PACS Exam 2 Learning Objectives

What anatomical landmarks are used to identify the anterior thorax?

The right anterior thorax includes the upper and middle lobes separated by the horizontal fissure at ~5th rib in midaxilla to ~4th rib at sternum; the left lower lobe is separated by a diagonal fissure from ~5th rib at axilla to ~6th rib at midclavicular.

What anatomical landmarks are used to identify the posterior thorax?

The posterior thorax primarily includes the lower lobe from T3 to T10, except for the apices.

What are the right lateral thoracic landmarks?

The right lateral thorax underlies the peak of the axilla to the 7th/8th rib; the upper lobe is at ~5th rib midaxillary and 6th rib anteriorly.

What are the left lateral thoracic landmarks?

The left lateral thorax underlies the peak of the axilla to the 7th/8th rib; the oblique fissure extends from the 3rd rib medially to the 6th rib anteriorly.

What is clubbing and what conditions is it associated with?

Clubbing is the enlargement of the terminal phalanges of fingers/toes and is associated with emphysema, lung cancer, congenital heart disease, cirrhosis, or cystic fibrosis.

What does barrel chest indicate?

Barrel chest, where the AP diameter approaches or equals the lateral diameter, indicates compromised respiration, often seen in chronic asthma, emphysema, or cystic fibrosis.

What is tachypnea and its significance?

Tachypnea is a persistent respiratory rate > 20 breaths per minute, which may indicate protective splinting from pain or other underlying conditions.

What is bradypnea and what can cause it?

Bradypnea is a respiratory rate slower than 12 breaths per minute, which can result from neurologic or electrolyte disturbances, infections, or high levels of cardiorespiratory fitness.

Define dyspnea and its potential causes.

Dyspnea is difficult and labored breathing with shortness of breath, often due to pulmonary or cardiac compromise, sedentary lifestyle, or obesity.

What is orthopnea?

Orthopnea is shortness of breath that begins or increases when the patient lies down, often requiring multiple pillows for comfort.

What is paroxysmal nocturnal dyspnea?

Paroxysmal nocturnal dyspnea is a sudden onset of shortness of breath after a period of sleep, where sitting upright provides relief.

What is hyperpnea?

Hyperpnea refers to deep breathing, which can occur during exercise, anxiety, or metabolic disturbances.

What is hypopnea?

Hypopnea is characterized by abnormally shallow respirations, often associated with pleuritic pain.

What is the significance of Kussmaul breathing?

Kussmaul breathing is always deep and often rapid, associated with metabolic acidosis.

What does periodic breathing indicate?

Periodic breathing involves regular patterns of breathing with intervals of apnea, often seen in seriously ill patients or those with brain damage.

What is the technique to assess thoracic expansion?

To assess thoracic expansion, stand behind the patient with thumbs along the spinal processes at the 10th rib and observe divergence during breathing.

What does asymmetric thoracic expansion suggest?

Asymmetric thoracic expansion suggests a problem on one or both sides, such as chronic obstructive pulmonary disease.

What is subcutaneous crepitus?

Subcutaneous crepitus is a crackly sensation indicating air in the subcutaneous tissue, often due to a rupture in the respiratory system or infection.

What is tactile fremitus and how is it assessed?

Tactile fremitus is assessed by palpating the chest while the patient recites numbers, checking for symmetry and intensity of vibrations.

What does decreased fremitus indicate?

Decreased fremitus suggests excess air in the lungs, such as in emphysema or pleural effusion.

What does increased fremitus indicate?

Increased fremitus often indicates the presence of fluids or solid masses within the lungs, such as lung consolidation.

What is the expected AP:transverse thorax diameter in healthy adults?

In healthy adults, the AP diameter of the chest is less than the lateral diameter, with a thoracic ratio of about 0.70 to 0.75.

What changes occur in the thorax of pregnant women?

Pregnant women experience an increase in lateral diameter of about 2 cm and an increase in circumference of 5 to 7 cm due to anatomical changes.

What is the significance of barrel chest in older adults?

Barrel chest in older adults results from loss of muscle strength and lung resiliency, often indicating compromised respiration.

What is the expected percussion note over lung fields in cases of hyperresonance?

An abnormal sound resulting from air trapping, associated with conditions like emphysema, pneumothorax, or asthma.

What conditions are associated with dullness or flatness in percussion notes?

Pneumonia, atelectasis, pleural effusion, or asthma.

What is diaphragmatic excursion?

The movement of the thoracic diaphragm during inhalation and exhalation.

Describe the technique for assessing diaphragmatic excursion.

Ask the patient to take a deep breath and hold it, percuss along the scapular line to locate the lower border, mark the point of dullness, breathe normally, then repeat on the other side.

What is the normal distance for diaphragmatic excursion?

Usually 3 to 5 cm.

What is a common finding regarding diaphragm height?

The diaphragm is usually higher on the right side due to the liver's position.

What are the expected breath sounds and their locations?

Bronchial (trachea), bronchovesicular (main bronchus), and vesicular (most lung fields).

What characterizes bronchial breath sounds?

Heard only over the trachea; high pitch; loud and long expirations.

What are crackles (rales)?

Discontinuous, fine crackling sounds that are high pitched.

What causes rhonchi?

Loud, low, coarse sounds often due to mucus accumulation in the trachea or large bronchi.

What is the significance of diminished breath sounds?

Indicates fluid or pus in the pleural space, bronchial obstruction, or hyperinflation of the lungs.

What is the Hamman Sign?

A mediastinal crunch sound synchronous with the heartbeat, indicating mediastinal emphysema.

What is the technique for pulmonary percussion?

Examine the back with the patient sitting, arms folded, then percuss systematically over intercostal spaces.

What is the technique for auscultation of the lungs?

Have the patient breathe deeply through the mouth while the stethoscope is placed firmly on the skin over intercostal spaces.

What is the difference between normal and abnormal vocal resonance?

Normal sounds are muffled; increased clarity indicates lung consolidation.

What is pulse pressure?

The difference between systolic and diastolic blood pressure, indicating potential health issues.

How does heart rate affect the duration of systolic and diastolic phases?

At higher heart rates, systole and diastole become more similar in length.

What are the four heart sounds and their origins?

S1: closure of mitral/tricuspid valves; S2: closure of aortic/pulmonic valves; S3: ventricular filling; S4: atrial contraction.

What is the clinical significance of abnormal breath sounds?

They can indicate underlying respiratory conditions or abnormalities in lung function.

What conditions can alter the inspiratory:expiratory (I:E) ratio?

Airway obstruction, with I/E ratios greater than 2:1 or 3:1 indicating severe conditions.

What is the expected finding on inspection of healthy lungs?

Symmetry of movement on expansion and absence of retractions.

What is the significance of tactile fremitus?

Symmetric, unaccentuated fremitus indicates normal lung function; changes can suggest pathology.

What is the proper patient positioning for auscultation?

Sitting upright, with arms overhead for lateral chest and shoulders back for anterior chest.

What is the expected percussion note in healthy lungs?

Resonant and symmetric percussion notes.

What is the clinical significance of increased vocal resonance?

Indicates consolidation of lung tissue.

What is the expected finding on palpation of healthy lungs?

Midline trachea without tug and symmetric tactile fremitus.

What cardiovascular changes occur during pregnancy?

Blood volume increases by 40% to 50%, heart rate increases, cardiac output rises by 30% to 40%, and the left ventricle increases in wall thickness and mass.

How does blood volume change after delivery in pregnant patients?

Blood volume returns to prepregnancy levels within 3 to 4 weeks after delivery.

What is the significance of the jugular venous pulse?

It reflects pressure changes in the right atrium and is visualized rather than palpated.

What are the five components of the internal jugular venous pulse wave?

a wave, c wave, v wave, x slope, y slope.

What does the a wave in the jugular venous pulse represent?

It results from a brief backflow of blood to the vena cava during right atrial contraction.

What does the c wave in the jugular venous pulse indicate?

It is caused by the closure of the tricuspid valve during right ventricular systole.

What is the significance of the v wave in the jugular venous pulse?

It reflects increasing volume and pressure in the right atrium late in ventricular systole.

How is the internal jugular venous pressure (JVP) measured?

The patient is supine, and the height of the JVP is measured in centimeters of water above the midaxillary line.

What is considered an abnormally high JVP?

A JVP greater than 9 cm H2O is considered abnormally high.

What is the technique for assessing hepatojugular reflux?

Apply firm pressure to the abdomen for 10 seconds and observe for a JVP elevation of at least 3 to 4 cm.

What does a positive hepatojugular reflux finding indicate?

It suggests right heart failure and is used to evaluate that condition.

Where is the apical impulse (PMI) typically located?

At the midclavicular line in the fifth left intercostal space.

What conditions can cause the PMI to become enlarged or more intense?

Increased cardiac output or left ventricular hypertrophy can cause these changes.

What is a ventricular heave?

A precordial impulse felt in patients with cardiac or respiratory disease, indicating right ventricular hypertrophy.

What is a palpable thrill?

A palpable murmur that is graded IV or higher.

What are the locations for auscultating the aortic and pulmonic valves?

Aortic valve: second right intercostal space; Pulmonic valve: second left intercostal space.

Where is Erb's Point located?

At the third left intercostal space at the left sternal border.

What is the best area to hear S1 and S2 heart sounds?

S1 is best heard at the apex, while S2 is best heard at the aortic and pulmonic areas.

What does splitting of heart sounds indicate?

It occurs when the mitral and tricuspid valves or the pulmonic and aortic valves do not close simultaneously.

What changes occur in the cardiovascular system of older adults?

Heart size may decrease, left ventricular wall thickens, stroke volume decreases, and myocardial contractility becomes less efficient.

What is the expected appearance of the jugular venous pulse?

It is visualized as a wave pattern rather than palpated, reflecting right heart activity.

What is the clinical significance of a positive hepatojugular reflux?

It indicates potential right heart failure and helps assess the severity of the condition.

What factors can obscure the apical impulse?

Obesity, large breasts, or muscularity can make the apical impulse less visible.

What is the expected diameter of a normal apical impulse?

It is usually no more than 1 cm in diameter.

What does a loss of thrust in the apical impulse suggest?

It may indicate overlying fluid or air or displacement beneath the sternum.

How does the loudness of S2 compare to S1 at the base of the heart?

S2 is louder than S1 at the base of the heart but usually softer than S1 at the apex.

What causes the splitting of S1?

The splitting of S1 occurs because the mitral and tricuspid valves do not close simultaneously, and the sound of the tricuspid valve is often too faint to hear.

What is a split S2 and when is it most often heard?

A split S2 occurs when the closure of the aortic valve (A2) and pulmonic valve (P2) are heard as two distinct sounds, especially during inspiration, and is more easily detected in younger individuals.

What is the early diastolic gallop rhythm and when is it best heard?

The early diastolic gallop rhythm is characterized by an intense S3 sound and is best heard when the patient is in the left lateral decubitus position.

What is the presystolic gallop rhythm and in whom is it commonly heard?

The presystolic gallop rhythm is characterized by an intense S4 sound and is most commonly heard in older patients or those with increased resistance to filling.

Which heart sounds are best heard with the diaphragm of the stethoscope?

S1 and S2 are best heard with the diaphragm.

Which heart sounds are best heard with the bell of the stethoscope?

S3 and S4 are best heard with the bell.

What patient positions are appropriate for auscultating S3 and S4?

S3 is best heard in the supine or left lateral position, while S4 is also best heard in these positions.

How is a Grade I heart murmur characterized?

A Grade I murmur is barely audible in a quiet room.

What distinguishes a Grade IV heart murmur?

A Grade IV murmur is loud and associated with a palpable thrill.

Describe the characteristics of mitral stenosis murmur.

Mitral stenosis presents as a low-frequency diastolic rumble, more intense in early and late diastole, with a palpable thrill at the apex.

What are the characteristics of aortic stenosis murmur?

Aortic stenosis is characterized by a midsystolic, medium-pitched, coarse, diamond-shaped crescendo-decrescendo murmur that radiates to the carotid arteries.

What is the hallmark of mitral regurgitation murmur?

Mitral regurgitation is a holosystolic murmur with a high pitch and harsh quality, often loud enough to obliterate S2.

How is a ventricular septal defect murmur characterized?

A ventricular septal defect presents as a holosystolic murmur, often loud and best heard along the left sternal border.

What are the signs of venous insufficiency?

Signs include dilated and tortuous veins, swelling, and sustained distention of veins upon palpation.

Differentiate between pitting and non-pitting edema.

Pitting edema leaves a dimple after pressure is applied, while non-pitting edema does not.

What conditions are associated with pitting edema?

Conditions include congestive heart failure, liver disease, kidney disease, deep vein thrombosis, and pregnancy.

What is the significance of Homan's Sign?

Homan's Sign indicates potential deep vein thrombosis (DVT) when passive dorsiflexion of the foot causes calf pain.

What is an innocent heart murmur and its characteristics?

An innocent heart murmur is usually grade I or II, midsystolic, without radiation, medium pitch, and often disappears when the patient changes position.

How is pitting edema quantified on a scale of 0 to 4+?

0: Absent; 1+: Slight pitting, disappears rapidly; 2+: Deeper pit, disappears in 10-15 seconds; 3+: Deep pit lasting over a minute; 4+: Very deep pit lasting 2-5 minutes.

What is the technique for assessing varicose veins?

Inspect the legs while standing, looking for dilated and tortuous veins, and have the patient stand on their toes to assess for venous distention.

What is a quadruple gallop?

A quadruple gallop is when S1, S2, S3, and S4 sounds are all heard separately.

What is a pericardial friction rub?

A pericardial friction rub is a grating sound produced by friction of the heart against the pericardium, indicative of pericarditis.

What is the primary nerve responsible for parasympathetic innervation of the abdominal viscera?

The vagus nerve

Which nerves provide sympathetic innervation to the abdominal viscera?

Thoracic splanchnic nerves (greater, lesser, least) and upper lumbar splanchnic nerves