Cardiovascular and Chest Assessments

Question 1

S4 Heart Sounds

Answer 1

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

Question 2

Pectus Carinatum

Answer 2

Chest abnormality where the sternum and ribs push outward

Question 3

Galactorrhea

Answer 3

Lactation not related with child bearing

Question 4

Diaphragmatic Excursion

Answer 4

Measurement of lung expansion by using percussion during inhalation and exhalation. Normal measurements are usually between 3-5 cm.

Question 5

Kyphosis

Answer 5

Forward rounding of the back

Question 6

Pectus Excavatum

Answer 6

Congenital abnormality where the sternum caved inward.

Question 7

S3 heart sound

Answer 7

Occurs in early diastole
KENTUCKY
Normal in young adults and athletes
Concerned after age 40
heart failure (think extra fluid)
pregnancy (think extra fluid)

Question 8

Thrill

Answer 8

Palpable heart murmur

Question 9

Tactile Fremitus

Answer 9

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.

Question 10

Gynecomastia

Answer 10

Male breast enlargement

Question 11

Beck’s Triad

Answer 11

Characterized by low arterial blood pressure, jugular venous distention, muffled heart sounds, indicating cardiac tamponade

Question 12

Vocal Resonance

Answer 12

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.

Question 13

S1 (Systole)

Answer 13

“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

Question 14

S2 (Diastole)

Answer 14

“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

Question 15

Systolic Murmur Pneumonic
*these are the only ones that radiate
MR. PASS MVP

Answer 15

“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

Question 16

Diastolic Murmur Pneumonic
*these are the bad ones
Diastolic = DOOM = referred out
MS. ARD

Answer 16

“MS. ARD”
Mitral Stenosis
Aortic Regurgitation
Diastolic

Question 17

Mitral Area location

Answer 17

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.

Question 18

Aortic Area location

Answer 18

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.

Question 19

Erb’s Point

Answer 19

Erb’s point is located at the third to fourth ICS on the left sternal border

Question 20

Diastolic Murmurs always indicate

Answer 20

heart disease

Question 21

Grade IV Heart Murmur

Answer 21

Grade IV: A louder murmur. First time that a thrill is present. A thrill is like a “palpable murmur.”

Question 22

Hypertensive Pregnant Mom Medications

Answer 22

New Little Momma
Nifedipine, Labetalol, Methyldopa / Aldomet

Question 23

Hypertension
s/s

Answer 23

• asymptomatic
• headache
• fatigue
• vision changes

Question 24

AHA/ACC Guidelines
Hypertension

Answer 24

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

Question 25

Hypertension Lifestyle Changes

Answer 25

diet exercise smoking cessation sodium restriction

Question 26

Hypertension Medications

Answer 26

ACE-I / ARB Thiazide Diuretics Calcium Channel Blockers

Question 27

HTN with ACE - I: all the - PRILS NO PREGNANT PATIENTS

Answer 27

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

Question 28

HTN with Thiazide Diuretics

Answer 28

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

Question 29

HTN with Calcium Channel Blockers

Answer 29

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

Question 30

HTN microvascular - all the "-opathies"

Answer 30

retinopathy nephropathy neuropathy

Question 31

HTN macrovascular

Answer 31

Myocardial Infarctions stroke heart failure

Question 32

HTN screening

Answer 32

- 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

Question 33

Hyperlipidemia high cholesterol

Answer 33

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

Question 34

Hyperlipidemia Screening & lipid panel checks

Answer 34

- screen every 5 years, unless - 1-3 months adjusting medications - yearly once stable

Question 35

Hyperlipidemia high cholesterol with -STATINs...we treat 4 groups

Answer 35

1. primary prevention (high ASCVD risk) 2. secondary prevention (cardiovascular event already) 3. LDL > 190 4. Patients with diabetes - ages 40-75 (can initiate earlier with sign. risk factors) - initiate regardless of ASCVD score Baseline liver function before prescribing

Question 36

Hyperlipidemia Atherosclerotic Cardiovascular Disease - ASCVD risk calculator cut off for meds

Answer 36

cut off to start medical management for hyperlipidemia is 7.5%

Question 37

Low Intensity Statin - no grapefruit juice

Answer 37

pravastatin (Provochol) simvastatin (Zocor)

Question 38

High Intensity Statin - no grapefruit juice

Answer 38

Atorvastatin (Lipitor) 80 mg Rosuvastatin (Crestor) 20-40 mg

Question 39

Main concerns with Statins

Answer 39

- jaundice - drug induced hepatitis check LFTs - rhabdomylosis (new muscle pain), check Ck/Cr levels, potential to lead to acute renal failure

Question 40

Medication for high triglycerides

Answer 40

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

Question 41

Hyperlipidemia is high signs - 2 things

Answer 41

1. Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous. 2. Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol

Answer 42

Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.

Question 43

Supplement for the Heart

Answer 43

CoQ10 or Co Enzyme 10

Question 44

Respiratory Sinus Arrhythmia

Answer 44

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

Question 45

Pulsus paradoxus - cardiac tamponade - status asthmaticus

Answer 45

fall in a patient's blood pressure during inspiration by greater than 10 mm Hg = medical emergencies 1. 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 2. status asthmaticus extreme form of asthma exacerbation characterized by hypoxemia, hypercarbia, and secondary respiratory failure

Question 46

Heart Failure Diagnostics

Answer 46

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%

Question 47

Heart Failure Meds

Answer 47

1. diuretic - do not gain more than 2 kg per day 2. HTN meds 3. ACE & beta blockers - good for HTN/DM/HF 4. S3 heart sound (kentucky) with fluid overload, also heard in pregnancy - stay away from TZDs and CCB - avoid NSAIDs

Question 48

Atrial Fibrillation

Answer 48

- high risk for clots - prescribe anticoagulants - absent p wave - irregular QRS - beta blockers for rhythm control

Question 49

Warfarin / Coumadin

Answer 49

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

Question 50

Hyperlipdemia is high - seen on face

Answer 50

Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.

Question 50

Hyperlipidemia is high - seen on eye

Answer 50

Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol

Question 51

Raynaud's Phenomenon What is it? What is a treatment?

Answer 51

- 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

Question 52

Heart Valve Order Pneumonic All People Take Money

Answer 52

All People Take Money Aortic Pulmonic Tricuspid Mitral

Question 53

Where do the systolic murmurs radiate to?

Answer 53

Mitral Regurgitation - radiates to armpit Aortic Stenosis - radiates to neck Mitral Valve Prolapse - rare

Question 54

Hyperlipidemia is high - seen on eye

Answer 54

Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol

Question 54

Heart Valve Order Pneumonic All People Take Money

Answer 54

All People Take Money Aortic Pulmonic Tricuspid Mitral

Question 54

Hyperlipdemia is high - seen on face

Answer 54

Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.

Question 54

Where do the systolic murmurs radiate to?

Answer 54

- 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

Question 55

Hyperlipidemia is high - seen on eye

Answer 55

Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol

Question 55

Heart Valve Order Pneumonic All People Take Money

Answer 55

All People Take Money Aortic Pulmonic Tricuspid Mitral

Question 56

Peripheral Arterial Disease (PAD) What is it? s/s Diagnosis? risk factor

Answer 56

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

Question 56

Hyperlipdemia is high - seen on face

Answer 56

Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.

Question 56

Where do the systolic murmurs radiate to?

Answer 56

- 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

Question 57

Chronic Venous Insufficiency What is it? Diagnosis? At risk for?

Answer 57

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.

Question 58

Hypertension - JNC 8

Answer 58

Persons older than 60 y.o. should have a BP goal less than 150/90.

Question 59

Where do the systolic murmurs radiate to?

Answer 59

- 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

Question 59

Hyperlipdemia is high - seen on face

Answer 59

Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.

Question 59

Heart Valve Order Pneumonic All People Take Money

Answer 59

All People Take Money Aortic Pulmonic Tricuspid Mitral

Question 59

Hypertension - JNC 8

Answer 59

Persons older than 60 y.o. should have a BP goal less than 150/90.

Question 59

Hyperlipidemia is high - seen on eye

Answer 59

Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol

Question 60

Where do the systolic murmurs radiate to?

Answer 60

- 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

Question 60

Hyperlipidemia is high - seen on eye

Answer 60

Arcus Senilis: white, light grey, or blueish ring around the edge of the cornea made of fatty substances (called lipids), mostly cholesterol

Question 60

Hypertension - JNC 8

Answer 60

Persons older than 60 y.o. should have a BP goal less than 150/90.

Question 60

Heart Valve Order Pneumonic All People Take Money

Answer 60

All People Take Money Aortic Pulmonic Tricuspid Mitral

Question 61

Hyperlipdemia is high - seen on face

Answer 61

Xanthelasma: yellowish plaques that occur most commonly near the inner canthus of the eyelids, that is soft, semisolid, or calcareous.