Exam 2 Study Guide Flashcards
(152 cards)
1
Q
What are true ribs?
A
Ribs 1-7 are considered true ribs.
2
Q
How do ribs 8-10 attach?
A
Ribs 8-10 attach to the costal cartilage of the ribs above.
3
Q
What are ribs 11 and 12 classified as?
A
Ribs 11 and 12 are free floating.
4
Q
What is the costotransverse joint?
A
It is the joint between the tubercle of the rib and the transverse costal facet of the corresponding vertebra.
5
Q
What is the costovertebral joint?
A
It is the joint between the head of the rib, the superior costal facet of the corresponding vertebra, and the inferior costal facet of the vertebra above.
6
Q
How many facets does rib one have?
A
Rib one has only one facet which articulates with the corresponding vertebra.
7
Q
What is unique about rib two?
A
Rib two has a roughened area on its upper surface from which the serratus anterior muscle originates.
8
Q
How many facets does rib 10 have?
A
Rib 10 has only one facet for articulation with its numerically corresponding vertebra.
9
Q
What is unique about ribs 11 and 12?
A
Ribs 11 and 12 have no neck and only one facet which articulates with the corresponding vertebra.
10
Q
Where is liver dullness located?
A
Liver dullness is located in the right fifth intercostal space in the right midclavicular line.
11
Q
What is tympany over gastric space?
A
Tympany is noted over the gastric space on the left.
12
Q
What is the Manubriosternal angle also known as?
A
It is also known as the angle of Louis or sternal angle.
13
Q
What does the Manubriosternal angle mark?
A
It marks the site of tracheal bifurcation into the right and left main bronchi.
14
Q
Where does the Manubriosternal angle lie in relation to the thoracic vertebrae?
A
It lies above the fourth thoracic vertebra on the back.
15
Q
What is the costal angle?
A
The costal angle is formed where the right and left costal margins meet at the xiphoid process.
16
Q
What should the costal angle measure?
A
The costal angle should be less than 90 degrees.
17
Q
What happens to the costal angle in emphysema?
A
The angle increases when the rib cage is chronically overinflated as in emphysema.
18
Q
How do spinous processes align with ribs?
A
Spinous processes align with the same rib down to T4.
After T4 they angle downward so much that they overlie the vertebral body
and the rib below and no longer correspond with the same rib
19
Q
What is unique about C7 vertebra?
A
C7 is the largest and most inferior vertebra in the neck region. It has no split tip.
20
Q
Where is the inferior border of the scapula located?
A
The inferior border of the scapula is at the 7th or 8th rib.
21
Q
How does the right lung differ from the left lung?
A
The right lung is shorter due to the liver; the left lung is narrower due to the heart.
22
Q
Where is the lung apex located?
A
The lung apex is 3-4 cm above the inner 1/3 of the clavicle.
23
Q
Where is the base of the lung located?
A
The base of the lung is around the 6th rib at the midclavicular line.
24
Q
What is the location of the oblique fissure?
A
The oblique fissure crosses the fifth rib at the midaxillary line and terminates at the sixth rib at the midclavicular line.
25
How far do the lungs extend posteriorly?
On the lateral chest, the lungs go down to the 7th or 8th rib.
26
What is the length of the trachea in adults?
The trachea is 10-11 cm long in adults.
27
What is the volume of air in the airway dead space?
There is 150 mL of air in the airway dead space, which is lined with goblet cells that secrete mucus.
28
What is an acinus?
The acinus is the functional unit in the lungs that consists of bronchioles, alveolar ducts, alveolar sacs, and alveoli.
29
What is the normal AP/transverse diameter ratio?
The normal AP/transverse diameter ratio is 0.7-0.75.
30
What are the three types of breath sounds?
The three types of breath sounds are bronchial (or tracheal/tubular), bronchovesicular, and vesicular.
31
What is tactile fremitus?
Fremitus is the use of hands to palpate vibrations as the patient talks, such as repeating '00' or 'blue moon'.
32
What is normal voice transmission?
Normal voice transmission is soft, muffled, and indistinct; you can hear sound through a stethoscope but cannot distinguish exactly what is being said.
33
What pathology affects lung density?
Pathology that increases lung density (e.g. tumor) enhances the transmission of voice sounds.
34
What are some surgical pulmonary complications?
Atelectasis, lobar pneumonia, bronchitis (acute or chronic), emphysema, pleural effusion or thickening, pneumocystis jiroveci pneumonia, pulmonary embolism.
35
What defines chronic bronchitis?
Productive cough for greater than 3 months for 2 consecutive years that is not attributed to another cause.
## Footnote
Causes include mucous gland hyperactivity and chronic inflammation of the airway causing bronchial secretions.
36
What characterizes emphysema?
Productive cough for greater than 3 months for 2 consecutive years that is not attributed to another cause, along with parenchymal destruction (loss of alveolar attachments and reduced elastic recoil of alveoli).
37
How do patients with COPD fare postoperatively?
Patients with COPD are twice as likely to have postoperative pulmonary complications.
## Footnote
Preoperative assessment should include evaluating severity, perioperative pulmonary risks, optimizing medical management, and planning perioperative care.
38
What is obstructive sleep apnea (OSA)?
Apnea lasting 10 seconds or longer; affects 9-25% of the general population.
39
What are standard screening tools for OSA?
STOP-Bang, P-SAP, Berlin, ASA checklist.
40
How is OSA diagnosed?
Diagnosed with overnight polysomnography (PSG) to determine apnea hypopnea index (number of abnormal respiratory events in an hour must decrease in saturation by 3-4%).
## Footnote
Severity classification: Mild (5-14), Moderate (15-30), Severe (>30).
41
What is the treatment approach for suspected OSA?
Treat like OSA until proven otherwise; assess adherence to PAP use and continue PAP use postoperatively.
42
What equipment or plan should a facility have for continuous monitoring in an OSA patient
The facility should have equipment (or a plan) for continuous pulse oximetry and overnight stay if needed.
43
What should be considered if the OSA diagnosis is unknown but suspected or non-compliant?
Easy on opioids.
44
Is EKG or chest X-ray necessary for unknown diagnoses?
No need for EKG or chest X-ray.
45
What should be considered in the management of anesthesia for an OSA patient?
Consider regional anesthesia, limit opioids, use short-acting medications, and ensure post-operative monitoring.
46
What is the diagnosis criteria for asthma?
Primary diagnostic tool is spirometry
Diagnosis is based on bronchial hyperresponsiveness and airflow obstruction.
47
What are the pathological features of asthma?
Chronic airway inflammation, increased bronchial smooth muscle mass, mucus hypersecretion, and luminal narrowing.
48
At what age is asthma typically diagnosed?
Typically diagnosed before age 20.
49
What is the primary diagnostic tool for asthma?
Spirometry.
50
What are some differential diagnoses for asthma?
Other obstructive pulmonary conditions like cystic fibrosis (CF), heart failure (HF), and tracheal stenosis.
51
When is asthma considered not controlled?
If symptoms occur more than 2 times a week, there are weekly nighttime awakenings, limitations in normal activity, use of short-acting bronchodilators for symptom control more than 2 days a week, FEV1 or peak expiratory flow rate is less than 80% of predicted personal best, or more than 2 exacerbations requiring systemic glucocorticoids in the last year.
52
What is the GOLD classification for COPD?
GOLD 1: Mild; FEV1 > 80% of predicted.
GOLD 2: Moderate; FEV1 < 80% of predicted.
GOLD 3: Severe; FEV1 > 30%.
GOLD 4: Very severe; FEV1 < 30% of predicted.
53
What are the New York classifications of heart disease?
I: No limitations.
II: Slight limitation but comfortable at rest; ordinary activity results in fatigue/SOB.
III: Marked limitation of physical activity but still comfortable at rest.
IV: Unable to carry on any physical activity without discomfort; symptoms at rest.
54
What characterizes restrictive disease in PFT results?
Decreased TLC, VEC1, and FVC
## Footnote
Normal/increased FEV1/FVC ratio
55
What are intrinsic causes of restrictive disease?
Inflammation, fibrosis of lung parenchyma, decreased distensibility, and increased recoil of lungs.
56
What are extrinsic causes of restrictive disease?
Pleural effusions, ankylosing spondylitis, kyphoscoliosis, obesity.
57
What neuromuscular disorders can cause restrictive disease?
Myasthenia gravis, Guillain-barre syndrome, muscular dystrophies.
58
What are common symptoms of restrictive disease?
Progressive dyspnea on exertion and non-productive cough.
59
What history is relevant in restrictive disease?
History of occupational exposure.
60
What physical findings are associated with restrictive disease?
Fine crackles, finger clubbing, abnormal surgical lung biopsy.
61
What should be assessed in chest X-rays?
Name/maker/rotation/penetration, lines/metal work, heart, mediastinum, lungs (zones), bones, diaphragm, soft tissue.
62
What is the proper placement of an NG tube?
Follows straight course down midline of chest to a point BELOW the diaphragm. Tube is not coiled anywhere.
63
How is heart size assessed in chest X-rays?
Heart = 1/3-1/2 the distance from spine to side in the PA erect view.
## Footnote
CANNOT comment on heart size on AP view because of magnification of heart.
64
What is the alignment of clavicles in chest X-rays?
Clavicles equidistant from spinous processes of thoracic spine, can just see lower thoracic spine.
65
What is the tidal volume and its percentage of total lung capacity?
Tidal volume is 500 mL, which is 9% of total lung capacity.
66
What is the inspiratory reserve volume and its percentage of total lung capacity?
Inspiratory reserve volume is 3,000 mL, which is 52% of total lung capacity.
67
What is the expiratory reserve volume and its percentage of total lung capacity?
Expiratory reserve volume is 1,300 mL, which is 22% of total lung capacity.
68
What is the residual volume and its percentage of total lung capacity?
Residual volume is 1,000 mL, which is 17% of total lung capacity.
69
What do pulmonary function tests (PFTs) measure?
PFTs measure how well the lungs work and show evidence of respiratory disease, progression of disease, efficacy of treatment, post-op evaluation, and signs of certain medication toxicities.
70
What characterizes an obstructive pattern in flow volume loops?
An obstructive pattern is shown by a baby carriage scoop, with decreased FEV1, normal or decreased FVC, and decreased FEV1/FVC ratio.
71
What conditions can an obstructive pattern indicate?
It can indicate asthma, COPD, chronic bronchitis, and emphysema.
72
What characterizes a restrictive pattern in flow volume loops?
A restrictive pattern shows a smaller loop overall, decreased TLC, FEV1, and FVC, with a normal FEV1/FVC ratio and low DLCO.
73
What conditions can a restrictive pattern indicate?
It can indicate interstitial lung disease, severe skeletal abnormalities, or diaphragmatic paralysis.
74
What is WPW and its triad of symptoms?
WPW links the atria and ventricles bypassing the AV node via an accessory pathway, characterized by a short P-R interval, Delta wave, and wide QRS.
75
What is the treatment of choice for WPW?
The treatment of choice for WPW is ablation.
76
What other treatments can be used for WPW?
Amiodarone and procainamide can also be used.
77
What medications should be avoided in WPW treatment?
B-blockers and calcium channel blockers should be avoided.
78
What is required for ST elevation to be significant?
ST must vary from isoelectric line by 1 or more millimeters in 2 consecutive limb leads or 2 or more millimeters in 2 consecutive chest leads.
79
What does ST elevation indicate?
ST elevation indicates infarction and benefits from emergent intervention like percutaneous coronary intervention or thrombolytics.
80
What is ST depression normally due to?
ST depression is normally due to ischemia.
81
What can ST segment depression indicate in digoxin toxicity?
ST segment depression may also be seen in digoxin toxicity, where it will be down sloping.
82
What characterizes Non-STEMI?
Non-STEMI usually involves multiple coronary lesions and requires coronary angiography within days of symptoms after initiation of medical treatment.
83
What is Type 1 MI?
Type 1 MI is spontaneous and related to primary events like plaque erosion, rupture, fissuring, or dissection. It can lead to STMEI or Non-STEMI.
84
What is Type 2 MI?
Type 2 MI results from oxygen supply/demand mismatch due to factors like tachycardia, coronary spasm, or anemia. It can ONLY lead to Non-STEMI.
85
What leads indicate Anterior STEMI?
Anterior STEMI is indicated by ST elevation in leads V3-V4 (LAD)
86
What leads indicate Posterior STEMI?
Posterior STEMI is indicated by ST depression in V1-V3 with upright T waves (PDA occlusion)
87
What leads indicate Inferior STEMI?
Inferior STEMI is indicated by leads II, III, aVF (RCA occlusion)
88
What is the mean pulmonary artery pressure (mPAP) threshold for pulmonary hypertension?
Mean pulmonary artery pressure (mPAP) >25 mmHg at rest.
89
What is the standard for diagnosing pulmonary hypertension?
Right heart catheterization is the standard for diagnosis.
90
What test can identify severity in pulmonary hypertension?
A walking test can identify severity; the ability to walk <600m indicates increased disease/risk.
91
What should be done regarding elective surgery in pulmonary hypertension?
Elective surgery should be postponed.
92
What should be avoided in patients with pulmonary hypertension?
Avoid hypotension and keep the patient on all medications.
93
What leads are used to determine the EKG axis?
Leads I and aVF.
94
What does it indicate if both leads I and aVF point up?
It’s normal.
95
What does it indicate if lead I is pointed down?
You have RIGHT axis deviation.
96
What does it indicate if aVF is pointed down?
You have LEFT axis deviation.
97
What are some causes of left axis deviation?
Can be normal if diaphragms are raised, left ventricular hypertrophy, left anterior hemiblock, hyperkalemia, ventricular tachycardia, paced rhythm.
98
What are some causes of right axis deviation?
Normal in children or young thin adults, right ventricular hypertrophy, pulmonary embolism, anterolateral myocardial infarction, left posterior hemiblock, septal defect.
99
Do murmurs in the immediate newborn period indicate congenital heart disease?
No, they should disappear within 2-3 days.
100
What does the absence of a murmur in a newborn indicate?
It does not indicate a healthy heart.
101
What is patent ductus arteriosus (PDA)?
Connection between pulmonary artery and aorta stays open.
102
What is an atrial septal defect (ASD)?
A congenital heart defect characterized by an opening in the atrial septum.
103
What is a ventricular septal defect (VSD)?
A congenital heart defect characterized by an opening in the ventricular septum.
104
What are the components of Tetralogy of Fallot?
Pulmonary valve stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy.
105
What is coarctation of the aorta?
Narrowing of the aorta.
106
What is BNP released due to?
BNP is released due to myocardial wall stretching.
107
What BNP level indicates heart failure is likely?
At 400 pg/mL, heart failure is likely (0-100 pg/mL indicates heart failure is unlikely).
108
What is HFrEF?
HFrEF is heart failure with reduced ejection fraction, defined as EF <40; systolic heart failure.
109
What is HFpEF?
HFpEF is heart failure with preserved ejection fraction, defined as EF >50; diastolic heart failure.
110
What labs are important in heart failure?
CBC; anemia results in a twofold increase in mortality postoperatively. Chemistries: electrolyte abnormalities/renal function. PT may be prolonged if liver congestion is present.
111
Is routine ECG recommended in heart failure?
Routine ECG is NOT recommended.
112
What are the treatments for heart failure?
Treat hypertension, control heart rate, manage arrhythmias, diuresis for symptomatic improvement, correction of anemia, treatment of underlying cause or precipitating conditions, ARB, ACEI, AngII inhibitors, beta blockers (continue day of surgery but do not initiate just prior to surgery).
113
Where do we listen for aortic stenosis?
Aortic stenosis is best heard at the right upper sternal border.
114
Where do we listen for aortic regurgitation?
Aortic regurgitation is best heard at the left sternal border.
115
Where do we listen for mitral stenosis/regurgitation/prolapse?
Mitral stenosis/regurgitation/prolapse is best heard at the apex.
116
Where do we listen for tricuspid regurgitation?
Tricuspid regurgitation is best heard at the lower left sternal border.
117
Where do we listen for hypertrophic cardiomyopathy?
Hypertrophic cardiomyopathy is best heard at the lower left sternal border.
118
Where is a murmur heard with a midsystolic crescendo-decrescendo and what does it indicate?
A midsystolic crescendo-decrescendo murmur is best heard at the left sternal border and is indicative of aortic stenosis
119
What type of disorder is Cystic Fibrosis?
Autosomal disorder; CFTR found on epithelial exocrine glands.
120
What are the pulmonary function test results in Cystic Fibrosis?
Decreased FEV1 and FEV1/FVC ratio; Increased residual volume.
121
What are common respiratory symptoms of Cystic Fibrosis?
Wheezing.
122
What should be avoided in patients with Cystic Fibrosis during anesthesia?
Avoid general anesthesia if possible.
123
What is the anesthetic plan for Cystic Fibrosis patients?
Restrict fluids, optimize pain control, chest physiology, use of I.S.
## Footnote
Continue CF meds, tight glucose control, plan for sputum clearance techniques.
124
What is the significance of Right Bundle Branch Block (RBBB)?
Can be an isolated anomaly without underlying disease; more common than Left.
## Footnote
May occur in chronic conditions affecting the right side of the heart including ASD, chronic pulmonary disease, pulmonary HTN, or PE.
125
What does Left Bundle Branch Block (LBBB) indicate?
More likely to indicate underlying disease; can lead to systolic or diastolic dysfunction/HF.
## Footnote
Requires more in-depth assessment: LV hypertrophy, CAD, valve problems.
126
How can you identify a Left Bundle Branch Block on an EKG?
If the QRS complex is widened and downwardly deflected in lead V1.
127
How can you identify a Right Bundle Branch Block on an EKG?
If the QRS complex is widened and upwardly deflected in lead V1.
128
What should be done regarding immunosuppressive agents in heart transplant patients?
Do not stop immunosuppressive agents but know their side effects: renal insufficiency, electrolyte abnormalities, and increased risk of infection (20%).
129
What baseline assessments are needed for heart transplant patients?
EKG, stress test, echo, heart cath, and myocardial biopsy.
130
What characterizes a denervated heart?
It lacks sympathetic, parasympathetic, or sensory innervation, resulting in a faster heart rate due to lack of parasympathetic tone. The Frank-Starling mechanism drives heart function.
131
What is the outcome of a bicaval heart transplant?
The entire atrium is removed, leading to more ventricular ectopy and bradycardia that requires a pacemaker.
132
What is observed in a biatrial heart transplant?
It presents with 2 P waves, numerous blocks, and atrial fibrillation (Afib).
133
What are the risks associated with surgery in patients with an AICD?
Monopolar cautery can impact the defibrillator; bipolar usually has minimal impact. Cutting above the umbilicus can have a significant impact, and nerve stimulators and block stimulators must be used cautiously.
134
What interventions are commonly performed during surgery for patients with an AICD?
Most commonly, the unit is disabled during surgery. It is important to know the magnet response for the specific unit; for pacemakers, it usually initiates asynchronous pacing, while defibrillators are usually deactivated while the magnet stays in place.
135
What are the two types of heart valves?
Atrioventricular (mitral/tricuspid) and semilunar valves (aortic/pulmonic).
136
What are the characteristics of innocent murmurs in children?
Innocent murmurs are soft, relatively short systolic ejection murmurs, medium pitch, vibratory, and best heard at the left lower sternal or midsternal border, with no radiation to apex, base, or back.
137
What are midsystolic ejection murmurs associated with?
Midsystolic ejection murmurs are associated with aortic stenosis and pulmonic stenosis.
138
What are pansystolic regurgitant murmurs associated with?
Pansystolic regurgitant murmurs are associated with mitral regurgitation and tricuspid regurgitation.
139
What are diastolic rumbles of atrioventricular valves associated with?
Diastolic rumbles of atrioventricular valves are associated with mitral stenosis and tricuspid stenosis.
140
What are early diastolic murmurs associated with?
Early diastolic murmurs are associated with aortic regurgitation and pulmonic regurgitation.
141
What does S1 represent in heart sounds?
S1 represents the closure of AV valves and the beginning of systole, with the mitral component (M1) slightly preceding the tricuspid component (T1).
142
What does S2 represent in heart sounds?
S2 represents the closure of semilunar valves and the end of systole, with the aortic component (A2) slightly preceding the pulmonic component (P2), and S2 is loudest at the base.
143
What are the abnormal systolic heart sounds?
Abnormal systolic heart sounds include ejection click, aortic prosthetic valve sounds, and midsystolic click.
144
What are the abnormal diastolic heart sounds?
Abnormal diastolic heart sounds include opening snap, mitral prosthetic valve sound, third heart sound, fourth heart sound, summation sound, and pericardial friction rub.
145
What is S3 and when does it occur?
S3 occurs when ventricles are resistant to filling during the early rapid filling phase.
146
What is S4 and when does it occur?
S4 occurs at the end of diastole, at presystole, when the ventricle is resistant to filling; it occurs just BEFORE S1.
147
What does the A wave represent in the Jugular pulse?
A wave: atrial contraction because some blood flows backward to vena cava during right atrial contraction.
148
What does the C wave indicate in the Jugular pulse?
C wave: ventricular contraction; blood backflows due to upward bulging of tricuspid valve when it closes at beginning of ventricular systole.
149
What is represented by the X descent in the Jugular pulse?
X descent: atrial relaxation when right ventricle contracts during END systole and pulls bottom of atria downward.
150
What does the V wave signify in the Jugular pulse?
V wave: Passive atrial filling because of increased volume in the right atria.
151
What does the Y descent represent in the Jugular pulse?
Y descent: passive ventricular filling when tricuspid valve opens right BEFORE atrial contraction.
152
