Physical Examination: Cardiovascular and Pulmonary Systems Flashcards
List 3 possible signs of decreased cardiac output and low oxygen saturation.
- Cyanosis: bluish color of the skin, nail beds, lips and tongue
- Pallor: washed out, absence of pink, rosy color
- Diaphoresis: excess sweating and cool, clammy skin
How is an apical pulse assessed?
Patient is placed in supine, palpate at 5th intercostal space and midclavicular line
What is the best site to monitor pulse in an infant?
Brachial artery (medial aspect of the antecubital fossa)
Explain the grading scale for peripheral pulses.
Grade 0 = absent pulse, not palpable Grade 1 = pulse diminished, barely perceptible Grade 2 = Easily palpable, normal Grade 3 = full pulse, increased strength Grade 4 = bounding pulse
What is the normal heart rate for adults, children and newborns?
- Adults and teenagers: 60-100 bmp (40-60 in aerobically trained)
- Children = 60-140 bpm
- Newborn = average is 127 bpm; normal range 90-164 bpm
A heart rate of ____ is considered tachycardia, and a heart rate of ____ is considered bradycardia.
Tachycardia = > 100 bpm Bradycardia = < 60 bpm
What is postural tachycardia syndrome?
Sustained heart rate increase greater than or equal to 30 bpm within 10 minutes of standing (> 40 bpm on teenagers)
Describe the difference between S1 and S2 sounds during auscultation.
S1 sound (lub): normal closure of mitral and tricuspid valves; marks the end of systole; decreased in first degree heart block
S2 sound (dub): normal closure of aortic and pulmonary valves; marks end of systole; Decreased in aortic stenosis.
Describe the S3 heart sound. Is this normal?
Vibrations of the distended ventricle walls due to passive flow of blood from the atria during the rapid filling phase of diastole
Normal in healthy young children
Abnormal in adults (ventricular gallop)
Describe the S4 heart sound. What 3 conditions is this sound associated with?
Pathological sound of vibration of the ventricular wall with ventricular filling and atrial contraction
Associated with hypertension, stenosis and MI (atrial gallop)
What is a thrill?
An abnormal tremor accompanying a vascular or cardiac murmur; felt on palpation
What is a bruit? What is this indicative of?
An adventitious sound or murmur (blowing sound) of arterial or venous origin
Indicative of atherosclerosis
Where is blood pressure typically taken?
At the brachial artery of the right arm using a sphygmomanometer
What values are considered to be normal, prehypertension, stage 1, stage 2 hypertension, and hypertensive crisis?
Normal BP: 120/80
Prehypertension: Systolic 120-129 or diastolic 80-89 mmHg
Stage 1 Hypertension: > 130/80
Stage 2 Hypertension: > or equal to 140/90
Hypertensive crisis: > 180/120
What is orthostatic hypotension? How is it assessed?
Drop in BP that accompanies change from supine to standing position
- Initial BP and HR assessment when patient supine, at rest for > 5 minutes
- Patient moves directly to standing position and repeat BP and HR assessment immediately and again at 3 minutes
A patient is considered orthostatic if systolic BP drops ____ or if the diastolic BP drops _____.
Systolic drops > 20 mmHg
Diastolic drops > 10 mmHg
What is mean arterial pressure (MAP)? Normal values? How is it calculated?
The arterial pressure within the large arteries over time; dependent on mean blood flow and arterial compliance
Normal values: 70-110 mmHg
MAP = [SBP + 2(DBP)] / 3
What is the normal respiratory rate for an adult, newborn, and child?
Adult = 12-20 bpm Newborn = 30-40 bpm Child = 20-30 bpm
What is the difference between tachypnea, bradypnea and hyperpnea?
Tachypnea = an increase in RR > 22 breaths per minute Bradypnea = a decrease of RR < 10 breaths per minute Hyperpnea = an increase in depth and rate of breathing
What is the difference between dyspnea, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea?
Dyspnea = shortness of breath
Dyspnea on exertion = shortness of breath brought on by exercise or activity
Orthopnea = inability to breath when in a reclining or supine position
Paroxysmal nocturnal dyspnea = sudden inability to breath occurring during sleep
Describe normal tracheal and bronchial sounds.
Loud tubular sounds normally heard over the trachea
Inspiratory phase is shorter than the expiratory phase and there is a slight pause between them
Bronchial sounds heard over the _____ are abnormal and indicate _____ or ____ of lung tissue that facilitates transmission of sound.
Distal airways
Consolidation
Compression
Describe vesicular sounds.
High pitched, breezy sounds normally heard over the distal airways in healthy lung tissue
Inspiratory phase is longer than expiratory phase and there is no pause between them.
_____ and _____ are considered adventitious (abnormal) breath sounds.
Crackles (rales/crepitation)
Wheezes
Describe crackles. List 3 conditions where crackles may be heard during auscultation.
An abnormal, discontinuous, high pitched popping sound heard more often during inspiration
Atelectasis, fibrosis, pulmonary lung disease
What is a pleural friction rub?
Dry, crackling sound heard during both inspiration and expiration.
Occurs when inflamed visceral and parietal pleurae rub together
Heard over the spot where the patient feels pleuritic pain
What is the difference between hypoxemia, hypoxia and anoxia?
Hypoxemia = abnormally low amount of oxygen in the blood Hypoxia = low oxygen levels in the tissue Anoxia = complete lack of oxygen
List 5 areas where cardiac pain can refer.
Shoulders Back Arms Neck Jaw
Pain referred to the back can occur from ______.
Dissecting aortic aneurysm
Explain the angina pain scale.
1 = mild, barely noticeable 2 = moderate, bothersome 3 = moderately severe, very uncomfortable 4 = most severe or intense pain ever experienced
What is diaphoresis? What can it be associated with?
Excess sweating that can be associated with decreased cardiac output
What is clubbing? What is it associated with?
Curvature of the fingernails with soft tissue enlargement at base of nail
Associated with chronic oxygen deficiency, chronic pulmonary disease and heart failure
What trophic changes are associated with peripheral arterial disease (PAD)?
Pale, shiny, dry skin, with loss of hair
What is Stemmer’s sign? What is it indicative of?
Dorsal skin folds of the toes or fingers are resistant to lifting
Indicative of fibrotic changes and lymphedema
Peripheral edema is associated with ____ and ____. Bilateral edema is associated with _____.
Peripheral = chronic venous insufficiency and lymphedema
Bilateral = congestive heart failure
Describe the grading scale for edema.
1+ Mild, barely perceptible indentation; <1/4 inch pitting
2+ Moderate, easily identifiable depression; returns to normal within 15 seconds; 1/4-1/2 inch pitting
3+ Severe, depression takes 15-30 seconds to rebound; 1/2-1 inch pitting
4+ Very severe, depression lasts for > 30 seconds or more; > 1 inch pitting
What is intermittent claudication?
Pain, cramping and LE fatigue occurring during exercise and relieved by rest
Explain the treadmill test for intermittent claudication.
Have the patient walk on a treadmill at 1mph and note the level of claudication pain and time of test pain was experienced
Describe the grading scale of intermittent claudication.
Grade 1 = minimal discomfort or pain
Grade 2 = moderate discomfort or pain; patient’s attention can be diverted
Grade 3 = Intense pain; patient’s attention cannot be diverted
Grade 4 = excruciating and unbearable pain
Describe the different sites of pain with intermittent claudication and their associated sites of stenosis.
Pain in the buttock, hip or thigh = obstruction of aorta and iliac arteries
Pain in the calf = stenosis of femoral and popliteal arteries
Pain in the ankle or foot = disease of the tibial or peroneal arteries
What is the ankle brachial index? How is it assessed? How is calculated?
ABI compares systolic blood pressure at the ankle and arm to check for peripheral artery disease.
Measure UE systolic BP at the brachial artery and LE systolic BP at posterior tibial and dorsalis pedis arteries
ABI is calculated by dividing the higher of the two BP measurements in the ankles by the higher of the two systolic BP measurements at the arms
Describe the significance of ankle brachial index values.
> 1.4 = indicates non-compliant, rigid arteries
1-1.4 = normal
0.91-0.99 = mild blockage, beginning of PAD
< 0.9 = moderate blockage; maybe associated with intermittent claudication
< 0.5 = severe blockage and arterial disease; may have claudication pain at rest
What is capillary refill time? How is it tested? Normal values?
The time it takes the capillary bed to refill after it is occluded by pressure is an indicator of impaired perfusion to the extremities
- Apply firm pressure over a nail bed or bony prominence until the nail or skin blanches.
- Release the pressure
- Observe the time for the nail or skin to regain its full color
Normal = full color returns in < 2 seconds Abnormal = refill time > 2 seconds
What is body mass index? How is calculated?
Describes relative weight for height to determine risk for obesity
BMI = weight (kg) / height (m^2)
Describe the normal versus abnormal BMI values.
< 18.5 = underweight 18.5-24.9 = normal 25-29.9 = overweight > 30 = obesity > 40 = morbid obesity
What is the percussion test? How is it performed? Positive findings?
Determines competence of greater saphenous vein
IN standing, palpate one segment of the vein while percussing vein approximately 20 cm higher
Positive: if pulse wave is felt by lower hand, the intervening valves are incompetent
What is the normal position of the trachea?
Positioned at midline, superior to the suprasternal notch
What is the normal thoracic excursion in healthy adults from full inspiration to end tidal volume expiration?
Between 2-3 inches
What is mediate percussion? How is it performed?
The act of tapping the surface of the body to identify areas of altered density
Place the palmar surface of the middle finger firmly against the chest wall in the intercostal space parallel to the ribs and strike this finger with a quick, sharp blow using the middle finger of the other hand.
______ is the normal percussion sound of an air-filled lung. ______ is the sound that occurs almost exclusively with a large pneumothorax.
Resonance is normal
Tympany = pneumothorax (hollow drumbeat sound)
What is the purpose of pulmonary function testing (PFT)? Describe the testing procedure.
Evaluate lung volumes, capacities and flow rates.
Subject exhales into spirometer as hard and as fast as possible for 6 seconds until no more air can be expelled
Obstructive ventilatory impairment is characterized by decreased _____. What is the primary PFT indicator of an obstructive impairment.
Decreased EXPIRATORY FLOW
Primary indicator = FEV1/FVC < 70%
List the classifications of obstructive lung disease based on FEV1/FVC ratios.
FEV1/FVC > 100% = normal variant
FEV1/FVC 70-100% = normal to mild obstruction
FEV1/FVC 60-70% = moderate obstruction
FEV1/FVC 50-60% moderate to severe obstruction
FEV1/FVC < 50% = severe obstruction
_____ is often used to get an estimate of SpO2.
Pulse oximetry
What is rate pressure product (RPP)? How is it calculated?
Index of myocardial oxygen consumption and coronary blood flow
RPP = HR x SBP
(Take HR and SBP during the same exercise workload)
How should the rate pressure product (RPP) be used when developing an exercise program for patients with angina?
Keeping the intensity of exercise below the RPP value will reduce the risk of developing angina
