragmatic Excursion = 3-5.5 cm
Asymmetric diaphragmatic excursion indicates pleural effusion
What side of the stethoscope should you use for Auscultation?
Diaphragm (larger side; used for detecting higher pitched sounds)
What are the 4 lung sounds and where should you hear them?
Bronchovesicular - Intermediate intensity and pitch; over the main bronchi, 1st and 2nd intercostal spaces anteriorly AND between the scapulae posteiorly
Vesicular - Soft and low pitch; Over the lesser bronchi, bronchioles, and lobes (most of the lung)
Bronchial - Loud and high pitched; over the trachea (especially manubrium of sternum)
Trachial - Very loud/high pitched; trachea in the neck
When would you hear Stridor?
Croup (upper airway infection)
Epiglottitis
Upper airway foreign body
Anaphylaxis
When would you hear Wheezing?
Caused by rapid airflow through narrowed brochial airway
RAD (reactive airway disease)
Asthma
COPD
When would you hear crackles?
Pneumonia CHF Atelectasis Pulmonary fibrosis bronchioextasis COPD Asthma
What is the vocal resonance test?
Auscultation while patient speaks
Normally speech sounds indistinct, but distinctness increases with lung consolidation (fluid in lung)
What does it mean when you find Bronchophony during vocal resonance test?
Bronchophony is when spoken words get louder than normal
What does it mean when you find Whispered pectoriloquy during vocal resonance test?
Whispered words are louder and clearer during ausculataion
What does it mean when you find Egophony during a vocal resonance test?
When you ask the pt to say an “ee” sound, on auscultation it sounds like “A” (which is nasal and localized)
What is Otitis Media?
Ear infection of middle ear (air filled space behind tympanic membrane
What is otitis externa?
Ear infection of outer ear canal
What is Labyrinthitis?
Infection of the inner ear structures
What are the criteria that indicate the greatest liklihood of GABHS (Group-A Beta-Hemolytic Streptococcus)
Children 5-15 Winter/Early Spring Absence of Cough Tender Anterior Cervical Lymphadenopathy Tonsiallar exudate Fever
How does the Centor Score Work?
1 Point for each of the following: -Absence of Cough -Swollen/tender anterir cervical nodes -Temp >100.4 -Tonsillar exudates or swelling Age 3-14
(-1 point for 45 years or older)
Score <= 0 means no testing or antibiotics needed
Score =1 means throat culture or rapid antigen detecting test (RATD) is optional
Score =2 OR Score = 3 means throat culture or RATD required
Score >=4 means no testing required, likely has GABHS and should be treated with antibiotics
What is otosclerosis?
Abnormal bone growth around the stapes bone
Can cause either conductive hearing loss or sensorineural hearing loss
What is Rhinosinusitis/Sinusitis?
Infection of mucosal lining in the nasal cavity
What are the 5 causes of Vertigo?
Eustachian tube Dysfunction - eustachian tube gets inflammed (caused by flu, sinus infection, allergies)
Benign Paroxysmal Positional Vertigo (BPPV) - sudden brief episodes of sensation of spinning. Triggered by specific changes in position of head.
Vestibular Neuritis - Inflammation of sensory nerves associated with balance. No hearing loss
Labyrinthitis - Inflammation of labyrinth (inner ear); affects bothbranches of vestibulocochlear nerve; hearing changes and dizziness
Meniere’s Disease - chronic condition of the inner ear, causes fluctuating hearing loss (eventually permanent). Feeling of fullness in ear.
What are the Two Types of BPPV?
Canalithiasis - Freely floating debris in canal portion of SCC (most common)
Cupulolithiasis - Debris adhered to the cupula of the crista ampullaris (not free floating; not common)
What tests do you use to diagnose/treat BPPV?
DIx-Hallpike (diagnose)
Epley maneuver (diagnosis/treatment)
What is Epiglottitis?
Inflammation of the epiglottis
Caused by GABHS or Haemophilus Type B influenze virus
Signs/Symptoms: Sore throat, muffled voice, drooling, child sitting forward
First thing to do is maintain the airway (intubate if necessary)
What is a common physical finding with patients who have a history of excessive cocaine/meth use?
Perforated nasal septum
What is the five finger method to the normal cardiovascular exam?
History Physical ECG Imaging Lab
Where do you palpate for the Apex beat?
Upright: 5th intercostal space, 1 cm medial to midclavicular line
Supine: 4th-5th intercostal space at midclavicular line
AKA PMI (Point of Maximal Impulse)
How can cardiac size be estimated in the physical exam?
Percussion. Start at left side where resonant, then move to the right until cardiac dullness
Where would you place the stethoscope to listen to each valve, and which part of the stethoscope would you use?
Aortic Valve - 2nd intercostal space, right sternal border
Pulmonic Valve - 2nd intercostal space, left sternal border
Tricuspid Valve - 4th intercostal space, left sternal border
Mitral valve - 5th intercostal space, midclavicular line
Use the diaphragm of the stethoscope
Describe where and how you would listen for bruits
Palpate one side at a time to find the carotid arteries.
Tell patient to hold their breath as you place the bell of the stethoscope against their neck and listen for bruits
What is the source of S1, and what point in the cardiac cycle does it represent?
S1 is the closing of the mitral/tricuspid valves
Indicates the start of ventricular systole
What is the source of S2, and what point in the cardiac cycle does it represent?
S2 is the closing of the Pulmonary/Aortic valves
Indicates the end of ventricular systole and the start of ventricular diastole
Explain the Physiologic Splitting of S2
Inspiration causes a delay in the pulmonic valve closing.
The sound of the Aortic valve closing is heard before the sound of the pulmonic valve closing.
What is the source of S3 and describe the significance
Occurs right after S2 (closing of Aortic and Pulmonic valves)
Mitral valve opens allowing blood to flow into the Left ventricle
The S3 sound is the result of the blood making contact withe compliant muscular wall of the left ventricle.
Sound is quiet and low pitch (heard using bell of stethoscope)
Normal in children, abnormal in adults
What is the source of S4 and describe the significance
Occurs before S1 (closing of mitral/tricuspid valves)
S4 sound comes from the Atrial contraction pushing fluid into a low compliant, filled ventricle.
Sound is quiet and low pitch
S4 can be heard trained athletes
Otherwise is abnormal
How do you grade a murmur?
I - Barely audible
II - soft but easily heard
III - loud without a thrill
IV - Loud with a thrill
V - Loud with minimal contact between stethoscope and chest - Thrill
VI - Loud enough to be heard without stethoscope - Thrill
What is JVD?
Jugular Venous Distention
Reflects the activity of Right side of heart
Level of visibility indicates Central venous pressure CVP and Right Atrial Pressure RAP
How is JVD measured?
Pt is put in supine position to allow veins to gorge, then they are raised to a seated at a 45 degree angle.
A rule is placed at the sternal angle point directly upward.
The height of the gorged vein is measured and 5 cm are added. The total height equals the pressure in cmH2O
What does the A wave on the JVP curve represent?
Atrial contraction
What does the C wave on the JVP curve represent?
Represents bulging of the tricuspid valve during right ventricular contraction
What does the X depression on the JVP curve represent?
Relief of pressure on tricuspid valve as ventricular ejection occurs
What does the V wave represent on the JVP curve?
Atrial filling on the closed tricuspid valve
What does the Y depression on the JVP curve represent?
Tricuspid valve opens and ventricular filling begins
What can cause an increase in JVD?
- Sever Heart failure
- Superior Vena Cava obstruction
- Cardiac Tampanade (fluid in pericardium restricts contraction of heart
- Constrictive pericarditis (chronic inflammation of the pericardium)
- Right ventricle infarction
- Restrictive cardiomyopathy
How do you grade pulses?
0 - Absent 1 - weak, barely palpable 2 - normal 3 - stronger than average 4 -bounding
Documented as +X/4
What is normal capillary refill time?
<2 seconds
How is edema scaled and where is it observed?
0 - absent
+1 - Barely detecable; non-pitting (2mm)
+2 - Slight indentation, pitting lasts for 10-15 seconds (4mm)
+3 - Deeper indentation, pitting lasts >1min (6mm)
+4 - Very deep indentation, pitting lasts 2-5 min (8mm)
Dorsum of foot
Anterior tibia (shin)
Behind medial malleolus
What is regurgitation?
Turbulent flow when blood is travelling in the opposite direction it normally should.
What is stenosis?
When blood flows through a stiff valve
When is a murmur normal vs pathologic?
Grade 2 or below can be normal
Grade 3 or above can be pathological
What are the general rules for what makes a murmur louder?
Insiration makes right sided murmurs (T and P valves) louder (RINspiration)
Expiration makes left sided murmurs (A and M valves) louder (LEXspiration)
Increased pre-load generally makes murmur louder
Increased afterload generally makes murmur louder
Exceptions to general rules of what makes murmurs louder:
MVP (Mitral Valve Prolapse) - increased pre-load improves murmur (quiter); increased afterload makes murmur quieter
HOCM (Hypertrophic Cardiomyopathy) - Increased pre-load improves murmur (makes it quieter); increased afterload makes murmur quieter
What is a Crescendo-Decrescendo Murmur?
Midsystolic (between S1 and S2) murmur caused by aortic stenosis
What is a Rheu-Mitral Murmur?
Occurs the entire time between S1 and S2 (holosystolic murmur)
Due to mitral regurgitation
Best heard at apex, radiates to axilla
How do you describe a Tricuspid Regurgitation?
Holosystolic murmur (occurs throughout time between S1 and S2)
Associated with Intravenous Drug Abuse
“Want to TRI some drugs??”
How do you describe an Aortic Regurgitation Murmur?
Early Blowing diastolic murmur
“AR thar she BLOWS”
Presents with connective tissue disorders such as Marfan’s syndrome
How do you describe a Mitral Stenosis murmur?
Produces an extra sound after S1, before S2 (opening snap) with murmur continuing from to S2 after snap
History of Rheumatic fever
The OS is MS - Operating System is MicroSoft
Opening Snap; Mitral Stenosis
Normal JVP
0-9 mmH2O
