Term
| know the physiology and significance of sounds heard when taking blood pressure measurements |
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Definition
"- listen with stethoscope at brachial artery, occlude the artery by increasing pressure of cuff
- slowly release the pressure. the first whooshing sound heard (1st Korotkoff sound) indicates the systolic pressure. the sound is made from turbulent blood flow
- continue to release cuff pressure until no sound is heard (5th Korotkoff sound). this indicates the diastolic pressure level. " |
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Term
| know the correct technique for measuring blood pressure |
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Definition
"- have patient seated and support the patient's arm
- put stethoscope on brachial artery and line up the cuff of the sphygmomanometer so that the arrow points to the brachial artery.
- tighten cuff. too small of a cuff will result in a falsely high blood pressure. too large of a cuff will result in a falsely low blood pressure reading. "
-patient should have rested for 5 minutes before the BP is taken |
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Term
| know the defintions of cyanosis, clubbing, dyspnea, orthopnea, proxysmal nocturnal dyspnea, tachypnea |
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Definition
"- Cyanosis: appearance of blue coloration of the skin due to low oxygen
- Clubbing: thickening of distal fingers, along with softening of nail and increased shiny-ness. occurs in a number of conditions including chronic hypoxia
- Dyspnea: Shortness of breath
- Orthopnea: Shortness of breath when lying flat
- Paroxysmal Nocturnal Dyspnea: attacks of shortness of breath and/or coughing during the night
- Tachypnea: rapid breathing (usually defined as >20 breaths / min)" |
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Term
| know the physiology and anatomic location of apical impulse |
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Definition
| - Apical impulse (aka Apex Beat) can be found at the 5th left intercostal space on the mid-clavicular line |
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Term
| know the physiology and signifiance of heart sounds |
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Definition
"-S1: occurs during systole; left ventricle starts to contract and ventricular pressure exceeds left atrial pressure, thus shutting the mitral valve
-S2: left ventricular pressure drops below aortic pressure, shutting the aortic valve
-S3: in children and young adults, occurs after the mitral valve opens during a period of rapid ventricular filling; in older adults, presence usually indicates a pathological change in ventricular compliance
-S4: marks atrial contraction; immediately precedes S1 of the next beat and reflects a pathological change in compliance. " |
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Term
| know the characterisitcs of aortic and mitral murmurs |
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Definition
" SYSTOLIC MURMURS
- Aortic stenosis: Systolic crescendo-decrescendo murmur following ejection click, heard best at R 2nd intercostal space (ICS) and radiating to carotid. Often due to age-related calcific aortic stenosis or bicuspid aortic valve.
- Mitral regurgitation: Holocystolic high pitched murmur, heard best at apex and radiating toward axilla. Enhanced by maneuvers that increase TPR (squatting) or LA return (expiration). Often due to ischemic heart disease, mitral valve prolapse, or LV dilation
DIASTOLIC MURMURS
- Aortic regurgitation: High pitched ""blowing"" diastolic murmur, heard best between L 2nd and 4th ICS. Can present with bounding pulses and head bobbing. Often caused by aortic root dilation, bicuspid aortic valve, or rheumatic fever
- Mitral stenosis: Late diastolic murmur following opening snap (due to tensing of chordae tendinae), heard mostly at the apex. Often secondary to rheumatic fever. Chronic MS can cause LA dilitation
JUST REMEMBER: MR. SAS (Mitral Regurg, Systolic, Aortic Stenosis)" |
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Term
| know the grading scale for cardiac murmurs |
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Definition
"Grade 1 : Very faint, heard only after listener has ""tuned in""; may not be heard in all positions
Grade 2: Quiet, but heard immediately after placing the stethoscope on the chest
Grade 3: Moderately loud
Grade 4: Loud, with palpable thrill
Grade 5: Very loud, with thrill. May be heard when the stethoscope is partly off the chest.
Grade 6: Very loud, with thrill. May be heard with stethoscope entirely off the chest" |
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Term
| know the characteristics of diastolic murmurs |
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Definition
"See AR and MS
Patent Ductus Arteriosus: Causes continuous machine like murmur, loudest at S2 (I guess this could technically count as diastolic)" |
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Term
| know how to assess jugular venous pressure |
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Definition
" Jugular Venous Pressure (JVP) is an indicator of right heart pressure. For instance, JVP is reduced when LV output or blood volume is low. JVP is elevated when right heart fails or there is pressure on RA (pericardial effusion).
To estimate the level of the JVP, you will learn to find the highest point of oscillation in the internal jugular vein or, if necessary, the point above which the external jugular vein appears collapsed. The JVP is usually measured in vertical distance above the sternal angle, the bony ridge adjacent to the second rib where the manubrium joins the body of the sternum." |
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Term
know the physiology and significance of cardiac waveforms
NORMAL EKG |
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Definition
Normal EKG
- P wave: The small P wave of atrial depolarization
- The larger QRS complex of ventricular depolarization (S1 correlates with QRS peak)
- the Q wave, a downward deflection from septal depolarization
- the R wave, an upward deflection from ventricular depolarization
- the S wave, a downward deflection following an R wave
- T wave of ventricular repolarization, or recovery |
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Term
know the physiology and significance of cardiac waveforms
ABNORMAL EKG |
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Definition
Abnormal EKG
- Atrial fibrilation: irregularly irregular with NO DISCRETE P WAVES between irregularly spaced QRS waves
- Atrial flutter: sawtooth identical back-to-back atrial depolarization waves
- AV Block (1st deg): PR interval is > 200ms (normal is <200ms)
- AV Block (2nd deg, Wenckebach or Mobitz I): Progressive LENGTHENING of PR interval until beat is dropped
- AV Block (2nd deg, Mobitz II): Normal PR intervals, abrupt non-conducted P waves. 2:1 block means 2 P waves to 1 QRS response
- AV Block (3rd deg): P waves bear no relation to QRS waves (atrial waves are faster than ventricular rate)
- Ventricular fibrillation: Complete erratic rhythm with no identifiable waves. Fatal without immediate defib |
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Term
know the physiology and significance of cardiac waveforms
JUGULAR VENOUS PULSE |
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Definition
Jugular venous pulse
- a wave: Atrial contraction causes slight rise in pressure (just before S1)
- x descent: Starts with atrial relaxation and RV contraction (pulls RA down)
- v wave: Tricuspid valve closes, RA begins to fill and pressure rises
- y descent: Tricuspid valve opens, RA empties
- In simple terms: atrial contraction, atrial relaxation, atrial filling, and atrial emptying |
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Term
| know the physical exam findings in patients with hypertension |
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Definition
"Hypertension: when a higher than normal blood pressure level has been found on at least two or more visits after initial screening.
In more severe cases, common findings:
*hypertensive retinopathy (AV nicking, cotton wool spots, papilledema, visual loss)
*headache
*left ventricular hypertrophy (an abnormal apical impulse and S4 gallop)
*neurologic deficits suggesting a stroke
*bruits
*decreased distal pulses
*signs of CHF (increased JVD)
" |
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Term
| know the physical exam findings in patients with cardiomegaly |
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Definition
"Cardiomegaly can be caused by chamber dilation, wall hypertrophy, or both. The underlying causes can be grouped into three categories: volume overload, pressure overload, or cardiomyopathy.
Common findings:
*syncope
*dyspnea
*fatigue
*angina
*rales
*pleural effusion with dullness to percussion
*decreased breath sounds
*visible or palpable PMI
*increased murmur with valsava maneuver
*bruits |
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Term
| know the anatomic location of arteries palapted during the vascular exam |
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Definition
"carotid artery (neck)
brachial pulse (inside of elbow)
radial/ulnar pulse (inside of wrist)
Abdominal (midepigastrum)
femoral (midpoint of inguinal ligament)
popliteal (posterior and below the medial malleolus)
Posterior tibial (posterior to the medial malleoli)
dorsal pedis (lateral to the tendon of Extensor Hallicus Longus) |
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Term
| know the risk factors for cardiovascular disease |
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Definition
"Age(65 and older)
male and post menopausal women
family history of heart disease, race (African America, Mexican American, American Indian)
smoking
high LDL and low HDL
uncontrolled HTN
physical inactivity
obesity
uncontrolled diabetes
high c-reactive protein
uncontrolled stress and anger |
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Term
| know the terminology of associated physical exam findings in patients with angina and myocardial infarction |
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Definition
| Angina pectoris: Temporary myocardial ischemia, usually secondary to coronary atherosclerosis; Myocardial infarction: Prolonged myocardial ischemia, resulting in irreversible muscle damage or necrosis; Pain: Location: Retrosternal or across anterior chest; sometimes radiating to the shoulders, arms, neck, lower jaw, or upper abdomen; Quality: Pressing, squeezing, tight, heave, occasionally burning; Severity: Mild to moderate with angina, often but not always severe with MI; Timing: Usually up to 10 min for angina, 20min-hours for MI; Aggravation: Exertion, esp in the cold; meals; emotional stress; may occur at rest; Palliation: Rest, nitroglycerin; Associated symptoms: dyspnea, nausea, sweating, vomiting, weakness; Physical exam: No physical exam findings are pathognomonic for angina pectoris; Levine sign: clenched fist over the chest; Hyperadrenergic state (hypertension, tachycardia, tachypnea, and/or diaphoresis during attack); signs of atherosclerosis, i.e. carotid bruit, diminished peripheral pulses, or AV nicking on ophthalmic examination); secondary causes such as aortic stenosis; other signs may be present such as 3rd or 4th heart sounds or mitral regurgitation due to papillary muscle dysfunction |
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Term
| know the physical exam findings in patients with peripheral vascular disease |
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Definition
| Intermittent claudication: exercise induced pain or cramping that resolves with rest; coldness, numbness or pallor in the legs or feet; peripheral edema: swelling of feet and legs; ulcers on lower legs, near ankles |
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Term
| know the physical exam findings in patients with congestive heart failure |
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Definition
| Hypertension or hypotension; cardiac arrhythmia; 3rd or 4th heart sounds; murmurs; laterally displaced PMI; increased JVP; crackles in the lungs (pulmonary edema); hepatic jugular reflex (congested liver); peripheral edema |
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