Download AHA Exam 2 Review Master Study Guide: Cardiac, Respiratory, Skin, and Neuro (Headaches) and more Exams Health sciences in PDF only on Docsity!
AHA Exam 2 Review Master Study Guide. Latest Version- 2025
**● Test consists of cardiac, respiratory, skin, and Neuro (Headaches) ● Make sure that you read the questions before answering- this test will have multiple scenarios, chief complaints, and assessment findings may be given. May be multiplequestions within one question so take time to read it. ● Know basic information and don’t go in depth while studying ● This exam covers the course content in weeks 4 – 7. ● • This exam has 10 multiple choice questions, and 6 short answer questions. Pleasenote that the multiple-choice questions are the first 10 questions and the short answers are questions 11-16. ● • You will have 60 minutes to complete all questions. Please note the exam willautomatically submit at 60 mins. ● • If you want to track your time during the exam, there is an individual studentsetting while taking the exam. ● • Only one attempt allowed for submission of your final answers. ● • Each multiple-choice question is worth 2 points. ● • Each short answer question is worth 2 – 4 points. ● When formulating differential diagnoses think worse thing first, and then narrow itdown by assessing patient and looking at vitals. ● How do you decide whether to do labs or x-rays on? Look at symptoms and decide(signs of systemic infection, history) HEART: ● Know how to percuss the chest – what do the findings suggest? ● Normal findings when palpating the chest ● Heart tones- where and what they mean ● Aortic stenosis ● Mitral stenosis ● Pulmonary stenosis ● How do you assess, auscultate, palpate and percuss the chest? ● •What are normal and abnormal findings of your assessment of the chest? ● •What would abnormal findings indicate? ● •What possible differential diagnoses can you think of? ● PVS ● • How to assess chest for cv and pv findings ● • Carotid artery ● • Palpate precordium and what are you assessing for? ● • Auscultate the cardiac system of the chest. What are you looking for. Document nl and abnl ● • How to listen to rate and rhythm of heart? Heart sounds? What is abnl and nl and what do they indicate? ● • S1, S2, S3, S ● • What do extra heart sounds indicate? ● • Where are heart murmurs heard and indication ● • Abnormal and normal indications
● • Know ekg strips. ● • Review the sample documentation. May see short answers about it. ● Pearl of Wisdom… ● •When I learned S3 and S4 in undergraduate nursing school, I learned S3 is a gallopand I often heard this in ER and ICU with the bell of my stethoscope. ● •I heard ken tuck EE ken tuck EE ken tuck EE. ● •An S4 I learned in undergraduate nursing school too. This is often in diastolic heartfailure, severe left ventricular hypertrophy, active cardiac ischemia. It goes S4, S S3. tenUHseetenUHseetenUHsee ● •Go go www.medzcool.com - It’s a site I like really well for heart sounds. Questions about chest pain and what you should be asking ▪ Subjective Data: o Substernal pain or intense pressure radiating to the neck, jaws, and arms; particularlyin the left arm o Often accompanied by shortness of breath, fatigue, diaphoresis, faintness, andsyncope ▪ Objective Data: o Are you having current chest pain? o What medicines are you currently taking? o Do you have any comorbidities (other medical dx)? o Is this your 1st time having CP or is this recurrent? o How long has the chest pain been occuring? o Is it constant or intermittent? o Does the pain radiate anywhere? o How long does the chest pain last? o What does the pain feel like (sharp, crushing, dull ache)? o What number would you state it is from 1-10? o Do you have any other symptoms with the chest pain (shortness of breath, nausea,vomiting, dizziness, syncope, palpitations, cough)? o What makes the chest pain worse (activity, intercourse, eating, stress, laying flat)? o What makes the pain better (rest, medications, sitting up)? o Have you had an injury to your chest recently? What are some causes of an increase or decrease in heart sounds ▪ Split S1: o May occur in RBBB and with PVCs ▪ Fixed splitting of S2: o Occurs with ASD and RV failure ▪ Wide splitting of S2: o Associated with delayed closure of the pulmonic valve o Caused by pulmonic stenosis o RBBB o Early closure of aortic valve in MR ▪ Paradoxical splitting of the S2:
o Second left intercostal space at sternal border; patient sitting or supine o Early systole, less intense than aortic click; intensifies on expiration, decreased oninspiration ▪ Pericardial friction rub o Widely heard, sound clearest to apex o May occupy all of systole and diastole; intense, grating, machine-like; may have 3 components, may sound like a murmur Mitral Stenosis: heard with bell at apex, patient in left lateral decubitus position Description: ▪ Narrowed valve restricts forward flow; forceful ejection into ventricle ▪ Often occurs with mitral regurgitation ▪ Caused by rheumatic fever or cardiac infectionFindings of Exam: ▪ Low-frequency diastolic rumble, more intense in early and late diastole, does not radiate ▪ systole usually quiet ▪ palpable thrill at apex in late diastole common ▪ S1 increased and often palpable at left sternal border ▪ S2 split often with accented P ▪ opening snap follows P2 closely ▪ Visible lift in right parasternal area if right ventricle hypertrophied ▪ Arterial pulse amplitude decrease Aortic stenosis: heard over aortic area; ejection sound at second right intercostal borderDescription: ▪ Calcification of valve cusps restricts forward flow; forceful ejection from ventricle intosystemic circulation ▪ Caused by congenital bicuspid (usually tricuspid) valve, rheumatic heart disease,atherosclerosis ▪ May be cause of sudden death, particularly in children and adolescents, either at rest orduring exercise; risk apparently related to degree of stenosis Findings of Exam: ▪ Midsystolic (ejection) murmur, medium pitch, coarse, diamond-shaped, crescendo-decrescendo ▪ radiates along the left sternal border (sometimes to the apex) and to carotid with palpablethrill ▪ S1 often heard best at apex, disappearing when stenosis is severe, often followed byejection click ▪ S2 soft or absent and may not be split ▪ S4 palpable ▪ Ejection sound muted in calcified valves ▪ The more severe the stenosis, the later the peak of the murmur in systole ▪ Apical thrust shifts down and left and is prolonged if left ventricular hypertrophy is alsopresent Subaortic stenosis: heard at apex and along left border
Description: ▪ Fibrous ring, usually 1- 4 mm below aortic valve ▪ Most pronounced on ventricular septal side ▪ May become progressively severe with time ▪ Difficult to distinguish from aortic stenosis on clinical grounds aloneFindings of Exam: ▪ Murmur fills systole, diamond-shaped, medium pitch coarse ▪ Thrill often palpable during systole at apex and right sternal border ▪ Multiple waves in apical impulses ▪ S2 usually split ▪ S4 often present ▪ Arterial pulse brisk, double wave in carotid common ▪ Jugular venous pulse prominent Pulmonic stenosis: heard over pulmonic area radiating to left and into the neck; thrill in secondand third left intercostal spaces Description: ▪ Valve restricts forward flow ▪ Forceful ejection from ventricle into pulmonary circulation ▪ Cause is almost always congenitalFindings of Exam: ▪ Systolic (ejection) murmur, diamond-shaped, medium pitch, coarse ▪ Usually with thrill ▪ S1 often followed quickly by ejection click ▪ S2 often diminished, usually wide split ▪ P2 soft or absent ▪ S4 common in right ventricular hypertrophy ▪ Murmur may be prolonged and confused with that of a ventricular septal defect Tricuspid stenosis: heard with bell over tricuspid areaDescription: ▪ Calcification of valve cusps restricts forward flow; forceful ejection into ventricles ▪ Usually seen with mitral stenosis, rarely occurs alone ▪ Caused by rheumatic heart disease, congenital defect, endocardial fibroelastosis, rightatrial myxoma Findings of Exam: ▪ Diastolic rumble accentuated early and late in diastole, resembling mitral stenosis butlouder on inspiration ▪ Diastolic thrill palpable over right ventricle ▪ S2 may be split during inspiration ▪ Arterial pulse amplitude decreased ▪ Jugular venous pulse prominent, especially a wave ▪ Slow fall of V wave Mitral regurgitation: heard best at apex; loudest there, transmitted into left axilla Description:
▪ Valve incompetence allows backflow pulmonary artery to ventricle ▪ Secondary to pulmonary hypertension or bacterial endocarditisFindings of Exam: ▪ Difficult to distinguish from aortic regurgitation on physical examination Tricuspid regurgitation: heard at left lower sternum, occasionally radiating a few cm to leftDescription: ▪ Valve incompetence allows backflow from ventricle to atrium ▪ Caused by confenital defects, bacterial endocarditis (esp. In IV drug abusers), pulmonaryHTN, cardiac trauma Findings of Exam: ▪ Holosystolic murmur over right ventricle, blowing, increased on inspiration ▪ S3 and thrill over tricuspid area common ▪ In pulmonary HTN, pulmonary impulse palpable ober second left intercostal space andP2 accented ▪ In right ventricle hypertrophy, visible lift to right of sternum ▪ Jugular venous pulse has large V waves Palpation of the CARDIAC SYSTEM-many many steps, know them all! ▪ Have the patient supine, palpate the precordium using the proximal halves of the fourfingers held gently together ▪ Touch lightly and let the cardiac movements rise to your hand s/t sensation decreasing as you increase pressure ▪ Begin at the apex, move to the inferior left sternal border, then move up the sternum tothe base and down the right sternal border and into the epigastrium or axillae ▪ Feel for apical impulse and identify its location by the intercostal space and the distancefrom the midsternal line ▪ PMI: is the maximal impulse point which is typically noted at the left 5th intercostalspace, midclavicular line o What is the diameter of the area? Usually no more than 1 cm o Impulse is usually gentle & brief not lasting as long as systole ▪ If obese or thick chest you may not be able to feel the apical pulse ▪ Feel for a thrill which is a fine, palpable, rushing vibration, a palpable murmur, over thebase of the heart in the area of the right or left 2nd intercostal space ▪ While palpating the precordium, use your other hand to palpate the carotid artery Normals on a cardiac exam for example…..the Apex should be free of any lifts heaves orthrills…….know your landmarks when listening to the heart ▪ S1 and S2 occur as single sounds with no splitting: S1 occurs in systole (M1 T1) and S2in diastole (A2 P2) ▪ There should be no pallor, cyanosis, diaphoresis, edema, restlessness, and confusion ▪ VS should be BP <120/80, HR<100 & > ▪ There should be no pulsus paradoxus, pulsus alterans, or bisferious pulse ▪ There should be no JVD and hepatojugular reflux ▪ Skin temperatures should be warm & dry ▪ Nail beds should not be cyanotic or have clubbing
▪ PMI: is the maximal impulse point which is typically noted at the left 5th intercostalspace, midclavicular line usually felt within a 1 cm area ▪ HR should be normal rhythm ▪ S1 is crisp (best heard at apex), split s2 increases with inspiration (best heard at aortic andpulmonic areas). No audible S3, S4, murmur, click, or rub ▪ There should be no lifts, heaves, or thrills ▪ Aortic valve should be heard at the second right intercostal space at the right sternalborder ▪ Pulmonic valve area: second left intercostal space at the left sternal border ▪ Second pulmonic area: third left intercostal space at the left sternal border ▪ Tricuspid area: fourth left intercostal space along the lower left sternal border ▪ Mitral (apical) area: at the apex of the heart in the fifth intercostal space at themidclavicular line Know your Murmurs – describe what they sound like and what they mean. FOCUS on these!!! FOCUS on what does S3 and S4 mean? Recognize these sounds, what would you dofor this? Example, if you heard a murmur in the pulmonic area what does that mean? ▪ You have a 72 y/o male that comes in with the complaint of chest pain, What would you do if this is all the information that you have? Obtain HPI/ OLDCARTS- Onset,Location, Duration, Character, Aggravating/ associated factors, relieving factors, temporal factors (other things going on), & severity of chest pain. ▪ If you have a patient come in with complaints of chest pain, what other assessmentswould you want to do other than cardiac? o Respiratory o Neuro (make sure that they are A & O) o Abdominal exam (because sometimes life threatening conditions like AAAcan present with abdominal pain) SKIN
- KNOW NORMAL AND ABNORMAL SKIN FINDINGS - KNOW HOW TO ASSESS RASH •WHAT KIND OF QUESTIONS SHOULD YOU INCLUDE IN YOUR HPI ABOUT THE RASH? •WHAT SHOULD YOU INCLUDE IN YOUR DIFFERENTIAL DIAGNOSES? •WHAT KIND OF EDUCATION CAN YOU PROVIDE TO PATIENTS ABOUT THEIR SKIN? ● Education on sun exposure: ● Application of sunscreen w/ high SPF and reapply every 30 min- 1 hour. ● Wear a hat and long sleeves. ● Do not lay in tanning beds. ● Freq. assess skin for changes in moles and freckles. ● Limit exposure during peak hours of the day when the sun is more intense. ● Patient education should be included while examining skin for cancers. ● Ask them if they use sunscreen while outdoors. Education can include: ● Use sunscreen with SPF 30 or greater; apply generously and often- especially if in water or perspiring. Apply it 15-20 minutes before sun exposure. Reapply after swimming andafter 2 - 3 hours of sun exposure. Try to avoid mid-day sun (or stay in shade). ● Abnormalities in the Nail Beds: o Fungal infection (onychomycosis) -
o Asymmetry - Halves do not match. o Borders - Irregular, ragged, blurred. o Color - Not the same all over, varying shades of the same color (reds or browns). o Diameter - More than 6 mm. o Elevation - Changes in existing pigmented lesions. Grows.Skin Cancer Screening ● Skin cancer risks: family history of skin cancer, considerable history of sun exposure andsunburn. ● Groups at increased risk for melanoma: ● • Fair-skinned men and women over the age of 65 years. • Patients with atypical moles. ● • Patients with more than 50 moles. ● Clinicians should remain alert for skin lesions with malignant features that are notedwhile ● performing physical examinations for other purposes. ● Features associated with increased risk for malignancy include: asymmetry, border irregularity, color variability, diameter >6mm ("A," "B," "C," "D"), or rapidly changinglesions. Suspicious lesions should be biopsied. ● A= Asymmetry ● This benign mole is not asymmetrical. If you draw a line through the middle, the twosides ● will match, meaning it is symmetrical. If you draw a line through this mole, the twohalves will not match, meaning it is asymmetrical, a warning sign for ● •B=Borders ● •A benign mole has smooth, even borders, unlike melanomas. ● The borders of an early melanoma tend to be uneven. The edges may be scalloped ornotched. ● C=Color ● Most benign moles are all one color — often a single shade of brown. Having a variety ofcolors is another warning signal. A number of different shades of brown, tan or black could appear. A melanoma may also become red, white or blue. ● D=Diameter ● Benign moles usually have a smaller diameter than malignant ones. Melanomas usuallyare larger in diameter than the eraser on your pencil tip (¼ inch or 6mm), but they may sometimes be smaller when first detected. ● Papules/Pustules from hygienic activity: know the difference between and how todescribe different skin lesions o Folliculitis – ▪ Patho: Inflammation and infection of the hair follicle and surroundingdermis. Inflammatory cells w/i the wall of the hair follicle creates follicular based pustule. Inflammation can be superficial or deep. ▪ Subjective: Acute onset of papules and pustules assoc w/ pruritis or milddiscomfort. May have pain with deep folliculitis. Risk factors: frequent shaving, hot tubs, occlusive dressing, obesity.
▪ Objective: Small pustules. Surrounding inflammation or nodule lesions.Suppurative drainage w/ crusting. o Furuncle (boil) – ▪ Patho: Deep-seated infection of pilosebaceous unit. Staph aureus most common. Starts as small perifollicular abscess. May occur as single or inmultiples. ▪ Subjective: Acute onset of tender, red nodules that become pustular. ▪ Objective: Skin is red, hot, and tender. Common in face, neck, arms,axillae, breasts, thighs, and buttocks. o Tinea (Dermatophytosis) – ▪ Patho: Group of noncandidal infections that involve the stratum corneum, nails, or hair. Infection of dermatophytes acquired by direct contact. Lesions classified according to the anatomic location on hairy or non-hairyparts. ▪ Subjective: May report pruritis. ▪ Objective: Maybe papular, pustular, vesicular, erythematous, or scaling. Secondary bacterial infection. Infected nails are yellow, thick, and mayseparate from the nailbed. ● Nodules in supraclavicular area and possible differential Dx: o Malignancy - Supraclavicular node that lies anterior to the sternocleidomastoidmuscle. o Non-Hodkin Lymphoma - Malignant neoplasm of the lymphatic system and thereticuloendothelial tissues. o Other lymphomas - abominal/thoracic neoplasms, thyroid/laryngeal disease, ormycobacterial/fungal infections. What are some of the skin lesions that you may see when a patient comes in? o Abnormal mole- When assessing a mole look at ABCDE (Asymmetry, Border, Color, Diameter, Evolving/ elevation (how it has looked over theyears, has it grown, has it got bigger?) o Skin cancer o What is the #1 thing, say a patient comes into the ED for? Abscess, cellulitis,cysts, lipomas o If you are assessing a skin lesion and it feels rubbery, what do you think of it? A cyst o Abscess or an infected cyst- see more of fluctuance and erythema over it o Papular lesions- Referring more to size ▪ Mosquito lesions-papular lesion (<1 cm) ● How do you assess for cellulitis? Redness, warm to touch, weeping ● If you have a patient that comes in to the clinic with cellulitis, what are some of the things that you are going to look for and decide to send the patient to the ED? Failedoral antibiotic treatment (been prescribed an antibiotic and the cellulitis got worse), look at risk factors (immunocompromised) ● What is the #1 thing that you want to ask your patient with any kind of skindisorder? History of IV drug use (use more precautions with this patient) ● When do you decide to drain an abscess or cellulitis? Drain abscess
- The postauricular nodes located superficially over the mastoidprocess.
- The preauricular nodes just in front of the ear.
- The parotid and retropharyngeal (tonsillar) nodes at the angle ofthe mandible
- The submandibular nodes halfway between the angle and the tip ofthe mandible.
- The submental nodes in the midline behind the tip of the mandible. ▪ Then move down to the neck, palpating in this order:
- The superficial cervical nodes at the sternocleidomastoid muscle.
- The posterior cervical nodes along the anterior border of thetrapezius muscle.
- The cervical nodes deep to the sternocleidomastoid (the deep cervical nodes may be difficult to feel id you press too vigorously;probe gently w/ your thumb and fingers around the muscle).
- The supraclavicular areas, probing deeply in the angle formed bythe clavicle and the sternocleidomastoid muscle, the area of Virchow nodes. o Axillae – ▪ Imagine a pentagonal structure: the pectoral muscle anteriorly, the back muscles (ie latissimus dorsi and subscapularis) posteriorly, the rib cage medially, the upper arm laterally, and the axilla at the apex. ▪ Let the soft tissue roll between your fingers, the chest wall, and themuscles you palpate. ▪ A firm, deliberate, yet gentle touch may feel less ticklish to the patient. ▪ Support the patient’s forearm with your contralateral arm and bring the palm of you examining hand flat into the axilla; let the patient’s forearmrest on that of your examining hand. ▪ Rotate your fingertips and palm, feeling the nodes; if they are palpableattempt to glide your fingers beneath the nodes.
o Epitrochlear – ▪ Support the arm in one hand as you explore the elbow with the other. ▪ Grasp the patient’s wrist, palm facing up, with your left hand. ▪ The elbow should be in the relaxed position at approx 90 degrees. ▪ Place your right hand under the patient’s right elbow and cup your fingersaround the elbow to find the area that is proximal and slightly anterior to the medial epicondyle of the humerus. ▪ There is a groove between the triceps and biceps muscles.
- Palpate that groove w/ you fingers using a circular motion. ▪ Repeat using your left hand for the patient’s left elbow. o Inguinal/Popliteal –
o Cluster - ▪ Adulthood, men. Unilateral. 30 min- 2 hour duration. Onset at night. Intense burning, boring, searing, knifelike. Assoc. personalitychanges, sleep disturbances. Causes: alcohol consumption. o Muscular tension – ▪ Unilateral or bilateral. Hours to days long. Happen anytime commonly inthe afternoon or evening. Bandlike, constricting. o Space-occupying lesion – ▪ Localized pain. Rapidly increasing w/ frequency. Awakens from sleep ****Review headaches; different types- and differential diagnosis'** o With Headaches the main thing that you need to know is the ONSET. ▪ If somebody says rapid and sudden onset, what are some of the differential diagnoses that you would think of? Intracranial bleed orsubarachnoid hemorrhage ▪ With a psyche patient complaining of headache- ask about theirmedications d/t it being a common side effect ▪ If a patient with any cardiac problems then your differentials may beCVA ▪ MAKE sure that you assess cranial nerves 2 & 12 when a patient c/oof HA – confrontation/visual acuity (II peripheral & snellen) and tongue side to side (hypoglossal XII) ▪ Make sure that they don’t complain of fever, chills, or neck pain to r/omeningitis THYROID ● Thyroid Problems: o** HPI questions - ▪ Have you had a change in temperature tolerance or preference? Have you had any neck swelling, difficulty swallowing, redness, or pain in the neck?Have you had a change in hair thickness or texture? Has your menses changed (amount, frequency, etc.)? Have you had a change in bowel habits? Have you had any racing heart, palpitations? Have you been tired recently? Have you had a change in mood or energy? Is there an increase in prominence of eyes, visual changes, visual disturbances? o Hypothyroidism – Signs and symptoms of Hypothyroid ▪ Pathophysiology: Primary: thyroid gland produces insufficient amounts ofthyroid hormone. Secondary: insufficient thyroid secretion due to inadequate secretion of either TSH from the pituitary or thyrotropin- releasing hormone (TRH) from the hypothalamus. More common than hyperthyroidism. ▪ Subjective: Weight gain. Constipation. Fatigue. Cold intolerance. ▪ Objective: Normal size - thyroid. Goiter. Nodules. o Hyperthyroidism – ▪ Patho : Excess thyroid hormone causes an increase in the metabolic rate.Assoc w/ increased total body heat production and increased heart
contractility, heart rate, vasodilation. Multinodular goiter (Plummer disease). ▪ Subjective : Weight loss. Tachycardia. Diarrhea. Heat sensitivity. ▪ Objective: Normal size thyroid. Goiter. Nodules. Fine hair. Brittle nails.Proptosis (protrusion of the eye). THYROID: What are some of the thing that you think of when you think of the thyroid?Hormonal changes/ imbalance- temperature intolerances, changes in hair thickness or texture, skin changes, changes in menses, mood changes, throat swelling. o A 26 y/o female presents with complaints of fatigue and hair falling out, Youwould check for what? Check TSH first and then if it is abnormal, then check a T3 and T o A 16 y/o female comes in saying that her periods are irregular, What are yougoing to do? Start by checking her thyroid levels (TSH) RESPIRATORY SIGNS AND SYMPTOMS ASTHMA PE PNEUMONIA PLEURAL EFFUSION LUNG SOUNDS- KNOW YOUR LUNG SOUNDS, BE ABLE TO DESCRIBE, POSSIBLY SHORT ANSWER
- KNOW HOW TO ASSESS A PATIENT WHO COMES IN WITH A RESPIRATORY ILLNESS •WHAT KIND OF HPI QUESTIONS WILL YOU ASK? •WHAT ARE NORMAL AND ABNORMAL RESPIRATORY BREATH SOUNDS? •WHAT DO ABNORMAL BREATH SOUNDS INDICATE? •WHAT ARE THE POSSIBLE DIFFERENTIAL DIAGNOSES THERE? ● Lung findings: o Pleurisy – ▪ Patho: inflammatory process of the visceral and parietal pleura. Result of pulmonary embolism, or infection bacterial or viral), or connective tissuedisease (lupus). Tumor or asbestosis. ▪ Subjective: Sudden onset w/ chest pain when taking a deep breath or cough. Rubbing of the pleural surfaces can be heard by the pt. Pain may bereferred to ipsilateral (same side) shoulder or may be close to the diaphragm. ▪ Objective: Pleural friction rub heard on auscultation. Fever. Tachypneathat is shallow. o Pleural Effusion – ▪ Patho: Excessive nonpurulent fluid in the pleural space. Sources of fluidmay vary and include infection, heart failure, renal insufficiency, connective tissue disease, neoplasm and trauma. ▪ Subjective : Cough w/ progressive dyspnea. Pleuritic CP if there isinflammation. ▪ Objective:
- Inspection : Diminished and delayed respiratory movement onaffected side.
▪ Objective: Tachycardia. Tachypnea. Low-grade fever. Hypoxia. Dullnessto percussion and decreased fremitus if there is an effusion. Pleural friction rub. ● COPD ● • -Chronic lung disease characterized by chronic obstruction of lung airflow that interfereswith normal breathing. ● • -Affects over 12 million adults is US and now the 4th leading cause of death. ● • -Most commonly caused by smoking; onset of symptoms usually middle- age; Ifyounger- suspect alpha- 1 - antitrypsin deficiency (genetic disorder) ● • -Made up of two coexisting and often related problems: Chronic bronchitis andemphysema. CVOPD is progressive and overall- irreversible. ● • -Symptoms include chronic cough and sputum production. Usually sputum is in the a.m., and is clear/whitish. The pt will c/o SOB with exertion. Symptoms are progressiveand not a sudden onset. Often a hx of frequent bronchitis and frequent COPD exacerbations. ● - PE: diminished BS along with wheezing. Always check for forced expiratory wheezing. ● Respiratory System-COPD ● HPI: - CC of SOB/cough ● Ask: ● when started; constant or intermittant, have they had it in the past; it is chronic- andworsening?; ● what makes it better/worse; any precipitating factors (fatigue, allergies; exposure to smoke, exercise, activity); worse at night? Can they lie down flat at night? How manypillows used? Do they sleep in recliner? ● Quality? I.E-is cough mild, tickling, vs sharp, paroxysmal? ● Accompanying factors--Accompanied by SOB? CP? Diaphoresis? Wheezing? Fevers/chills? Head or nasal congestion? Any other accompanying factors? ● What have they done for self-treatment? OTC agents? Illicit drugs? ● Medical and Family History: ● Allergies? Hx emphysema, bronchitis, asthma, pneumonia, recent or recurrent URI; TB?Hx of cancer, CHF? Any family hx of above ● Social hx: smoker? How many packs per day for how long? State this as "pack year hx".Example: 1ppd x40 years = 40 pack year history. ● Any occupational or recreational exposure to toxins? Travel history? Pets? Herbal use?Alternative therapies? ● Physical Exam: ● Your historical findings will guide your attention within your physical exam, however, athorough and orderly approach is recommended. ● Other systems that should be included in PE are: cardiac, musculoskeletal, neurological,and ENT (upper respiratory) ● (For example: would want to assess cardiac to help R/O any cardiac issues going on such as a hearing a rub with heart tones may indicate pericarditis and be causing pleuritic pain along with SOB; you wouldbe assess ENT to determine if differential diagnosis is URI) ● Respiratory PE ● Inspection:
● Note rate/rhythm, depth and effort of respirations. Are they using abdomen accessorymuscles? Are they in distress? Is chest symmetrical? ● Trachea midline? Note the ratio of anterior-to-posterior (AP) diameter compared with transverse chest diameter—with COPD, the AP diameter will be increased ("barrel chest") Other terms: Pectus Carinatum- Pigeon chest; Pectus excavatum- breastbone sinksinto the chest; kyphosis-exaggerated forward rounding of back- seen in osteoporosis; scoliosis-S curvature of spine. ● Palpation: ● Chest excursion- is it equal? (place hands posterior back at 10th rib) Less than anticipatedmovement is seen with COPD and pleural effusions. ● The quality of tactile fremitus ("99") Helps guide you to determine if further testing isneeded. ● Increased fremitus seen with consolidation such as pneumonia, tumor, or pulmonaryfibrosis. ● Decreased fremitus is seen with fluid- or air- filled spaces such as pleural effusions,pneumothorax or emphysema. ● Percussion: ● Provides estimate of air, fluid, or solid matter; helps identify margins of organs- includinglungs. Areas of hyperresonance suggests air trapping (as COPD), and also can be heard superior to site of atelectasis and pleural effusions. ● Dullness is detected over the actual site of atelectasis and pleural effusion- as intumors or pneumonia. ● Auscultation: ● Most helpful assessment. Pay special attention to areas of abnormalities that werepalpated. ● Note if you hear rales, rhonchi, wheezing, crackles. Can describe as coarse, fine, soft,high-pitched, low-pitched. ● Any friction rub heard? ● (With COPD- you will hear wheezing-especially if having an exacerbation) ● If abnormal findings: can do bronchophony, egophony and/or whispered pectriloquy. ● (Know what physical findings you might see with COPD; and know what somedifferential diagnosis' you may have) ● Diagnostic Studies ● Spirometry – to confirm diagnosis. The ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity is decreased from the norm of 80% t0 60% or lower. Unless there is some degree of asthma, post bronchodilator spirometer does not improvemore than 12%. ● CXR- reveals hyperinflation of lungs, with flattened diaphragm. ● If alpha- 1 - antitrypsin deficit is suspected- a qualitative serum should be ordered RESPIRATORY: o Review lung sounds o Know lung infections o Review asthma, pneumonia, PE, and pulmonary effusion. likely short answer o If the patient has a history of asthma and is exposed to allergens, what wouldyou expect if the patient comes in with wheezing? SOB, coughing
