quiz 3

melanoma

Arise from pigment-producing melanocytes in epidermis 4%-5% of skin cancer Most lethal of skin cancers Early-stage thin close to 100% curable Occurrence doubled Risk 1 in 75 #12 Indoor tanning increases risk 75% Most common cancer in adults specific to ages 25-29 Median diagnosis age 40

JVP Waveforms a,x,v,& y

S1 first s1 sound JVP highest right before systole!!!!! Listen to the heart, highest right before S1

hemangioma

a benign tumor made up of newly formed blood vessels

Tinea Versicolor

a fungal infection that causes painless, discolored areas on the skin multiple 2-5 mm hypopigmented, hyperpigmented, or tan round to oval macules o upper neck and back, upper chest and arms with slight inducinle scale on scraping

Atopic Eczema

a genetically determined inflammatory allergic skin disorder characterized by itching; also called atopic dermatitis

Purpuric Lesions

purpura; lesions resulting from hemorrhages into the skin deep red or reddish purple, fading overtime, petechia, 1-3 mm; purupura is larger rounded shape, sometimes irregular; flat absent or no effect from pressure variable distribution significants: blood outside the vessel may suggest a bleeding disorder, or if petechiae emboli to skin, palpable purpura in vasculitits

Carotenemia

yellow-orange color in light-skinned persons from large amounts of foods containing carotene

Jaundice

yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood

Seborrheic Keratoses

¨Benign, beige, brown or black plaques ¨"Stuck on" appearance ¨Freckle appearance change to mole-like lesions ¨Liquid nitrogen changes area to "white" area often have verrucuous texture appear like a stuck on or flattened ball of wax may crumble or bleed if picked specific features on dermoscopy such as milia-like cyst or comedone-like openings are reassuring, if present may be eruthematous if inflammed

Folliculitis & Furuncle

¨Inflammation of Hair Follicle may progress to localized infection with a "boil" ¨Caused by Staphylococcus aureus bacterial folliculitis- 30 or more 2-5mm erythematous papules and pustules on frontal, temporal and parietal scalp two large (2cm) furuncles on forehead without fluctuance; furunnclulosis (note fluctuant deep infections are abscess)

carbuncle

¨Much larger than furuncle ¨Caused by Staphylococcus aureus ¨May be necrotizing inflammed hair follicle, multiple furuncles together for a carbuncle

Actinic Keratoses

¨Small reddened areas ¨Pre-malignant squamous cell ¨Liquid Nitrogen acitinic keratosis after field therapy with 5 fluorouracil often easier to feel than see superficial keratotic papules "come and go" on sun damaged skin

Paronychia

¨Staph around nail fold ¨Manicure gone bad! a superficial infection of the proximal and lateral nail folds adjacent to the nail plate. The nail folds are often red, swollen and tender Represents the most common infection of the hand, usually staphylococcus aureaus or streptococcus species and may spread until it is completely surrounding the nail plate creates a felon if it extends into the pulp space of the finger. Arise from local trauma due to nail bitting, manicuring or frequent hand immersion in water. Chronic infections can be related to candida

Hidradenitis Suppurativa

¨Staph infection groin/axilla, others ¨Abscess common Aminoglycoside tx

Erysipelas

¨Usually caused by streptococcus ¨Upper dermis to superficial lymphatic vessels

ABCDEs

"Sensitive" screening mnemonic with 2 or more ~ 97% Metastasis may be to any "organ" Treatment biopsy and surgical excision Melanoma ABCD method: asymmetry, B boarder irregularity, color variation, and diameter > 6mm When screening want to do the ABCDE-EFG method A- asymmetric, B boarder irregularity especially if ragged, notched or blurred, C color variation (more than 2 colors, especially blue-black, white or red) D- diameter > 6mm (the top of a pencil eraser), E evolving or changing rapidly in size, symptoms or morphology, E- elevation, F- firmness to palpitation and progressive, G growing over several weeks

atrials, ventricles, ect

***understanding the interrelationships of the pressure gradients in the left heart (left atrium, left ventricle, and aorta), together with the position and movement of the four heart valves, is fundamental to understanding heart sounds Trace the changing left ventricular pressures and sounds through one cardiac cycle. Note that S1 and S2 define the duration of systole and diastole

Atria... the receiving chambers1

-Auricles- small wrinkled appendages...- increase atria volume slightly - - -Right atrium has two basic parts: -Smooth posterior portion -Anterior portion with bundles of muscle tissue formed ridges in the walls Chambers of the heart: the mitral and tricuspid valves are the atrioventricular AV valves The aortic and pulmonic valves are semi-lunar valves because the valve leaflets are shaped like half moons In most adults, the diastolic sounds of s3 and s4 are pathologic and are correlated with systolic and diastolic heart failure, respectively As the heart valves close, the heart sounds of S1 and S2 arise from vibrations emanating from the leaflets, the adjacent cardiac structures and the flow of blood An S3 corresponds to an abrupt deceleration of inflow across the mitral valve An S4 corresponds to increased left ventricular end diastolic stiffness which decreases compliance

additional special techniques

. Valsalva Maneuver...increased intrathoracic pressure.... -1st phase...transient increase during onset of "strain" -2nd phase...normalizing during "strain" phase -3rd phase...drop of BP & L ventricular volume during "release" phase -4th phase..."overshoot" seconds later •Hypertrophic cardiomyopathy...is only systolic murmur that increases during "strain phase" ***** HCM is the only systolic murmur that increases during straining, or valvsva phase

screening questions

1. . Have you experienced any changes in your skin, hair, or nails? ● 2. Developed any rashes, sores, lumps, or itching? 3. Observed any new growths? ● 4. Or moles that have changed size, shape, color, or sensation?

Acne

15-20 pustules and acneiform papules on buccal and parotid cheeks bilaterally

Anatomy

4 Chambers •2 superior atria and 2 inferior ventricles •Interatrial Septum...internal partition (longitudinally) separate atria •Interventricular septum separates ventricles •Right ventricle ..anterior cardiac surface "base of the heart" •Left ventricle ..."apex of the heart" and PMI (5th ICS 7cm-9cm lateral to midsternal line) Note that the right ventricle is the most anterior structure of the heart. This chamber and the pulmonary artery form a wedge like structure behind and to the left of the sternum The inferior border of the RV lies below the junction of the sternum and the xiphoid process. The RV narrows superiorly and joins the pulmonary artery at the level of the sternal angle, or the base of the heart, a clinical term that refers tot eh superior aspect of the heart at the valve plane, which is near the right and left second intercostal spaces adjacent to the sternum Left ventricle behind the RV and to the left, forms the left lateral margin of the heart Its tapered inferior tip is often termed the cardiac apex Lecture: right ventricle being called the base of the heart - base is the top The left ventricle is the apex of the heart- is the bottom A question of what is louder where S1 is louder at the apex S2 is louder at the base

Elevated JVP...Correlated with acute & chronic R & L sided Heart Failure

98% specific for... •Increased L ventricular end diastolic pressure •Low left ventricular ejection fraction •Increased risk of death from heart failure •In Obstructive lung disease...only elevated on expiration 98%!!! Specific- this is great! This can be very good to determine End diastolic pressure, low left ventricular ejection fraction EJ- the cardiologist does this JVP can do this Increase risk of death with heart disease Only elevated on expiration with Obstructive lung disease

nails

Angle between proximal nail fold & nail plate < 180 Nails protect the distal ends of the fingers and toes The firm rectangular and usually curving nail plate get it pink from the vascular nail bed to which the plate is firmly attached The cutical extends from the fold and functioning as a seal protects the space between the fold and the plate from external moisture Fingernails grow approximately 0.1mm daily, toenails grow more slowly

obstructive sleep apnea

Asymptomatic patients with morbid obesity or refractory hypertension may have OSA Severity of OSA is based on the hourly number of epsiodes of apnea and hypoapnea The definitive diagnosis is made by polysomnoraphy performed in a sleep lab that measures brain waves The primary treatment for OSA is positive airway pressure, delivered through BIPAP or CPAP or autotrating (APAP) machines Other management strategies include mandibular advancement devices, weight loss reduction, and a variety of airway surgeries While treatment can improve symptoms of sleepiness, improve airflow and lower blood pressure, evidence is sufficient to determine whether it prevents cardiovascular events or all cause mortalilty

skin cancers

Basal Cell ...head, neck & upper limbs Squamous Cell...head, neck, & upper limbs Melanomas...often on nonexposed areas from sunburns Skin lesions: it is important to use specific terminology to describe skin lesions and rashes. Good descriptions include each of the following elements: size, number, color, shape, texture, primary lesion, location and configuration The best defense against skin cancer is to avoid UV radiation exposure by limiting time in the sun, avoiding midday sun, using sunscreen and wearing sun protective clothing with long sleeves and hats with wide brims. Advise patients to avoid indoor tanning, especially children, teens and young adults Signs of chronic sun damage include numerous solar lentigines on the shoulders and upper back, many melanocytic nevi, solar elastosis (yellow, thickened skin with bumps, wrinkles, or furrowing), cuffs, rhomboidalis nuchae (leathery thickened skin on the posterior neck) and actinic purpura. Using tanning beds, especially before age 35 years, increases risk of melanoma by as much as 75%

Auscultation Sequence

Before beginning auscultation, ask the patient to cough once or twice to clear mild atelectasis or airway mucus that can produce unimportant added sounds Bedclothes, paper gowns, and even chest hair can generate confusing crackling sounds that interfere with auscultation. For chest hair, press harder or moisten the hair Always place the stethoscope directly on the skin, clothing alters the characteristics of breath sounds and can introduce friction and added sounds Like auscultation over clothing, air movement through a partially obstructed nose or nasopharynx can also introduce abnormal sounds

Things to rememeber for the test

Carotid upstroke- look at this and see the upstroke and the bruits JVP on baseline to look **be very familiar on how to rate murmur, see if you feel the thrill Do the buzzing ball Sternal heave- like it was about to bounce off the chest, the rib cage keeps it in place Will ask question on JVP, timing, dynamic neck, listen to the sethoscope, before S1 will hear JVP S1 after is carotid CO output is very important- preload, afterload, contractility Understand concept A math question on JVP Timing and location of murmurs, if the valve is open then its probably stenosis Femeral pulses are important- CPR checking carotid and femeral pulses Miss the coarch- repair because caught at the age of 26 Dextacardiac- the heart is switched, they will hear beats on the opposite side Bruit is tuberulence- can be plague that is making more tubulence Plague can fly off with bruit- can be with TIA- can cause due to plague dislodge PND wakes up with SOB- Rheumatic fever- mitral!!! Aspirin- can cause reyes syndrome Hypokinetic- less movement, yucky movement- not going to have a good carotid upstroke Normal is 7, so above 7 is bad S1 is intense in intensity, loud P2 Early diastolic, s3, wants to stay close, the S3 not able to fill in the early stages Diastolic is when the mitral valve stenosis S4 doesn't want the atrial to completely empty because end diastolic Aortic regurge- tricuspid stenosis Only timing and location Here a murmur in the aortic area and during diastole- so this would be an aortic stenosis Diastole with aortic and pulmonic closed S3 is down by the ventricles, S4 down by ventricles Anything above 9-10 is JVP elevated 6 or 14 Matching- S3 and S4, ones early and ones late Both diastolic, herd best at the apex Timing and location 4 heart murmurs on each of the messing, S1 louder than S2, where is that The carotid upstroke When squatting which one goes up and which ones goes down Doubling the TIA and Stoke for bruit And then valsva JVP comes before S1 carotids immediately after S1 Systolic- get carotid pulse right after Caridiac ouput is the most important, very important to know and making decisions on that For manuvers look at the different murmurs and what this causes Make sure to know timing and location and don't worry about the fluff in the question 2 or 3 skin, 2 or 3 lung

cyanosis

Central...O2 level is low in the arterial blood Peripheral...cutaneous blood flow decreases and slows...tissue extract more O2 than usual...may be a normal response to anxiety or cold Pallor indicates anemia Cyanosis a blue color can indicate decreased oxygenation in the blood or decreased blood flow in response to cold environment

Lung Expansion... Inspiration Expiration

Chest: to assess this symptom of chest pain, you must pursue dual investigation of both thoracic and cardiac causes Chest pain is reported in one in four patients with panic and anxiety disorders A clenched fist over the sternum suggest angina pectoris; a finger pointing to a tender spot on the chest wall suggests muscloskeletal pain; a hand moving from the neck to the epigastrium may suggest heart burn Ask the patient to point to the location of the pain in the chest Lung tissue has no pain fiber, the pericardium has a few

acute coronary syndrome

Clinical syndromes caused by an acute MI •1. Unstable angina •2. Non-ST elevation •3. MI •4. ST elevation infarction Women > 65 may report atypical s/s...upper back, neck, or jaw pain, SOB, paroxysmal nocturnal dyspnea, n/v, & fatigue Classic exertional pain; pressure, or discomfort in the chest, shoulder, back, neck or arm in angina pectoris is seen in 18% of patients with acute MI Atypical descriptors also are common, such as cramping, grinding, pricking, or rarely, tooth or jaw pain *both men and women with acute coronary syndrome usually present with the classic symptoms of exertional angina, however, women particularly those over age 65, are more likely to report atypical symptoms that may go unrecognized, such as upper back, neck, or jaw pain; shortness of breath; paroxysmal nocturnal dyspnea; nausea or vomiting; and fatigure, making careful history taking especially important Cause of chest pain in the absence of obstructive coronary artery disease on angiogram include microvascular coronary dysfunction and abnormal cardiac nocioception, which requires specialized testing. Roughly half of women with chest pain and normal angiograms have microvascular coronary dysfunction Acute coronary artery syndrome is increasingly used to describe the clinical syndromes caused by acute myocardial ischemia, which include unstable angina, non-ST elevation, MI and ST elevation infarction

ABCDEs for Early Recognition of Possible Melanoma ABCDEs

Clinicians should apply the ABCDE method which screening moles for melanoma (this dose not apply for nonmelanocytic lesions like seborrgeic keratoses). The sensativity for this tool for detecting melanoma ranges from 43%-97% and specificity ranges from 36% to 100%; diagnostic accuracy depends on how many criteria are used to define abnormality With the exceptrion of homogenous blue color in a blue nevus, blue or black color within a larger pigmented lesion is especially concerning for melanoma Early melanomas may be less than (<) 6mm and may benign lesions are greater than (>) 6mm Evolution or change, is the most sensitive of these criteria. A reliable history of change may be prompt biopsy of a benign-appearing lesion The most sensitive is E, for evolution or change. Pay close attention to nevi that has changed rapidly based on objective evidence

Herpes Simplex

Clustered #2 Herpes Simplex multiple 2-4mm vesicles and pustules on erythemous base, grouped together on left neck vesicle (fluid-filled, small)

acne stages

Comedones Open = "Blackheads" openings "capped" with blackened skin debri Closed = "Whiteheads" with "obstructed openings"

skin examination techniques

Commit 1-2 minutes to inspect the entire surface of the skin. Note: 1. Color 2. Moisture 3. Temperature 4. Texture 5. Mobility & Turgor 6. Lesions Instruct patient with risk factors for skin cancer and melanoma, especially those with a history of high sun exposure, prior, or family history of melanoma, and >50 moles or >5 to 10 atypical moles, to perform regular skin self exams Approximately half of melanomas are initially detected by patients or their partners

health history

Common & Concerning Symptoms 1. Hair Loss 2. Rash 3. Growths Lesions- look for lesions suggesting melanoma, basal cell carcinoma or squamous cell carcinoma, throughout the skin examination regardless of the patient's skin color. Detecting skin cancer at an early stage can increasely likelihood of successful treatment "Have you seen any changes in your skin?" "ABCDE" of skin Rashes and itching- causes of generalized itching without an apparent rash, include dry skin, pregnancy, uremia, jaundice, lymphomas and leukemia, drug reactions and less common polycythemia vera and thyroid disease Ask about dry skin, encourage use of moisturizers to replace the lost moisture barrier Hairloss: for hairloss ask if its thinning or shedding and if so where. Be familiar with common nail changes, such as onychomycosis, habit tic deformity and melanomychia The most common cause of diffuse hair thinning are male and female pattern baldness Hair shedding at the roots is common in telogen effluvium and alopecia areata. The hair breaks along the shaft suggest damage from hair care or tinea capitis

Dermatomyositis...Heliotrope

Connective-tissue disease Polymyositis Inflammation of Muscles & Skin Systemic

amplitude of carotid pulse

Correlates to pulse pressure •Decreased pulsation.... -Decreased stroke volume -Atherosclerotic narrowing or occlusion -Small-thready-weak...cardiogenic shock - Bounding pulsation...aortic insufficiency *never palpate both carotid arteries at the same time. This may decrease blood flow to the brain and induce syncope **pressure on the carotid sinus may cause reflex bradycardia or a drop in blood pressure Carotid pulse is small, thready (barely detectable) or weak In cardiogenic shock; the pulse is bounding in aortic regurgitation The carotid upstroke is delayed in aortic stenosis Thrills in aortic stenosis are transmitted to the carotid arteries from the suprasternal notch or second right intercostal space **pulsus alternans almost always indicates severe left ventricular dysfunction The initial kortokoff sounds are the strong beats.. As you lower the cuff, you will hear the softer sounds of the alternating weak beats, which will eventually disappear, causing the remaining Korotkoff sounds to double **alternatively loud and soft Korotkoff sounds or a sudden doubling of the apparent heart rate as the cuff pressure declines signals pulsus alternans Placing the patient in the upright position may accentuate this finding Lecture: right after the S1 is big

Varicella Zoster Virus

Crops Develop In Stages Macule Papular Vesicle Pustular Crust

Carotid Pulse Wave Abnormalities

Delayed upstroke...aortic stenosis Pulsus Alternans...beat to beat variation... severe L sided heart failure Paradoxical Pulse...varies with respiration... Pericardial tamponade Constrictive pericarditis Obstructive airway disease Thrill felt? Paradoxial pulse or pulsus paradoxus is a greater than normal drop in systolic blood pressure during inspiration If the pulse varies in amplitude with respiration or you suspect cardiac tamponade (BECAUSE jugular vein distention, dyspnea, tachycardia, muffled heart tones, or hypotension), use a BP cuff to check for a paradoxical pulse *the pressure when Korotkoff sounds are first heard is the highest systolic pressure during the respiratory cycle. The pressure when sounds are heard throughout the cycle is the lowest systolic pressure. A difference between these levels of > or equal to 10mm hg to 12 mm hg constitutes a paradoxical pulse **paradoxical pulse is found in pericardial tamponade, a life threatening condition. It is also (more commonly) found in acute asthma and obstructive pulmonary disease. IT also occurs in constrictive pericarditis and acute pulmonary embolism Pulsus alternans and a bigeminal pulse vary beat to beat; a paradoxical pulse varies with respiration Lecture: delayed upstroke is aortic stenosis, slow trickle coming up Beat to beat variation can be in left sided heart failure

basic cardiac exam

Describe chest wall anatomy...key listening areas 2. Evaluate JVP, Carotid upstroke, & Carotid bruits 3. Identify & describe PMI 4. Identify S1 & S2 both at base and apex (S1 >S2 @apex & S2 >S1 at base) 5. Recognize effect of P-R interval on S1 intensity 6. Identify physiologic & paradoxical splitting of S2 JVP- jugular venous pressure, reflects right atrial pressure, which, in turn, equals central venous pressure and right ventricular end-diastolic pressure The JVP is best estimated from the right internal jugular vein, which has the most direct channel into the right atrium Changing pressure in the right atrium during diastole and systole produce oscillations of filling and emptying in the jugular veins, or jugular venous pulsation Atrial contraction produces an A wave in the JVP just before S1 As right atrial pressure begins to rise with the inflow from the vena cava during right ventricular systole, there is a second elevation, the V wave, followed by the Y descent as blood passively empties from the right atrium into the RV during early and middistole ***a simplified way to remember the 3 peaks is a for atrial contraction, C for carotid transmission (although this may represent closure of the tricuspid valve) and V for venous filling ***abnormal prominent cannon a waves occur in increased resistance to right atrial contraction, as in tricuspid stenosis; also in severe first- second- and third-degree AV block, supraventricular tachycardia, junctional tachycardia, pulmonary hypertension, and pulmonic stensosis **absent a waves signal atrial fibrillation **increased V waves occurs in tricuspid regurgitation, atrial septal defects, and constrictive pericarditis Lecture: Any bruit is not good!! ***Describe where the PMI is- the 5th intercostal medial to the medialstinal Is there any split, have them take a deep breath and hold it, see if the splitting defuses and goes away, this is non fixed If its fixed then it will not go away after holding breath

Palpation

Diaphragmatic Excursion 3-5cm normal 7-8cm well-conditioned 2-3cm COPD Unilateral decrease-delay: chronic fibrosis, pleural effusion, pleural pain, splinting pain, lobular pneumonia, unilateral bronchial obstruction, paralysis of hemidiaphragm Palpate both lungs for tactile fremitus Tactile fremitus is decreased or absent when the voice is higher pitched or soft, or when the transmission of vibration from the larynx to the surface of the chest is impeded by a thick chest wall, an obstructed bronchus, COPD, pleural effusion, fibrosis, air (pneumothorax) or an infiltrating tumor Asymetric decreased fremitus raises the likelihood of unilateral pleural effusion, pneumothorax, or neoplasm, which decreases transmission of lower frequency sounds; asymmetric increased fremitus occurs In unilateral pneumonia which increases transmission through consolidated tissues Percussion helps you establish whether the underlying tissues are airfilled, fluid filled, or consolidated

lung disease

Diseases of the airway resulting in impaired ventilation

lung disease

Diseases with reduced blood flow, resulting in impaired perfusion of the lung. PE

percussion

Dullness........represents airway obstruction from inflammation or secretions Such as in Pneumonia Hyperresonance...may obscure "dullness" over the heart...... Such as in COPD

Café' Au-Lait Spot

Early s/s of Neurofibromatosis

Erythema Infectiousum

Etiology: Parvovirus B19 Sx: "slapped cheek appearance" Tx: benign - resolves on its own. Most contagious prior to rash

important concepts

Factors influencing Arterial Pressure 1. L ventricular SV 2. Distensibility of aorta and large arteries 3. PVR...particularly at the arteriolar level 4. Volume of blood in arterial system Aortic and large arteries This is going to influence arterial pressure At the arterial level, the volume of blood in the actual system S1 and S2, The S1 is apex And S2 is base Looking at the chest wall anatomy Looking in general and the PMI, looking for any sternal heaves, can sometimes see a thrill or fill it The heart can look like its coming out of the chest if the ribs weren't there Looking at the blood flow going through

additional sounds

Friction Rub... Harsh, grating sound May be systole and/or diastole A/W pericarditis Pleural friction rub- the rubbing of the pericardium area

tinea capitis

Geographic Represents Continents & Islands Annular #3 ring worm, there are round scaling patches of alopecia, mostly seen in children. There may be black dots of broken hair and comma or corkscrew hairs on dermoscopy

melanoma risk factors

HARMM Melanoma Risk Model History of previous melanoma = 3.3 Age over 50 =1.2 Regular dermatologist absent =1.4 Mole changing =2.0 Male gender =1.4 Increased risk of Melanoma US prevention service task force has issued a grad B recommendation supporting behavioral conunseling to minimize UV radiation exposure in fair skinned persons aged 6 months to 24 years. The task force suggest considering risk factors for skin cancer in selectively counseling fair-skinned adults older than age 24 (grade C). Advise patients to use at least spf 30 and broad spectrum protection the ADD recommends using sunscreen to cover all exposed skin areas whenever going outside, even on cloudy days. Sunscreen should be reapplied every 2 hours when outside and after being in the water ADD encourages persons at high risk for melaoma to ask a dermatologist how often to receive a clinical skin examination. The ADD further recommended that individuals perform regular skin self examination and see a dermatologist for any new or suspicious spots and spots that are changing, itching or bleeding Patients who have clinical skin examinations within the 3 years prior to melanoma diagnosis have thinner melanomas than those who did not have a clinical skin examination. Both new and changing nevi should be closely examined as at least half of melanomas arise de novo from isolated melanocytes rather than pre-existing nevi Detection of melanoma requires knowledge of how benign nevi change over time, often going from flat to raised or acquiring additional brown pigment.

squamous cell carcinoma

More mature cells Resemble spinous layer of epidermis Arise out of actinic keratoses 16% of skin cancers Firm papule or nodule to crusted hyperkeratotic lesion Inflamed and Ulcerated appearance that appears over short period (few months) Keratotic~Scaly bleeding Metastasis rare (1%) Mohs procedure used for removal

location of murmurs

Heart murmurs are distinct heart sounds distinguished by their pitch and their longer duration. They are attributed to turbulent blood flow and usually indicate valvular heart disease At times, they may also represent "innocent" flow murmurs, especially in young adults A stenotic valvue has an abnormally narrowed orifice that obstructs blood flow as in aortic stenosis and causes a characteristic murmur Valves can also close abnormally resulting in regurgitation, such a valve allows blood to leak backward in a retrograde direction and produce a regurgitant murmur

Auscultation...Grades of Murmurs

I/VI...Very faint, may not be in all positions II/VI...Quiet, heard immediately after placing stethoscope III/VI...Moderately loud IV/VI...Loud, with palpable thrill V/VI...Very loud, with thrill, may be heard with stethoscope partly off chest VI/VI...Very loud, with thrill, may be heard with stethoscope entirely off chest Grade systolic murmurs using the 6 point scale (Levine grading system) (p 527) Note the grades 4-6 require additional palpable thrill. Grade diastolic murmurs using the four point scale (p 527). A different scale is used by convention for diastolic murmurs as they are not commonly associated with a palpable thrill Locate the point of maximal intensity and its radiation: for example, a murmur best heard in the second right intercostal space often originates at or near the aortic valve The murmur of aortic stenosis often radiates to the neck in the direction of arterial flow, especially on the right side. In mitral regurgitation the murmur often radiates to the axilla, supporting transmission by bone conduction A fully described murmur might be: a medium pitched, grade 2/4, blowing descescendo diastolic murmur, best heard in the fourth left intercostal space, with radiation to the apex" (aortic regurgitation) Right sided heart murmurs generally increase with inspiration; left sided murmurs genrally increase with expiration Lecture: last two were 3 out of 4 If they had thrill then 4,5,6 !!! Certification **** ask question on this

approach to chest pain

INITIAL GOAL in ED is to identify life threats •MI, PE, aortic dissection • Remember ABCs always first

tactile fremitus

Increased in: •Pneumonia Decreased in: •Bronchial obstruction with •Mucus plug or foreign object •Pleural effusion ("dull lung") •Pneumothorax •COPD ("hyper-inflation') •Tumor or mass •Pulmonary Fibrosis

hair

Inspect and Palpate Assess Quantity, Distribution, & Texture To examine hair for shedding from the roots, perform a hair pull test by gently grasping 50-60 hairs with your thumb and index and middle fingers, pulling firmly away from the scalp. If all the hairs have telogen bulbs, the most likely diagnosis is telogen effluvium Possible internal cause of diffuse nonscarring hair shedding in young women are iron deficiency anemia, and hyper hypothyroid Most hair loss is non sccaring but any scarring namely shiny spots without any hair follicles on close examination with a magnifying class, should prompt referral to dermatology

nails assessment

Inspect and Palpate Fingernails & Toenails...Note 1. Color ● 2. Shape 3. Nail Angle

additional special techniques

Isometric Handgrip...increases systolic murmurs of MR, PS, & VSD and diastolic murmurs of AR & MS (68% sensitive and 92% specific) 4. Transient Arterial Occlusion...transient compression of both arms via bilateral BP cuff inflation to 20mm Hg > peak SBP augments murmurs of MR, AR, & VSD Isometric handgrip- increases the systolic murmurs of mitral regurgitation, pulmonic stenosis and ventricular septal defects as well as the diastolic murmurs of aortic regurgitation and mitral stenosis Transient arterial occlusion- compression of both arms by bilateral BP cuff inflation to 20mm hg greater than peak systolic blood pressure augments the murmurs of mitral regurgitation, aortic regurgitation and ventricular septal defects **the murmurs of mitral regurgitation and ventricular septal defects could be differentiated from other systolic murmurs by augmentation of their intensity with handgrips (68% sensitivity, 92% specificity) and during transient arterial occlusion (78% sensitivity, 100% specificity) JVD- above 3CM- these findings suggest heart failure with volume overload with possible left carotid occlusion and mitral regurgitation

Lateral Lung View Comparison

Large volumes of purulent sputum are present in bronchiectasis and lung abscess Diagnostically helpful symptoms include fever, productive cough in pneumonia; wheezing in asthma, and chest pain dyspnea and orthopnea in acute coronary syndromes Causes of cough and hemoptysis include bronchitis; malignancy; cystic fibrosis, and less commonly bronchiectasis, mitral stenosis good-pasture syndrome, and grandulomatosis with polyangiitis Massive hemoptysis (>500 ml over a 24 hour period or > or equal to 100 ml a day) may be life threatening Symptoms associated with cough can often lead to its cause Before using the term hemoptysis, try to confirm the source of the bleeding. Blood orgininating in the stomach is usually darker than the blood from the respiratory tract and may be mixed with food particles

Pericardium

Layers of the heart, there are 3 different layers It could be one of those different layers The myocardial is where covid is hitting The way that covid is attacking the cells The flow of blood IVC + SVC Right atrium - pacemaker, SV node, then we have AV node that can take over (60-100 BP), has some cardiac output, muscular atrium, the lining is different and some cardiac output Tricuspid valve Right ventricle- not the same muscular Pulmonic valve Pulmonary artery- de02 blood occurring, BP that is much less than the aorta (this does not like a lot of blood pressure) can get irimyers syndrome To the lungs Pulmonary veins Left atrium Mitral valve Left ventricle Then to the aortic valve To the aorta - then systemic rotation A fib- the heart is quivering, the sloshing happens and clots can form, when we have A fib we lost some cardiac output (10% CO lossed) This occurs in right atrium Any backflow can cause a decrease in the CO

Steven Johnson Syndrome

Lesions start as a bulls eye. HIV pts have a 40 fold increased risk of SJS to Bactrim

Koebner phenomenon

Linear #1 Koebner phenomenon "Koebner response" "isomorphic response" on lines of trauma.

Skin Anatomy and Physiology

Maintain temperature homeostasis Synthesizes Vitamin D Heaviest Single Organ 16% of body weight The skin is the heaviest single organ of the body, accounting for 16% of body weight It contains 3 layers, the epidermis, the dermis and the subcutaneous tissues The most superficial layer is the epidermis This is where melanin and keratin are formed Migration from the inner to outer layer takes approximately 1 month Dermis- is a dense layer of innerconnecting collagn and elastic fibers containing epidermal appendages Normal skin color depends on the amount and type of melanin but is also influenced by underlying vascular structures, changing hemodynamics and changes in carotene and bilirubin

additional special techniques

Maneuvers for Systolic Murmurs & Heart Failure 1. Standing & Squatting... Squatting...induces the opposite...identifies prolapsed mitral valve & helps distinguish hypertrophic cardiomyopathy from aortic stenosis Standing...decreases venous return, PVR, arterial BP, SV, and volume in L ventricle

Urticaria

May be Temporary or Chronic many variable sized (1-10cm) wheals on lateral neck, shoulders, abdomen, arms, and legs area of localized dermal edema that evancesces (comes and goes) within a period of 1-2 days; this is the essential primary lesion of urticaria

skin color

Melanin Carotene Oxyhemoglobin Deoxyhemoglobin Normal skin color depends on the amount and type of melanin but is also influenced by underlying vascular structures, changing hemodynamics and changes in carotene and bilirubin The amount of melanin is depending on the exposure to sunlight Carotene a yellow pigment is found in subcutaneous fat and heavily keratinized areas such as the palms and soles Bilirubin a yellow-brown pigment arises from the breakdown of heme in the red blood cells Hemoglobin in the red blood cells transports oxygen in the form of oxyhemoglobin After passing though the capillary bed and releasing oxygen tissues, the darker blue pigment of deoxyhemoglobin circulates in the veins Jaundice- or yellowing of the skin results from increased bilirubin

Tinea Corporis

Serpiginous #4 Worm-like

measuring JVP

Place ruler on sternal angle 8. Place a rectangular object at an exact R angle 9. Move it up or down until lower edge rests at top of jugular pulsations 10. Read vertical distance on ruler...round to nearest cm 11. Readings > 3-4cm above sternal angle (8-9cm from R atrium) is above normal

the heart

Position...supine...HOB 30 degrees Inspect Palpate Percuss Auscultate Might see movement, and feeling for a thrill, palpate The thrill will feel like a ball buzzing underneath Each rib cage is going to be flat The heart is an organ Liver is dull Percuss the chest to figure the size of the heart Listen to he change and percussion sounds Ausculate the heart sounds

bedbound patient

Pressure Sores...from sustained compression obliterating arteriolar and capillary blood flow Risk: Neurologically Impaired Emaciated Elderly Friction/Shear Injury Pressure ulcers or ulcers result from sustained compression that obliterates arteriolar and capillary blood flow to the skin and from shear forces created by body movements Local redness of the skin warns of impending necrosis, although some deep pressure sores develop without antecedent redness. Fever, chills, and pain suggest osteomyelitis Assess every susceptible patient by carefully inspecting the skin that overlies the sacrum, buttocks, greater trochanter, knees and heels Inspect for infection, as well as roll pt to side to look at sarcral Friction and moisture further increase the risk of abrasion and sores. Pressure injury are classified through staging systems Pressure ulcers are especially present in people confined to the bed, especially when they are emaciated, elderly or neurologically impaired and are particualry suspectable to skin damage and ulcerations

Lichenification

Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)

JVP

QRS starting with systole The right atrium regardless of position of body is always 5 cm below If you get JVP of 2, then add 5= so total is 7 ***question on total JVP number- must add 5 to the JVP value Will not see fluttering until laying flat It is not going to change your number always add 5!!

JVP anatomy

RIJ...(deep to sternomastoid muscle) Identify IJ & EJ Pulsations (transmitted to surface) Measure... vertical distance above sternal angle (Manubrium joins sternum... bony ridge adjacent to 2nd rib) Lecture: put the ruler at the sternal angle, knowing that the sternal notch is here, it is important to count with PMI Should be at least 30 degrees to look Look at the external jugular, look for a little bit of fluttering, and try to see where it is the highest at the angle

basic cardiac exam continued

Recognize key abnormal sounds... early diastole...S3, pericardial know, & opening snap of MS ...late diastole...S4 8. Identify systolic & diastolic murmurs, & friction rubs...using maneuvers when needed 9. Evaluate & interpret pulsus paradoxus 10. Identify normal physiological findings...Heart rate & rhythm, and characteristics Changes overtime, also effect the location of the apical impulse, the pitch of heart sounds and murmurs, the stiffness of the arteries and the blood pressure PMI is usually easily palpated in children and young adults, a chest deepens in its anteroposterior (AP) diameter, the impulse gets harder to find Further more, at some time during the life span, almost everyone has a heart murmur. Most murmurs occur without evidence of cardiovascular abnormalilties and are considered normal varients If the LV is not moving blood adequetly, fluid will retain in the lungs (pulmonary edema) and the patent will experience shortness of breath, especially with exertion or with lying flat (orthopnea) Additionally the patient can experience lightheadedness or loss of consciousness if the blood supply to the brain is inadequet. If the RV is not moving blood adeuqetly, fluid can build up in the legs, a condition known as peripheral edema It is important to rememember that the end result of all heart disease is pump malfunction The patient with an abnormal heart rhythm may present with loss of consciousness, as the abnormal rhythm prevents adequet LV function and cerebral perfusion. IF the blood supply to the heart is compromised, patients can experience SOB in addition to chest pain

HEALTH PROMOTION & PRVENTION

Reduce sun exposure Sunscreen with SPF 15+ Avoid sunbathing, tanning beds, & sunlamps Teach patients the ABCDE method

prevention

Remain Alert Most Common is "total body skin examination" Average patient 15-30 moles/nevi Junctional, Intradermal, & Compound Office examination enhanced with dermoscopy The use of a dermoscope is an increasingly useful office practice for deciding whether a melanocytic lesion is benign or malignant The handheld device provdes cross-polarized or unpolarized light to visualize patterns of pigmentation or vascular structures With adequet clinical training, use of a dermoscopy improves the sensitivity and specificity of differentiating melanomas from benign lesions Make sure the room is adequetly lit and good overhead ambient lighting or natural light from windows is usually adequet, you may wish to add a stronger lught source if the room is dark You will need to also add a small ruler or tape measure, a magnifying glass may help you see things more clearly

percussion

Resonance.......Loud/Low/Long......Normal lung/bronchitis Dullness........Medium/Medium/Medium.....Lobar Pneumonia Flatness.........Soft/high/short.............Large pleural effusion Hyperresonance...Louder/Lower/Longer.......COPD, Emphysema/Pneumothorax Tympanitic.........Loud/high/musical........Large pneumothorax Percussion: an abnormally high level suggests a pleural effusion or an elevated hemidiaphragm from atelectasis or phrenic nerve paralysis

Ventricles..."Discharging Chambers"

Right ventricle (most of anterior surface) Left ventricle (most of heart's volume ) During diastole, pressure in the blood filled left atrium slightly exceeds that in the relaxed LV, and blood flows from left atrium to left ventricle cross the open mitral valve During systole, the LV starts to contract and ventricular pressure, rapidly exceeds left atrial pressure, closing the mitral valve ***closure of the mitral valve and the tricuspid valve in the right side of the heart produce the first heart sound, S1 As left ventricular pressure continues to rise, it quickly exceeds the pressure in the aorta and forces the aorta valve to open In some pathologic conditions, an early systolic ejection sound (Ej), accompanies the opening of the aortic valves ***Normally, maximal left ventricular pressure corresponds to systolic blood pressure **Aortic valve closure, as well as the closure of the pulmonic valves, produce the second heart sound, S2 and another diastole begins

Pityriasis Rosea

Salmon Colored Maculopapules Herald Lesion single, oval, flat-topped superfiical erythematous to skin-colored plague on right abdomen, herald patch of piryriasis rosea multiple round to oval scaling violaeous plagues on abdomen and back

sebeceous glands and sweat glands

Sebaceous Glands....present all surfaces except palms & soles Sweat Glands 1. Eccrine...open onto Skin surface 2. Apocrine...axillary & genital regions open into hair follicles Pilosebaceous glands (oil) glands- produce a fatty substance secreted onto the skin surface through the hair follicles These glands are present on all skin surfaces except the palms and soles Sweat glands- there are two types, eccrine and apocrine The eccrine sweat glands are widely distributed, open directly onto the skin surface and help to control body temperature by their sweat production Appocrine glands- are found chiefly in the axillary and genital regions and usually open into hair follicles Bacterial decomposition of apocrine sweat is responsible for adult body oder

Herpes Zoster

Shingles grouped 2-5mm vesicles on erythematous base on left upper abdomen and trunk in a dermatomal distribution that does not cross the midline

Bedside Maneuvers to Identify Systolic Murmurs

Squatting (Valsalva release phase) increase venous return = increase L ventricular volume increase vascular tone = increase arterial pressure & PVR Decreases prolapse of Mitral valve (MVP delayed click & shortened murmur) Decreases HCM murmur due to decreased outflow obstruction Increased AS due to increased blood ejected into aorta Squatting: the murmur of hypertrophic obstructive cardiomyopathy is distinguished from all other murmurs by an increase in intensity during squatting to standing action (95% sensitivity, 84% specificity) and by a decrease in intensity during standing to squatting action (95% sensitivity, 85% specificity) There is another is valsva- can have them stand up, when standing up, the blood goes down When you suddening squad then you should all the blood up The tatollogy of fallop- they squat right away to get more blood in When I squat have more blood that goes right into the heart HCM- then that murmur will decrease because more blood flow goes into the heart Mitral valve prolapse- like jelly fish because it bobs up and down quickly, and then decrease The aortic stenosis- increases with the squatting, it will sound louder in this Standing does the opposite, the aortic stenosis will decrease because less blood pumping ***will have a question on this

Bedside Maneuvers to Identify Systolic Murmurs

Standing (Valsalva strain phase) decrease venous return = decrease L ventricular volume decrease vascular tone = decrease arterial pressure Increases MVP (earlier click & lengthened murmur) Increases HCM murmur due to increased outflow obstruction Decreases AS with decreased flood ejected into aorta Valsva maneuver: the murmur of hypertrophic cardiomyopathy is the only systolic murmur that increases during the "strain phase" of the valsva manuever due to increased outflow tract obstruction (65% sensitivity, 96% specificity) In patients with severe heart failure, blood pressure remains elevated and there are Korotkoff sounds during the phase 2 strain phase, but not during phase 4 release, termed "the square wave" response. This response is highly correlated with volume overload and evaluated left ventricular end-diastolic pressure and pulmonary capillary wedge pressure, in some studies outperforming brain natriuretic peptide Standing is the opposite HCM- this is a heart manuver

JVP measurement

Starting point is 30 degrees 2. Tangential lighting 3. Identify the EJ vein on each side 4. Find IJ venous transmitted pulsations 5. Assess pulsations at the suprasternal notch (attachments of sternomastoid muscle on the sternum & clavicle) 6. "Identify Highest Oscillation point or meniscus" (extend a long rectangular object or card from highest point to the vertical cm ruler) Looks like a trickling of water, JVP- listen with stethoscope S1 goes with coradit The JVP will be the highest level of fluttering before S1 Only on the right side, place ruler and look for the highest level

lungs

The degree of dyspnea, combined with spirometry, is a key component of important chronic obstructive pulmonary disease (COPD) classification system that guide patient management Anxious patient may have episodic dyspnea during both rest and exercise and also hyperventilation, or rapid shallow breathing Wheezing occurs in parital lower airway obstruction from secretions and tissue inflammation in asthma, or from a foreign body Cough can signal left-sided heart failure The most common cause of acute cough is viral upper respiratory infections. Also consider acute bronchitis, pneumonia, left-sided heart failure, asthma, foregin body, smoking, and ACE inhibitor therapy. Postinfectious cough, pertussis, acid reflux, bacterial sinusitis and asthma can cause subacute cough Chronic cough is seen in postnasal drip, asthma, gastroesphogeal reflux, chronic bronchitis and bronchiectasis Mucoid sputum is translucent, white, or gray and seen in viral infections and cystric fibrosis; purulent sputum- yellow or green- often accompanies bacterial pneumonia Foul-smelling sputum is present in anaerobic lung abscess, thick tenacious sputum in cystic fibrosis

anatomy of the heart

The left ventricle behind the RV and to the left forms the left lateral margin of the heart. Its tapered inferior tip is often termed the cardiac apex. It is clinically important because it produces the apical impulse, identified during palpation of the percordium as the point of maximal impulse (PMI). This impulse locates the left border of the heart and is normally found in the fifth intercostal space at or just medial to the left midclavicular line In supine patients, the PMI is approximately 1 to 2.5 cm It is not always palpable even in the healthiest people Rarely, in dextrocardia, the PMI is located on the right side of the chest A PMI >2.5cm is evidence of left ventricular hypertrophy (LVH), often seen in hypertension or dilated cardiomyopathy In some patients, the most prominent percordial impulse may not be at the apex of the left ventricle. For example, in patients with chronic obstructive pulmonary disease, the most prominent palpable impulse or PMI may be in the xiphoid or epigastric area due to right ventricular hypertrophy Displacement of the PMI lateral to the midclavicular line or >10 cm lateral to the midsternal line occurs in LVH and also in ventricular dilation from MI or Heart failure Lecture: right looks different than left atrium, tricuspid on right and left is the mitral valve Knowing the flow of the blood is important Got the two main ventricles, the two pumps, we have different kinds of valves Pulmonic and aortic- these is pressure only, The mitral and tricuspid has the cordae tendae When they get damaged there are different reasons why they are not closing Problems if there is a whole Left has a higher pressure of the heart The left ventricle is stronger and the pressure will be higher The lungs don't like to have extra flow, the extra blood is going in and getting more The left side is higher

basal cell carcinoma (BCC)

The most common skin cancer Immature cells...similar to basal layer cells 80% of all skin cancers Waxy, Pearly, erythematous translucent papules, some with central depression and telangiectatic vessels Subtle red macules Slow Growing 1-2 cm after years Punch or shave biopsy

lung disease

Thickened interface between alveoli and adjacent capillaries, resulting in impaired diffusion of gases.

JVP

To measure : the JVP is usually measured in vertical distance above the sternal angle (also called the angle of louis), the bony ridge located around T4 adjacent to the second rib where the manubrium joins the body of the sternum Note that the height of the venous pressure as measured from the sternal angle is similar in all three positions, but your ability to measure the height of the column of venous blood, or JVP, differs according to how you position the patient

ventricles

Trabeculae carneae ... & Papillary Muscles ....valvular function Trabeculae carneae ... contraction pulls on the chordae tendineae, preventing inversion of the mitral (b **the opening of the mitral valve may be audible as a pathologic opening snap if valve leaflet motion is restricted, as in mitral stenosis **in children and young adults, a third heart sound S3 may arise from rapid deceleration of the column of blood against the ventricular wall **in older adults, an S3, sometimes termed "an S3 gallop" usually indicates pathology **although not often heard in normal adults, a fourth heart sound, S4, marks atrial contraction. It immediately precedes S1 of the next beat and can also reflect a pathologic ventricular stiffness, as seen in hypertension or an acute myocardial infarction Splitting of the heart sounds: ***note that right sided cardiac events usually occur slightly later than those on the left

hair types

Vellus... short, fine, relatively unpigmented Terminal... coarse, thicker, & usually pigmented There are two types of hair, vellus hair which is short fine inconspicuous and relatively unpigmented and terminal hair which is coarser, thicker, more conspicuous and usually pigmented Scalp and eyebrows are examples of terminal hair

contour of carotid pulse

Upstroke...usually brisk, smooth, rapid, & follows S1 almost immediately but precedes S2 Summit...smooth, rounded, & roughly midsystolic Downstroke...less abrupt than upstroke Thrills....? Bruit...? stenosis the amplitude of the pulse will correlate well with pressure the contour of the pulse is named the speed up of the upstroke, the normal upstroke is brisk, it is smooth, rapid and follows s1 almost immediately. The summit is smooth, rounded and roughly midsystolic. The downstroke is less abrupt than the upstroke the normal carotid upstroke follows S1 and preceeds S2, especially when the heart rate is increased and the duration of diastole, normally longer than systole, is shortened and appproaches the duration of systole

Impetigo

bacterial skin infection characterized by isolated pustules that become crusted and rupture

Psoriasis

chronic skin condition producing red lesions covered with silvery scales scattered erythematous to bright pink well-circumscribed flat-topped plagues on extensor knees and elbows, with overlying silvery scale

Scabies

contagious skin disease transmitted by the itch mite multiple 3-6 mm erythematous papules on abdomen, buttocks, scrotum, and shaft and head of penis, with four burrows noted on interdigital web spaces

Ichthyosis Vulgaris

increased thickness of the stratum corneum, absent granular layer

Vitiligo

localized loss of skin pigmentation characterized by milk-white patches large confluent completely depigmented patches on dorsal hands and distal forearms

Keloid

overgrowth of scar tissue solitary 4cm pink and brown scar-like nodule on central chest at site of pervious trauma

Insect Bite

several tense bullae on lower legs

Auscultation

the most widely used method of screening for valvular heart disease"......"inch" the stethoscope Apex-base...PMI medially to LSB, superiorly to 2nd LICS, then across sternum to 2nd RICS at R sternal border or Base-Apex...2nd RICS across sternum to 2nd LICS, down to 5th ICS, and then to apex The diaphragm is better for picking up the relatively high pitched sound of S1 and S2, the murmurs of aortic and mitral regurgitation and pericardial friction rubs. The bell is more sensitive to low pitched sounds of S3 and S4 and the murmur of mitral stenosis The correct timing of systole and diastole is the fundamental prerequisite for identifying events in the cardiac cycle S1 falls just before the carotid upstroke and S2 follows the carotid upstroke

Spider Angioma

vascular lesion fiery red, from very small to 2cm central body, sometimes raised surrounded by erythema, and radiating legs often seen in the center of the spider when pressure with glass slide is applied, pressure on the body causes blanching of the spider distribution can be seen on face, neck, arms, and upper trunk, almost never below the waist signficance- single spider angiomas are normal and are common on the face and chest; also seen in pregnancy and liver disease

Cherry Angioma

vascular lesions bright or ruby red; may become purplish with age 1-3mm flat, round or somtimes raised; may be surrounded by a pale halo absent effect of pressure, may show partial blanching, especially when pressure applied with edge of pinpoint distribution on trunk and extremities and no significants, increases in size and number with aging

health history

•Wheezing •Wheezes are musical respiratory sounds that may be audible to the patient and to others •Cough •Cough is typically a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi; it may sometimes be cardiovascular in origin

additional sounds

•"Opening Snap"... high-pitched, diastole, MV -stenosis from rheumatic fever An opening snap- this is an Mitral stenosis High pitched and this is diastole and in rheumatic fever Rheumatic fever- this can cause with strep Strep can cause peritonsilor absess, rheumatic fever, and glomerularnephritis The mitral valve is very problematic in rheumatic

making adjustments

•*If hypovolemic...may need to lay flat 0 degrees •*For high JVP...may need to elevate to 60-90 degrees to see neck veins Lecture: might need to lay them flat if they are dehydrated Someone who has tons of fluid can be over 90 degrees

Angina Pectoris

•1/1,000 in > 30 years of age • •50% exhibit classic exertional pain, pressure, or discomfort in chest, shoulder, back, neck, or arm...having an acute MI • •Atypical s/s...cramping, grinding, pricking, or tooth/jaw pain For chest symptoms, be systematic as you think through the range of possible cardiac and pulmonary etiologies as well as those outside the thoracic cavity **** Chest pain is one of the most serious of all patient complaints and accounts for 1% of primary care outpatient visits **anterior chest pain, often tearing or ripping and radiating into the back or neck, occurs in acute aortic dissection Not too much into angina, guys have different presentation than women

Auscultation technique

•Diaphragm...high-pitched sounds of S1 & S2 -Aortic & mitral regurgitation -Pericardial friction rubs • •Bell...low-pitched sounds of S3 & S4... -Mitral stenosis ***certification will ask Bell for the low pitch Dipahram for the low pitch Might hear aortic or mital regurge The quiz is just the timing or the location and will get the quiz correct!!!! Might ask this but the certification will ask this Will not ask if the mitral is loud or low pitched

Health History

•1st quantify the patient's baseline •Chest Pain...most common s/s CHD...16 million •CHD...leading killer of both men and women •Chest Pain...consider angina pectoris, MI, dissecting aortic aneurysm, & PE •Distinguish from disorders of the...Pericardium, trachea & bronchi, parietal pleura, esophagus, neck, gall bladder, & stomach Screening for cardiovascular risk: begin routine screening at 20 Years for individual risk factors and for any family history of premature heart disease (less than (<) 55 years in first degree male relative and age <65 years in first degree female relatives) Calculate 10 year and lifetime goal of CVD: use the global CVD risk calculator show in box 16-21 (pg 535) to establish 10 year and lifetime risk for patients ages 40 to 79 years. The primary use of these risk estimates is to support and facilitate important clinician- patient discussions regarding risk reduction Hypertension: high blood pressure or hypertension is definied as a systolic BP > or equal to 130 mm HG or a diastolic BP > or equal to 80 mm HG Projections show that by 2035, the total direct costs of hypertension could increase to an estimate $220 billion Smoking, family history and other risk factors: smoking increases the persons risk of CHD and stroke by 2 to 4 fold compared to nonsmokers Along with family history of premature revascularization, this risk factor is associated with about 50% increase lifetime risk for CHD and CVD mortality The USPSTF has given a grade B recommendation for referring adults who are overweight or obese and have additional cardiovascular risk factors to intensive behavior counseling interventions. The AHA/ACC recommendations of lifestyle management address diet, physical activity, body weight, and tobacco avoidance, as well as controlling hypertension and diabetes Chest pain- is a very big thing, leading killer-

The Heart...Inspection & Palpation

•2nd R and L interspaces •R ventricle •L Ventricle •Apical pulse -Diameter -Location -Amplitude -Duration **for precordial examination, stand at the patient's right side To assess the PMI and extra heart sounds such as S3 and S4, ask the patient to turn to the left side- the left lateral decubitus position, which brings the ventricular apex closer to the chest wall. To bring the left ventricular outflow tract closer to the chest wall and improve detection of aortic regurgitation, have the patient sit up, lean forward and exhale ***S1 is usually louder than S2 at the apex, S2 is usually louder than S1 at the base **palpation of carotid artery during auscultation is an invaluable aid to the timing of sounds and murmurs. Since the carotid upstroke always occurs in systolic immediately after S1, sounds or murmurs coinciding with the upstroke are systolic; sounds or murmurs following the carotid upstroke are diastolic *S1 is diminished in first degree heart block; S2 is diminished in aortic stenosis

chest pain that can kill

•Acute Coronary Syndromes •Pulmonary Embolism •Aortic Dissection •Esophageal Rupture •Pneumothorax •Pneumonia • Various others: Pulmonary HTN, Myocarditis, Tamponade

semilunar valves

•Aortic and Pulmonary (semilunar, SL) valves prevent backflow into ventricles •3 cusps...crescent moon shape •Open & close in response to pressure differences •Ventricles contract...pressure rises higher than aorta and pulmonary trunk pressures...valves forced open...and their cusps flatten as blood rushes in •Ventricles relax...blood flows back toward the heart...cusps become full and close. •Damaged valves forces heart to re-pump blood over and over...weakening heart due to overwork Lecture: Pulmonic and aortic is the semilunar valves They are going to pop open the valve The valve is going to close shut **key damage valves force hear to be re-pumped over and over weakness Regurg- the heart is pump over and over again, things are leaking because the valve is not completely shut Some of it keeps back flowing because it cant keep up Damage muscle that is not effective Stenosis- things flow out slower because part of the valves are stenosised Systolie - S1 is the start of systole Tricuspid and mitral are the start of systole- close Open- aortic and pulmonic - Diastolie- sS2 is the start of diastole Closed- aortic and pulmonic Open is the tricuspid and mitral - they open to fill the ventricles They are resting and repolarizing during systole***** Ventricles are suppose to be filling and resting as well as open and take blood Ventricle diastolic S3- is an early diastolic S4 is a late diastolic Kuntucky kuntcy kunctcy- this is early ventricle non compliance, normal person should not hear S3 Tennessee tennesse tennesee- this is S4, it needs to get more and more blood because it wants to spasm and not get the last little bit of blood Can hear with age, or ventricle resistance over time Ventricle noncompliance is the most important for both of these!!!! S3- is like the ballons that are heart to blow into because its stiff The S4- is when your blowing up a balloon is filling up with too much air and it is getting thin

Apical Pulse/PMI Cont...

•Apical pulse/PMI...4th-5th ICS MCL -1cm-2.5cm (quarter) when supine -Larger lying in LLD position •Note... -Diameter...2.5cm (quarter) when supine & larger lying in LLD position -Amplitude...small, brisk, tapping -Duration...1st 2/3rds of systole or less... Sustained = may be LV hypertrophy •Sustained low = dilated cardiomyopathy A diffused PMI (usually >3cm) may indicate left ventricular enlargement If the PMI is forceful and terminates quickly (does not extend through systole), it is hyperkinetic and may occur in hypermetabolic states such as severe anemia, hyperthyroidism and also may occur in volume overload of the left ventricle from aortic regurgitation A substained left parasternal movement beginning at S1 points to pressure overload from pulmonary hypertension and pulmonic stenosis or the chronic ventricular volume overload of an atrial septial defect. A substained movement later in systole can be seen in mitral regurgitation In obstructive pulmonary disease, hyperinflation of the lungs may prevent palptation of the hypertrophied RV in the left parasternal area. The RV impulse is readily palpated high in the epigastrium where heart sounds are also more audible A prominent pulsation here often accompanies dilatation or increased flow in the pulmonary artery. A palpable S2 also known as a pulmonary artery tap, points to increased pulmonary artery pressure from pulmonary hypertension

Inspection: Chest Contour

•Barrel Chest... •Scoliosis... •Kyphosis... •Pectus Carinatum... Pectus Excavatum... Asymetric expansion occurs in large pleural effusions Retractions occur in severe asthma, COPD, or upper airway obstruction Unilateral impairment or lagging suggest pleural disease from asbestosis or silicosis; it is also seen in phrenic nerve damage or trauma Intercostal tenderness can develop over inflamed pleurae, costal cartilage tenderness in costochondritis

Ventricular gallop S3

•Early in diastole •Low-pitched "plop" right after dub, resembles the word Ken-tuc-ky, where S1 represents "Ken," S2 carries the accent on "tuc," and S3 is the "ky." •Normal in children and young adults •Abnormal > age of 30...may indicate ischemia, heart failure, left ventricular failure •Caused by vibration of non-compliant ventricles resisting rapid filling in early phase of diastole Can see a gallop Should not be hearing it in adults!!!! The S3- doesn't want to take blood, stay empty, they might have some type of ischemia, pumping way too hard for too long If an older man and has S3 you need to refer him

Transmission of Voice Sounds

•Bronchophony "99" •Increased loudness and clarity of the spoken voice •With lung consolidation •Egophony (E to A change) •The spoken "ee" sounds like "ay" •Over fluid/abnormal lung tissue •Whispered Pectoriloquy •Increased loudness and clarity of the whispered voice •With Fluid/Mass Pleural friction rubs may be heard in pleurisy, pneumonia and pulmonary embolism Increased transmitted voice sounds suggest that embedded airways are blocked by inflammation or secretions If "ee" sounds like "A" and has a nasal bleating quality, an E to A change, or egophony, is present Localized bronchophony and egophony are seen in lobar consolidation from pneumonia. In patients with fever and cough, the presence of bronchial breath sounds and egophony are more than triples the likelihood of pneumonia Ask the patient to say ninety-nine or one two three. The whisper voice is normally faintly and indistinctly heard, if at all. Loud, clearer whispered sounds are called whispered pectoriloquy

important concepts

•Cardiac output...volume of blood ejected from each ventricle per one minute... (product of HR x SV) •SV...volume of blood ejected with each heart beat... (dependent on: preload, contractility, and afterload) •Preload...load that stretches the cardiac muscle before contraction (measure of volume status) •Contractility...ability of the cardiac muscles to shorten after given a load (increases when stimulated by SNS & decreased with impaired blood flow or O2 delivery) •Afterload...degree of SVR to ventricular contraction... (tone of aorta, small arteries & arterioles) The heart as a pump: cardiac output is the volume of blood ejected from each ventricle in 1 minute, is the product of heart rate and stroke volume **heart failure has two common manifestations, and the classification is determined by the EF The term heart failure with preserved EF and heart failure with reduced EF are two distinct entities with different treatment agorithms **causes of decreased right ventricular preload include exhalation, dehydration, and pooling of blood in the capillary bed or the venous system ***pathologic increases in preload and afterload, called volume overload and pressure overload, respectively, produce changes in ventricular function that may result in clinical heart failure, when the heart becomes ineffective a a pump Lecture: CO= SV x HR Preload- how much volume you have on site If you have too much then give Lasix If too little then give fluids - could be tachycardic because heart trying to maintain cardiac output After load- BP, the systolic BP, what is your heart pumping against 150/90, got too much after load If you have someone who 70/30- give fluids Contractility- how well the cells are contracting, what is the quality of the contraction These 3 things are getting added to our stroke volume ****have to know theses!!!!!

heart valves

•Cardiac...one direction flow: •Two atrioventricular (AV) valves (one at each AV junction) prevent backflow into atria when ventricles contract. -The right AV valve, or tricuspid valve, has three flexible cusps. -The left AV valve has two cusps. It's called the mitral valve and is sometimes called the bicuspid valve. The second heart sound S2 is of two components, A2 and P2, are caused primarily by closure of the aortic and pulmonic valves, respectively During inspiration, the right heart filling time is increased, which increases right ventricular stroke volume and the duration of right ventricular ejection compared with the neighboring LV This delays the closure of the pulmonic valve, P2, splitting s2 into audible components During expiration, the right ventricular ejection period is faster, and A 2 and P2 fuse into single sounds, S2 ***of the two components of the S2, A2 is normally louder, reflecting the high pressure in the aorta, It is heard throughout the precordium. In contrast, P2 is relatively soft, reflecting the lower pressure I the pulmonary artery and as such is best auscultated near its anatomic location, the second and third left intercostal spaces close to the stermum Lecture: this is a one way flow AV valves- arterio- that is the tricuspid, mitral valves Right AV tricuspid Left AV mitral

the health history

•Chest pain •Initial questions should be as broad as possible, such as, "Do you have any discomfort or unpleasant feelings in your chest?" •Ask the patient to point to the location of the pain •Attempt to elicit all seven attributes of the patient's symptom Percussion- dullness represents airway obstruction from inflammatory or secretions. Because pleural fluid usually sinks to the lowerest part of the pleural space (posteriorly in supine patient), only a vary large effusion can be detected anteriorly The hyperresonance of COPD may obscure the heart The dullness of right middle lobe pneumonia is typically occurs behind the right breast, unless you displace the breast, you may miss the abnormal percussion note. The hyperinflated lung of COPD often displaces the upper boarder of the liver downward and lowers the level of diaphragmatic dullness posteriorly

chest pain

•Common complaint in ED •5% of all ED visits or 5 million visits per year •Wide range of etiologies •Cardiac, Pulmonary, GI, Musculoskeletal •Why does distinguishing these causes matter? •How do you distinguish causes of chest pain?

health history

•Cough (cont.) •Ask whether the cough is dry or produces sputum, or phlegm •Ask the patient to describe the volume of any sputum and its color, odor, and consistency

adventitious lung sounds

•Crackles •Fine...soft high-pitched •Coarse...louder, lower-pitched Late inspiratory....Interstitial lung disease Early CHF Early inspiratory....Chronic bronchitis •Rhonchi •Wheezes •Stridor Pleural rub Many clinicians use the term "rhonchi" to describe sounds from secretions in large airways that may change with coughing Fine inspiratory crackles that persist from breath to breath suggest abnormal lung tissue The crackles of heart failure are usually best heard in the posterior inferior lung fields Clearing of crackles, wheezes, or rhonchi after coughing or position change suggest inspissated secretions, seen in bronchitis or atelectasis Beware of the silent chest, in which air movement is minimal. In the advanced airways obstruction of severe asthma, wheezes and breath sounds may be absent due to low respiratory airflow (silent chest), a clinical emergency Stridor and laryngeal sounds are loudest over the neck, whereas true wheezes and rhonchi are faint or absent over the neck

PE diagnosis

•D-dimer •Very sensitive in low to moderate probability •Not sensitive enough for high probability •Not specific (Lots of false positives) •Spiral CT •Current gold standard •Quick and available •Caution if impaired creatinine clearance •V/Q •Many studies will be "Indeterminate" •PVL of LE •Surrogate maker, but DVT is treated in similar.

left atrium

•Entirely smooth surface (unlike right atrium)... -Pectinate muscles are only found in the auricle -Internal septum...shallow depression: fossa ovalis where foramen ovale existed in fetal heart...closing after birth • • • •Atria are small, thin walled chambers, minimal contraction - Blood enters the right atrium through 3 veins... superior vena cava, inferior vena cava, coronary sinus The cardiac cycle describes complete movement of the heart and include the period from beginning of one heart beat to the beginning of the next one Systole is the period of ventricular contraction*, when the left ventricle ejects blood into the aorta The period of ventricular relaxation is called diastole, late in diastole, ventricular pressure rises slightly during inflow of blood from atrial contraction Note that during systole, the aortic valve is open, allowing ejection of blood from the LV into the aorta The mitral valve is closed, preventing blood from regurgitating back into the left atrium In contrast in diastole, the aortic valve is closed, preventing regurgitation of blood from the aorta back into the LV. The mitral valve is open allowing blood to flow from the left atrium into the relaxed LV At the same time, during systole, the pulmonic valve opens, and the tricuspid valve closes as blood is ejected from the RV into the pulmonary artery During diastole, the pulmonic valve closes, and the tricuspid valve opens as blood flows into the relaced right ventricle

Techniques of Examination Anterior Chest

•Examination •As for examination of the posterior chest, proceed in an orderly fashion: inspect, palpate, percuss, and auscultate •With percussion, the heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces •Supraclavicular retraction is often present Persons with severe COPD may prefer to sit leaning forward, with lips pursed during exhalation and arms supported on their knees or a table Abnormal retractions occur in severe asthma, COPD, or upper airway obstruction Lag occurs in underlying diseases of the lung or pleura Tender pectoral muscles or costal cartilage suggest, but do not prove, that chest pain has a localized musculoskeletal origin

techniques of examination

•Examination of the anterior chest •As for examination of the posterior chest, proceed in an orderly fashion: inspect, palpate, percuss, and auscultate •With percussion, the heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces •Supraclavicular retraction is often present

techniques of examination

•Examination of the posterior chest •Auscultation oAuscultation of the lungs is the most important examination technique for assessing air flow through the tracheobronchial tree oTogether with percussion, it also helps to assess the condition of the surrounding lungs and pleural space oListen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth oUse the pattern suggested for percussion, moving from one side to the other and comparing symmetric areas of the lungs oListen to at least one full breath in each location

techniques of examination

•Examination of the posterior chest •Inspection oFrom a midline position behind the patient, note the shape of the chest and the way in which it moves •Palpation oAssess any observed abnormalities and identify any tender areas oTest chest expansion: place thumbs at the level of the 10th rib with fingers loosely grasping and parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during inspiration oFeel for tactile fremitus, or palpable vibrations as the patient is speaking Tenderness, bruising and bony step offs are common over fractured ribs. Crepitius may be palpable in overt fractures and arthritic joints; crepitius and chest wall edema are seen in mediastinitis Although rare, sinus tracts suggest infection of the underlying pleura and lung (as in tuberculosis, or actinomycosis) Unilateral decreased or delayed in chest expansion occurs in chronic fibrosis of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, unilateral bronchial obstruction and paralysis of the hemidiaphragm

Techniques of Examination

•Examination of the posterior chest •Percussion oPerform from side to side to assess for asymmetry oStrike using the tip of your tapping finger oUse the lightest percussion that produces a clear note oPercussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid oPercussion notes qFlatness, dullness, resonance, hyperresonance, tympany Estimate the extent of diaphragmatic excursion Percussion- A thick chest wall requires more forceful percussion blow than a thin one. However, if a louder note is needed, apply more pressure with the pleximeter finger Dullness replaces resonance when fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your percussing finger. Examples include lobar pneumonia, in which the alveoli are filled with fluid and blood cells and pleural accumulation od serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrosis tissue or tumor Dullness makes pneumonia and pleural effusion three to four times more likely, respectively Generalized hyperresonance is common over the hyperinflated lungs of COPD, or asthma. Unilateral hyperresonance suggest a large pneumothorax or an air-filled bulla Identify the diaphrgmaic excursion- this technique tends to overestimate actual movements of the diaphragm

techniques of examination

•Examination of the posterior chest (cont.) •Auscultation (cont.) oNormal breath sounds qVesicular: soft and low pitched; usually heard over most of both lungs qBronchial: louder and higher in pitch; usually heard over the manubrium qBronchovesicular: intermediate intensity and pitch; usually heard over the 1st and 2nd interspaces oAdventitious (added) sounds: Crackles, wheezes, and rhonchi Breath sounds may be more decreased when airflow is decreased (as in obstructive lung disease or respiratory muscle weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD) A gap suggest bronchial breath sounds In cold or tense patients, watch for muscle contraction sounds- muffled, low pitched rumbing, or roaring noises. Changing the patient's position may eliminate this noise, to reproduce these sounds on yourself, do a valsva manuver (straining down) as you listen to your own chest

Pattern of IJ vein Oscillations

•First elevation...presystolic a wave= slight rise in atrial pressure that accompanies atrial contraction (just precedes S1 and the carotid pulse) •X descent...from atrial relaxation-R ventricle contraction during late systole (just before S2) •V wave...After tricuspid valve closes and atrial begin to fill increasing atrial pressure •Y descent...tricuspid valve opens early diastole and blood passively flows into R ventricle

key emergency physicial

•General Appearance •Vital Signs •Heart (Muffled? Regular? Fast?) •Lungs (Equal? Wet? Tympanitic?) •Neck (JVD?) •Abdomen (Distention?) LE (Edema? calf tenderness?)

Thorax & Lungs: Inspection

•General appearance •SOB •Cough •Color •Retractions •Pursed lip Breathing Abnormalilites in rate and rhythm of breathing include bradycardia, tachypnea, hyperventilation, Cheyne-strokes breathing, and ataxic breathing. Delayed expiration occurs in COPD Cyanosis in the lips, tongue, and oral mucosa signals hypoxia. Pallor and sweating (diaphoresis) are common in acute coronary syndromes and heart failure. Clubbing of the nails occurs in bronchiectasis, congenital heart disease, pulmonary fibrosis, cystic fibrosis, lung abscess and malignancy Audible high pitched inspiratory whistling or stridor, is an ominous sign of upper airway obstruction in the larynx or trachea that requires urgent airway evaluation

Techniques of Examination

•General techniques •Examine the posterior thorax and lungs while the patient is sitting •Examine the anterior thorax and lungs with the patient supine •Compare one side of the thorax and lungs with the other, so the patient serves as his or her own control •Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate Daytime sleepiness: these symptoms especially daytime sleepiness and snoring are hallmarks of obstructive sleep apnea, commonly seen in patients with obesity; posterior malocclusion of jaw (retrognathia), treatment- resistant hypertension, hear failure, atrial fibrillation, stroke, and type 2 diabetes. Mechanism include instability of the brainstem, respiratory center, disordered sleep arousal, disordered contraction of upper airway muscles (genioglossus malfunction) and anatomic changes contributing to airway collapse such as obesity, among others. Be considerate when drapping the patient, allow for maximal exposure of the area to be examined yet mindful of the patients sense of comfort with the examination

health history

•Hemoptysis •Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood •Ask the patient to describe the volume of blood produced as well as other sputum attributes •Try to confirm the source of the bleeding by history and examination before using the term "hemoptysis"; blood may also originate from the mouth, pharynx, or gastrointestinal tract

PE embolism risk

•Hypercoaguability •Malignancy, pregnancy, estrogen use, factor V Leiden, protein C/S deficiency •Venous stasis •Bedrest > 48 hours, recent hospitalization, long distance travel •Venous injury Recent trauma or surgery

PE treatment

•IV fluid to maintain blood pressure •Heparin (Will limit propagation but does not dissolve clot) •Unfractionated: 80 u/kg bolus, 18 h/kg/hr •Fractionated (Lovenox): 1 mg/kg SC BID •Fibrinolytics •Consider with large if pt is unstable •No study has shown survival benefit, but very difficult to study. Alteplase 50-100 mg infused over 2-6 hrs, (bolus in severe shock)

Techniques of Examination

•Initial survey of respiration and the thorax •Observe the rate, rhythm, depth, and effort of breathing •Inspect for any signs of respiratory difficulty oAssess the patient's color oListen to the patient's breathing oInspect the patient's neck Observe the shape of the chest Accessory muscles use can signal increased ventilatory requirements due to airways and/or parenchymal lung disease or respiratory muscle fatigue. Lateral displacement of the trachea occurs in pneumothorax, pleural effusion and atelectasis. The AP ration may exceed 0.9 in COPD, producing a barrel chest appearance, although evidence of this correlation is conflicting

Inspection & Palpation of Carotid

•Inspect carotid pulsations...medial to sternomastoid muscle •Palpate...index & middle or L thumb in lower third of neck, medial to sternomastoid, at level of cricoid cartilage •Slowly increase to feel maximum pulsation •Slowly decrease for sense of atrial pressure & contour ***carotid artery stenosis causes ~10% of ischemic strokes and doubles the risk of coronary heart disease. In the NASCENT study, patients with 70% carotid stenosis had a stroke rate of 24% after 1.5 years, and those with 50% to 69% stenosis had a stroke rate of 22% over 5 years *palpataion of the carotid pulse, assess for presence or absence of thrills **a tortuous and kinked carotid artery may produce a unilateral pulsatile bulge *causes of decreased pulsation include decreased stroke volume from shock or MI and local atherosclerotic narrowing or occlusation Lecture: too little fluid have decreased stroke volume Poor afterload, preload or contractility then will have stroke volume decrease If it is athloscrotic- it is stenotic so hard time pumping though If heart is in shock then have a threaty carotid Bounding pulse can be aortic insuffiency or septic shock

Edema

•Interstitial tissue accommodates up to 10% weight gain before pitting edema •Dependent edema...lowest body parts...heart failure, hypoalbuminemia, positional •Non-dependent...renal and liver disease...periorbital puffiness, tight rings, enlarged waistline **causes are frequently cardiac (right or left ventricular dysfunction, pulmonary hypertension) or pulmonary (obstructive lung disease) but can also be nutritional (hypoalbuminemia) and/or positional Dependent edema appears in the lowest body parts: the feet and lower legs when sitting or the sacrum when bedridden Anasarca is severe generalized edema extending to the sacrum and abdomen *consider asking patients who retain fluid to record daily morning weights because edema may not be obvious until several liters of extra fluid have accumulated; however, rapid weight gain (more than 1 to 2 lb/day) will occur prior to visible edema **look for the periorbital puffiness and tight rings of nephrotic syndrome and an enlarged waistline from ascities and liver failure

JVP changes continued

•JVP decreases....blood loss • •JVP increases... -R & L heart failure -Pulmonary HTN -Tricuspid stenosis Pericardial compression/tamponade

Auscultation

•Keep left index & middle fingers on R carotid artery in lower 1/3 of neck to facilitate correct identification of S1 and S2 •At base...S2 > S1 and may split with respiration •At apex...S1 > S2 unless PR interval is prolonged •Systole...interval between S1 & S2 Diastole...interval between S2 & S1 Note that S1 is louder at more rapid heart rates and PR intervals are shorter When either A2 or P2 is absent, as in aortic or pulmonic valve disease, S2 is persistently single Expiratory splitting suggest a valvular abnormalility Persistent splitting results from delayed closure of the pulmonic valve or early closure of the aortic value A loud P2 points to pulmonary hypertension The systolic click of mitral valve prolapse is the most common extra sound

Auscultation technique

•LLD position...brings L ventricle close to chest wall (use bell) elicits L sided S3 & S4, mitral murmurs of mitral stenosis • •Patient sit and lean forward, exhale, & stop breathing....LSB & at apex (diaphragm) elicits soft diastolic murmur of aortic regurgitation Can listen to better, the heart rate is usually better once they breath and listen Can also lay them down for left lateral decub, may need to bring this closure to the chest Left lateral decub- to help bring the heart close if they are bigger or you cant hear This can occur with left lateral stenosis Leaning forward- this brough the base to the front, and will hear the aortic close to the chest Aortic pulmonic area better

Atrial Gallop (S4)

•Late in diastole, just prior to S1 •Low-pitched sound heard best over the apex •Presence creates a rhythm that sounds like the word Ten-nes-see. Here, S4 represents the "Ten," S1 represents "nes," and S2 carries the accent on the syllable "see." •Normal in infants and children and common in the elderly. •Adults...linked to aortic stenosis, CAD, myocardial ischemia, heart failure, HTN, ventricular hypertrophy •Caused when stiff, over-distended ventricles are forced to accept blood in late diastole Both called gallops, this is the last little bit of blood to get into the ventricle Right before the S1 sound Infants and children not worried Might hear in elder In 40 year old man this is not normal!!!! Aortic stenosis, CAD, MI, HTN S4 atrial gallop, think about what is the blood pressure, 150/90, now have an S4 Does not mean the ventricle is stronger and better, it's a bad big Stiff overdistented ventricle, very late in diastole

anatomy and phys of lungs

•Locating findings on the chest •Describe abnormalities in two dimensions oVertical axis oCircumference of the chest •To make vertical locations, count the ribs and interspaces; sternal angle is the best guide Special landmakers: 2nd intercostal space for needle insertion for decompression of a tension pneumothorax Intercostal space between the 4th and 5th ribs for chest tube insertion Level of the 4th rib for the lower margin of a well-placed endotracheal tube on a chest x-ray Neurovascular strucutres run along the inferior margin of each rib, so needles and tubes should be placed just at the superior rib margin Note that the intercostal space between the 7th and 8th ribs as a landmark for thoracentesis with needle insertion immediately superior to the 8th rib Note that the number of the intercostal space between two ribs is the same number as the rib above it

history matters

•Location: Central, left, or right •Associated symptoms: SOB, sweating, nausea •Timing: Gradual or sudden onset •Provocation: What makes worse or better? •Quality: Visceral vs somatic •Radiation: Back, neck, arm •Severity: Scale of 1-10 to asses this symptom, you must investigate both thoracic and cardiac sources chest pain is reported in one in four patients with panic and anxiety disorders

the health history

•Lung tissue itself has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura •Other surrounding structures may also irritate the parietal pleura, causing pain

A & P of lungs

•Lungs, fissures, and lobes •Each lung is divided roughly in half by an oblique (major) fissure •The right lung is further divided by the horizontal (minor) fissure •These fissures divide the lungs into lobes oThe right lung is divided into upper, middle, and lower lobes oThe left lung is divided into upper and lower lobes Aspiration pneumonia is more common n the right middle and lower lobes because the right main bronchus is more vertical. For this same reason, if an endotracheal tube is advanced too far during intubation, it will likely enter the right mainstem bronchus Accumulation of pleural fluid or pleural effusions, may be transudates, seen in heart failure, cirrhosis and nephrotic syndrome, or exudates, seen in numerous conditions including pneumonia, malignancy, pulmonary embolism, tuberculosis and pancreatitis Irritation of the parietal pleura produces pleuritic plan with deep inspiration in viral pleurisy, pneumonia, pulmonary embolism, pericarditis, and collagen vascular disease

shortness of breath (SOB)

•May represent... •Dyspnea...uncomfortable awareness of breathing inappropriate to level of exertion •Orthopnea...occurs with lying down •Paroxysmal nocturnal dyspnea...sudden dyspnea that awaken patient from sleep usually 1-2 hours after going to bed...associated wheezing and coughing... -(L ventricular heart failure & MS) **sudden dyspnea occurs in pulmonary embolus, spontaneous pneumothorax, and anxiety **orthopnea and PND (paroxysmal nocturnal dyspnea) occur in left ventricular heart failure and mitral stenosis and also in obstructive lung disease **PND may be mimicked by nocturnal asthma attacks **ask patients are they sleeping with extra pillows at night, or sleeping upright due to SOB and not other causes Orthopnea occurs when the patient is supine and improves when the patient sits up Lecture: ***** PND: always ask this under the review of systems, sudden dyspnea that awakes them and wake out of panic Left ventricular heart failure and left ventricular stenosis

chest pain without CAD

•Microvascular coronary dysfunction....spasms and decreased flow to heart muscle • •Abnormal cardiac nociception... angina-like chest discomfort, ST segment depression during exercise, and normal epicardial coronary arteries...highly prevalent in women and linked to poor quality of life Syncope: the more concerning cause of syncope involve the heart not providing adequet blood flow to the brain, as occurs in end-stage heart failure and arrhythmias Microvascular coronary dysfunction- they have symptoms of MI but they do not have occlusion, this can occur after a family member dies ST elevation may have that, or troponin increase but not actually having an MI The path is clear but they look like a heart attack Stress, death, women

benign signs of chest pain

•Musculoskeletal Costochondritis •Esophagitis and Esophageal Spasm •GERD •Bronchitis (Chest Pain secondary to cough) •Recently placed nipple rings •Anxiety and Panic Disorder •"Non-Specific Chest Pain" * *Most common - means we don't know, but it is not going to hurt you. lung tissue has no pain fibers pain in conditions such as pneumonia and pulmonary infarction usually arise from inflammation of the adjacent parietal pleura Muscle strain from prolonged recurrent coughing or costochondral inflammation may also be responsible The pain of pericarditis stems from inflammation of the adjacent parietal pleura

Jugular Vein Pressure (JVP)

•One of the most important & frequently used > 12 years of age • •Reflects pressure in the Right Atrium/CVP • •Best assessed RIJ vein REJ vein The JVP is the best assessed from pulsation in the right internal jugular vein, which is directly in line with the superior vena cava and right atrium **although JVP accurately depicts elevations in fluid volume in heart failure, it is prognostic value for heart failure outcomes and moralility rate is unclear Lecture Can only do it in adults, around 12 Will only do it on the right side, the left side is not the right atrial pressure The right atrial pressure is what it is mostly reflecting Best assess in the right IJ- use the right EJ to look for the highest level of fluttering Looking at the right atrial pressure Hardly any blood flow because dehydrated because there is not a lot of right atrial filling If drinking a lot of water then will see an elevated right atrial filling Gives an idea of fluid status It could be backing up to the right atrium The JVP will have extra blood if it keeps backing up AV block, slows the process of going through, might see some of that with JVP changes

the rest of the history

•PMH •Meds - Cardiac meds? Nitro? ASA? Plavix? Coumadin? •Allergies - Always important! •Social - Smoker? Alcoholic? Cocaine? Family - Sudden Death?Early MI?DVT?PE? ask the patient to point to the location of the pain in the chest a clenched fist over the sterum (levine sign) suggest angina pectoris; a finger pointing to a tender spot on the chest wall suggest Musculoskeletal pain a hand moving from the neck to the epigastrium may suggest heart burn

Palpation

•Palpate R ventricle...3rd, 4th, & 5th ICS between MCL & sub-xiphoid area •Pulmonic artery...2nd L ICS •Aortic artery...2nd R ICS •Left ventricle...roll to LLD position...palmar surface of several fingers •Once located apical pulse/PMI •? S3 & S4 It is aways best to describe the apical impulse in relation to the midsternal or midcalvicualr line, or the anterior axillary line if the apical impulse is displace d *pregnancy or high left diaphragm may shift the apical impulse upward and to the left *lateral displacement toward the anterior axillary line from ventricular dilation is seen in heart failure, cardiomyopathy, and ischemic heart disease as well as in thoracic deformities and mediastinal shift *a markedly dilated failing heart may have a hypokinetic apical impulse displaced far to the left A large pericardial effusion may make the impulse undetectable

Palpation

•Palpate for S1 & S2 (firm pressure) •R hand on chest •L index & middle finger on carotid •S1 is right before carotid upstroke •S2 is just after the upstroke S3 & S4 lighter pressure at cardiac apex Palpation is less useful in patients with a thickened chest wall (obesity) or increased AP diameter (obstructive lung disease) The prescence of a thrill changes the grading of the murmur, a thrill is always above a grade 4 (pg 553) a brief early middiastolic impulse represents a palpable S3; an outward movement just before S1 signifies a palpable S4 In most examples, the apical impulse is the PMI Pathologic conditions such as right ventricular hypertrophy, a dilated pulmonary artery, or an aortic aneurysm may produce a different pulsation that is more prominent that the apex beat In dextrocardial with situs inversus, a rare congenital transposition of the heart, the heart is situated in the right chest cavity and generates a right-sided apical impulse. Use percussion to help locate the heart border, the liver, and stomach. In full situs inversus toralis, the heart, trilobed lung, stomach, and spleen are on the right, and the liver and gallbladder are on the left Obesity, a very muscular chest wall, or an increased AP diameter of the chest may obscure detection of the apical impulse

percussion

•Palpation replaced percussion •May be helpful when you cannot estimate cardiac size •Start at L on chest •Percuss from resonance toward cardiac dullness in 3rd, 4th, & 5th... maybe 6th interspaces Pulsation in this area suggest a dilated or aneurysmal aorta

Pattern of IJ Vein Oscillations Abnormalities

•Prominent a waves indicate...increased resistance to R atrial contraction such as tricuspid stenosis; 1st degree AV block; SVT; Junctional rhythms; Pulmonary HTN; & Pulmonic Stenosis • •Absent a waves indicate...atrial fibrillation • •Large v waves indicate...tricuspid regurgitation & constrictive pericarditis dont really need to know this

auscultation tips

•Quiet room •Time of murmur •Location of maximum intensity...radiation? •Conduct necessary maneuvers •Determine shape (crescendo/decrescendo/holosystolic •Grade intensity I-VI •Identify associated features...S3 & S4 •Pitch...high/medium/low •Quality...blowing/harsh/rumbling/muscial Identifying murmurs: murmurs that coincide with the carotid upstroke are systolic Diastolic murmurs usually represent valvular heart disease. Systolic murmurs point to valvular disease but can be physiologic flow murmurs arising from normal heart valves In the left lateral decubitus: this position accentuates a left sided S3 and S4 and mitral murmurs, especially mitral stenosis. Otherwise, you may miss these important findings You may easily miss the soft diastolic decrescendo murmur of aortic regurgitation unless you listen at the position of the patient leaning forward Murmurs detected during pregnancy should be promptly evaluated for possible risk to the mother and fetus, especially those of aortic stenosis or pulmonary hypertension Midsystolic murmurs typically arise from blood flow across the semilunar valves Early diastolic murmurs typically reflect regurgitant flow across incompetent semilunar valves Mid-diastolic and presystolic murmurs reflect turbulent flow across the AV valves Congential patient ductus arteriosus and AV fistulas, common in dialysis patients, produce continuous murmurs that are nonvalvular in origin. Venous hums and pericardial friction ribs also have both systolic and diastolic components Not the presystolic murmur of mitral stenosis in normal sinus rhythm Listen for the mid-systolic murmur of aortic stenosis and innocent flow of murmurs Note the pansystolic murmur of mitral regurgitation Lecture: is there a thrill or not, is there a judgement, is it a 1-3 or 4,5,6 Left lateral decub or bringing forward Grade it apporpiately, see if there is an S3 or S4 appropriately Blowing harsh rumbing can be heard These are all things that we will hear a cardiologist write, quality, pitch, identity An Identicial degree of tuberlence would cause a louder murmur in a thin person than in a very muscular or obese person, emphysematous lungs may diminish the intensity of murmurs Pansystolic murmurs often occur with regurgitant (backward) flow across the AV valves. a late systolic murmur: this is the murmur of the mitral valve prolapse and is often but not always, preceded by systolic click; the murmur of mitral regurgitation may also be late systolic

blood flow to atria

•R Atrium... -superior vena cava returns blood from body regions superior to the diaphragm -inferior vena cava returns blood from body areas below the diaphragm -coronary sinus collects blood draining from the myocardium. • •L Atrium...four pulmonary veins enter the left atrium Collects from the heart so that we can recirculate

JVP changes

•R atrial filling...Volume Status • •Contraction...R & L Ventricular function, arrhythmias (junctional and AV block) • •Emptying...tricuspid & pulmonary valves, pericardium pressure The dominant movement of the JVP is inward, coinciding with the x-descent. In contrast, the dominant movement of the carotid pulse, often confused with the JVP, is outward ***JVP falls with loss of blood or decreased venous vascular tone and increase with right or left heart failure, pulmonary htn, tricuspid stenosis, AV dissociation, increased venous vascular tone and pericardial compression or tamponade Lecture: can decrease with some heart failure Sit up right in the chair, and see the fluttering in the JVD because it is pumping so poor Pulmonary HTN- the right side of the heart, likely to get a split S2 This is really high BP Might have a higher JVP because pressure is building Tricupsid stenosis, and pericardial tampanode- the JVP is going to be increased because it's not flowing JVP increasing, ethier tons or too much fluid Will back up to the right side, the when left occurs It will eventually back up, back up from right to left, if bad enough

obstructive sleep apnea (OSA)

•Repeated episodes of upper airway collapse (*REM sleep)= hypoxemia •Daytime sleepiness •A/w cognitive impairment, DM, CV morbidity •Risk factors: obesity, gender, age, craniofacial and upper airway abnormalities, post-menopausal •Severity based # and degree of episodes per hour •Treatment CPAP, BPAP, or APAP machines OSA is characterized by a disorder of repeated rapid episodes of upper airway collapse, particularly during rapid eye movement (REM) sleep, leading to hypoxemia and disrupted sleep OSA can cause ecessive daytime sleepiness which increases risk for motor vehicle accidents and occupational accidents and is associated wth higher risk of cognitive impairment, diabetes, cardiovascular morbidity and all-cause mortality Risk factors for OSA include obesity, male sex, older age, craniofacial and upper airway abnormalilites and being postmenopausal Symptoms suggesting OSA include excessive daytime sleepiness (which can be assessed by the Epworth sleep scale), loud snoring, or choking or gasping during sleep

Palpatation

•S3 & S4...synchronous with ventricular movements...pathologic •Palpable S2 @ aortic area...systemic HTN •Pulsation S2 @ aortic area...dilated or aneurysmal aorta •Pulsation S2 @ pulmonic area...Pulmonary HTN

Health History

•Shortness of breath (dyspnea) •Dyspnea is a non-painful but uncomfortable awareness of breathing that is inappropriate to the level of exertion •Begin assessment with a broad question, such as, "Have you had any difficulty breathing?" •Determine the severity of dyspnea based on the patient's daily activities Forced Expiratory Time- Patients > or equal to 60 years with a forced expiratory time of > or equal to 9 seconds are four times more likely to have COPD Identification of a fractured rib- an increase in the local pain (distant from your hands) suggest ribs fracture rather than just a soft tissue injury The thoracic with moderate kyphosis and increased AP diameter and decreased expansion- this suggest finding of COPD

splitting of the heart sounds

•Since R ventricular & PA pressures are lower than L ventricular and Aortic pressures.... •S2 may split into A2 & P2 •During inspiration, R heart filling time increases, increasing R ventricular SV & duration of R ventricular ejection compared to L ventricle •During expiration the 2 components fuse into a single sound or S2 S2- was made by closure of aortic and pulmonic valves This is the beginning of diastole Sometimes S2 can sound like 2 sounds Split S2, bumb, bundump- can be fixed or non fixed Going to hear a split S2 in clinical Do some mauvers with that person Pulmonic closes a little bit later than the pulmonic valve The pulmonic pressures are higher at the moment Inspiration- increased the intrathoracic pressure, pulmonic valve may close a little bit later Split S2- have them take a deep breath, see if its more pronuced and see if it goes away S2 is going to sound like one sound again Fixed S2 fixed- inspiration and expiration, COPD, pulmonary fibrosis, sarcoid fibrosis, this might be the first thing thats going on with patients Pulmonic closes after the aortic in split S2 Hear it louder at the base!! The delay in closure of the pulmonic valve, P2, splitting S2, into two aubdible components. During expiration, the right ventricular ejection period is faster and A2 and P2 fuse into a single sound, S2. Distensibility and impedance in the pulmonary vascular bed contribute to the hangout time that delays P2

PE diagnosis with chest pain

•Symptoms •SOB or dyspnea- Present in 90% •Chest pain (pleuritic)- 66% of patients with PE •Cough •Sudden onset • •Signs •Tachycardia > 100 beats per minute •Tachypnea > 20 breaths per minute •Hypoxia < 95% on RA (no other cause) •Lower extremity swelling

cardiac cycle of systole and diastole

•Systole...ventricles contract -Pulmonic and Aortic valves open -Tricuspid and Mitral valves closed....closure of mitral valve produces first heart sound....S1 - • Diastole...ventricles relax -Tricuspid and Mitral valves open -Pulmonic & Aortic valves closed....aortic valve closure produces second heart sound....S2 Murmurs we would have S1- these closed and made sound Closing of mitral and tricuspid Open of pulmonic and aortic Hear some regurg from the closing of mitral and tricuspid- but heard a nice murmur here S2- open of aortic and pulmonic Close of mitral and tricuspid If the aortic and pulmonic didn't open wouldn't have pulse The stenosis would occur in the pulmonic and aortic- hear more turbulence A murmur is turbulence ***Stenosis goes with open valve ***Regurge occurs with closed valve Diasolte- aortic and pulmonic closed, regurged In S2 and S3 If we hear in tricuspid and mitral these are open and this might be stenosis Produce the first S1 Heart sound Diastole has to be open or else they will have to be full Systole- these sounds make the beginning of the time period Acts the whole time until S2 comes **know where the valve is, the timing, what should be open and closed Look to see how stable the patient is

assess carotid pulse

•Valuable information...Aortic valve stenosis or insufficiency Assess 1. Inspect 2. Palpate 3. Auscultate • Start...HOB at 30 degrees *as the presence of carotid atherosclerosis could potentially narrow the carotid arteries, it is important to auscultate the carotid arteries prior to palpating the carotid pulse *the most feared complication of carotid artery palpitation is the dislodgement of an atherosclerotic plague which could result in stroke **note that higher-grade stenoses may have lower frequency or even absent sounds, more amendable to detection with the bell **although usually caused by atherosclerotic luminal stenosis, bruits are also caused by tortuous carotid artery, external arterial disease, aortic stenosis, the hypervascularity of hyperthyroidism, and external compression from thoracic outlet syndrome. Bruits do not correlate with clinically significant underlying disease Lecture: bell for low and diaphragm for high S1 sound happens, then we have carotid pulse Inspecting, it is right by sternoclamasoid Try to find the maxium pulsation How well the ventricle is contraction is what the carotid can tell

blood pressure

•Systolic Blood Pressure...pressure generated by the L ventricle during systole -Pressure waves in the arteries create pulses • Diastolic blood pressure...Pressure generated by blood remaining in the arterial tree during diastole -Ventricles relaxed • • Pulse pressure....difference between SBP & DBP Blood pressure in the arterial system varies during the cardiac cycle, peaking in systole and falling to its lowest trough in diastole These are the levels that are measured with the blood pressure cuff, or sphymomanometer Normal is less than 120/80 At higher arm levels, the blood pressure recordings will be lower, at lower levels, the blood pressure recordings will be higher **a growing literature documents the poor reliability of clinic blood pressure measurements. Multiple average measurements improve precision, especially when using automated home and ambulatory blood pressure readings, which are more reliable, accurate, and better correlated with cardiovascular outcomes than clinic readings Lecture: pulse pressure is the difference between them, this is not good, not getting a lot of output Bleeding patient, cardiac tamponade- this is compressing the heart, there is no where to go, the pulse pressure will change Left ventricular stroke volume, how much is coming out with each heart beat

inspection

•Tangential lighting -Reveal apical impulse (PMI) -Ventricular movements S3 & S4 •Palpate for heaves or lifts (use Palm & or fingerpads) •Lifts & heaves....sustained impulse... (enlarged R or L ventricle or atrium & aneurysms) •Thrills...(ball of hand)...buzzing underlying turbulence ***changes murmur grading to IV-VI/VI Looking for PMI, the thrill is the ball buzzing underneath If thrill then you have a grade 4, 5 or a 6 murmur grade if there is a thrill It at least has to be a 4 with a thrill There was no thrill when there was a murmur so the loudest will be a 3 This will be a quiz question!!!!! No thrill 1-3 Thrill 4-6

anatomy and phys continued

•The trachea and major bronchi •The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly •The pleurae •The pleurae are serous membranes that cover the outer surface of each lung (visceral pleura), and also the inner rib cage and upper surface of the diaphragm (parietal pleura) Pain in conditions such as pneumona and pulmonary infarction usually arise from inflammation of the adjacent parietal pleura. Muscle strain from prolonged recurrent coughing or costochondral inflammation may also be responsible The pain of the pericardium stems from inflammation of the adjacent parietal pleura

JVP measurement

•Three positions...30, 60, and 90 degrees... •Sternal angle remains 5cms above R Atrium **as you begin your assessment, consider the patient's volume and whether you need to alter the elevation of the head of the bed or examining table **Some authors report that at 30 to 45 degrees, the estimated JVP may be 3cm lower than catheter measurements from the right mid-atrium **JVP measured at >3cm above the sternal angle or more than 8cm in total distance above the right atrium, is considered elevated above normal **An elevated JVP is >95% specific for an increased left ventricular end-diastolic pressure and low left ventricular EF, although its role as a predictor of hospitalization and death from heart failure is less clear ***In patients with obstructive lung disease, the JVP can appear elevated on expiration, but the veins collapse on inspiration. This finding does not indicate heart failure Lecture: JVP is when you are seeing this in primary care and when you suspect someone is in heart failure then you are going to determine if they need to be treted sooner by cardiologist JVP was 7 and now 13

Cardiac Thrills....Bruit

•Thrills...Listen for a bruit with the diaphragm (high) & bell (low) for higher-grade stenoses... turbulent arterial blood flow...listen @ upper end of thyroid cartilage •Prevalence increases with age...adult 75 years = 8% •Sensitivity & specificity...vary 30-90% •Associated Risk is doubled for -TIA -Stoke -CAD Lecture: Thrill- thinking TIA, stroke and CADif you do hear something, then you send for carotid US Do not want to miss this, it is doubled for this if you hear a cardiac thrill Now you have a reason for a TIA and stroke 30-90% goes with patient and technique for thrill evaluation

anatomy and phys of lungs

•To locate findings around the circumference of the chest, imagine a series of vertical lines The triangle of safety is an anatomical region in the midaxillary line formed by the lateral border of the pectorais major muscle amteriorly, lateral border of the latissimus forsi posteriorly and the nipple line (4th or 5th intercostal space) inferiorly. This triangle represents a "safe position" for the chest tube insertion The right lung is thus divided into upper, middle and lower lobes (RUL, RML, RLL) and the left lung only has 2 lobes (LUL, LLL)

health maintance

•Tobacco cessation •Smoking is the leading cause of preventable death in the United States •Remember the five "A"s oAsk about smoking at each visit oAdvise patients regularly to stop smoking using a clear, personalized message oAssess patient readiness to quit oAssist patients to set stop dates and provide educational materials for self-help oArrange for follow-up visits to monitor and support patient progress

lung sounds

•Tracheal...Insp=Exp Very loud/over trachea •Bronchial...Insp <Exp Loud/over manubrium •Bronchovesicular...Insp=Exp Medium 1st-2nd ICS/Interscapular area •Vesicular....Insp>Exp Soft-low/over most of lungs If bronchiovesicular or bronchial breath sounds are heard in locations distant from those listed, suspect replacement of air-filled lung by fluid filled or consolidated lung tissue Crackles can arise from abnormalilites of the lung parenchyma (pneumonia, intestitial lung disease, pulmonary fibrosis, atelectasis, heart failure) or of the airways (bronchitis, bronchiectasis) Wheezes arise in the narrowed airways of asthma, COPD, and bronchitis

Chest Palpation

•Unpleasant awareness of heartbeat • •Skipping, racing, fluttering, pounding, or stopping • •Irregular heartbeat from rapid rise/fall in rate ***Anxious and hyperthyroid patients may report palpitations **the most serious dysrhythmias such as ventricular tachycardia, often do not produce palpitations **if there are symptoms or signs of irregular heart action, obtain an ECG. This includes atrial fibrillation, which causes an "irregularly irregular" pulse often identified at the bedside Teach selected patients how to take serial measurements of their pulse rates in case they have further episodes *clues in the history include transient skips and flip-flops (possible premature contractions); rapid, regular beating of sudden onset and offset (possible paroxysmal supraventricular tachycardia) and a rapid regular rate of <120 beats/min, especially if gradually starting and stopping (possible sinus tachycardia) Lecture: might have fluttering, pounding, skipping beats