Cardiovascular and Chest Assessments Flashcards
S4 Heart Sounds
Late atrial contraction aka atrial gallop
Heard before S1
TENNESSEE
Most commonly heard in older adults
hypertension
heart disease
coronary artery disease
Loud S4, further evaluation is necessary
Pectus Carinatum
Chest abnormality where the sternum and ribs push outward
Galactorrhea
Lactation not related with child bearing
Diaphragmatic Excursion
Measurement of lung expansion by using percussion during inhalation and exhalation. Normal measurements are usually between 3-5 cm.
Kyphosis
Forward rounding of the back
Pectus Excavatum
Congenital abnormality where the sternum caved inward.
S3 heart sound
Occurs in early diastole
KENTUCKY
Normal in young adults and athletes
Concerned after age 40
heart failure (think extra fluid)
pregnancy (think extra fluid)
Thrill
Palpable heart murmur
Tactile Fremitus
Assessment technique where the chest is palpated assessing for vibrations while the patient is speaking. It may be increased or decreased based on varying conditions, such as COPD, PNA, and pleural effusion.
Gynecomastia
Male breast enlargement
Beck’s Triad
Characterized by low arterial blood pressure, jugular venous distention, muffled heart sounds, indicating cardiac tamponade
Vocal Resonance
Auscultation technique where spoken voice transmits through the lung fields. Generally spoken voice is muffled. Voice may transmit with increased sound in conditions such as consolidation of the lungs. It may decrease when there is loss of tissue such as emphysema.
S1 (Systole)
“Motivated”
M = Mitral
T = Tricuspid
AV = Atrial ventricular Valves
“lub” sound (of “lub-dub”) is the closure of the mitral and tricuspid valves, AV valves
S2 (Diastole)
“Apples”
A = Aortic
P = Pulmonic
S = Semilunar Valves
“dub” sound (of “lub-dub”) is the closure of the aortic and pulmonic valves, semilunar valves
split S2 is abnormal in inspiration (refer), but on expiration it is normal
Systolic Murmur Pneumonic
*these are the only ones that radiate
MR. PASS MVP
“MR. PASS MVP”
Mitral Regurgitation
Pathological Aortic Stenosis
Systolic
Mitral Valve Prolapse
Mitral Valve Prolapse: two valve flaps of the mitral valve don’t close smoothly or evenly, but bulge (prolapse) upward into the left atrium, then this prolapsed valve lets a small amount of blood leak backward through the valve, called regurgitation, which may cause a heart murmur
Diastolic Murmur Pneumonic
*these are the bad ones
Diastolic = DOOM = referred out
MS. ARD
“MS. ARD”
Mitral Stenosis
Aortic Regurgitation
Diastolic
Mitral Area location
The mitral area is also known as the apex (or apical area) of the heart.
Fifth left ICS is approximately 8 to 9 cm from the midsternal line and slightly medial to the midclavicular line.
PMI or the apical pulse is located in this area.
Aortic Area location
The aortic area is the second ICS to the right side of the upper border of the sternum.
The location of the aortic area can also be described as the “second ICS by the right side of the sternum at the base of the heart.”
It can also be described as a murmur that is located on the right side of the upper sternum.
Erb’s Point
Erb’s point is located at the third to fourth ICS on the left sternal border
Diastolic Murmurs always indicate
heart disease
Grade IV Heart Murmur
Grade IV: A louder murmur. First time that a thrill is present. A thrill is like a “palpable murmur.”
Hypertensive Pregnant Mom Medications
New Little Momma
Nifedipine, Labetalol, Methyldopa / Aldomet
Hypertension
s/s
- asymptomatic
- headache
- fatigue
- vision changes
AHA/ACC Guidelines
Hypertension
Normal: <120/ <80
Elevated: 120-129 / < 80
- lifestyle modifications, including home BP log
Stage 1: 130-139 / 80-89
- Start ASCVD risk to determine when to start medications
- think hyperTENsion=treat HTN when ASCVD risk > 10%
Stage 2: > 140 or > 90
- Start medications no matter what
Goal = 130/80 when treating HTN
Hypertension
Lifestyle Changes
diet
exercise
smoking cessation
sodium restriction
Hypertension
Medications
ACE-I / ARB
Thiazide Diuretics
Calcium Channel Blockers
HTN with ACE - I: all the - PRILS
NO PREGNANT PATIENTS
GOOD:
RENAL PROTECTIVE
drug of choice for kidney stage III
BAD:
dry, hacking cough
angioedema - no matter for how long pt is on it
hyperkalemia
worsening kidney function
Monitor:
renal function and electrolytes
DISCONTINUE:
eGFR drops > 30% or below 30
Creatinine increases > 30%
ACE-i and ARB are good for HTN and diabetes
HTN with Thiazide Diuretics
GOOD
osteoporosis (decrease urinary calcium secretion)
*chlorthalidone = shown to decrease cardiovascular risk over hydrochlorothiazide
BAD:
increase in uric acid
increase triglycerides
increase in glucose
Do not use in gout, severe triglycerides, diabetic/pre-diabetic
CANNOT PRESCRIBE IF EGFR < 30
HTN with Calcium Channel Blockers
Two Classes for this Exam
Dihydropyridines
- amlodipine (Norvasc)
Non-Dihydropyridines = cannot prescribe for heart failure patients
- verapamil (Verelan)
- diltiazem (Cardizem)
BAD
edema, ankle edema
headache
GERD
HTN microvascular
- all the “-opathies”
retinopathy
nephropathy
neuropathy
HTN macrovascular
Myocardial Infarctions
stroke
heart failure
HTN screening
- fundoscopic (eye) exam
- papilledema is an emergency that is the swelling of optic discs in your eyes due to increased intracranial pressure (intracranial hypertension)
- refer annual eye eval with eye doc
- monitor renal function
*diabetes and hypertension are the top leading diseases to cause chronic kidney disease
Hyperlipidemia
high cholesterol
limit LDL (bad cholesterol)
HDL is cardio-protective and we want this higher
Lipid Profile
Total Cholesterol < 200
HDL 40-60
LDL < 100
Triglycerides < 150
Hyperlipidemia Screening & lipid panel checks
- screen every 5 years, unless
- 1-3 months adjusting medications
- yearly once stable
Hyperlipidemia
high cholesterol
with -STATINs…we treat 4 groups
- primary prevention (high ASCVD risk)
- secondary prevention (cardiovascular event already)
- LDL > 190
- Patients with diabetes
- ages 40-75 (can initiate earlier with sign. risk factors)
- initiate regardless of ASCVD score
Baseline liver function before prescribing
Hyperlipidemia
Atherosclerotic Cardiovascular Disease - ASCVD risk calculator cut off for meds
cut off to start medical management for hyperlipidemia is 7.5%
Low Intensity Statin
- no grapefruit juice
pravastatin (Provochol)
simvastatin (Zocor)
High Intensity Statin
- no grapefruit juice
Atorvastatin (Lipitor) 80 mg
Rosuvastatin (Crestor) 20-40 mg
Main concerns with Statins
- jaundice - drug induced hepatitis check LFTs
- rhabdomylosis (new muscle pain), check Ck/Cr levels, potential to lead to acute renal failure
Medication for high triglycerides
Fenofibrate
hypertriglyceridemia is a fasting TG level >200 mg/dL without an accompanying elevation in LDL-C (with or without statin therapy)
Normal – <150 mg/dL (<1.7 mmol/L)
Moderate hypertriglyceridemia – 150 to 499 mg/dL (1.7 to 5.6 mmol/L)
Moderate to severe hypertriglyceridemia – 500 to 999 mg/dL (5.65 to 11.3 mmol/L)
Severe hypertriglyceridemia – ≥1000 mg/dL (≥11.3 mmol/L)
High triglycerides > 500 can lead to acute pancreatitis
Hyperlipidemia is high signs - 2 things
- Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.
- Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol
Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.
Supplement for the Heart
CoQ10 or Co Enzyme 10
Respiratory Sinus Arrhythmia
variance in heart rate between inspiration and expiration
where heart rate rises in inspiration and decreases on expiration
- associated with young and healthy athletes, no treatment
Pulsus paradoxus
- cardiac tamponade
- status asthmaticus
fall in a patient’s blood pressure during inspiration by greater than 10 mm Hg = medical emergencies
- cardiac tamponade
abnormal amounts of fluid accumulate in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock
TRIAD: hypotension, jugular venous distension, and muffled heart sounds - status asthmaticus
extreme form of asthma exacerbation characterized by hypoxemia, hypercarbia, and secondary respiratory failure
Heart Failure
Diagnostics
Right: sent to body - fluid retention in periphery of body
Left: sent to the lungs - respiratory symptoms
BNP elevated
EKG
chest xray = cardiomegalogy
ECHO = ejection fraction = < 40%
Heart Failure Meds
- diuretic - do not gain more than 2 kg per day
- HTN meds
- ACE & beta blockers - good for HTN/DM/HF
- S3 heart sound (kentucky) with fluid overload, also heard in pregnancy
- stay away from TZDs and CCB
- avoid NSAIDs
Atrial Fibrillation
- high risk for clots
- prescribe anticoagulants
- absent p wave
- irregular QRS
- beta blockers for rhythm control
Warfarin / Coumadin
Normal INR is ~ 1
Atrial Fib: 2-3
Mechanical Valves: 2.5-3.5
Reversal - vitamin K
Start vitamin K with INR > 10
May start with INR 5-10 with signs of bleeding
otherwise hold
Hyperlipdemia is high - seen on face
Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.
Hyperlipidemia is high - seen on eye
Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol
Raynaud’s Phenomenon
What is it?
What is a treatment?
- causes the blood vessels in the extremities to narrow, restricting blood flow affecting the fingers and toes, sometimes ears and nose
- exposure to cold or emotional stress
- treat with calcium channel blockers and avoid triggers
Heart Valve Order Pneumonic
All People Take Money
All People Take Money
Aortic
Pulmonic
Tricuspid
Mitral
Where do the systolic murmurs radiate to?
Mitral Regurgitation - radiates to armpit
Aortic Stenosis - radiates to neck
Mitral Valve Prolapse - rare
Hyperlipidemia is high - seen on eye
Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol
Heart Valve Order Pneumonic
All People Take Money
All People Take Money
Aortic
Pulmonic
Tricuspid
Mitral
Hyperlipdemia is high - seen on face
Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.
Where do the systolic murmurs radiate to?
- Mitral Regurgitation - radiates to armpit
- Aortic Stenosis - radiates to neck
- Mitral Valve Prolapse - rare, but you can hear a click and that can be heard in children who have Marfan’s syndrome
Hyperlipidemia is high - seen on eye
Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol
Heart Valve Order Pneumonic
All People Take Money
All People Take Money
Aortic
Pulmonic
Tricuspid
Mitral
Peripheral Arterial Disease (PAD)
What is it?
s/s
Diagnosis?
risk factor
narrowing or blockage of the vessels that carry blood from the heart to the legs caused by the buildup of fatty plaque in the arteries (atherosclerosis)
s/s: pain in legs relieved with rest, but sometimes it will not go away
diagnosis: ankle brachial index (ABI): measures the blood pressure in the ankles and compares it with the blood pressure in the arms at rest and after exercise
biggest risk factor: smoking
Hyperlipdemia is high - seen on face
Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.
Where do the systolic murmurs radiate to?
- Mitral Regurgitation - radiates to armpit
- Aortic Stenosis - radiates to neck
- Mitral Valve Prolapse - rare, but you can hear a click and that can be heard in children who have Marfan’s syndrome
Chronic Venous Insufficiency
What is it?
Diagnosis?
At risk for?
valves in your veins (usually in the leg or sometimes the arms) don’t work, causing blood to pool in your legs and putting increased pressure on the walls of the veins
s/s: varicose veins, edema, or skin color changes
diagnosis: ultrasound test (duplex Doppler) to find out how well blood is flowing in your legs - refer to vascular
Highest Risk: Deep Vein Thrombosis - localized swelling and erythema (d-dimer and doppler)
Homan’s sign test also called dorsiflexon sign test is a physical examination procedure that is used to test for Deep Vein Thrombosis (DVT), no longer considered specific enough for DVT diagnosis.
Hypertension - JNC 8
Persons older than 60 y.o. should have a BP goal less than 150/90.
Where do the systolic murmurs radiate to?
- Mitral Regurgitation - radiates to armpit
- Aortic Stenosis - radiates to neck
- Mitral Valve Prolapse - rare, but you can hear a click and that can be heard in children who have Marfan’s syndrome
Hyperlipdemia is high - seen on face
Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.
Heart Valve Order Pneumonic
All People Take Money
All People Take Money
Aortic
Pulmonic
Tricuspid
Mitral
Hypertension - JNC 8
Persons older than 60 y.o. should have a BP goal less than 150/90.
Hyperlipidemia is high - seen on eye
Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol
Where do the systolic murmurs radiate to?
- Mitral Regurgitation - radiates to armpit
- Aortic Stenosis - radiates to neck
- Mitral Valve Prolapse - rare, but you can hear a click and that can be heard in children who have Marfan’s syndrome
Hyperlipidemia is high - seen on eye
Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol
Hypertension - JNC 8
Persons older than 60 y.o. should have a BP goal less than 150/90.
Heart Valve Order Pneumonic
All People Take Money
All People Take Money
Aortic
Pulmonic
Tricuspid
Mitral
Hyperlipdemia is high - seen on face
Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.
