Semester 3 Final Flashcards
1
Q
Levels of consciousness
A
Alert: responds fully and appropriately
Lethargic: requires loud voice for response
Obtunded: Need to shake patient gently for response
Stupor: Need painful stimulus for response
Coma: Unarousable even with painful stimuli
2
Q
Normal respiratory rate
A
14-20 per minute in adults up to 44 per minute in infants
3
Q
What is tachypnea?
A
Rapid shallow breathing
4
Q
What is Cheyne-Stokes Breathing?
A
Oscillatory breathing with periods of deep breathing alternating with periods of apnea
5
Q
Describe breathing pattern of obstructive breathing
A
Prolonged expiration because of increased resistance to air flow (asthma, chronic bronchitis, COPD)
6
Q
Normal heart rate
A
60-100 bpm
7
Q
What is sinus arrhythmia?
A
Heart rate varies cyclically with breathing. Speeds up with inspiration and slows down with expiration.
8
Q
Name the following regions of the ear
A
9
Q
What is wrong with this ear?
A
Acute Otitis Media
10
Q
What is wrong with this ear?
A
Serous Otitis Media
11
Q
What is wrong with this ear?
A
Hemotympanum
12
Q
What is wrong with this ear?
A
Pressure equalizer (PE) tube
13
Q
What is wrong with this ear?
A
Tympanic membrane perforation
14
Q
What is wrong with this ear?
A
Otitis Externa
15
Q
Identify the structure below
A
Nasal polyp
16
Q
Identify the structure below
A
Middle turbinate adhesions
17
Q
What condition does this patient have?
A
Allergic rhinitis
18
Q
What condition does this patient have?
A
Nasal septal perforation
19
Q
What does this patient have?
A
Patient had tonsils removed
20
Q
What is this structure called?
A
Bifid uvula
21
Q
Differential diagnosis for neck masses
A
Branchial cleft cyst
Goiter
Infected cyst
Submental cyst
Lymph node metastasis
Submandibular abscess
22
Q
Describe diffuse enlargement of the thyroid
A
No palpable nodules
Caused by: Grave’s disease, Hashimoto’s thyroiditis and endemic goiter
23
Q
What could cause a single nodule of the thyroid
A
Could be cyst, benign tumor, or malignancy
24
Q
What could cause a multinodular goiter?
A
Metabolic disorder
Check family history
25
Symptoms of hyperthyroidism
Nervousness
Weight loss even with increased appetite
Excessive sweating, heat intolerance
Palpitations
Frequent bowel movements
Tremor and proximal muscle weakness
26
Signs of hyperthyroidism
Warm, smooth, moist skin
Graves: eye signs
Increased systolic and diastolic blood pressures
Tachycardia or Afib
Hyperdynamic cardiac pulsations with accentuated S1 tremor, proximal muscle weakness
27
Symptoms of hypothyroidism
Fatigue, lethargy
Modest weight gain with anorexia
Dry course skin, cold intolerance
Swelling of face, hands, legs
Constipation
Weakness, muscle cramps, arthralgias, paresthesias, impaired memory and hearing
28
Signs of hypothyroidism
Dry coarse skin, yellowish, nonpitting edema, hair loss
Periorbital puffiness
Decreased systolic and diastolic BP
Bradycardia
Decreased heart sounds
Impaired memory, hearing loss, somnolence
29
Location of branchial cleft cyst vs. thyroglossal duct cyst
Branchial cleft cysts are anterior to the midportion of the sternocleidomastoid muscle.
Thyroglossal duct cysts are at midline of neck just above thyroid cartilage.
30
Steps of the eye exam
Visual acuity and visual fields
Pupils
External eye exam
Extraocular muscles
Fundus exam
31
Patient is completely blind in the right eye, where is the defect?
Right optic nerve
32
Patient has bitemporal hemianopsia, where is the defect?
Optic chiasm
33
Patient has left homonymous hemianopsia, where is the defect?
Right optic tract or right optic radiation
34
What is Horner's syndrome?
Ptosis, miosis, and anhydrosis of one side.
Affected pupil is small, reacts briskly to light and near effort. Eyelid is droopy, with loss of sweating on forehead.
35
What is ptosis?
Drooping of the upper eye lid
36
What is exophthalmos?
Wide eyed stare with retracted eyelids seen in hyperthyroidism
37
Describe the innervation and actions of the extraocular muscles
LR6, SO4, 3
IO, UO; SO, DO
38
What is ectropion?
Lower eye lid is turned outward exposing the pulpebral conjunctiva
39
What are the components of the retina visible on fundoscopic exam?
40
What is wrong with this optic disc?
Nothing. This is a normal optic disc.
41
What is wrong with this optic disc?
Papilledema due to increased intracranial pressure. There are no clear margins of the optic disc.
42
What is wrong with this optic disc?
Glaucoma
43
What is wrong with this eye?
Hypertensive retinopathy
44
What is wrong with this eye?
Retinal emboli
45
What is wrong with this eye?
Age related macular degeneration
46
What is wrong with this eye?
Diabetic Retinopathy
47
What are the two processes that cause the majority of vascular disease in the US?
Atherosclerosis and Thrombophlebitis
48
What are the risk factors for atherosclerosis?
Diabetes mellitus
Hyperlipidemia
Hypertension
Smoking
49
What are the risk factors for thrombosis?
Stasis
Hypercoagulable state
Endothelial injury
("Virchow's triad")
50
Describe the Allen's test
Test for patent ulnar artery by having patient elevate hand and make fist for 30 seconds. Doctor compresses radial and ulnar arteries and patient opens hand. With pressure on the radial artery, doctor releases ulnar artery. All 5 fingers should turn pink within 7 sec if ulnar artery is patent.
51
What is the grading system for pulses?
0= nonpalpable
1+ = weak pulse
2+ = normal
3+ = increased
4+ = bounding/ aneurysmal
52
What is the difference between a thrill and a bruit?
Thrills are palbable vibrations wheras bruits are audible sounds. Both indicate turbulent flow.
53
What is Buerger's test?
Tests for arterial insufficiency in the lower extremity. Elevate patient leg to 45 degrees for 1 minute and observe pallor. Allow patient to sit with foot dangling and observe rubor.
54
What are some signs of arterial insufficiency?
Shiny skin
Hair loss
Thickened toenails
Gangrene
Foot ulceration (especially diabetics)
Color changes indicating vasospasm (Raynaud's)
55
What are the signs of acute venous insufficiency caused by a DVT?
Edema
Skin discoloration (redness)
Congested foot veins
Homan's sign: calf pain w/ passive dorsiflexion
56
What are the signs of chronic venous insufficiency?
Edema
Hyperpigmentation
Ulceration
Pitting edema
\*\*Caused by venous valve damage\*\*
57
How does the location of commonly found ulcers differ between arterial and venous insufficiency?
In arterial insufficiency, ulcers are typically found on the toes and feet. Venous insufficiency usually causes ulcers over the medial malleolus
58
What is the shape of the normal doppler ultrasound waveform of a peripheral artery? What causes changes to this?
Triphasic
Calcifications: biphasic
Poor arterial flow: monophasic
59
What is the ABI?
Ankle-brachial index
= systolic pressure at ankle / systolic pressure in arm
\*\*Normal is 1
Change of .15 is considered significant
60
What are the physiologic changes to vital signs that occur with aging?
Height and weight: malnutrition, osteoporosis, increased fat/decreased muscle mass
Blood pressure: Systolic rises with age, diastolic rises until age 60, atherosclerosis, orthostatic hypotension
HR and rhythm: resting HR may decrease, loss of SA pacemaking increases arhythmia risk
Temperature regulation decreases
61
How do the eyes change with aging?
Loss of periorbital fat: entropion/ectropion
Rigid iris
Loss of lens elasticity and ciliary muscle atrophy: loss of depth perception, ability to distinguish details, and night vision
Decreased lacrimal secretions
Near vision declines dramatically (presbyopia) by 5th decade
62
How do the ears change with aging?
Lose ability to hear high pitched sounds
Presbycusis: gradual loss of hearing beginning around 50 yo
63
What does the CV system change with aging?
Tortuous neck vessels
Loss of LV complience
Decreased early diastolic filling, atrial kick contributes more
Increased left atrial size, audible S4
Aortic scleoris, audible systolic murmur
Increased PR interval
64
What are the activities of daily living (ADL)?
Elements of basic self care including: bathing, dressing, toileting, transfers, continence, feeding
65
What are the instrumental activities of daily living?
Activities requiring a higher level of function than ADLs, including: food preperation, shopping, laundry, housework, telephone, medication, finance and transportation
66
What are the "generalizations" of the pediatric assessment?
Growth and development colors history taking and physical exam
Children do not exist in a vacuum, need 3rd party input
Children are NOT small adults, or aliens
67
What is unique to the pediatric cardiac exam?
Murmurs are present in over 50% of children
Benign/Innocent
Characteristics: systolic, I-III/VI, musical, @LSB, Non-radiating, unassoicated with other cardiac findings
68
What are the definitions for overweight and obese in pediatric patients?
Overweight: BMI 85-95%ile
Obese: BMI\>95%ile
69
Describe the changes seen in pediatric vital signs with age
Temperature taken rectally until 3yo
Pulse and respiratory rate decrease with age
BP increases with age
70
Approach to child 1-4 yo
Challenges: physical struggle, crying child, distraught parents, stranger anxiety
Perform least distressing procedures first, work to more distressing
71
What is one of the most important indicators of infant health?
Somatic growth as assessed by growth charts
These look at length, weight and head circumference
72
Mnemonic for adolescent history?
"HEADS"
Home: environment, relationships
Education: academic performance, grade level, career aspirations
Eating: nutrition, attitudes
Activities: intersts, work, participation
Affect/Anxiety
Drugs: smoking, drinking, drugs
Sexuality: behavior, orientation, attitudes
Safety: driving behavior, violence, abuse
73
What are the visible signs of breast cancer?
Retraction
Abnormal contours
Skin dimpling
Nipple retraction and deviation
Edema of skin
Paget's disease
74
What are common breast masses?
Fibroadenoma
Cysts
Cancer
75
Describe the lymphatic drainage of the breast
The pectoral, subscapular, and lateral nodes drain breast tissue into the central nodes (deep in axilla), which drain into the infraclavicular and supraclavicular nodes
The pectoral node drains the majority of the breast
76
What are the modifiable risk factors for breast cancer?
Post menopausal obesity
Hormone replacement therapy
Alcohol ingestion
Physical inactivity
Breast feeding choices
Type of contraception
77
What are the non-modifiable risk factors for breast cancer?
Age
Family history
Breast tissue density
Proliferative lesions with atypia on biopsy
Duration of estrogen exposure
History of radiation
78
What are the causes of non-physiologic nipple discharge?
Papillomas
Duct ectasia
Non-lactational infections
Fibrocystic breast changes
Ductal carcinoma in-situ/invasive carcinoma
79
Physical exam findings of anemia
Scleral icterus
Spoon nails and pica
Paresthesias and diarrhea
Smooth tongue/glossitis
80
Physical exam findings of coagulation disorders
Petechiae
Ecchymoses, hematomas, hemarthroses
Purpura
81
How does lymphatic drainage from males and females genetalia differ?
Male genetalia drain to the horizontal inguinal lymph nodes
Exterior female genetalia drain to the horizontal inguinal nodes, internal genetalia drain to pelvic and abdominal nodes which are not palpable.
82
What does the P wave represent?
Depolarization of the atria
Duration \< 0.12sec
Amplitude \<0.25 mV
83
What does the PR interval represent?
AV nodal conduction (also includes atrial depolarization time and conduction through bundle of His)
Normal length: 0.12- 0.2 sec
84
What does the QRS complex represent?
Depolarization of the ventricles
Normal length = 0.06 - 0.1 sec
Q= first deflection, downward, representing depolarization of septum
R = first upward deflection, negative in aVR, progression in precordials
S = first downward deflection after R wave
85
What does the ST segment represent?
The time between ventricular depolarization and repolarization
Normally isoelectric
86
What does the T wave represent?
Repolarization of the ventricles
Opposite direction from depolarization (epi to endo)
87
What does the QT interval represent?
The duration of all ventricular electrical events in one cardiac cycle
Depends on HR
Normally 0.2-0.4
Corrected QT = QT/sqrt(RR)
88
Which are the anterior leads of an EKG?
V1, V2, V3, V4
89
Which are the inferior leads of an EKG?
II, III, and avF
90
Which are the left lateral leads of an EKG?
I, aVL, V5 and V6
91
Which are the right leads of an EKG?
aVR and V1
92
What is the normal paper speed and calibration of an EKG?
Paper speed = 25 mm/s
Calibration = 10.0 mm/mV
93
What are the characteristics of sinus rhythm?
Normal identical P wave before every QRS
Narrow QRS
Normal rhythm (60 - 100 bpm)
94
What are the EKG characteristics of atrial flutter?
Saw tooth p waves with atrial rate 250-350 bpm
95
What are the EKG characteristics of atrial fibrillation
Irregularly irregular
No visible p waves
96
What is the normal axis of the heart?
-30 to +90 degrees
LAD is -30 to -90 degrees
RAD is \> 90 degrees
97
EKG criteria for RBBB
Widened QRS \>0.12 sec
RSR' in V1 and V2 with ST depression and T wave inversion
98
EKG criteria for LBBB
Widened QRS
Broad or notched R wave with prolonged upstroke in V5, V6, I, and aVL with ST depression and T wave inversion
99
EKG criteria for left anterior hemiblock
LAD with no other cause of LAD (no hypertrophy)
100
EKG criteria for left poserior hemiblock
RAD with no other cause for RAD
101
What is a bifasicular block?
Either RBBB with left anterior hemiblock
OR
RBBB with left posterior hemiblock
102
EKG criteria for left atrial enlargement
Negative portion of p wave \> 1 mm in V1 with duration \> 0.04 sec
103
EKG criteria for right atrial enlargement (RAE)
P wave amplitude \> 2.5 mm in leads II, III, and aVF with normal duration
104
EKG criteria for Left ventricular hypertrophy
Amplitude of R in V5/V6 + amplitude of S in V1/V2 \> 35 mm
Amplitude of R in aVL \> 13 mm
LAD \> -15 degrees
105
EKG criteria for right ventricular hypertrophy
RAD \> 100
R \> S in V1, S \> R in V6
106
What are the characteristics of a murmur that must be described?
Timing: systole or diastole
Location: where it is best heard
Shape: crescendo, decrescendo, or holosystolic
Intensity: 1 (barely audible) to 6 (stethoscope off chest), thrill felt at 4/6
Pitch: high or low
Quality: harsh or blowing
Changes: changes with maneuvers like squatting
107
The diaphragm of the stehoscope is used to hear ______ pitches whereas the bell is used to hear ______ pitches
The diaphragm of the stehoscope is used to hear HIGH pitches whereas the bell is used to hear LOW pitches
High pitches: S1, S2, midsystolic click, regurgitation
Low pitches: S3/S4, mitral stenosis
108
Heart sound for mitral regurgitation
Holosystolic high pitched harsh blowing murmur heard at apex, radiates to left axilla
109
Heart sound for aortic stenosis
Harsh, crescendo-decrescendo systolic murmur heard in 2nd right intercostal space, radiates to carotids
110
Heart sound for mitral valve prolapse
Late systolic crescendo murmur with midsystolic click
111
Heart sound for mitral stenosis
Rumbling diastolic low pitched
112
Describe the physiolocal splitting of S2
Splitting of S2 on inspiration due to more negative pleural pressure
Increases on inspiration, decreases on expiration
113
Describe the pathologic splitting of S2
Widened splitting: persists throughout respiratory cycle, could be due to pulmonic stenosis, RBBB or mitral stenosis
Fixed splitting: ASD and RV failure
Reverse splitting: split on expiration but absent on inspiration, due to LBBB causing delayed closure of aortic valve
114
What is S3?
Extra diastolic sound during rapid ventricular filling
Called "gallop" or "Kentucky" sound
115
What is S4?
Increased resistance to ventricular filling, heard just before S1
116
What are the components of the 3 part plan?
Diagnostic
Therapeutic
Education
117
Admitting orders contain the following instructions
ADC VAAN DISML
Admit to
Diagnosis of patient
Condition of patient
Vital signs
Activity permitted / limitations
Allergies
Nursing orders
Diet
IV fluids
Special orders
Medications
Labs/tests
118
Lung auscultation findings on patient with acute lobar pneumonia
Increased bronchial breath sounds because consoldated lung tranmits sound more readily
Vocal fremitis: hear whispered "99" louder than normal, clearer than normal
Egophony: E to A sound
119
Physical exam findings on emphysema patient
Hyperresonance on percussion due hyperinflated lungs
Pink puffer appearance
120
Physical exam findings on patient with interstitial lung disease
Crackles
Sometimes get clubbing, hypoxemia, desaturation with exercise
121
Physical exam findings of pneumothorax
Hyperresonance of affected lung
Decreased breath sounds
On CXR, absent lung markings, trachea shifted away from affected lung
122
Physical exam findings of pleural effusion
Dullness to percussion, decreased breath sounds
CXR shows blunding of costodiaphragmatic angle, meniscus sign, complete white out
Trachea shifted away from effusion
