respiratory Flashcards
what does decreased tactile fremitus indicate
Decreased or absent fremitus may be caused by excess air in the lungs or may indicate emphysema, pleural thickening or effusion, massive pulmonary edema, or bronchial obstruction.
What does increased tactile fremitus indicate?
Increased tactile fremitus (often coarser or rougher in feel) occurs in the presence of fluids or a solid mass within the lungs and may be caused by lung consolidation, heavy but nonobstructive bronchial secretions, compressed lung, or tumor.
Percussion tone indicators for lungs (resonance, hyperresonance, dullness)
resonance– normal
hyperresonance– may be normal in thin patients but may indicate hyperinflation
dullness– abnormal, found in solid or fluid filled structures (pneumonia who get symmetry of sounds)
bronchitis physical exam findings
INSPECTION: occasional tachypnea, shallow breathing, often no deviation from expected findings. PALPATION: tactile fremitus Undiminished. PERCUSSION: resonance. AUSCULTATION: breath sounds may be prolonged; occasional crackles, expiratory wheezes, and rhonchi.
pneumonia physical exam findings
INSPECTION: tachypnea, shallow breathing, flaring of alae nasi, occasional cyanosis, limited movement at times on involved side, splinting.
PALPATION: increased fremitus in presence of consolidation; decreased fremitus in presence of a concomitant empyema or pleural effusion.
PERCUSSION: dullness if consolidation is great. AUSCULTATION: a variety of crackles with lobar and occasional rhonchi; bronchial breath sounds, egophony, bronchophony, whispered pectoriloquy
pneumothorax physical exam findings
INSPECTION: tachycardia, cyanosis, respiratory distress, bulging intercostal spaces, respiratory lag on affected side, tracheal deviation with tension pneumothorax.
PALPATION: diminished to absent tactile fremitus; subcutaneous crepitance from air leaking.
PERCUSSION: Hyperresonance.
AUSCULTATION: diminished to absent breath sounds, Hamman sign if air underlies that area; diminished to absent whispered voice sounds.
asthma physical exam findings
INSPECTION: tachypnea, nasal flaring, intercostal retractions.
PALPATION: tachycardia, diminished fremitus. PERCUSSION: occasional hyperresonance, limited diaphragmatic descent; lower diaphragmatic level. AUSCULTATION: prolonged expiration, wheezes, diminished lung sounds
atelectasis physical exam findings
INSPECTION: delayed &/or diminished chest wall movement (respiratory lag), narrowed intercostal spaces on affected side, tachypnea.
PALPATION: diminished fremitus, apical cardiac impulse deviated ipsilaterally, trachea deviated ipsilaterally. PERCUSSION: dullness over affected lung. AUSCULTATION: upper lobe: bronchial breathing, egophony, whispered pectoriloquy; lower lobe: diminished or absent breath sounds, wheezes, rhonchi, and crackles in varying amounts
Bronchiectasis physical exam findings
INSPECTION: tachypnea, respiratory distress, hyperinflation, clubbing (esp. cystic fibrosis).
PALPATION & PERCUSSION: few, if any consistent findings. AUSCULTATION: variety of crackles, usually coarse, and rhonchi, sometimes disappearing after cough
COPD physical exam findings
INSPECTION: respiratory distress, audible wheezing, cyanosis, distention of neck veins, peripheral edema (in presence of right-sided heart failure); nail clubbing. PALPATION: somewhat limited mobility of diaphragm and diminished vocal fremitus.
PERCUSSION: occasional hyperresonance. AUSCULTATION: postpertussive rhonchi (sonorous wheezes), sibilant wheezing, inspirational crackles
emphysema physical exam findings
INSPECTION: tachypnea, deep breathing, pursed lips, barrel chest, thin/underweight.
PALPATION: apical impulse may not be felt; liver edge displaced downward; diminished fremitus.
PERCUSSION: hyperresonance, limited descent of diaphragm on inspiration; upper border of liver dullness pushed downward.
AUSCULTATION: diminished breath and voice sounds with occassional prolonged expiration; diminished audibility of heart sounds; only occasional adventitious lung sounds
Stridor
a harsh, high-pitched, crowing, piercing inspiratory sound, such as the sound often heard in acute laryngeal (upper airway) obstruction; may sound like crowing and be audible without a stethoscope. This is always an abnormal finding at any age.
RALES
An abnormal sound heard on auscultation of the chest, produced by passage of air through bronchi that contain secretion or exudate or that are constricted by spasm or a thickening of their walls, also known as crackle.
rhonchi
oud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucus accumulation in trachea or large bronchi)
fine crackles
high-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; NOT cleared by a cough
Coarse crackles (Coarse rales)
Loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration. Sounds like opening a velcro fastener.
Pleural Friction Rub
A coarse grating or crunching sound.
Caused by inflamed surgace of the visceral and parietal pleura rubbing together.
May be associated with pleurisy, TB, pneumonia, pulmonary infarction, cancer, etc.
Steroids and antibiotics may be incicated.
Wheeze
Continuous, high-pitched, musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway.
bronchophony
9 heard louder and clearer even at a distance from larynx - usually muffled normally - shows signs of fluid or solid tissue in alveoli–> pneumonia, atelectasis, tumor
whisper pectoriloquy
whisper “1, 2, 3” the transmission of sounds should be faint and muffled. it may be inaudible.
IF clearly audible → Indicative of consolidation
Egophony
The patient is instructed to say “E” and it sounds like “A”. This would indicate consolidation of the lung tissue as with a pneumonia-like condition.
Stethoscope diaphragm
its flat edge is best for high-pitched sounds such as:
breath
bowel
normal heart sounds
Hold the diaphragm firmly against the person’s skin – firm enough to leave a slight ring afterward
bell of stethoscope
good for listening to low pitched sounds; apply lightly to chest (weight of stethoscope); make sure entire circumference is in contact with the skin
How should paradoxical breathing in a newborn be treated?
No intervention is needed. Paradoxical breathing in a newborn is common, especially during sleep. Newborns rely primarily on the diaphragm for their respiratory effort, only gradually adding the intercostal muscles. Infants quite commonly also use the abdominal muscles.
mitral regurge
5ICS and MCL
Mitral Stenosis
5th ICS
Aortic insuffencency
2nd ICS RSB diastole
aortic stenosis
2nd ICS RSB systole
s1
lubb” - marks the beginning of SYSTOLE
closure of tricuspid and mitral valves dull quality and low pitch onset of ventricular systole (contraction)
S2
Aortic and pulmonic valve closure “dub” - marks the beginning of DIASTOLE
What patient position is best for auscultating high-pitched cardiac murmurs?
siting up and leaning slightly forward during expiration (with the stethoscope DIAPHRAGM)
What patient position is best for auscultating low-pitched cardiac filling sounds during diastole?
left lateral recumbent position (with BELL of stethoscope)
pulsus alternans
a physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis.
Hear S1and S2
with the Diaphragm
Hear S3 and S4
with the bell
Aortic is heard at
2nd ICS R
Pulmonic
2nd ICS L
Tricuspid
5th ICS L
Mitral
5th ICS L MCL
S3 seen with
CHF, wet,
S3 is herd at the Apex why
ventricular gallop
s4 is herd at the base why
atrial gallop
intensity grades of murmurs
1= faint only herd if the practitioner is aware 2= quite but herd immediately 3= moderately loud 4= loud with palpable thrill 5= very loud hear with stethoscope partly off chest 6= herd with out stethoscope
Non modifiable risk for CVD
Age, Gender, Genetics
Modifiable risk for CVD
HTN, HLD, DM
CHADS model is
congestive, heart, age, diabetes, stroke
CHADs model stand for
score helps to predict how high the is of not using anticoagulation.
Xanthomas
high blood lipids,
A 52 yr old female with known CHF reports dyspnea with minimal exertion (walking from room to room). In what NYHA functional class is she?
Class III
whisper pectoriloquy
whisper “1, 2, 3” the transmission of sounds should be faint and muffled. it may be inaudible.
IF clearly audible → Indicative of consolidation
aortic stenosis sound like
harsh systolic murmur
Cardiac cycle systole is
ventricular contraction
disastolye is
ventricular relaxation
S1 is when
closing of the mitral/tricuspid valve
S2 is when
closing of the aortic/ pulmonic valves.
Sinus node is the
pacer 60 /min
AV node is at the
atrial septum
Bundle of His
to the ventricles
End of conduction is at the
Perkinje fibers
Blood flows from the SVC to
RA, Tricuspid valve, RV, Pulmonic valve.
Pulmonic valve to the
Pulmary artery , LA, LV, Aortic valve, aorta
P wave is
atrial depolarization
P-R interval is
filling of the ventricles
QRS
impulse throug the budle of hiss to the L perkinje fibers
t wave is
repolarization of ventricles
Histroy cues for cardiac assessment
sob with excertion
chest pain
Main complain is Fatigue
child cardiac history clues
working at breathing, pallor, limited activity
cardiac lifestyle risk factors
smoking, seditary lifestyle, obesity, hostility( type A)
emerging risk factors
chlamydia pnemonia, elevated homocystinemia, CRP
Most common presenting symtoms
fatigue/ activity intolerance
stable angina is
predictable pattern
NY heart association ( NYHA) for SOB in heart failure class 1=
No symptoms and no limita>on in ordinary physical activity,
NYHA class2=
No symptoms and no limitation in ordinary physical activity,
NYHA class 3=
Marked limitation in activity due to symptoms, even during less-than- ordinary activity walking shortt distance < 100m
NYHA class 4=
Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
CHADS scorehelps to predict how high the risk is of not using
anticoagulation
CHADs score of 2 or above indicates
need for anticogulation coumadin
CHADS score of 1 indicates
nedd for ASA or coumadin
Osler’s nodes
painful erythematous nodules Associated w/infective carditis
Janeway lesion
seen in acute bacterial Endocardid>s..flat..painless
Xanthomas
people with high blood lipids
Arcus senilis
high lipids
ABI is for
Predict severity of peripheral arterial disease
ABI normal is
1.0or >
ABI at 0.9 is
at risk
ABI at ,0.6-0.8 is
borderline ischemia
ABI at < 0.5 is
severe ischemia
edema 1+ is
mild pitting 0-1/4”
edema 2+ is
1/4-1/2” moderate pitting
edema 3+ is
1⁄2 - 1” piting (severe)
edema 4+ is
> 1” (severe)
JVP of >4cm is
Right-sided Heart Failure (most common)
• Increased right atrial pressure
S1 is loudest at
Loudest at apex- mitral & tricuspid areas
S2 is the loudest at
Loudest at base-aortic & pulmonic areas
Mitral heat sound at the
5th ICS L, MCL, >S1
Aortic heart sound at the
2nd ICS R, >S2,
S3 is heard with
Pathological seen in CHF, sign of being “wet”, ventricular gallop
S4 is heard with
Atrial gallop,Always pathological
Murmurs sound like
blowing, harsh, rumbling, musical
Mitral regurge haer at
5ICS MCL
Pericardial friction rub sounds like
a high-pitched or squeaking sound; it may be systolic, diastolic and systolic
murmur grade 1=
faint heard only if know 1/6
murmur grade 2=
quiet but heard immediately 2/6
murmur grade 3=
moderately loud 3/6
murmur grade 4=
loud 4/6 w/palpable thrill
murmur grade 5=
very loud heard w/stethoscope partly off chest wall 5/6
murmur grade 6=
heard w/stethoscope totally off the chest wall
What makes the first heart sound (S1)?
Closure of the mitral valve
a history of chronic congestive heart failure with an enlarged heart, but his condition is well controlled by medication. You perform a cardiac examination. With the patient in the leu lateral decubitus position, what is your most likely finding when palpating for his apical impulse?
A diffuse apical impulse greater than 3.0 cm that occupies more than one interspace
