Physical Examination: Cardiovascular and Pulmonary Systems

Question 1

List 3 possible signs of decreased cardiac output and low oxygen saturation.

Answer 1

1. Cyanosis: bluish color of the skin, nail beds, lips and tongue
2. Pallor: washed out, absence of pink, rosy color
3. Diaphoresis: excess sweating and cool, clammy skin

Question 2

How is an apical pulse assessed?

Answer 2

Patient is placed in supine, palpate at 5th intercostal space and midclavicular line

Question 3

What is the best site to monitor pulse in an infant?

Answer 3

Brachial artery (medial aspect of the antecubital fossa)

Question 4

Explain the grading scale for peripheral pulses.

Answer 4

Grade 0 = absent pulse, not palpable 
Grade 1 = pulse diminished, barely perceptible 
Grade 2 = Easily palpable, normal 
Grade 3 = full pulse, increased strength
Grade 4 = bounding pulse

Question 5

What is the normal heart rate for adults, children and newborns?

Answer 5

1. Adults and teenagers: 60-100 bmp (40-60 in aerobically trained)
2. Children = 60-140 bpm
3. Newborn = average is 127 bpm; normal range 90-164 bpm

Question 6

A heart rate of ____ is considered tachycardia, and a heart rate of ____ is considered bradycardia.

Answer 6

Tachycardia = > 100 bpm
Bradycardia = < 60 bpm

Question 7

What is postural tachycardia syndrome?

Answer 7

Sustained heart rate increase greater than or equal to 30 bpm within 10 minutes of standing (> 40 bpm on teenagers)

Question 8

Describe the difference between S1 and S2 sounds during auscultation.

Answer 8

S1 sound (lub): normal closure of mitral and tricuspid valves; marks the end of systole; decreased in first degree heart block

S2 sound (dub): normal closure of aortic and pulmonary valves; marks end of systole; Decreased in aortic stenosis.

Question 9

Describe the S3 heart sound. Is this normal?

Answer 9

Vibrations of the distended ventricle walls due to passive flow of blood from the atria during the rapid filling phase of diastole

Normal in healthy young children
Abnormal in adults (ventricular gallop)

Question 10

Describe the S4 heart sound. What 3 conditions is this sound associated with?

Answer 10

Pathological sound of vibration of the ventricular wall with ventricular filling and atrial contraction

Associated with hypertension, stenosis and MI (atrial gallop)

Question 11

What is a thrill?

Answer 11

An abnormal tremor accompanying a vascular or cardiac murmur; felt on palpation

Question 12

What is a bruit? What is this indicative of?

Answer 12

An adventitious sound or murmur (blowing sound) of arterial or venous origin

Indicative of atherosclerosis

Question 13

Where is blood pressure typically taken?

Answer 13

At the brachial artery of the right arm using a sphygmomanometer

Question 14

What values are considered to be normal, prehypertension, stage 1, stage 2 hypertension, and hypertensive crisis?

Answer 14

Normal BP: 120/80
Prehypertension: Systolic 120-129 or diastolic 80-89 mmHg
Stage 1 Hypertension: > 130/80
Stage 2 Hypertension: > or equal to 140/90
Hypertensive crisis: > 180/120

Question 15

What is orthostatic hypotension? How is it assessed?

Answer 15

Drop in BP that accompanies change from supine to standing position

1. Initial BP and HR assessment when patient supine, at rest for > 5 minutes
2. Patient moves directly to standing position and repeat BP and HR assessment immediately and again at 3 minutes

Question 16

A patient is considered orthostatic if systolic BP drops ____ or if the diastolic BP drops _____.

Answer 16

Systolic drops > 20 mmHg

Diastolic drops > 10 mmHg

Question 17

What is mean arterial pressure (MAP)? Normal values? How is it calculated?

Answer 17

The arterial pressure within the large arteries over time; dependent on mean blood flow and arterial compliance

Normal values: 70-110 mmHg
MAP = [SBP + 2(DBP)] / 3

Question 18

What is the normal respiratory rate for an adult, newborn, and child?

Answer 18

Adult = 12-20 bpm 
Newborn = 30-40 bpm
Child = 20-30 bpm

Question 19

What is the difference between tachypnea, bradypnea and hyperpnea?

Answer 19

Tachypnea = an increase in RR > 22 breaths per minute 
Bradypnea = a decrease of RR < 10 breaths per minute 
Hyperpnea = an increase in depth and rate of breathing

Question 20

What is the difference between dyspnea, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea?

Answer 20

Dyspnea = shortness of breath
Dyspnea on exertion = shortness of breath brought on by exercise or activity
Orthopnea = inability to breath when in a reclining or supine position
Paroxysmal nocturnal dyspnea = sudden inability to breath occurring during sleep

Question 21

Describe normal tracheal and bronchial sounds.

Answer 21

Loud tubular sounds normally heard over the trachea

Inspiratory phase is shorter than the expiratory phase and there is a slight pause between them

Question 22

Bronchial sounds heard over the _____ are abnormal and indicate _____ or ____ of lung tissue that facilitates transmission of sound.

Answer 22

Distal airways
Consolidation
Compression

Question 23

Describe vesicular sounds.

Answer 23

High pitched, breezy sounds normally heard over the distal airways in healthy lung tissue

Inspiratory phase is longer than expiratory phase and there is no pause between them.

Question 24

_____ and _____ are considered adventitious (abnormal) breath sounds.

Answer 24

Crackles (rales/crepitation)

Wheezes

Question 25

Describe crackles. List 3 conditions where crackles may be heard during auscultation.

Answer 25

An abnormal, discontinuous, high pitched popping sound heard more often during inspiration Atelectasis, fibrosis, pulmonary lung disease

Question 26

What is a pleural friction rub?

Answer 26

Dry, crackling sound heard during both inspiration and expiration. Occurs when inflamed visceral and parietal pleurae rub together Heard over the spot where the patient feels pleuritic pain

Question 27

What is the difference between hypoxemia, hypoxia and anoxia?

Answer 27

``` Hypoxemia = abnormally low amount of oxygen in the blood Hypoxia = low oxygen levels in the tissue Anoxia = complete lack of oxygen ```

Question 28

List 5 areas where cardiac pain can refer.

Answer 28

``` Shoulders Back Arms Neck Jaw ```

Question 29

Pain referred to the back can occur from ______.

Answer 29

Dissecting aortic aneurysm

Question 30

Explain the angina pain scale.

Answer 30

``` 1 = mild, barely noticeable 2 = moderate, bothersome 3 = moderately severe, very uncomfortable 4 = most severe or intense pain ever experienced ```

Question 31

What is diaphoresis? What can it be associated with?

Answer 31

Excess sweating that can be associated with decreased cardiac output

Question 32

What is clubbing? What is it associated with?

Answer 32

Curvature of the fingernails with soft tissue enlargement at base of nail Associated with chronic oxygen deficiency, chronic pulmonary disease and heart failure

Question 33

What trophic changes are associated with peripheral arterial disease (PAD)?

Answer 33

Pale, shiny, dry skin, with loss of hair

Question 34

What is Stemmer's sign? What is it indicative of?

Answer 34

Dorsal skin folds of the toes or fingers are resistant to lifting Indicative of fibrotic changes and lymphedema

Question 35

Peripheral edema is associated with ____ and ____. Bilateral edema is associated with _____.

Answer 35

Peripheral = chronic venous insufficiency and lymphedema Bilateral = congestive heart failure

Question 36

Describe the grading scale for edema.

Answer 36

1+ Mild, barely perceptible indentation; <1/4 inch pitting 2+ Moderate, easily identifiable depression; returns to normal within 15 seconds; 1/4-1/2 inch pitting 3+ Severe, depression takes 15-30 seconds to rebound; 1/2-1 inch pitting 4+ Very severe, depression lasts for > 30 seconds or more; > 1 inch pitting

Question 37

What is intermittent claudication?

Answer 37

Pain, cramping and LE fatigue occurring during exercise and relieved by rest

Question 38

Explain the treadmill test for intermittent claudication.

Answer 38

Have the patient walk on a treadmill at 1mph and note the level of claudication pain and time of test pain was experienced

Question 39

Describe the grading scale of intermittent claudication.

Answer 39

Grade 1 = minimal discomfort or pain Grade 2 = moderate discomfort or pain; patient's attention can be diverted Grade 3 = Intense pain; patient's attention cannot be diverted Grade 4 = excruciating and unbearable pain

Question 40

Describe the different sites of pain with intermittent claudication and their associated sites of stenosis.

Answer 40

Pain in the buttock, hip or thigh = obstruction of aorta and iliac arteries Pain in the calf = stenosis of femoral and popliteal arteries Pain in the ankle or foot = disease of the tibial or peroneal arteries

Question 41

What is the ankle brachial index? How is it assessed? How is calculated?

Answer 41

ABI compares systolic blood pressure at the ankle and arm to check for peripheral artery disease. Measure UE systolic BP at the brachial artery and LE systolic BP at posterior tibial and dorsalis pedis arteries ABI is calculated by dividing the higher of the two BP measurements in the ankles by the higher of the two systolic BP measurements at the arms

Question 42

Describe the significance of ankle brachial index values.

Answer 42

> 1.4 = indicates non-compliant, rigid arteries 1-1.4 = normal 0.91-0.99 = mild blockage, beginning of PAD < 0.9 = moderate blockage; maybe associated with intermittent claudication < 0.5 = severe blockage and arterial disease; may have claudication pain at rest

Question 43

What is capillary refill time? How is it tested? Normal values?

Answer 43

The time it takes the capillary bed to refill after it is occluded by pressure is an indicator of impaired perfusion to the extremities 1. Apply firm pressure over a nail bed or bony prominence until the nail or skin blanches. 2. Release the pressure 3. Observe the time for the nail or skin to regain its full color ``` Normal = full color returns in < 2 seconds Abnormal = refill time > 2 seconds ```

Question 44

What is body mass index? How is calculated?

Answer 44

Describes relative weight for height to determine risk for obesity BMI = weight (kg) / height (m^2)

Question 45

Describe the normal versus abnormal BMI values.

Answer 45

``` < 18.5 = underweight 18.5-24.9 = normal 25-29.9 = overweight > 30 = obesity > 40 = morbid obesity ```

Question 46

What is the percussion test? How is it performed? Positive findings?

Answer 46

Determines competence of greater saphenous vein IN standing, palpate one segment of the vein while percussing vein approximately 20 cm higher Positive: if pulse wave is felt by lower hand, the intervening valves are incompetent

Question 47

What is the normal position of the trachea?

Answer 47

Positioned at midline, superior to the suprasternal notch

Question 48

What is the normal thoracic excursion in healthy adults from full inspiration to end tidal volume expiration?

Answer 48

Between 2-3 inches

Question 49

What is mediate percussion? How is it performed?

Answer 49

The act of tapping the surface of the body to identify areas of altered density Place the palmar surface of the middle finger firmly against the chest wall in the intercostal space parallel to the ribs and strike this finger with a quick, sharp blow using the middle finger of the other hand.

Question 50

______ is the normal percussion sound of an air-filled lung. ______ is the sound that occurs almost exclusively with a large pneumothorax.

Answer 50

Resonance is normal Tympany = pneumothorax (hollow drumbeat sound)

Question 51

What is the purpose of pulmonary function testing (PFT)? Describe the testing procedure.

Answer 51

Evaluate lung volumes, capacities and flow rates. Subject exhales into spirometer as hard and as fast as possible for 6 seconds until no more air can be expelled

Question 52

Obstructive ventilatory impairment is characterized by decreased _____. What is the primary PFT indicator of an obstructive impairment.

Answer 52

Decreased EXPIRATORY FLOW Primary indicator = FEV1/FVC < 70%

Question 53

List the classifications of obstructive lung disease based on FEV1/FVC ratios.

Answer 53

FEV1/FVC > 100% = normal variant FEV1/FVC 70-100% = normal to mild obstruction FEV1/FVC 60-70% = moderate obstruction FEV1/FVC 50-60% moderate to severe obstruction FEV1/FVC < 50% = severe obstruction

Question 54

_____ is often used to get an estimate of SpO2.

Answer 54

Pulse oximetry

Question 55

What is rate pressure product (RPP)? How is it calculated?

Answer 55

Index of myocardial oxygen consumption and coronary blood flow RPP = HR x SBP (Take HR and SBP during the same exercise workload)

Question 56

How should the rate pressure product (RPP) be used when developing an exercise program for patients with angina?

Answer 56

Keeping the intensity of exercise below the RPP value will reduce the risk of developing angina