Etp Pa Exam Ii

Front 1

anterior thoracic cage

Back 1

-suprasternal notch
-sternum (manubrium, body, xiphoid process)
-manubriosternal angle (angle of louis)
-costal angle
-ribs

Front 2

manubriosternal angle aka "angle of louis"

Back 2

-elevated part of sternum where manubrium meets the body of the sternum
-continuous w/ 2nd rib--2nd intercostal space is right below this rib
-corresponds w/ upper atria of the heart
-where trachea bifurcates

Front 3

What is a normal costal angle? What would be abnormal?

Back 3

< 90
> 90 may indicate emphysema; barrel chest increases this angle

Front 4

How many ribs?

Back 4

We have 12!
1-7 are directly attached to sternum via cartilage
8, 9, 10 fuse with the above ribs; "false ribs"
11, 12 are floating ribs w/ no anterior connections

Front 5

posterior thoracic cage

Back 5

-vertebra prominens (C7)
-spinous processes
-inferior border of scapula is ~7/8th rib
-12th rib- palpate midway b/w spine and side to find " free tip"

*C7-T4 is usually palpable

Front 6

anterior reference lines

Back 6

anterior axillary, midclavicular, midsternal

Front 7

posterior reference lines

Back 7

scapular, vertebral

Front 8

lateral reference lines

Back 8

anterior axillary, posterior axillary, midaxillary

Front 9

thoracic cavity

Back 9

1/ mediastinum- esophagus, heart, trachea, great vessels (aorta, vena cavae, pulmonary artery)

2/ R pleural cavity

3/ L pleural cavity

Front 10

everything you wanted to know about lungs

Back 10

2 lobes on left; 3 lobes on R

R side is shorter (b/c of liver)
L side is narrower (b/c of the heart)

anterior landmarks--
apices of lungs are above clavicle
base of lungs rest on diaphragm ~6th rib

posterior landmarks--
apex is C7
base is T10
During inspiration, lungs will expand to T12

when listening anteriorly- upper lobes
when listening posteriorly- lower lobes (easier to hear congestion when patient is sedentary)

Front 11

Where do you auscultate RML?

Back 11

laterally, more anterior

Front 12

visceral v. parietal plurae

Back 12

visceral lines the lungs
parietal lines chest walls

*pleural cavity is filled w/ moisture and allows lungs to deflate/inflate
(-) pressure holds lungs against the chest walls

Front 13

purposes of respiration

Back 13

*respiration is the physical act of breathing

1/ supply O2 to body for energy production
2/ remove CO2 as waste product
3/ maintain acid-base balances of arterial blood
4/ maintain heat exchange

Front 14

What happens to the thoracic cavity during inspiration and expiration?

Back 14

During inspiration, thoracic cavity has (-) pressure, diaphragm descends. Intercostal muscles are used.

Expiration is passive; diaphragm relaxes, creating (+) pressure, and air expels.

Front 15

subjective questions for respiration

Back 15

-cough
-dyspnea
-orthopnea (need pillow to sleep)
-chest pain w/ breathing
-hemoptysis
-hx respiratory infections
-hx smoking
-environmental exposure

Front 16

What does a dry cough indicate? What about a congested cough?

Back 16

dry cough- cardiac
congested cough- bronchitis pneumonia

Front 17

parasimal nocturnal dyspnea

Back 17

patient lying flat at night and suddenly needs to sit up due to SOB; related to fluid accumulation in lung

Front 18

barrel chest

Back 18

thorax is squared off
AP transverse is 1:1
e.g. emphysema

*normal AP transverse is 1:2

Front 19

pectus excavatum v. pectus carinatum

Back 19

pectus excavatum- sternum indented
pectus carinatum- sternum extended

usually cosmetic but can affect heart and breathing

Front 20

scoliosis v. kyphosis

Back 20

scoliosis- spine is curved from side to side
kyphosis- hunchback, usually due to aging

Front 21

pink puffer v. blue bloater

Back 21

pink- emphysema; tripoding due to barrel chest--lungs are always inflated

blue- COPD, chronic bronchitis; decreased lung capacity

*smokers will have combination

Front 22

respiration patterns

Back 22

tachypnea- RR > 20; exercise, fever, pneumonia

bradypnea- RR < 12; drugs, increased intracranial pressure

kussmaul- faster than normal, deep hyperventilation; anxiety, fear, diabetic ketoacidosis

cheyne-stokes- waxing and weaning w/ periods of apnea; ESRD, CHF, increased intracranial pressure

biot's- irregular, shallow; brain trauma, heat stroke, end of life

Front 23

palpation: symmetric expansion of lungs

Back 23

both hands on posterior chest w/ thumbs @ T9 or T10

thumbs should move apart symmetrically when patient takes a deep breath

if not symmetrical, could be pneumonia or collapsed lung

Front 24

T/F. Sound is conducted better through a dense/solid structure than porous.

Back 24

True

Therefore, anything that increases density of lung will increase fremitus.

Front 25

name a condition w/ increased tactile fremitus

Back 25

pneumonia

Front 26

name three conditions w/ decreased tactile fremitus

Back 26

1/ pneumothorax
2/ lung collapse
3/ any sort of obstruction

Front 27

percussion

Back 27

*intercostal space
*only good for 6-7cm; cannot detect small pneumonia, but if you need pleural infusion, want to percuss to outline the area
*would only percuss if patient comes in with

*start at apices of lungs and go side to side

Front 28

percussion sounds

Back 28

resonance- healthy lung (louder, deeper sound; air allows it to move freely)

dullness- liver, heart, pneumonia (high, shorter sound)

flat- bone

Front 29

expected notes on posterior chest

Back 29

resonance cuts off ~T8

Front 30

diaphragmatic excursion

Back 30

should be 3-5 cm bilaterally; runners can be > 5 cm

Front 31

lung sounds

Back 31

*use diaphragm
ratio represents inspiration : expiration

vesicular; 2:1
bronchial vesicular; 1:1
bronchial; 1:2

Front 32

adventitous breath sounds

Back 32

crackles, rales, crepitations (fine to medium)
crackles, rales, crepitations (medium to coarse)
wheezes (sonorous)
wheezes (sibilant)
stridor
pleural friction rub

Front 33

crackles, rales, crepitations (fine to medium)

Back 33

end of inspiration

air is colliding w/ secretions; possible in AM- if it doesn't go away, something could be in alveoli

Front 34

crackles, rales, crepitations (medium to coarse)

Back 34

beginning of inspiration- sounds like velcro pulling apart

Front 35

wheezes (sonorous)

Back 35

low pitch, snoring sound aka rhonchi

Front 36

wheezes (sibilant)

Back 36

high pitch, musical, squeak
e.g. bronchitis, emphysema

Front 37

stridor

Back 37

high pitch, loud, crowing during inspiration; something caught in trachea
e.g. child w/ croup

Front 38

pleural friction rub

Back 38

"leather rubbing together"
e.g. pleural inflammation

Front 39

costal diaphragmatic recess

Back 39

empty space under lung that can fill up w/ extra fluid

Front 40

Where is the trachea?

Back 40

trachea is anterior to esophagus and bifurcates below angle of louis

Front 41

What is the difference between the R and L bronchus?

Back 41

R bronchus is shorter, wider, and straighter making it easier to aspirate. L bronchus is at angle.

Front 42

Explain the bifurcation of the bronchus. Where does gas exchange occur?

Back 42

bronchus >> bronchiole >> alveoli
Gas exchange occurs in the alveoli.

Front 43

If concerned about pneumonia, what other sounds are you listening for?

Back 43

transmitted voice sounds--normally is muffled, if you have consolidation, will be able to hear sound

bronchophony: "99" is clear rather than muffled
egophony: "E" changes to "A"
whispered pectoriloquy: whispered 99 is heard clearly rather than faint or absent sound

Front 44

T/F. Lungs are higher anteriorly than posteriorly.

Back 44

True

Front 45

percussion sounds, anterior chest

Back 45

resonance @ apices, down to 6th rib
dullness @ heart/lung
tympani @ stomach

Front 46

auscultation sounds, anterior chest

Back 46

Front 47

normal lung

Back 47

trachea- midline
tactile fremitus- normal
breath sounds- vesicular except over bronchi/trachea
percussion- resonant
adventitious sounds- none

Front 48

atelectasis

Back 48

bronchial obstruction; diaphragm elevates to fill in space left by shrunken section
e.g. lobar obstruction

trachea- shifted toward involved side
tractile fremitus- absent
breath sounds- absent when bronchial is plugged
percussion- dull over airless area

Front 49

consolidation

Back 49

alveoli consolidated w/ fluid, bacteria, RBCs, WBCs
e.g. pneumonia

tactile fremitus- increased over involved area
breath sounds- bronchial or bronchial/vessicular
percussion- dull over airless area
adventitious sounds- late inspiratory crackles

Front 50

bronchitis

Back 50

bronchial inflammation w/ copious secretions; deflated alveoli

adventitious sounds- none OR scattered coarse crackles in early inspiration/expiration; wheezes and rhonchi

Front 51

emphysema

Back 51

hyper-inflated lungs; overdistended alveoli w/ destruction of septa

tactile fremitus- decreased
breath sounds- decreased/absent
percussion- hyperresonant (tympani)
adventitious sounds- none OR scattered coarse crackles in early inspiration/expiration; wheezes and rhonchi

Front 52

asthma

Back 52

similar to bronchitis, but with more spasms
edema of bronchial mucosa, thick mucus

tactile fremitus- decreased
breath sounds- obsured by wheezes
percussion- resonant to hyperresonant
adventitious sounds- wheezes, possibly crackles

Front 53

pleural effusion

Back 53

compressed alveoli

trachea- shifted toward opposite site of large effusion
tactile fremitus- decreased/absent
breath sounds- decreased/absent; bronchial sounds can be heard near top of large effusion
percussion- dull to flat over fluid
adventitious sounds- possible rub

Front 54

pneumothorax

Back 54

lung collapse; air in pleural space due to rupture in lung wall, leak in chest wall

trachea- shifted toward opposite side if there is a lot of air
tactile fremitus- decreased/absent over pleural air
breath sounds- decreased/absent over pleural air (because lung is not inflated)
adventitious sounds- possible pleural rub

Front 55

CHF

Back 55

like pneumonia; dependent airways deflated, engorged capillaries, bronchial mucosa may be swollen

tactile fremitus- decreased
adventitious sounds- late inspiratory crackles in dependent portions of lungs; possible wheezing

Front 56

external anatomy of breasts

Back 56

between 2nd and 6th ribs
between sternal edge to mid axillary line
nipple is just below center
*tail of spence- superior lateral corner; projects up and into axilla

Front 57

What is breast tissue composed of?

Back 57

-Glandular tissue; 15-20 lobes surrounding the nipple
-Fibrous bands i.e. suspensory ligaments (Cooper's) which support the glandular tissue
-Fat/adipose tissue surrounds breasts (it's the most abundant)

Front 58

What happens to suspensory ligaments in Breast Cancer patients?

Back 58

shortens & tightens

Front 59

Where are most breast cancers found?

Back 59

Females: upper outer quadrant (tail of spence)
Males: deep under nipple

Front 60

lymphatics of breasts

Back 60

*drains into supraclavicular and infraclavicular

axillary nodes
-central axillary
-pectoral
-subscapular
-lateral

Front 61

T/F. Malignant tumors have increased blood supply due to increased venous return.

Back 61

True

Front 62

T/F. Sometimes there's a 2nd nipple following the milk line; it also has glands.

Back 62

False; 2nd nipple has no glands

Front 63

How long should a thorough breast exam take?

Back 63

3 minutes

Front 64

things to note about lump(s)

Back 64

-location
-size
-shape
-consistency (firm, hard, soft)
-motility
-distinctness
-nipple retraction
-overlying skin
-tenderness (cancer is not usually tender, although they can be)
-lymphadenopathy

Front 65

T/F. Pituitary tumors usually result in milky discharge.

Back 65

True

Front 66

pulmonary/systemic circulation

Back 66

Front 67

Where is the heart?

Back 67

2nd to 5th intercostal
R border of sternum to L clavicular line

Front 68

Where is the apical impulse (PMI)?

Back 68

5th intercostal
midclavicular line

Front 69

compare the base/apex of the heart and lungs

Back 69

lungs- apex top, base bottom
heart- base top, apex bottom

Front 70

Where are the R and L ventricle?

Back 70

R ventricle- anterior
L ventricle- posterior

Front 71

great vessels

Back 71

Front 72

Where do the common carotid arteries go?

Back 72

Common carotid arteries go to the brain.

Front 73

layers of the <3

Back 73

1/ epicardium- protective connective tissue covered by epithelium
2/ myocardium- thick muscle tissues responsible for pumping out blood
3/ endothelium- inner connective tissue w/ epithelium; purkinje fibers

Front 74

<3 internal anatomy

Back 74

know the pathway of blood

Front 75

compare the pressure of the R and L <3

Back 75

R <3 is lower pressure system
L <3 is higher pressure system

Front 76

compare the L and R atriums

Back 76

R atrium- thinner walls, reservoir
L atrium- thicker walls, pump

Front 77

systole

Back 77

"lub"
S1- closing of the AV valves (MT)
*ventricles contract

-right ventricle pumps blood into pulmonary arteries via pulmonic valve
-left ventricle pumps blood into aorta via aortic valve

Front 78

diastole

Back 78

"dub"
S2- closing of semilunar valves (AP)
*ventricles relax

-blood flows from R atrium >> R ventricle via tricuspid valve
-blood flows from L atrium >> L ventricle via mitral valve

Front 79

What is so special about S1?

Back 79

It correlates to carotid pulse and QRS on ECGs.

Front 80

What happens to the <3 of a HTN patient?

Back 80

If diastolic is 100 (or generally high), it takes more isometric muscle contractions to open the valve--patient will develop L ventricular hypertrophy and the heart will go into failure.

Front 81

After S2, what should you hear during diastole?

Back 81

Usually very silent; will hear a rumbling if ventricles are resistant to filling (stiff due to hypertrophy or excess fluid); S3 and S4

Front 82

S3 v. S4

Back 82

S3- beginning of diastole
S4- end of diastole after atria contracts to get rids of blood (atrial systole or atrial kick)

Front 83

cardiac output (CO)

Back 83

stroke volume x heart rate
stroke volume- the amount of blood in systole

Front 84

blood pressure

Back 84

CO x SVR
SVR- systolic ventricular resistance in artery

Front 85

preload

Back 85

length of which ventricular muscle stretch at the end of diastole

Starling's Law:
greater stretch = stronger contraction

Front 86

afterload

Back 86

opposing pressure ventricle has to generate to open aortic valve against aortic pressure

Front 87

How much blood does a resting adult pump out every minute?

Back 87

4-6 L

Front 88

cardiac risk factors

Back 88

smoking, poor diet, weight, family history, high BP & cholesterol, sedentary life style

Front 89

cardiac subjective data

Back 89

chest pain
dyspnea
orthopnea
cough
fatigue
cyanosis/pallor
edema
nocturia; CHF heart is too lazy to bring fluid back so it will go to kidneys instead

Front 90

T/F. Bruit can be heard if 30% of artery is occluded.

Back 90

False; 70%

Front 91

blood pressure

Back 91

SBP- pressure generated by L ventricle during systole; LV ejects blood into aorta and arterial tree

DBP- pressure generated by blood remaining in arterial tree during diastole; ventricles are relaxed

Front 92

When will you see distention of neck veins?

Back 92

R heart failure; fluid is backed up
> will also cause fluid overload in legs

Front 93

jugular venous pressure

Back 93

-indicates how R <3 is working
-expressed as vertical height (cm) of column of blood relation to angle of louis
-mean height of this column represents hydrostatic pressure within right atrium

Front 94

How deep is the right atrium to the sternum?

Back 94

5 cm deep

Front 95

How do you measure jugular venous pressure?

Back 95

one at right atrium (5 cm)
one at height of distended vein, where internal jugular vein collapses

ADD!

*normal is height is 8-10 cm

Front 96

<3 auscultation sounds

Back 96

@ AP, S2 > S1
@ TM, S1 > S2
@ erb's point, S1 = S2

Front 97

Where is erb's point?

Back 97

3rd intercostal

Front 98

What are the three positions for auscultation? What purposes do they serve?

Back 98

sitting, lying down, L lateral decubitus

sitting- base of heart is closer to chest wall; can hear AP better

L lateral decubitus- L and R ventricles are closer; can hear MT, S3 and S4 better

Front 99

What are you inspecting for when looking at precordium?

Back 99

Looking for heaves and lifts; if present--
@ tricuspid- RV hypertrophy due to fluid
@ mitral- LV hypertrophy due to pressure

Front 100

S2 split

Back 100

will hear aortic valve before pulmonic valve b/c there's more blood in R <3 than L <3

*normal during inspiration; heard @ base

Front 101

S3

Back 101

ventricular gallop
"ken-tuc-ky"

best w/ bell, L lateral decubitus position
can be normal in children and young adults--will go away if they sit up; if this doesn't go away in adults >> CHF

Front 102

S4

Back 102

atrial gallop
ten-ne-see

best w/ bell
may hear in athletes; usually in adults w/ <3 disease (stiffness due to CAD, systemic HTN)

Front 103

summation gallop

Back 103

when you hear both S3 and S4

Front 104

first signs of CHF

Back 104

fluid overload, edema, neck distention, S3

Front 105

rating of mumurs

Back 105

i. barely audible
ii. clearly audible
iii. moderately loud
iv. loud, associated w/ thrill
v. very loud
vi. heard w/ steth off the chest wall

Front 106

mumurs

Back 106

*turbulence through a valve

timing- systolic or diastolic?
location- apex, base, sternal border?
loundness/intensity
pitch
pattern- plateau, crescendo, decrescendo
quality
radiation- to neck?
position of patient

Front 107

T/F. Diastolic murmurs are worse than systolic murmurs.

Back 107

True

Front 108

structural changes that may cause murmurs

Back 108

stenotic valve- calcification can cause turbulence
incompetent valve- blood goes backwards (e.g. varicose vein or mitral valve)

Front 109

murmurs during systole

Back 109

midsystolic ejection- aortic stenosis, pulmonic stenosis
pansystolic- mitral regurgitation, tricuspid regurgitation

*aortic stenosis & mitral regurgitation are more common b/c it is a higher pressure system

Front 110

murmurs during diastole

Back 110

diastolic rumbles- mitral stenosis, tricuspid stenosis
early diastolic- aortic regurgitation, pulmonic regurgitation

Front 111

pericardial rub

Back 111

inflammation in lining of heart; treated w/ advil

Front 112

ischemia v. infarction

Back 112

ischemia- deficient supply of oxygenated blood
e.g. pain s/p exercise in smokers

infarction- complete blockage

Front 113

T/F. Body has more arteries and they are closer to the skin.

Back 113

False; veins

Front 114

T/F. Veins and arteries run parallel.

Back 114

True

Front 115

mechanisms of venous flow

Back 115

-contract skeletal muscles to milk the blood proximally back to heart
-intraluminal valves ensure unidirectional flow
-patent lumen
-inspiration: (-) thoracic pressure, (+) abdominal pressure helps blood get back to heart

Front 116

lymphatic ducts & draining patterns

Back 116

thoracic ducts drains most of body

R lymphatic duct drains R face, arm, mediastinum (heart and lung)

Front 117

functions of lymphatic system

Back 117

-conserve fluid and proteins that leak out of capillaries
-immune system
-absorb lipids from intestinal tract

Front 118

subjective PV

Back 118

1/ pain or cramps
2/ skin changes on arms or legs
3/ swelling
4/ lymph node enlargement
5/ medications- oral contraceptives can cause more blood clots

Front 119

clubbing

Back 119

greater than 160 degrees; normal is less

Front 120

palpate aortic pulsation

Back 120

patient should be supine, knees flexed

-press firmly on ABD left of midline, just above belly button
-should be less than 3 cm wide

*important to perform on older people (over 50), smokers, HTN

Front 121

inguinal lymph nodes

Back 121

palpable--should be soft, mobile, less than 1 cm
*normal to feel them in groin area

Front 122

indications for ABD aneurysm

Back 122

-if femoral is decreased compared to carotid
-if bruit is heard over ABD area
-if aortic pulsation is greater than 3 cm

Front 123

edema

Back 123

1+ to 4+ (if indentation remains)

causes--
1/ deep venous thromosis (DVT)- blood clot in veins, swelling in one leg but not the other, femoral vein tenderness
2/ chronic venous insufficiency- previous DVT or varicose vein; skin will thicken and get brawny brown color
3/ lymphedema- lymph obstruction from inflammation or tumor, does not pit
4/ orthostatic edema- prolonged standing
5/ CHF- heart has decreased ability to take up fluid

Front 124

allen test

Back 124

make sure ulnar artery is working if IV is on radial artery

Front 125

manual compression test

Back 125

compress vein

competent valves- if no wave is felt
incompetent valve- if wave felt

Front 126

chronic arterial insufficiency v. chronic venous insufficiency

Back 126

Front 127

venous insufficiency

Back 127

varicose veins- regurgitating blood back to legs
browning will lead to ulcer

Front 128

arterial insufficiency

Back 128

when you raise feet, pallor
standing, erythema

Front 129

homan's sign

Back 129

support thigh & bend knee slightly, abruptly dorsiflex ankle
(+) if patient experiences deep calf pain which could indicate blood clot in the calf

30% accurate

Front 130

What are better indicators of DVT?

Back 130

red, hot, swollen behind knees

Front 131

T/F. Heart and great vessels develop during first 3 to 8 weeks of gestation.

Back 131

True

Front 132

fetal circulation

Back 132

lung sacs are collapsed and blood is oxygenated through the placenta

high pulmonary vascular resistance limits blood flow into the lungs and redirects it through the patent ductus arteriosus (PDA) to the descending aorta and lower body

with a baby’s first breaths, pulmonary vascular resistance falls, causing a dramatic increase in pulmonary blood flow

at birth, the right ventricle is larger than the left due to high pulmonary resistance during fetal life

Front 133

notable cardiac differences in peds

Back 133

infant's <3 is proportionately larger to body

depended to HR and rhythm to maintain CO; cannot adjust (+) stroke volume

myocardial muscle is less efficient >> more sensitive to volume pressure overload

heart sounds are higher pitched, greater intensity

Front 134

maternal health history related to cardiac function

Back 134

rubella is associated w/ <3 defects
lithium
DM esp. if untreated

Front 135

What is one of the best health indicators in infants?

Back 135

weight gain, height, BMI (starts at age 2), head circumference (until age 3)

Front 136

How many bpm does an increase in one degree fahrenheit cause?

Back 136

8-10 bpm

Front 137

T/F. It is normal for pulse to increase w/ inspiration.

Back 137

True

Front 138

peds cyanosis

Back 138

central- mouth
acrocyanosis- hands and feet, common in infants

Front 139

T/F. The infant heart is more horizontal.

Back 139

True

-apex is higher, 4th intercostal space
-PMI is usually palpated at an intercostal space higher (~3rd or 4th intercostal space)
-apex is in the adult position (5th intercostal space) by age 7

Front 140

T/F. You should palpate the radial and femoral pulses simultaneously.

Back 140

True. Absence or weaker pulses in the lower extremities compared to the upper extremities is suggestive of coarctation of the aorta.

Front 141

What is the most important assessment skill in evaluation of infants?

Back 141

auscultation- sitting and lying down, use diaphragm

Front 142

T/F. It is unusual for peds to have skipped heart beat, fast HR, or an extra beat.

Back 142

False; it is NOT unusual

Front 143

other usual findings for peds

Back 143

-S2 split; w/ inspiration
-S3 is common; benign
-murmurs are common; 50% are innocent

Front 144

What does S4 indicate in peds?

Back 144

S4 is rare; decreased ventricular compliance

Front 145

physiological murmurs in peds

Back 145

innocent, systolic, vibratory, musical, does not transmit to other areas of heart

short duration
grade III or less; do not increase over time

Front 146

pathological murmurs in peds

Back 146

diastolic, loud
long duration
greater than grade II

usually caused by aortic or pulmonic regurgitation or mitral stenosis