What age does bronchiolitis occur?
most common at age 6 months- does not occur after age 2
main symptom of bronchiolitis
wheezing-lasts about 7
... [Show More] days
most common cause of bronchiolitis
RSV
Treatment for bronchiolitis
No specific treatment
Order of lung exam
inspect, palpate, percuss, auscultate
Pectus Excavatum
congenital posterior displacement of lower aspect of sternum
-hollowed-out appearance
-concave appearance of lower sternum
Pectus carinatum
at birth
-post CABG
mid childhood and 11-14 year old pubertal males undergoing a growth spurt
-convex deformity
-97% have MVP
Barrel Chest
associated with emphysema and lung hyperinflation
-accompanying x-ray demonstrates increased ant-post diameter as well as diaphragmatic flattening
Tactile fremitus
palpable vibrations of the bronchiopulmonary tree as the patient is speaking (99 or 1-2-3)
-impeded in COPD, pulm effusion or pneumothorax
-increased in consolidation and PNA
percussion:
flatness
(thigh)
Large Pleural effusion
Percussion- dullness
(liver)
Lobar PNA
Percussion: resonance
(Lung)
simple chronic bronchitis
Percussion: hyperresonance
None
-emphysema, pneumothorax
Percussion: tympany
(gastric bubble)
-large pneumothorax
Auscultation: vesicular
soft and low pitched; usually heard over most of both lungs
Auscultation: bronchial
louder and higher in pitch; usually heard over the manubrium
Auscultation: bronchovesicular
intermediate intensity and pitch; usually heard over the 1st and 2nd interspaces
Auscultation: tracheal
over the trachea and neck, very loud
Rhonchi
low-pitched snore-like sounds, often characterized by secretions w/in the large airways
-sometimes cleared with a cough
Wheezes
continuous, high-pitched, musical, sounds that are produced by air flowing through narrowed bronchi
-predominately expiratory
stridor
loud, rough, continuous, high-pitched sound that is pronounced during inspiration
-indicates proximal airway obstruction
absent/attenuated sounds
NO airflow to the region being auscultated
-can occur in a pneumothorax, hemothorax, pleural effusion, or parenchymal consolidation
Crackles
intermittent, nonmusical, very brief, more pronounced during inspiration
-fine or course
fine (softer, higher in pitch)
course (louder, lower in pitch)
Bronchophony
ask pt to say "99"
-should be muffled and indistinct
-CLEAR sounds are called bronchophony
Egophony
ask pt to say "ee"
-you should hear a muffled long ee sound
-"ee" sounds like "ay" it is positive and called egophony
-present over consolidation
whispered pectoriloquy
ask pt to say "99 or 1-2-3"
-whispered voice is normally faint and indistinct
-louder, clearer sounds are called whispered pectriloquy- heard over consolidation
Pleural effusion
-fremitus, percussion, whispered pectoriloquy, breath sounds
frem= decreased
perc=dull
whis pect= decreased
breath sounds= decreased
Consolidation or PNA
-frem, perc, whisp pect, breath sounds
frem=increased
prec= dull
whispered pect= increased
breath sounds=decreased
emphysema
-frem, perc, whisp pect, breath sounds
frem=decreased
perc=hyperresonant
whisp pect= decreased
breath sounds= crackles
pneumothorax
-frem, perc, whisp pect, breath sounds
frem= decreased
perc= hyper-resonant
whisp pect= decreased
breath sounds= decreased
PNA:
breath sounds, bronchophony, egophany, whisp pect
breath sounds bronchial or bronchovesicular over involved area
positive bronchophony: spoken words louder, clearer
-pos egophony: Ee heard as ay
-pos whisp pectroiloquy: whisp words louder and clearer
-increased tactile fremitus
CAP
Cxray often lags behind clinical presentation
Tobacco cessation- 5 A's
-ASK about smoking at each visit
-ADVISE patients regularly to stop smoking using a clear, personalized message
-ASSESS patient readiness to quit
-ASSIST patients to set stop dates and provide educational materials for self-help
-ARRANGE for follow-up visits to monitor and support patient progress
preload
volume of blood returning to the heart
contractility
ability of ventricles to contract during systole
afterload
vascular resistance against contraction
cardiac output
SV x HR
BP
CO x SVR
Ventricular systole
ventricles contract
-mitral and tricuspid valves close producing S1
-right ventricle pumps blood into PA (pulmonic valve is OPEN)
-left vent pumps blood into aorta (aortic valve is OPEN)
V systole=S1
V diastole = S2
Ventricular diastole
ventricles relax
-aortic and pulmonic valves close producing s2
-Tricuspid valve OPEN- blood flows from RA to RV
-Mitral valve OPEN- blood flows from LA to LV
Left coronary arteries
-LEFT MAIN
*LAD- left anterior descending
-supplies walls of BOTH VENTRICLES AND SEPTUM
*CIRCUMFLEX-
-supplies walls of the LA and lateral wall of LV
-also may supply SA and AV node (if not supplied by RCA)
Right Coronary arteries
RCA
-branch to SA node
-branch to AV node
-branches to LV
posterior descending artery
-supplies RA, RV, SA node and some of AV node
How is the metabolic syndrome diagnosed?
*waist circ-
female 35, male 40
*triglycerides- >150
*HDL male <40, female <50
*BP 130/85
*fasting glucose 100
2-3 confirms diagnosis: 3/5 definite metabolic syndrome
palpation- finger pads
palpates for heaves or lifts from abnormal ventricular movements
palpation- ball of hand
palpate for thrills- turbulence transmitted by a damaged heart valve
PMI
point of maximal impulse
-palpate at apex for PMI
-tapping- normal
-sustained- suggests LV hypertrophy from HTN or aortic stenosis
-diffuse- suggests a dilated ventricle from CHF or CMO`
Cardiac palpation and auscultation sites
aortic- 2nd ICS, right sternal border
pulmonic- 2nd ICS, left sternal border
tricuspid- lower left sternal border 4th ICS
mitral- mid clavicular line and 5th ICS (apex)
diaphragm of stethoscope
listens to high pitched noises
-heart sounds, murmurs, lung sounds, bowel sounds
-some bruits
-picks up S1 and S2, aortic and mitral regurg
-press firmly for pericardial friction rubs
Bell of stethoscope
-hears low pitched noises
-recommended for extra heart sounds (S3 and S4)
-rumble of mitral stenosis
-to identify some bruits
S1 heart sounds
BEGINNING OF SYSTOLE
-occurs with closure of AV valves (tricuspid and mitral)
S2 heart sounds
END OF SYSTOLE/BEG OF DIASTOLE
-occurs with closure of semi-lunar valves (aortic and pulmonic)
split s2
ventricular pressure is higher in left than right
-closure of aortic valve a2 occurring followed by closure of pulmonic valve p2
S3 heart sounds
DIASTOLE
-heard just after S2
-turbulent blood flow
(may be normal in pregnancy and kids)
S4 heart sounds
END DIASTOLE
-just before S1
-ventricles resistant to filling, r/t weak ventricles
-ALWAYS PATHOLOGIC
M
S
A
R
D
M
R
P
A
S
S
M
V
P
-DIASTOLIC MURMURS- indicate valvular heart disease
-SYSTOLIC MURMURS- occur when heart is not diseased
-MVP- most common valvular abnormality
--affects approx 2-6% of USA population
--many asymptomatic
MS.ARD
Mitral
Stenosis
Aortic
Regurg
DIASTOLIC
MR.PASSMVP
Mitral
Regurg
Pulmonic -and-
Aortic
stenosis
SYSTOLIC
M
V
P
Heart murmur grade
Grade 1- Barely audible
Grade 2- quiet but audible
grade 3- moderate
grade 4- loud
grade 5- loud with palpable thrill
grade 6- very loud, heard with stethoscope almost off the chest wall and has a palpable and visible thrill
Acute MI
-inferior MI
II, III, and aVF
Lateral MI
I, aVL, V5, V6
Septal MI
V1, V2
Anterior MI
V3, V4
MVP
-presenting symptoms
-anxiety, panic attacks, arrhythmias, exercise intolerance, palpitations, atypical chest pain, fatigue, orthostasis, syncope
MVP
-testing and assessment
mid-systolic click and/or mid-to-late systolic murmur
Assessing JVP
reflects right atrial pressure
-horizontal line from top of JVP to ruler, making right angle
-measure distance above sternal angle in centimeters
-3 to 4 CENTIMETER ELEVATION IS NORMAL
Carotid pulse palpation
-upstroke
brisk-normal
delayed-suggests aortic stenosis
bounding- suggests aortic insufficiency
PAD- peripheral arterial disease
Intermittent claudication
-pale or blue; ischemia to muscle
Venous peripheral vascular disease
swelling of feet and legs
-ulcers on lower legs
red/purple areas [Show Less]