Test 2 Flashcards
(202 cards)
1
Q
Angina
A
Heavy and tight gripping central chest pain/discomfort
Associated with exercise or emotional stress
Eased with rest
SOB and light headedness
Reproducible with exertion
Caused by atheroma or spasm in the coronary arteries
2
Q
Acute Coronary Syndrome
A
Unwell and distress with new onset chest pain or deterioration of pre-existing angina
Central retrosternal chest pain = crushing, often radiating to the left arm or neck
SOB, anxiety, sweating and restlessness
Due to atherosclerosis in the coronary arteries = coronary artery plaque ruptures or erodes leading to severe ischaemia
3
Q
Myocardial Infarction
A
Acute coronary syndrome is not recognized and treated
Cardiac myocytes die due to myocardial ischaemia
Reperfusion therapy with percutaneous coronary intervention (PCI) or fibrinolysis
Can lead to heart failure
4
Q
Peripheral Vascular Disease
A
Intermittent claudication/acute lower limb ischaemia
Atherosclerosis affect the aorto-iliac or infra-inguinal arteries
Aching immobilizing pain in calves which gets worse on exertion, improves with rest
Ischaemic limb = painful, white, cold, reduced sensation and movement
5
Q
Hypertension
A
No symptoms
Can cause vascular disease, arrhythmias, HF
6
Q
Heart failure
A
Reduction in cardiac function leading to compromised blood flow
RHF: peripheral oedema (ankle, sacral, abdominal), weight gain, elevated JVP, congested liver, anorexia and nausea
LHF: SOB on exertion, orthopnoea, paroxysmal noctural dyspnoea, may have a cough/fatigue, pulmonary oedema. Can be caused by myocardial diseases, volume overload, pressure overload, aortic stenosis.
Biventricular heart failure = symptoms of both left and right heart failure
7
Q
Atrial Fibrillation
A
SOB on exertion, decreased exercise tolerance, fatigue
Unusual feeling in chest
Aware of palpitations, heart beating out of rhythm
Can be asymptomatic
May present symptoms of cerebrovascular accident (stroke) due to embolus from the atrium
8
Q
Neurocardiogenic/Vasovagal Syncope
A
Temporary loss of consciousness after being exposed to specific triggers e.g. standing or emotion
Usually occurs in upright position
Resolves with lying down - may feel washed out/tired afterwards
Preceded by nausea, sweating, light headedness, blurred vision, headaches, palpitations, pallor and paraesthesiae
9
Q
Cardiac Valve Disease
A
Congenital, RF, Atherosclerosis, MI, HTN, Aging, Endocarditis Symptoms of cardiac pump failure Mitral Stenosis Mitral Regurgitation Aortic Stenosis Aortic Regurgitation
10
Q
Aortic Stenosis (CVD)
A
Breathlessness, chest pain/tightness with exertion, palpitations, pre-syncope or syncope
11
Q
Mitral Stenosis (CVD)
A
Breathlessness, paroxysmal nocturnal dyspnoea, palpitations, ankle swelling
12
Q
Aortic Regurgitation (CVD)
A
Breathlessness, exertion, chest pain on exertion, feeling tired, feeling faint, palpitations and symptoms of heart failure
13
Q
Mitral Regurgitation (CVD)
A
SOB, fatigue, orthopnoea, ankle swelling, increased volume in left atrium = pulmonary oedema
14
Q
Deep Vein Thrombosis
A
Usually after inactivity due to surgery/travel or injury
Clot in venous system
Calf pain, swelling, redness, engorged superficial veins
May be asymptomatic
Only diagnosed when patient presents with PE
15
Q
Pulmonary Embolism
A
Sudden unexplained SOB
Lung infarction = chest pain gets worse with breathing and haemoptysis
Sudden collapse with severe central chest pain, shock, pallor, sweatiness with syncope and sudden death
Embolus from a thrombus in venous system (often legs)
Causes DVT
16
Q
List the CVS symptoms
A
Chest pain Claudication Dyspnoea Syncope/Presyncope Palpitations Oedema
17
Q
Pain
A
Presentation of ischaemic heart disease
Acute coronary syndrome = retrosternal, crushing pain or heavy
Can radiate to arms, throat, jaws or teeth
Associated with dyspnoea, sweating, anxiety, nausea, vomiting
Not relieved by sublingual GTN
Precipitated by exercise, dull discomfort
Relieved by rest
Severity can vary widely = asking about chest discomfort is more sensitive than chest pain
18
Q
Dyspnoea
A
Unexpected awareness of breathing/air hunger
Assessment of exercise tolerance is important e.g. climbing stairs
Orthopnoea = redistribution of collected fluid in the lungs causing more widespread lung stiffness. Usually upper lobes. Ask about number of pillows slept on
Paroxysmal Nocturnal Dyspnoea = wake up breathless
19
Q
Palpitations
A
Unexpected/unpleasant awareness of heartbeat
20
Q
Syncope and Pre-syncope
A
Fainting
Loss of consciousness resulting from cerebral anoxia
Can be caused by arrhythmia or sudden emotional stress (vasovagal syncope)
Medications interfering with BP can be a cause
Enquire about circumstances of onset, preceding symptoms, duration and nature of recovery
Presyncope: decreased cerebral perfusion leading to light headedness and near fainting
21
Q
Oedema
A
Collection of fluid in interstitial space
Peripheral oedema = RHF and Bilateral HF
Ankle swelling due to cardiac failure is worse at end of day
Sacral oedema in patients lying in bed
Pulmonary oedema = dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea
Other causes of bilateral oedema = varicose veins, vasodilating Ca channel antagonists, hypoalbuminaemia (low albumin concentration
22
Q
Claudication
A
Ischaemic pain in muscles of leg
Crushing pain in calves after exercising
Relieved by rest
Normally due to peripheral vascular disease - inadequate vascular supply to the muscles of the leg
23
Q
List the places where temperature can be taken
A
Oral, tympanic, axillary, rectal
24
Q
What affects temperature?
A
Age, gender, ovulation, time of day (usually low in the morning, high in the evening)
25
List the advantages/disadvantages of tympanic temp
Quick and easy, tricky with small ear canals or hearing aids
26
List the advantages and disadvantages of axillary temperature.
Used in small babies. Difficult to keep in place with mobile patients. Takes longer than tympanic or rectal
27
List the advantages and disadvantages of oral temp
Comfortable, easily accessible, affected by recent intake of hot/cold drinks
Takes longer than oral rectal/tympanic
28
List the advantages/disadvantages of rectal temp
Closest to core temp, useful in assessing hypothermia
| Quick, but invasive
29
How long do you measure pulse for?
15s x 4
30
Why do we need to assess carotid pulse instead of radial pulse?
Low BP - cannot feel radial pulse
31
What is the normal pulse range?
55-95 beats/min
32
List what we assess when taking pulse.
Rate (tachycardia/bradycardia)
Rhythm (regular/irregularly irregular/regularly irregular)
Character and volume
33
Where can pulses be taken?
```
Carotid
Radial
Brachial
Popliteal
Femoral
Posterior tibialis and dorsalis pedis
```
34
How long do we measure resp rate for?
30s x 2
Remember patient needs to be unaware of this as it is under voluntary control
One minute measurement if irregular
35
What is the normal resp rate?
12-20 breaths/min
36
Define tachypnoea and bradypnoea.
Tachy - greater than 25 breaths/min
| Brady - less than 8 breaths/min
37
Define systolic BP and diastolic BP
Systolic - peak pressure in the artery with ventricular systole
Diastole - trough pressure in artery with ventricular diastole
*** REVISE NORMAL VALUES***
38
Why do we palpate before taking the BP?
Palpation gives you a good estimate of what pressure you expect to hear on auscultation.
39
What factors are used to calculate CVS risk?
Age, gender, ethnicity, smoking status, medical history and family history, diabetes, renal disease, cholesterol level and BP
40
When should BP be treated?
If it is consistently greater than 170/110mmHg
41
How many measurements are enough to calculate CVS risk?
2 measurements at a single visit
42
What can cause BP to be too high?
```
Small cuff size
Incorrectly placed cuff
Make sure arm is relaxed and well supported
Make sure px is comfortable and relaxed
Take BP again after 5min quiet rest
```
43
How many measurements are needed to diagnose HTN?
At least two measurements should be made at 3 separate visits
44
What increases blood pressure?
```
Stress/anxiety
White coat HTN
Full bladder
Over-hydration
Exertion
Pain
Stimulants - amphetamine, caffeine (<30mmHg and effect lasts for 3hrs), cocaine, nicotine (immediate)
Salt/baking soda
Liquorice
```
45
What lowers blood pressure>
```
Heat
Dehydration
Being relaxed
Serious illness (septic shock, MI)
Neurological condition (Parkinsons disease)
Endocrine condition (Addisons)
Prolonged bed rest
Recent meal
```
46
What conditions cause secondary HTN?
Chronic kidney disease
| Endocrine disorders
47
What causes changes/artefacts in blood pressure?
```
Heat
Cuff too small (increased)
Cuff too big (decreased)
Arm not relaxed/supported
Cuff over clothing (incorrect)
Dehydration
```
48
What are the sounds of blood pressure called?
Korotkoff Sounds
49
What causes the Korotkoff sounds to be heard?
Turbulent nature of blood flow through a partially compressed artery.
Only occurs when pressure is between systolic and diastolic
50
Name and describe the Korotkoff sounds.
```
Phase 1 = 1st sound heard --> systolic
Phase 2 = more intense sound
Phase 3 = softer sound
Phase 4 = muffling of sound --> diastolic
Phase 5 = sound disappears
```
51
Name the 5 moments of handwashing.
```
Before touching px
After touching px
Before aspetic/clean procedure
After contact with bodily fluids
After touching px surroundings
```
52
Which part of the stethoscope do you use for BP?
Diaphragm - high pitched sounds
| Remember ear pieces point forwards
53
Where is the brachial pulse found?
In the antecubital fossa medial to the biceps tendon
54
Why do we measure by palpation?
Use this measurement to set it 10mmHg greater when auscultating
55
List the steps of the CVS exam
Inspection
Palpation
Percussion
Auscultation
56
What is the function of percussion?
Determine the density of a structure by tapping over it
57
List the aspects looked at in General Obs
```
Look well or unwell
What is the px first doing when you see them
Appearance consistent with stated age
Any syndrome for increased CVS risk (e.g. marfans = aortic regurgitation, DS = congenital heart disease, Turners = coarctation of aorta)
Distressed or in pain
Breathing
RR
Colour/complexion (pale, cyanosed - blue, plethoric - red faced)
Clammy or sweaty
Underweight/overweight
Able to exert themselves
Able to lie flat
```
58
What may be the cause of absent pulses?
Due to an occlusion (thrombus, embolus, dissection, transection) or due to cardiac arrest
59
What type of rhythm of pulse does AF give?
Irregularly irregular pulse
60
Which pulses do we use to assess for character and volume?
Carotid and brachial pulses
| Weak, strong, bounding, collapsing, thready, full
61
What does a low volume pulse suggest?
Low cardiac output from shock or myocardial infarct, dilated cardiomyopathy, valvular stenosis, pericardial tamponade, pericarditis
62
What does a high volume pulse suggest?
Anxiety, exercise, fever, hyperthyroidism, anaemia, patent ductus arteriosus with normal pulmonary pressures, large arterial venous fistulas or severe aortic regurgitation
63
Define the location of the carotid pulse.
Medial to the sternocleidomastoid muscle
64
When is the carotid pulse assessed?
Assessed instead of radial in low BP
65
Where is the femoral pulse and how can it be palpated?
Lateral to the femoral vein and medial to the femoral nerve
NAVY (N is lateral, Y is medial)
Two hands pressing deeply below the inguinal ligament and midway between the symphysis pubis and anterior superior iliac spine
66
How do you palpate the popliteal pulse?
Index, middle and ring fingers deep into the popliteal fossa
67
Describe the pedal pulses.
Posterior tibialis pulse is 2cm behind the medial malleolus
| Dorsalis pedis is found on the dorsum of the tarsal bones
68
What is the function of assessing the pedal pulses?
Assess for peripheral vascular disease
69
What is the function of capillary refill?
Assess peripheral perfusion
70
What affects capillary refill?
Peripheral vascular disease, hypovolemic shock, direct trauma
71
How do you perform the capillary refill?
Press on for 5s
| Colour should return in less than 2s (if longer = poor peripheral perfusion)
72
What common cardiac conditions could cause a RR of over 25 breaths/min?
Pulse of 116 and irregularly irregular?
Capillary refill in toes of 6 seconds and absent dorsalis pedis on both legs?
A blood pressure of 90/60?
1 - angina, PE
2 - AF
3 - DVT
4 - HF, mitral regurgitation
73
Where do the jugular veins take blood from?
Blood from the head to the right atrium
74
Where does the internal jugular vein drain?
Directly into the SVC - it has no valves
75
What does the pressure in the internal jugular vein reflect?
It reflects pressure in the right atrium
76
What creates the jugular venous pulse?
Two waves caused by two events which increase pressure in RA
77
Name and describe the two waves of the jugular venous pulse?
a wave = increase in pressure in atrial systole
| v wave = ventricular systole when the atrium continues to fill
78
What does the height of the jugular venous pulse reflect?
Reflects the jugular venous pressure (JVP) = pressure in the right atrium
79
How can you see the JVP?
When the patient lies down at 45 degrees
80
Which vein do you use for the JVP?
Right Internal Jugular Vein - deep to the medial aspect of the sternocleidomastoid
81
What effect does inspiration have on the JVP?
Makes JVP fall and height is reduced
82
What is the name of pressure over the abdomen causing the JVP to rise?
Abdomino-jugular reflux (upper right quadrant of the abdomen)
83
What does persistent elevation of the JVP suggest?
Right heart failure - JVP takes a few moments to fall after the abomino-jugular reflux = indicative of RHF
84
Where does the JVP sit?
Sit at or just below the levels of the clavicle
85
NOTE: helpful way to identify JVP is to ask patient to exhale completely or perform gentle Valsalva manoeuvre
xxx
86
What do you look for while inspecting the praecordium?
Scars - median sternotomy scar from cardiac surgery
Skeletal abnormalities - pectus excavatum (pigeon chest), kyphoscoliosis. These can alter the position of the Apex Beat and interfere with pulmonary function leading to pulmonary HTN.
Pacemaker/defib box or cardioverter
Apex beat: 5th left intercostal space, mid-clavicular line
87
Where do you find the apex beat?
Most lateral and inferior point on the anterior chest wall - heart striking against the chest wall during systole
Apex beat palpable in only about 50% of adults
88
Why might you be unable to palpate the apex beat?
Due to obesity, emphysema, pericardial effusion , dextrocardia (apex beat on right side of body)
Most common cause of lateral and inferior displacement = enlarged heart
89
What are the heart sounds caused by?
Closure of the heart valves
90
Describe S1 heart sound.
Closure of the mitral and tricuspid (AV) valves
Mitral valve closes slightly before the tricuspid valve, but only one sound is heard.
Beginning of ventricular systole
91
Describe S2 heart sound.
Closure of aortic and pulmonary (semilunar) valves. Shorter and softer than S1.
End of systole
92
Why do we use the carotid pulse in auscultation?
To determine timing of heart sounds and distinguish them
| Pulsation of the carotid pulse corresponds with systole
93
Describe the aortic area, pulmonary area, tricuspid area and mitral area.
Aortic area = 2nd ICS, right sternal border
Pulmonary area = 2nd ICS, left sternal border
Tricuspid area = 4th/5th ICS, left sternal border
Mitral area = 5th ICS, towards the apex
94
What causes the splitting of S2?
Pulmonary valve closes later than the aortic valve - lower pressure in the pulmonary circulation compared with aorta = flow continues into pulmonary artery after the end of right ventricular systole
A split S2 is a normal finding when the px is asked to breathe in = inspiration causes a decrease in intrathoracic pressure, causing an increase in venous return
95
Where is the Lubb ta Dubb best heard?
Pulmonary region along left sternal border
96
Name abnormal heart sounds.
S3 and S4
| Murmurs - pathology at different valves
97
Define regurgitation.
Valve does not completely close - blood can flow backwards rather than being pumped out of the heart
Volume overload and dilation
98
Define stenosis
Valve thickens or becomes stiff
Block or limit blood flow to heart
Hypertrophy and increased oxygen demand
99
What causes cardiac valve disease?
```
Aging
Atherosclerosis
Congenital heart defect
RF (mitral stenosis)
Infarction
HTN
Endocarditis
Myocardial disease
```
100
List 4 non-cardiac causes of a raised JVP.
Renal failure
Excessive IV fluid admin
Emphysema
Pulmonary fibrosis/PE
101
What is something I need to remember to do before any exam?
WIPER
Ask the patient if they experience any pain before starting
Communicate and ensure comfort throughout
102
Name the important PMHx for CVS diseases
```
Previous heart disease (congenital, infectious, ischaemic)
Hypercholesterolemia
HTN
RF
Dental decay/infection
Diabetes
Cerebrovascular disease
Peripheral vascular disease
Down Syndrome - coarctation of aorta
Marfan Syndrome - aortic regurgitation
Chronic lung disease (RHF)
Chronic kidney disease
RA (pericarditis)
```
103
Name some medications that are important to note in CVS.
```
NSAIDs
Beta blockers
Thyroxine
Cocaine and amphetamine
Complementary and alternative medicines
ABC - aspirin, beta blocker, clopidogrel = ischaemic heart disease
```
104
Name important Family Hx in CVS
```
Ischaemic Heart Disease
Thrombophilia
Inherited arrhythmia
Cardiomyopathy
Diabetes
HTN
Hypercholesterolemia
```
105
Name personal and social history which is important in CVS.
```
Ethnicity
Smoking
Alcohol
Recreational drugs
Sedentary lifestyle
Diet
Occupation
Physical activity history
```
106
Define Standard Precautions
A group of infection prevention practices that apply to all patients, irrespective of confirmed or suspected infection status, in any setting where healthcare is delivered.
107
Give examples of standard precautions.
Hand hygiene
PPE
Resp hygiene - coughing etiquette
Patient Care Equipment e.g. sharps, waste, linen
108
When do you wash your hands instead of using alcohol rub?
Buildup of alcohol rub
Hands are visibly soiled
When advised to do so
After contact with px who have diarrhoea/vomiting
109
Name the symptoms in the respiratory system.
```
Dyspnoea
Cough
Sputum
Chest Pain
Wheeze
Hoarseness
Cough
Haemoptysis
Systemic symptoms
```
110
Dyspnoea
Shortness of breath
Breathlessness
Uncomfortable increased work of breathing
Many causes - non-cardiorespiratory, cardiac or respiratory
Graded 1 - 5b
111
Cough
Explosive expiration following a deep inspiration - airway to be cleared of secretions and foreign bodies
Voluntary act or reflex response to irritation of respiratory mucosa
Acute (lasting less than 3 weeks) vs chronic (more than 8 weeks)
Acute cough - infection, inhaled foreign body, inhalation of an irritant
Chronic cough - asthma, COPD, gastro-oesophageal reflux, post viral hyperreactivity, postnasal drip, medications e.g. ACE inhibitors, cancer, bronchiectasis, interstitial lung disease
112
Sputum
Any material brought up from the respiratory tract
| Normal lung produces 100ml clear sputum a day, transported to oropharynx and swallowed.
113
Name the different appearances of sputum and relations with diseases.
Mucoid (clear, grey or white)
E.g. chronic bronchitis/COPD = clear or grey
Asthma = white
Purulent (dark yellow or green) = acute bronchopulmonary infection
Yellow due to live neutrophils
Asthma: yellow due to esinophils
Chronic infection e.g. bronchiectasis = green due to dead neutrophils
Mucupurulent (yellowish) - resp tract infection
Serous (frothy, watery, pink)
Broncho-alveolar cancer = clear and watery
Pulmonary oedema = pink
Rusty = pneumococcal pneumonia (lysis of red cells)
114
What are other important questions to ask about sputum?
When is it produced (acute = throughout the day, chronic = teaspoon of grey sputum in the morning)
How often and how much - teaspoons/tablespoons/cups
Taste/smell - foul tasting and smelling = anaerobic infection
Infection with bronchiectasis = smell/taste of sputum changes
115
Haemoptysis
Coughing up blood from airways/lungs
Blood streaked mucus or frank blood
Suggests malignancy, trauma, infection or bleeding of vascular origin
116
Chest Pain
Lung tissue has no pain fibres - pain in lungs usually arises from inflammation of pleura
Pleuritis pain is sharp and localized, exacerbated by inspiration or coughing
Pain can also be caused by muscle strain from prolonged coughing
Ribs/sternum due to trauma causing fracture or malignancy causing bony metastases
MSK, GI, cardiac or vascular related
117
Wheeze
Sound heard during breathing caused by turbulent flow of air through constricted airways
Commonly heard in obstructive lung disease e.g. asthma/emphysema
High pitched squeaks and whistles heard maximally at inspiration
Ask about what precipitates their wheeze
118
Hoarseness
Acute inflammation of the vocal cords
Chronic due to tumour on vocal cord
Recurrent laryngeal nerve palsy
119
Systemic Symptoms of Resp
Fever, feeling generally uwell, fatigue and myalgia (muscle pains) = infection
Weight loss = chronic disease (e.g. COPD/idiopathic pulmonary fibrosis, malignancy, TB)
Drenching night sweats = TB or lymphoma
120
Common Cold (Acute Coryza)
Variety of resp viruses - highly contagious
Usually caused by rhinovirus
Lasts about 5 days
Gradual onset tiredness, slight fever, sore nose and throat, sneezing, profuse watery nasal discharge (coryza)
Nasal discharge changes to become thick and mucopurulent (this happens with improvement in wellbeing)
Usually self-limiting, but secondary bacterial infection can occur
121
Influenza "flu"
Moderate to severe viral illness
7-10 days
Abrupt onset of fever, shivering, generalized aching in limbs
Often confined to bed
Severe headache, sore throat, dry cough for several weeks
Some strains may cause diarrhoea
Followed by weeks to months of low mood and reduced energy
Secondary bacterial infection is common
122
Acute Bronchitis
Viral infection
Irritating non-productive cough
Chest discomfort behind the sternum
Chest tightness, wheezing, mild fever, SOB
May become productive with yellow or green sputum
Normal X-ray
Usually self-limiting, but a secondary bacterial infection can occur
123
Sinusitis
Bacterial infection of the paranasal sinuses
Commonly associated with preceding URTI & can occur with asthma
Frontal headache, purulent nasal discharge, facial pain, fever
124
Pneumonia
Acute respiratory infection (viral, bacterial or fungal) affects the lungs.
Alveoli fill with pus and fluid
Dyspnoea, cough, fever, wheeze
125
Lobar Pneumonia
Inflammation of one or more lobes of lung
Exudation into the alveoli
Usually caused by bacterial infection
Chest x-ray = consolidation, usually in lobar pattern
Acute feeling very unwell with malaise, cough, sputum, breathlessness, high fever
Sputum if present is often purulent, may be haemoptysis
Pneumococcal pneumonia, sputum is often rust coloured
126
COVID-19
Acute respiratory infection with cough, sore throat, SOB, coryza (runny nose), anosmia (loss of smell), with or without fever.
SOB = possible sign of pneumonia
127
TB
Bacterial infection caused by myobacterial TB
Productive cough lasting more than 3 weeks
Haemoptysis can occur
Associated systemic symptoms of unexplained weight loss, fatigue, fevers, night sweats (end of day through the night)
128
Pneumothorax
Air enters the pleural space
Spontaneous (arising from a breach in the pleura)
Trauma (arising from a breach in the chest wall)
CXR will demonstrate free air in the pleural space
129
Name the two types of pneumothorax.
Primary pneumothorax - no underlying disease, caused by a rupture of the pleural blebs. Aged between 10 and 30. Male who is tall and thin.
Secondary pneumothorax - older people with underlying pulmonary problem e.g. emphysema or asthma. Abnormal lung anatomy due to the underlying disease.
Spontaneous pneumothorax = sudden (instantaneous) onset of breathlessness often with unilateral pleuritic pain
Traumatic pneumothorax = penetrating and blunt trauma to the chest
130
Describe tension pneumothorax
Air enters the pleural space during inspiration, cannot be expelled during expiration
Valvular mechanism develops to prevent air leaving the pleural space during expiration.
Intra-pleural pressure remains positive throughout the breathing cycle = further lung deflation and shift of the mediastinum with decreased venous return to the heart
Medical emergency = respiratory and cardiac compromise
Death if untreated
131
Asthma
Obstructive lung disease
Variable airflow limitation, airway hyper-responsiveness and bronchial inflammation
Attacks precipitated by exposure to allergen, viral infection, cold air, exercise, emotion, irritant dust and fumes e.g. cigarette smoke, genetic factors, atmospheric pollution, occupational sensitizers and certain drugs (NSAIDS; beta blockers)
Wheezing attack, dry productive cough and episodic SOB
Worse at night
Precipitated by exercise
132
COPD
Obstructive lung disease
Airway obstruction that is not fully reversible
Cigarette smoke causes over 90% of cases
Cough that may produce sputum, wheeze, breathlessness
"cold always goes straight to my chest"
Infective exacerbations with purulent sputum & heightened symptoms of wheeze and breathlessness
HTN, osteoporosis, depression, weight loss, reduced muscle mass with general weakeness
133
Pleural Effusion
Collection of fluid in pleural space
Causes - heart failure, bacterial pneumonia, carcinoma of the bronchus, TB
SOB, chest pain (may be pleuritic), cough
Slowly worsen as fluid accumulates
CXR = fluid in pleural space
134
Pulmonary Embolism
Thrombus usually deep in the veins of the legs dislodges and embolizes to the pulmonary arterial system.
Risk factors = cancer, recent travel immbolization or surgery, previous episode, oral contraceptive pill or hormone replacement therapy, family history of PE or DVT.
135
Describe the symptoms of PE
SOB with very sudden onset
Pleuritic chest pain
Swollen painful leg due to DVT
CXR will be normal
136
Bronchial Carcinoma/Lung Cancer
Most common cause of cancer death
Cigarette smoking accounts for >90% of lung cancer
Only 14% of px with lung cancer are alive 5 years after diagnosis
137
What is the presentation of lung cancer/bronchial carcinoma?
Presentation is variable, depending on the extent and site of disease
Symptoms are often mistaken for infection or wrongly ascribed to "smokers cough" (misnomer - potentially normalizes diseases such as COPD or malignancy)
Cough, breathlessness, haemoptysis, pleuritic chest pain, wheeze, voice hoarseness, compression of the left recurrent laryngeal nerve or recurrent chest infection
138
Idiopathic Pulmonary Fibrosis
```
Restrictive Lung Disease
Cause is unknown
Mean age of onset is in the 6th decade
Males are twice as likely to be affected
Mean life expectancy is 2.5 years
```
139
How does idiopathic pulmonary fibrosis present?
Progressive shortness of breath over months
Cough, with or without sputum production
History of cigarette smoking
Systemic symptoms are rare
Not as common in real life
140
Bronchiectasis
Abnormal and permanently dilated airways cause impaired clearance of mucus and chronic infection
Associated with other lung diseases e.g. CF and COPD
TB the leading cause
Develops at any age, but begins most often in early childhood
Maori and Pasifika at greater risk
141
What are the symptoms of bronchiectasis?
Persistent cough, production of large amounts of purulent sputum, breathlessness, recurrent resp infections, sometimes haemoptysis, pleuritic chest pain
142
CF
Autosomal recessive condition
Multisystem disease
Mucus stasis, inflammation and infection in small airways leading to progressive airway obstruction and bronchiectasis & ultimately end stage resp failure
Usually diagnosed through newborn screening - baby fails to pass meconium (first bowel motions) & develops a bowel obstruction.
Older child = recurrent cough and wheeze
Malabsorption due to pancreatic insufficiency = fail to grow as expected
143
Paediatric Resp Conditions
Asthma, pneumonia, pertussis (whooping cough), bronchiolitis and croup
144
Name the relevant past medical history for resp.
Resp illnesses
Atopic conditions (asthma, eczema, hayfever)
HIV/AIDs or immunosuppressant condition
Previous abnormal chest Xray
145
Name the relevant medications in resp.
Inhalers - short acting beta agonists (SABA), Inhaled corticosteroid (ICS), LABA, LAMA
Oral steroids
Combined oral contraceptive pill (DVT and PE)
Cytotoxics (methotrexate) causing interstitial lung disease
BB, aspirin, NSAIDS causing bronchospasm
ACEi causing cough
Nitrofurantoin causing interstitial lung disease
146
Name the relevant Family Hx in resp conditions
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Asthma
CF
Emphysema
Alpha 1 antitrypsin deficiency
TB
Passive smoking through family members who smoke
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147
Name the personal and social history factors involved in resp conditions.
Smoking tobacco - emphysema/COPD/lung cancer/spontaneous pneumothorax
Pipe smokers - oropharyngeal cancer
Cannabis - emphysema//COPD
Alcoholics - aspiration pneumonia and Adult Respiratory Distress Syndrome
IV drug users - lung abscesses and pulmonary oedema
148
Other aspects for resp conditions
Poor housing conditions - cold, damp homes
Some occupations e.g. asbestos and asbestosis, silica and silicosis, mining and pneumocosis
Animals
Recent travel - PE, TB, Covid
Recent immigration
Physical activity history
149
General Obs for Resp
- look well
- what is the px doing when you first see them
- distressed or in pain
- px of normal body weight
- what colour is the px (cyanosed - blue, pale, plethoric, red-faced)
- RR
- pattern of breathing (pursed lipped, prolonged expiration, regular)
- pain while breathing
- patient's posture
- oxygen mask
- cough
- what does the cough sound like (wheezy, dry, moist)
- does the cough cause pain
- is the cough productive
- are there any other sounds (wheeze, stridor)
- can the px talk = full sentences, what does their voice sound like
- is the px mobile, what effect does moving have on their breathing
- hands - clubbing or peripheral cyanosis
- nicotine staining (fingers and fringe of hair)
150
What position should the px be in for examination of the chest?
Sitting upright = allow adequate inflation of lungs
151
What is the framework of the examination of the chest?
Inspection
Palpation
Percussion
Auscultation
152
Inspection of Chest
Signs of dyspnoea
- increased RR (normal is 12 to 25 breaths/min)
- use of accessory muscles (sternocleidomastoid, platysma, strap muscles of neck, intercostal muscles, diaphragm)
- increased shoulder movement
Pattern of resp
- expiration normal or prolonged
- breathing regular
Shape and symmetry of chest
- pectus excavatum
- pectus carinatum
- hyperinflation
- Harrison's sulcus
- kyphosis, scoliosis or kyphoscoliosis
- lesions of chest wall
Movement of chest wall
- symmetrical or asymmetrical
- chest wall movement reduced
153
Describe the features describing the shape/symmetry of chest.
Pectus excavatum: funnel chest, a developmental defect where lower end of the sternum is depressed, restricting lung capacity in severe cases
Pectus carinatum: pigeon chest, an outward bowing of the sternum and costal cartilages, may be associated with chronic resp illness in children
Hyperinflation: barrel chest, increased anteroposterior diameter (AP) which should be less than the lateral diameter, seen in airtrapping conditions e.g. severe asthma and emphysema
Harrison's sulcus: depression of the lower ribs near their attachment to the diaphragm, severe asthma in childhood
Kyphosis, scoliosis, kyphoscoliosis: reduce lung capacity and increase work of breathing if severe
Lesions of chest wall: history of heart disease, cancer, pneumothorax or TB
154
What disorders could cause chest pain?
Angina
155
Disorders causing dyspnoea?
Acute coronary syndromes
156
Disorders causing paroxysmal nocturnal dyspnoea?
Congestive HF
157
Disorder causing sacral oedema?
Right HF
158
Condition causing syncope?
Vasovagal syncope
159
Condition causing reduced appetite?
MI
HF
RF
160
Condition causing calf pain.
DVT, peripheral vascular disease
161
Condition causing orthopnea?
Left heart failure
| Mitral regurgitation
162
Condition causing orthopnea?
Left heart failure
| Mitral regurgitation
163
Condition causing leg oedema?
Right heart failure, mitral stenosis, mitral regurgitation
DVT
Pulmonary embolusm
164
Disorder causing palpitations?
AF
| Neurogenic/vasovagal syncope
165
Disorders causing presyncope?
Aortic stenosis
| Neurogenic/vasovagal syncope
166
Disorders causing weight change?
RHF - oedema
167
Disorders causing reduced energy.
LHF
AF
Aortic regurgitation
168
How many lobes does the left and right lobe have respectfully?
Right lobe has 3 and left has 2
169
In full inspiration, name the levels where the lungs reach.
Anteriorly - 6th intercostal space
Mid-axillary - 8th intercostal space
Posteriorly - tenth intercostal space
170
Which lobe occupies most of the posterior aspect of the thorax?
Lower lobe
171
Which lobe occupies most of the anterior aspect of the thorax?
Upper lobe
172
What is the term given to the upper lobe and where is it positioned?
Apex
Deep to the supraclavicular fossa and extends above the first rib superiorly
Upper lobes are also mapped posteriorly above the scapula
173
How can your left hand map the lung?
Left hand on right anterior chest, palm just right to the sternum & fingers extending towards the right mid axillary line = right middle lobe
Thumb rests across the right nipple area, the horizontal fissure lies at the level of the radial border of your hand.
Ulnar border of your hand is the level of the 6th rib and overlies the lower part of the middle lobe
174
What does displacement of the trachea suggest?
Disease of the upper lobes of the lungs
175
Describe the different types of displacement of trachea and associated conditions.
Displaced towards (pulled towards the side of the lesion) due to upper lobe collapse, upper lobe fibrosis or pneumonectomy
Displaced away from (pushed away from) the side of the lesion due to massive pleural effusion or tension pneumothorax
Displaced either way by an upper mediastinal mass such as retrosternal goitre, lymphoma or lung cancer
176
What is the aim of the tracheal examination?
Assess if the trachea is in the midline behind the suprasternal notch or if it is deviated to one side
Gap between the lateral margins of the trachea and medial heads of the sternocleidomastoid on each side is compared.
Slight deviation to the right is normal.
177
Define chest expansion and the normal findings.
Chest wall expands during inspiration = can be assessed to give estimate of the volume of airflow.
5cm expansion of chest is normal
178
Symmetrical bilateral decrease in chest expansion due to hyperinflation
Asthma
| Emphysema
179
Unilateral decrease in chest expansion
Consolidation
Pneumothorax
Localized collapse of an area of lung
Pleural effusion
180
NOTE: there are no conditions that cause an increase in chest expansion
xx
181
Describe how you assess chest expansion and how the px should be positioned.
Fully exposed.
Measurement from back will assess lower lobes
Measurement from front will assess upper lobes
Sitting upright
182
NB: find out if reaction to allergy is a real allergy or just a side effect of medication
xxx
183
Identify two causes of generalized (bilateral) reduction in chest expansion and why does reduction ocur?
Emphysema
Asthma
Due to air trapping - hyperinflation
184
Identify four causes of localized reduction in chest expansion
Consolidation
Pneumothorax
Localized collapse of an area of lung
Pleural effusion
185
Name 6 causes of tracheal deviation.
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Upper lobe collapse
Lymphoma
Pleural effusion
Retrosternal goitre
Upper lobe fibrosis
Lung cancer
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186
What is percussion?
Comparing the density of a structure with neighbouring structures
Done by tapping firmly on the surface of the body = characteristic percussion note can be elicited
Heard and felt and indicates whether the underlying structure is solid, filled with fluid or filled with gas. Can compare the density of an organ like the liver with density of a body cavity e.g. abdominal cavity
187
Describe the percussion notes heard.
Percussion note is dependent upon the density of the underlying structure or organ.
Resonant: normally inflated lung field
Dull: solid structure e.g. organ like liver
Stony dull: fluid-filled area e.g. pleural effusion
Hyper-resonant: completely hollow structure e.g. chest cavity with underlying pneumothorax
188
Describe how to percuss.
Non-dominant hand on the surface with fingers separated = non-percussing hand
Middle finger of non percussing hand firmly against the surface, slightly lifting adjacent fingers and palm = sound should not be dampened.
Middle finger of percussing hand, strike the middle phalanx of the middle finger of the non-percussing hand.
Loose swinging movement of the wrist, not the forearm.
Remove percussing finger quickly so sound is not dampened.
At least two contacts should be made at each site being assessed.
189
Name the locations which are percussed.
Lung apices in the supraclavicular fossa
Clavicles at the medial third
Anterior chest in at least three places from below the clavicles to the diaphragm
Lateral chest in at least three places from the axilla to the diaphragm
Posterior chest: ask patient to lean forward and fold their arms across their chest to move the scapula out the way. Percuss in at least four places from the proximal chest to the diaphragm.
Always percuss with a side to side comparison
190
Resonant indicates
Normal lung
191
Hyperresonant indicates
Pneumothorax
192
Dull indicates
Pulmonary consolidation
Pulmonary collapse
Severe pulmonary fibrosis
193
Stony dull indicates
Pleural effusion
| Haemothorax
194
What causes breath sounds?
Movement of the air both into and out of the large airwards and transmitted to the chest wall
195
What do we look at when assessing breath sounds?
Quality
Intensity
Added (or adventitious) sounds
196
How do we describe the quality of breath sounds?
Vesicular - produced in large airways, transmitted through normal aerated alveolar tissue. Originally thought to arise in the alveoli which are known as vesicles. Louder and longer on inspiration, expiratory sounds follow immediately after the inspiratory sounds. Gentle rustling of leaves
Bronchial - abnormal lung e.g. consolidation caused by pneumonia. Sound is conducted more effectively through a denser tissue or fluid. Therefore these sounds are harsher in nature, hollow blowing quality. More pronounced with expiration and an audible gap is present between expiration and inspiration.
197
Describe the intensity of breath sounds.
Related to airflow and the tissue through which the sound travels.
Normal - vesicular sounds, intensity related to airflow and the tissue through which the sound travels.
Reduced/absent breath sounds - intensity of vesicular sounds is diminished.
198
What causes reduced or absent breath sounds?
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Reduced conduction of sound (obesity, thick chest wall, pleural effusion, pleural thickening, pneumothorax)
Reduced airflow (COPD or collapse due to foreign body or cancer)
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199
Describe the symmetry of reduced breath sounds.
Either symmetrical or asymmetrical.
Symmetrical - obesity, thick chest wall, COPD
Asymmetrical - unilateral pleural effusion, unilateral pneumothorax, collapse due to occlusion of major bronchus by foreign body or carcinoma)
200
What causes additional (or adventitious) breath sounds?
Crackles (crepitations, rales)
Wheezes (rhonchi)
Pleural rubs
201
Crackles
Interrupted non-musical sounds
Sounds like strips of Velcro/hair rubbed between fingers
Infection, left heart failure, COPD, pulmonary fibrosis
Timing of crackles in resp cycle is helpful to determine the cause
Pitch of crackles will determine the cause
202
Wheezes (Rhonchi)
Continuous musical noises caused by vibration of the walls of narrowed airways
Heard throughout the lung fields
Usually heard in expiration, but can be heard in inspiration in a more severe airway obstruction
Asthma, COPD
