Bates Chapters 8, 9, 12 Review

Front 1

Clenched fist over sternum suggest?

Back 1

Angina pectoris

Front 2

what can cough indicate with regard to heart failure?

Back 2

symptom of LSHF

Front 3

Dullness replaces resonance when...

Back 3

fluid or solid tissue replaces air containing lung or occupies thepleural space beneath percussing fingers.

Front 4

Examples of dullness replacing resonance

Back 4

Examples: lobar pneumonia, alveoli are filled with fluid and blood cells;and plural accumulation of serous fluid (pleural effusion), blood (hemothorax),pus (empyema), fibrous tissue, or tumor.

Front 5

Generalized hyperresonance-

Back 5

heard over hyperinflated lungs of COPD or asthma.

Front 6

Vesicular breath sounds

Back 6

soft and low pitch. Duration: inspiratory sounds last longer thanexpiratory.

Front 7

Bronchovescular breath sounds

Back 7

intermediate intensity and pitch. Duration: often in 1st and 2nd interspacesanteriorly and between the scapulae

Front 8

Bronchial

Back 8

Loud and high pitched. Duration: Expiratory sounds last longer thaninspiratory.

Front 9

Tracheal

Back 9

very loud and high in pitch. Duration: inspiratory and expiratory areequal.

Front 10

Crackles that do not clear after coughing

Back 10

may be from abnormalities of the lungs (pneumonia, fibrosis, early heartfailure) or of the airways (bronchitis, bronchiectasis).

Front 11

Wheezes suggest...

Back 11

narrowed airways as in asthma, COPD, bronchitis.

Front 12

Asthma

Back 12

widespread narrowing of tracheobronchial tree

Front 13

findings suggestive of COPD

Back 13

Combinations of symptoms and signs, especially wheezing by self-reportor examination, plus a hx of smoking, age, and decreased breath sounds.

Front 14

percussion with COPD

Back 14

Hyperresonant

Front 15

Auscultation with COPD

Back 15

decreased to absent (associated chronic bronchitis is common)

Front 16

What would you hear with lobar consolidation when performingegophony?

Back 16

Consolidation area sounds the ‘ee’ changes to ‘aa’ seen in pneumonia. The “A” is a nasalbleating quality and should be localized.

Front 17

What in particular are you noting when inspecting the anteriorchest?

Back 17

Shape of the chest- normal is elliptical. Movement of the chest wall. Local lag or impairment in respiratory movements.

Look for deformities or asymmetry, abnormal retraction of the lower interspaces during inspiration.

Front 18

Abnormal retraction suggests what conditions?

Back 18

-abnormal retractions occur in severe asthma, COPD, or upper airway obstruction.

Front 19

Angina pectoris

Process, location, quality, severity, timing, aggrevation, relieve, associated Sx:

Back 19

Process:temporary myocardial ischemia, usually secondary to coronary atherosclerosis

Location: anterior chest,shoulders, arms, jaw

Quality: pressing, squeezing,tight, heavy, occasionally burning

Severity: may be mild to moderate

Timing: 1-3 minutes but up to 10. Prolonged episodes up to 20 mins.

Aggrevate: exertion

rest, nitro

nausea

Front 20

Dissecting Aortic Aneurysm:

process

Location

quality

severity

Back 20

Process: A splitting within the layers of the aortic wall,allowing passage of blood to dissect a channel.

Location:Anterior chest, radiating to neck, back, abdomen

Quality:Ripping

Severity:VERY

Front 21

Dissecting Aortic Aneurysm:

Timing

aggrevate

associated Sx:

Back 21

Timing: persistent,abrupt onset, early peak, persistent for hours or more

Aggrevate:HTN

Associated Sx: if thoracic, hoarseness, dysphagia, also syncope, hemiplegia, paraplegia

Front 22

Pleuritic pain

process

location

duration

severity

Back 22

Process: Inflammation of the parietal pleura, as in pleurisy, pneumonia, pulmonary infarction or neoplasm.

Location:chest wall overlying process

Quality: sharp, knife-like

Severity: often severe

Front 23

Pleuritic pain

timing

aggravating factors

associated Sx

Back 23

Timing: Persistent

Aggravating:deep inspiration, coughing, movements of trunk

Associated Sx: of the underlying illness

Front 24

Left sided heart failure

process:

timing

setting

Back 24

Process: Elevated pressure in the pulmonary capillary bed with transudation of fluid into interstitial spaces and alveoli, decreased compliance (increased stiffness) of the lungs, increased work ofbreathing.

Timing: Dyspnea may progress slowly, or suddenly as in acute pulmonary edema.

Setting: Hx of heart disease.

Front 25

LSHF:

Aggravating factors

relieving factors

associated Sx:

Back 25

Aggravate: lying down, exertion

Relieve:rest, sitting up, though dyspnea may be persistent

Associated Sx: cough, night time dyspnea

Front 26

COPD

Process

Timing

Aggravate:

Back 26

Process: Overdistention of air spaces distal to terminal bronchioles, with destruction of alveolar septa, alveolar enlargement and limitation of expiratory air flow

Timing:slowly progressive dyspnea; relatively mild cough later

Aggravate:exertion

Front 27

COPD

Relieve

Associated Sx

Back 27

Relieve: rest, dyspnea may become persistent

Associated sx: cough with scant mucoid production

Front 28

Pneumonia

process

timing

Relief

associated Sx

Back 28

inflammation of lung parenchyma from the respiratory bronchioles to the alveoli

Timing:acute illness, timing varies with the causative agent

Associated sx: pleuritic pain, cough, sputum, fever, though not necessarily present

Setting:varies

Front 29

Spontaneous pneumothorax

process

timing

Back 29

leakage of air into pleural space through blebs on visceral pleura, with resulting partial or complete collapse of the lung.

Sudden onset dyspnea, and pleuritic pain

Front 30

Associated Sx spontaneous pneumothorax

Back 30

often none. Retrosternal oppressive pain if the occlusionis massive. Pleuritic pain, cough, and hemoptysis may follow an embolism if pulmonary infarction ensues. Symptoms of anxiety.

Front 31

Viral pneumonia or mycoplasma

Back 31

Dry hacking cough Acute febrile, HA, malaise

Front 32

Bacterial pneumonia

Back 32

Mucoid or purulent sputum (rusty sputum), may be blood streaked, diffusely pinkish, or rusty

Front 33

Asthma

Back 33

Cough, with thick mucoid sputum, especially near end of attack. Mucoid, episodic wheezing and dyspnea

Hx allergies

Front 34

Barrel Chest:

Back 34

Increased anteroposterior diameter

AP Diameter 1:1

In infancy, aging, and COPD

Front 35

Funnel Chest (Pectus Excavatum)

Back 35

Depression of lower sternum

Check closely for heart murmurs

Front 36

Scoliosis

Back 36

Abnormal curvature and rotation

Front 37

Adventitious breath sounds

Crackles

Back 37

Discontinuous

intermittent, non musical and brief

like dots in time

Front 38

Fine crackles

Back 38

soft, high-pitched, very brief (5-10 msec)

Front 39

coarse crackles

Back 39

somewhat louder, lower in pitch, brief (20-30 msec)

Front 40

Wheezes and Rhonchi

Back 40

Continuous

>250 msec, musical, prolonged (but not necessairly persistent throughout the resp cycle.)

like dashes in time

high-pitched with hissing or shrill quality

Front 41

rhonchi

Back 41

relatively low pitched with snoring quality

suggests secretions in large airways

Front 42

Systole:

Back 42

the ventricles contract (closure of mitral and tricuspid valves) (S1)

The right ventricle pumps blood into the pulmonary arteries (pulmonic valve is open)

The left ventricle pumps blood into the aorta

Front 43

Diastole

Back 43

the ventricles relax (closure of aortic and pulmonic) (S2)

Blood flows from the right atrium → right ventricle (tricuspid valve is open)

Blood flows from the left atrium → left ventricle (mitral valve is open)

Front 44

Cardiac Apex and PMI

Back 44

In supine patients with the diameter of the PMI may be as large as a quarter, approximately 1-2.5 cm.

Front 45

PMI > 2.5 cm indicative of...

Back 45

LVH, or enlargement, seen in HTN and aortic stenosis.

Front 46

Cardiac pulse

Back 46

Provides info about cardiac function and is especially useful for detecting aortic stenosis or insufficiency of the aortic valve.

Front 47

S1 and S2 heart sounds

Back 47

S2>S1 Aortic and Pulmonic

S2=S1 Erbs

S1>S2 Tricuspid and Mitral

Front 48

What is an invaluable aide in timing the sound of a murmur

Back 48

Palpation of the carotid artery during auscultation.

The carotid upstroke always occurs in systole immediately after S1 (lub) (closing of tricuspid and mitral)

sounds or murmurs coinciding with the upstroke are systolic; sounds or murmurs occurring aftercompletion of the upstroke are diastolic.

Front 49

Location:

Back 49

Assess location with the patient supine, because the left lateral decubitus position displaces the apical impulse to the left.

Front 50

2 points for location:

Back 50

Interspaces, usually the 5thor possibly the 4th ICS, MCL.

Lateral displacement from cardiac enlargement is seen in heart failure,cardiomyopathy, and ischemic heart disease.

Front 51

Amplitude

Back 51

Usually small and feels brisk and tapping. Some young adults have an increased amplitude or hyperkinetic impulse, when excited or after exercise,duration is normal.

Front 52

Increased amplitude indicates

Back 52

hyperthyroidism, severe anemia, pressure overload of the left ventricle (aortic stenosis), or volume overload of the left ventricle(mitral stenosis).

Front 53

Landmarks of heart valves:

Aortic

Pulmonic

Erbs

Tricuspid

Mitral

Back 53

Aortic 2nd ICS RSB

Pulmonic 2nd ICS LSB

Erbs 3rd ICS LSB

Tricuspid 4th ICS LSB

Mitral 5th ICS LSB

Front 54

What position will accentuate a left-sided S3 and S4, mitral murmurs?

Back 54

Left lateral decubitus accentuates S3, S4, mitral murmurs, especially mitral stenosis

Front 55

Sitting leaning forward:

Back 55

end exhalation accentuates aortic murmurs- aortic regurgitation- a soft diastolic murmur.

Front 56

Aortic stenosis location and radiation

Back 56

Location: Right 2nd interspace

Radiation: to the carotids, down the left sternal border,even to the apex

Intensity: sometimes soft but often loud, with a thrill

Aids: Best heard pt sitting up and leaning forward

Front 57

Mitral stenosis location and radiation

Back 57

Location: usually limited to the apex. Radiation: little or none

Pitch: low, use the bell.

Aids: turn patient into a left lateral position, heard better with exhalation.

Front 58

Careful assessment is essential for detecting what?

Back 58

Peripheral arterial disease

Front 59

How many Americans and what percent of those > 80?

Back 59

Prevalence increases with age.

7% in adults 60-69 y/o

23% ages 80+

Front 60

Where is the brachial artery located?

Back 60

at the bend of the elbow just medial to the biceps tendon

Front 61

Radial artery

Back 61

on the lateral flexor surface

Front 62

Ulnarartery-

Back 62

medial flexor surface, although overlying tissues may obscure the ulnar artery.

Front 63

PAD refers to...

Back 63

stenotic, occlusive, and aneurysmal disease of the aorta, its visceral arterial branches, and the arteries of the lower extremities, exclusive of the coronary arteries.

Front 64

Intermittent claudication

Back 64

Pain or cramping in the legs during exertion that is relieved by rest within 10 minutes.

Front 65

Symptomatic limb ischemia

Back 65

with exertion is present in atherosclerotic PAD.

Front 66

Neurogenic claudication

Back 66

Pain with walking or prolonged standing, radiating from the spinal areainto the buttocks, thighs, lower legs, or feet

Front 67

What to ask about in regard to PVD

Back 67

coldness, numbness, or pallor in the legs or feet or loss of hair over the anterior tibial surfaces.

Front 68

What does hair loss over the anterior tibiae indicate?

Back 68

Occurs with decreased arterial perfusion. “Dry” or brown-black ulcers from gangrene may ensue.

Front 69

Ankle brachial index

Back 69

Measure systolic blood pressure in the arms and in the pedal pulses, using Doppler ultrasound.

Front 70

Important areas to examine

Back 70

Arms- size, symmetry, skin color. Radial pulse, brachial pulse, epitrochlear lymph nodes

Abdomen- aortic width, pulsatile mass

Legs- size, symmetry, skin color, femoral pulse and inguinal lymph nodes, popliteal, dorsalis pedis, and posterior tibial pulses, peripheral edema.

Front 71

What to look for when inspecting the ankles and feet?

Back 71

Size,symmetry, and swelling. Venous pattern. Color of skin and nail beds and texture of skin.

Front 72

What might bounding pulses indicate?

Back 72

Aortic insufficiency, asymmetric diminished pulses occur in arterial occlusion from atherosclerosis or embolism.

Front 73

How would you grade pulses?

Back 73

3+ bounding

2+brisk, expected

1+ diminished, weaker than expected

0 Absent, unable to palpate

Front 74

If you suspect arterial insufficiency, what pulse would you palpate?

Back 74

brachial pulse

Front 75

What to assess when inspecting legs...

Back 75

Size, symmetry, and any swelling

Venous pattern and venous enlargement

Pigmentation, rashes, scars, ulcers

Color and texture of skin, color of nail beds, distribution of hair on lower legs, feet, and toes.

Front 76

Dorsalis pedis pulse

Back 76

Feel the dorsum of the foot (not ankle) just lateral to the extensor tendon of the great toe. If you can’t feel a pulse, explore the dorsum of the foot more laterally.

Front 77

Posterior tibial

Back 77

curve fingers behind and slightly below the medial malleolus of the ankle. This pulse maybe hard to feel with fat or edematous ankle.

Front 78

Temperature assessment:

Back 78

Coldness, especially when unilateral or associated with other signs,suggests inadequate arterial perfusion.

Front 79

sudden arterial occlusion from embolism or thrombosis causes.....

Back 79

pain and numbness or tingling

Front 80

If limb distal to occlusion becomes cold, pale, and pulseless....

Back 80

Emergency treatment required.

Front 81

What is the allen test?

Back 81

Useful to ensure the patency of the ulnar artery before puncturing the radial artery for blood samples. Arterial occlusive disease is much less common in the arms than in the legs.

Front 82

Absent or diminished pulses at the wrist are found in....

Back 82

acute embolic occlusion and in Buergers Disease or Thromboangiitis obliterans.

Front 83

marked pallor on elevation suggests...

Back 83

arterial insufficiency

Front 84

How to assess for pallor on elevation..

Back 84

Raise both legs to about 60 degrees until maximal pallor of the feet develops, usually 1 minute. In light-skinned people, either maintenance of normal color.

Then, ask patient to sit up with legs dangling down.

Front 85

When comparing both feet, noting the time required for assessing pallor on elevation... look for....

Back 85

Return of pinkness to the skin, normally about 10 seconds.

Filling the veins of the feet and ankles, normally about 15 sec.

Front 86

Chronic venous insufficiency

Back 86

Edema is soft, with pitting on pressure, and occasionally bilateral. Looking for brawny changes and skin thickening, especially near the ankle.

Front 87

Chronic venous insufficiency pigmentation

Back 87

ulceration and pigmentation and edema in the feet are common

Front 88

Lymphedema

Back 88

Edema is soft int he early stages, then becomes indurated, hard, and non-pitting. Skin is markedly thickened; ulceration is rare. No pigmentation

Front 89

Lymphedema develops when

Back 89

lymph channels are obstructed by tumor, fibrosis, or inflammation, and in cases of axillary node dissection and radiation

Front 90

intermittent claudication location of pain

Back 90

usually calf muscles, but also may be in the buttock, hip, thigh, or foot, depending on level of obstruction

Front 91

DVT

Back 91

tight bursting pain, if present, usually in the calf; may be painless

Front 92

Interpretation of ABI

Normal range

Back 92

>.90 (with a range of 0.90 - 1.30)

Front 93

Mild PAD

Back 93

<0.89 to >.60

Front 94

Moderate PAD

Back 94

<.59 to >.40

Front 95

Severe PAD

Back 95

<.39

Front 96

Chronic arterial insufficiency

pain

mechanism

pulses

color

Back 96

intermittent claudication, progressing to pain at rest

tissue ischemia

decreased or absent

pale, esp on elevation; dusky red on dependency

Front 97

Chronic arterial insufficiency

edema

skin changes

ulceration

gangrene

Back 97

absent or mild edema

trophic changes: thin, shiny, atrophic skin; losses of hair over the foot and toes; nail thickened and ridged

if present, involve toes or points of trauma on feet

Front 98

Gangrene is present in

Back 98

chronic arterial insufficiency

Front 99

Chronic venous insufficiency

Back 99

often painful

venous HTN

color is normal, or cyanotic

brown pigmentation may appear

thickening of the skin

Front 100

chronic venous insufficiency

Back 100

ulceration develops at sides of ankles, especially medially

Front 101

Chronic venous insufficiency

borders and ulcers

Back 101

borders are irregular, flat, or slightly steep.

ulcer contains small, painful granulation tissue and fibrin; necrosis or exposed tendons are RARE.

Front 102

Arterial insufficiency

pain

Back 102

pain is often severe unless neuropathy masks it.

Front 103

Arterial insuffiency and gangrene

Back 103

may be associated; along with decreased pulses, trophic changes, foot pallor on elevation, and dusky rubor on dependency.

Front 104

Lateral displacement from cardiac enlargement is seen in

Back 104

heart failure,cardiomyopathy, and ischemic heart disease.