Cardiac cycle and sounds

Question 1

landmarks to look for upon inspection of CV system

Answer 1

1. sternal notch
2. sternal angle
3. sternal border
4. mid-clavicular line.
5. anterior axillary line
6. xiphoid process
7. nipples

Question 2

what to look at when inspecting

Answer 2

1. general appearance
2. shape of chest
3. landmarks
4. neck veins
5. scars

Question 3

what to look for during palpation

Answer 3

PMI (point of maximal impulse) is used to estimate the location of the apex/L border of the heart.

Palpated near the 4th/5thintercostal space in the mid-clavicular line; pt may have to lift breast. It may not be felt in a healthy pt and should be small, brisk and less than 2.5 cm.

Question 4

PMI should be what

Answer 4

small, brisk and less than 2.5 cm

Question 5

percuss of the CV system

Answer 5

done to estimate the cardiac size when PMI cannot be found.

Start at the far left where more resenonant –> medially to find cardiac dullness.

Question 6

Auscultate

Answer 6

Identify the 2 heart sounds

Ask yourself two questions

• Is the rhythm normal or abnormal?
• Are there any abnormal sounds?

Question 7

Murmur

Answer 7

sound made when flow of blood through a valve is turbulent or disrupted.

Valve is non-compliant, incompetent, stiff or damaged

. Doesn’t always mean a problem. Should be evaluated with ECG.

Question 8

AV valves

Answer 8

1. R side of heart–> tricuspid valve
2. L side of heart–> bicuspid/mitral valve

Question 9

Semilunar valves

Answer 9

R side of heart (pulmonic valve)

L side of heart (aortic valve)

Question 10

Ventricular systole (ventricular contraction and ejection)- pressure force that opens the semilunar valves (aortic/pulmonic) and closes the AV valves.

Answer 10

Opens semilunar valves

closes the AV valves

Question 11

atrial systole

Answer 11

—occurs late in ventricular diastole—

AV valves open while semilunar are closed

Question 12

S1

Answer 12

AV valves close: blood hits the closed valve as it tries to get into the ventricle

Question 13

S2 (dub)

Answer 13

Semilunar valves close

Question 14

cardiac listening post

Answer 14

1. Aortic valve: second intercostal space, R sternal border
2. Pulmonic valve: second intercostal space, L sternal border
3. Erbs point: third intercostal space, L sternal border *
4. Tricuspid valve: fourth or fifth intercostal space, L sternal border
5. Mitral area or apex: fifth intercostal space, L midclavicular line

Question 15

use diaphragm for what

Answer 15

high pitched sounds (s1, S2. AR, MR, friction rubs_

Question 16

Use bell for

Answer 16

low pitch sounds (S3, S4, MS and carotid bruits)

Question 17

always listen on

Answer 17

BARE SKIN

Question 18

S3 (Ken-tuckee)

Answer 18

dull, low pitch sound heart best with bell during rapid ventricular filling. Normal sound in children but can indicate heart path in adult.

AV valves are now open.

Question 19

S4 (Tenness-ee)

Answer 19

)àDull, low pitch, best heard with bell. Atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle.

Can be normal in trained athletes. (Ten-Nes-See). Occurs before S1

Question 20

assessment of CV sustem includes (5 finger rule)

Answer 20

1. Hx
2. Physical
3. ECG
4. Imaging via exhocardiogram
5. lab

Question 21

what to ask in hx

Answer 21

fatigue, chest pain, palpations, syncope,

family hx

Question 22

familial clustering is common in

Answer 22

hypertrophic cardiomyopathy

marfans

CAD

prolonged QT sundome

Question 23

physical on CV exam

Answer 23

• Inspection,
• palpation,
• percussion,
• auscultate
• heart sounds,
• grade murmurs,
• JVP

Question 24

how to conduct PMI?

Answer 24

PMI should be felt for thrill.

1. pt lays supine at 45 degrees of lateral decubitis position
   - if upright, will be felt at the 5th ICS, medial to MCL

Question 25

Jugular vein tells us the activity of the _____ side of te heart

Answer 25

RIGHt

Question 26

Measuring our JVP can give us an indication of

Answer 26

· CVP (central venous pressure) and RAP (right atrial pressure)

Question 27

· Internal jugular (IJ) is a better estimate than \_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 27

**external jugular (EJ)**

Question 28

how to measure JVP

Answer 28

o Pt is supine to allow veins to engorge o Pt is raised 30-45 degrees

Question 29

Normal JVP is

Answer 29

0-9

Question 30

Most common cause of elevated JVP is d/t

Answer 30

elevated RV diastolic pressure

Question 31

· Causes of increased JVD include

Answer 31

o 1. SVC obstruction o 2. Severe heart failure o 3. Constrictive pericarditis, cardiac tamponade o 4. RV infarction o 5. Restrictive cardiomyopathy

Question 32

a wave

Answer 32

o atrium is contracting and the triscupid valve is opening. Occurs during diastole.

Question 33

x descent

Answer 33

àatrium is relaxing and filling: triscuspid valve is closed. Occurs during ventricular systole

Question 34

V wave

Answer 34

o atrium is tense, full; tricuspid valve is closed. Marks the beginning of diastole

Question 35

y descent

Answer 35

atrium is emptying and the tricuspid valve is open.

Question 36

S1 is heard when

Answer 36

beginning of systole and is loudest at the apexof the heart. o MV closure--\> 1stcomponent o TV closure--\> 2ndcomponent

Question 37

S2 occurs at the

Answer 37

end of systole (beginning of diastole) and is loudest at the **base** of the heart. o AV closure--\> 1stcomponent o PV closure--\> 2ndcomponent

Question 38

gradiing murmurs

Answer 38

· Graded on a scale from 1-6 o Grade 1àvery faint o Grade 2àquiet, but heard easily with a stethoscope o Grade 3àmoderately loud, no thrill o Grade 4àloud, with a palpable thrill o Grade 5àvery loud with stethoscope partially off of the chest o Grade 6àheard with stethoscope entirely off of the chest

Question 39

· Systolic murmurs occur in between\_\_\_\_\_\_\_ · Diastolic murmurs fall in between \_\_\_\_\_\_

Answer 39

· Systolic murmurs occur in between S1 and S2 · Diastolic murmurs fall in between S2 and S1

Question 40

problem focused visit with CC need a h&p and HPI?

Answer 40

needs hpi but not n&p

Question 41

wellness visit

Answer 41

need a **H&P AND HPI** ## Footnote **need immunizations, health care maintenance, and prevention**

Question 42

sick vs not sick, vs really is absed on

Answer 42

general appearance and vital signs

Question 43

cystitis is a bladder localized UTI pyelonephritis is what

Answer 43

kidney localized UTI--- tested by Lloyds punch- costovertebral angle tenderness- flank pain

Question 44

gi origin

Answer 44

appendicitis colitis divertisculitis

Question 45

. Female reproductive processes

Answer 45

Menarche dysmenorrhea ovarian cyst ovarian cyst rupture

Question 46

**Assessment** should be listed from most likely--\> least

Question 47

Identify _________ on Review of Symptoms (ROS) as a sign of possible urinary tract cancer (kidney, ureter, bladder, urethra, prostate)

Answer 47

hematuria (blood in urine) -can be seen with naked eye if not, perform a UA (dipstick) an a urine microscope

Question 48

Transitional cells line from

Answer 48

**renal pelvis --\> proximal 2/3 of the urethra**, so almost any area can be pre-disposed to cancer by smoking, toxin exposure, etc

Question 49

Impression (assessment is based on

Answer 49

H& p

Question 50

what lab work is cost effective for

Answer 50

UA, dipstick, reagent stick

Question 51

other tests performed when heamturia

Answer 51

TSH Lipid panal CBC CMP

Question 52

when to run a urine culture

Answer 52

not indicated if drip and micro are NEGATIVE

Question 53

CT

Answer 53

more expensive and contrast can cause renal toxicity

Question 54

After US demonstrates mass in UT, _____ is important to determine extent of primary tumor and possible metastasis- also helps more clearly define anatomy for likely surgery which is the treatment choice for renal cell carcinoma and can be curative

Answer 54

**_CT_**

Question 55

PET scan

Answer 55

assess mets- most expensize

Question 56

bone scane

Answer 56

determine **bony metasisis**, the most common site in RCC

Question 57

MRI

Answer 57

xpensive and **NOT beneficial**

Question 58

9. Determine significant Family History that may predispose to hematuria or other urinary tract disorders and develop a unified approach to patient problems and differential diagnosis.

Answer 58

Smoking, infection, glomerulonephritis, kidney stones (renal lithiasis), autoimmune diseases, **respiratory complaints, upper or lower respiratory sx along with hematuria,**