preventive care points
smoking cessation
environmental exposures
vaccines
mgmt of chronic diseases
screenings
smoking cessation 5As
ask
advise
assess
assist
arrange
common respiratory complaints
cough
dyspnea
hemoptysis
chest pain
respiratory differentials
URI
asthma, COPD
pneumonia
bronchitis
nosocomial pneumonia
TB
CA
ILD
sleep apnea
smoking
respiratory relevant family history
TB
CF
Emphysema/COPD
CA-smoking
allergies and asthma
systemic disease - RA, SLE, sarcoidosis
dermatitis
acute
< 3wks
subacute
3-8wks
chronic
> 8wks
on examination...
privacy, unclothed, stethoscope to skin
respiratory inspection
general assessment - is it an emergency
audible sounds
speech - can they speak in sentences
VS
chest movement
chest shape and symmetry
inspiration:expiration ration
1:2, 1:3
expiration
increases with obstruction
inspiration
increases with fibrotic lung tissue
pectus excavatum
sunken appearance of chest
not a problem unless causing a problem
pectus carinatum
protrusion of the sternum and ribs
congenital or after open heart surgery
respiratory inspection systems
ENT
skin/nails - cyanosis, bruising, clubbing
neck - JVD, tracheal position
mouth - open mouthed, pursed lip, color
rib excursion
place hands at either side of chest at 10th rib, inhale
affected side will lag behind normal side
tactile fremitus
99"
test pneumonia, pneumothorax, COPD
percuss above diaphragm
resonant
percuss below diaphragm
dull
flatness
high pitched
watery, fatty tissue or dense bone
practice on thigh
dullness
soft bass
fluid-filled (consolidation)
practice on liver
resonance
longer, louder bass
air-filled lung tissue
practice on 2nd R interspace
tympany
musical, light
air-filled chamber
practice on puffed cheeks
hyperresonance
booming bass
hyper inflated lung (COPD)
adventitious sounds
rhonchi
wheeze
crackles (rales)
rubs
rhonchi
low snore
wheeze
high pitched, musical, whistling
crackles
high to low pitched, popping
rubs
walking in snow
egophony
patient says E but you hear A over areas of consolidation
pediatric auscultation
focus on inspiration
start with auscultation in kids
listen to respirations first
respiratory measurements
peak flow
PFM
Spirometry
rib fracture test
walk test
forced expiratory time test
PFM
regularly monitor lung fcn and response to tx
determine severity of asthma attack
assess response to tx during an attack
spirometry
diagnoses pulmonary disease (COPD)
rib fracture test
anteroposterior pressure test
hands on sternum and spine
location of pain suggests fracture
walk test
used for COPD and asthma
VS before and after
measures distance walked in 6 minutes
forced expiratory time
inhale and exhale completely w/ open mouth
listen at trachea for audible expiration/3 readings
COPD
onset in midlife
symptoms slowly progressive
long smoking hx or environ exposure
asthma
onset early in life
symptoms vary day to day
usually worse at night/early morning
family hx asthma
parent smokes
asthma on exam
expiratory wheezes
accessory muscle breathing
increased resp rate
cyanosis
pulse ox trend
asthma causes
airway obstruction
airway inflammation
airway hyper-responsiveness to stimuli
recurrent inflammation induced bronchospasm
COPD on exam
scattered inspiratory and expiratory wheezes and crackles
cyanosis
pulse ox trends
signs of R sided heart failure
I:E is 1:4 of greater
ace inhibitors
SE - cough
CURB score
assess for outpatient pneumonia or hospitalization
viral rhinitis
cough, congestion, sore throat, fever, chills, myalgias
acute bronchitis
<3mos, hx URI, hacking productive cough, course fine crackles or rhonchi on auscultation
hemoptysis
most common cause bronchitis
dyspnea
increased awareness or work of breathing
foreign body PE
apnea/tachypnea
retractions
stridor
wheeze
anaphylaxis PE
angioedema
rash
wheezes bilat
tachypnea
tachycardia
pneumothorax/hemothorax PE
decreased breath sounds
decreased tactile fremitus
lung hyper-resonance
HTN
tracheal shift
croup PE
fever
horse, seal-like barking cough
acute epiglottis PE
fever
drooling
strider
muffled voice
status asthmaticus PE
coughing, wheezing, tachycardia
botulism PE
hypoventilation, drooling, weak cry, ptosis, loss of head control
Pulmonary embolism PE
anxiety, fear
tachypnea, tachycardia
decreased breath sounds
crackles, wheezes
pulmonary embolism risk factors
> 60
pulmonary HTN, CHF, CA, CVA
medications (oral contraceptive, blood thinners)
recent trauma or immobility
costochondritis
reproducible pain on palpation
L sided symptoms
fluid backs up in lungs
SOB
R sided symptoms
fluid backs up into ABD, legs, feet
peripheral edema
cardiovascular risk factors
family hx of premature CVD
smoking
poor diet
physical inactivity
central obesity
ischemia red flag
chest pain that occurs with activity and resolves with rest
chest pain differentials
cardiac
musculoskeletal
GI
pulmonary
thoracic aortic dissection
severe sharp, ripping, tearing or searing quality
starts at chest and moves to ABD over time
diminished pulses
sinus tachycardia
moderate to severe hypotension
thoracic aortic dissection risk factors
male
cocaine or ecstasy use
advanced age
pregnancy
Turner's Syndrome or Marfan"s
thoracic AA x-ray findings
widening of mediastinal silhouette
displacement of trachea from midline
displaced calcification
opacification
pulmonary chest pain differentials
pleurisy
pneumonia
bronchitis
PE
pneumothorax
PE differentials
unexplained tachy
hypoxia
syncope
GI chest pain
GERD/PUD
pancreatitis
esophagitis
esophageal rupture
gall bladder disease
chest wall pain
costochondritis
rheumatic disease
skin and sensory pain
rib fx
classic" chest pain
left sided pressure radiating to left arm or jaw
dyspnea, nausea, dizziness and diaphoresis
non-ischemic pain signs
points to pain with 1 finger
mid or lower abd
pleuritic pain
reproducible pain
constant pain
radiation to lower extremities or above jawl
essential bp
without cause
90-95% of HTN
orthopnea
dyspnea that occurs when lying down and improves when sits up
paroxysmal nocturnal dyspnea
sudden dyspnea that awakens pt from sleep
1-2 hrs after going to bed
can't sleep lying down
Ca+ channel blockers
SE - LE edema
leg pain/cramps causes
DVT
musculoskeletal
peripheral neuropathy
spinal stenosis
claudication
"charley horse"
PAD
venous pain
increased with standing
decreased with elevation
better with walking
localized at site of vein
arterial pain
relieved with rest
increased with elevation
worse with walking
regional areas of arterial flow
charley horse causes
could be first sign of claudication
poor circulation
fatigue
overexertion
mineral deficiency
medications
claudication
reproducible , intermittent, tight squeezing pain involving a defined group of muscles that is induced by exercise and relieved by rest - usually a smoker - caused by artery occlusion
edema
incompetent valves in the veins compromise venous return to the heart
lower extremities worse at the end of the day
best check at shin
peripheral neuropathy
burning sensation
sciatic nerve pain
intense and sharp
spinal nerve compression
radiation of pain along nerve distribution
spinal neuropathy
AKA degenerative disc disease, pain radiates along dermatome
risk factors for PVD
smoking
HTN, hyperlipidemia
DM
prolonged standing
sedentary lifestyle
obesity
PAD
build up of fatty substances in the wall of the artery
leg pain/cramps differential
PAD
venous insufficiency
neuropathic pain
musculoskeletal
arterial insufficiency
intermittent pain
decreased or absent pulses
pale, cool, absent or mild edema
thin skin, loss of hair over foot/toes
may develop gangrene
venous insufficiency
no pain
normal to difficult to feel pulses
normal or cyanotic color
edema
brown pigmentation around ankles
factors that influence arterial pressure
left ventricular strike volume
elasticity of artery
peripheral vascular resistance
blood volume in arterial system
internal jugular pulsation
non-palpable
soft, bi-phasic
pulsation eliminated by light pressure on vein
height of pulsation changes with position
height of pulsation falls with inspiration
carotid pulsations
palpable
vigorous thrust, single component
height of pulsation unchanged with position
no affected by inspiration
jugular venous pressure
reflects right atrial pressure
best estimated from right jugular vein
helps show volume status
useful in patients on diuretics
bell
sensitive to low pitched sound
S3 and S4
mitral stenosis murmur
press lightly for low pitch
diaphragm
sensitive to higher pitched sounds
S1 and S2
aortic murmurs
mitral regurgitation
pericardial friction rubs
press firmly
S1
closure of mitral valve
S2
closure of aortic valve
systole
interval between S1 and S2
diastole
interval between S2 and S1
S3
heard best in apex with bell
early in diastolic phase
associated with CHF
S4
heard best in apex with bell
late in diastolic phase
associated with CHF, MI, HTN, CAD
not heard with Afib
murmur grades 1-6
very faint
quiet
moderately loud, no thrill
loud with palpable thrill
very loud with thrill
can be heard w/o stethoscope
timing of murmurs
diastolic worse than systolic
mitral regurgitation
harsh 2/6 medium pitched holosystolic murmur heard at the apex
aortic regurgitation
soft, blowing 3/6 decrescendo diastolic murmur heard best at lower left sternal border
schamroth's test
assess for clubbing
carotid doppler studies
used to detect narrowing of the carotid arteries
CXR
tests: cardiac size, pleural effusion, pulmonary congestion, mediastinal configuration, infiltrates
echocardiogram
most useful in evaluation of heart failure
heart failure patient should have at least 1/yr
pulses 0
absent pulse
pulses 1+
diminished/barely palpable
Pulses 2+
expected
Pulses 3+
full/bounding
medications and falls in elderly
xanax
beta blockers
HA red flags
stiff neck and papilledema - meningitis
progressive in symptoms or severity
thunderclap - subarachnoid hemorrhage
new onset > age 50
focal neuro deficits
wakes you up out of sleep w/ weight loss - malignancy
migraines
one sided
pulsing or throbbing
better with darkness or sleep
nausea and/or photophobia
basic neuro exam
mental status
CNs
motor/coordination
sensory system
reflexes
mini mental status exam
orientation
3 object recall
serial 7's
common objects
3 step command
copy shape
CN II
optic
CN I
olfactory
CN III
oculomotor
CN IV
trochlear
CN V
trigeminal
CN VI
abducens
CN VII
facial
CN VIII
vestibularcochulear
CV IX
glossopharyngeal
CN X
vagus
CN XI
accessory
CN XII
hypoglossal
Weber test
tuning fork on top of head
checks symmetry of hearing
Rinne test
assess hearing not feeling of AC and BC
AC>BC normal
conduction loss
AC=BC
coordination 4 systems
motor - muscle
cerebellar - rhythmic movements
vestibular - balance coordination
sensory - position
radiculopathy
no feeling in a specific area
hyperalgesia
hyper sensation
diabetic foot exam
monofilament test, document 6 areas
cortical sensations
tactile recognition/stereognosis
graphesthesia
2-point discrimination
point localization
tactile extinction
dermatomes
area of skin innervated by single nerve root
hyperactive DTR
CNS lesion, low magnesium
hypoactive DTR
spinal nerve roots, plexuses, peripheral nerves, symmetrically diminished or absent can be normal, increase magnesium
DTRs
grade 0-4+
2+ normal
UE reflexes
triceps
biceps
brachioradialis
LE reflexes
patellar
achilles
plantar
meningeal signs
nuchal rigidity - test neck mobility
Kernig's - flex at hip/kee, straighten...pain
Brudzinski's - flex neck...flexion of hip/knee
ancillary testing
CT, MRI, B12 and ENMG
electro nerve mylogram (ENMG)
tests for neuropathy, carpal tunnel