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foundations of clinical medicine > Cardiovascular part 1 > Flashcards

Cardiovascular part 1 Flashcards

1
Q

What is an auscultatory gap?

A

An auscultatory gap is when the phase 1 Korotkoff sounds normally appear at systolic pressure but then disappear for varying lengths of time before they reappear above the diastolic pressure

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2
Q

What percentage of people have an auscultatory gap?

A

20% of the elderly.

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3
Q

what is the significance of an auscultatory gap?

A

This is important because inflation of the cuff only to the initial disappearance of sounds (i.e., the auscultatory gap) significantly underestimates the true systolic blood pressure.

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4
Q

how do we detect an auscultatory gap?

A

Palpating the loss of the radial pulse before using the stethoscope is essential to detecting this gap, and careful auscultation in such patients will reveal the return of sounds, allowing accurate pressure determinations.

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5
Q

what do those with auscultatory gaps generally have?

A

patients with auscultatory gaps have twice as much arterial atherosclerotic plaque as those without a gap,

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6
Q

what does atherosclerotic plaque generally suggest in those with auscultatory gaps?

A

suggesting perhaps that the gap is somehow related to arterial stiffness

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7
Q

what also seems to promote auscultatory gaps?

A

Venous congestion also seems to promote auscultatory gaps because slow cuff inflation (which increases venous congestion) sometimes makes auscultatory gaps appear and elevation of the arm before inflating the cuff makes them disappear.

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8
Q

what does excessive pressure with the stethoscope do?

A

artificially lowers the diastolic reading, sometimes by 10 mm Hg or more, although the systolic reading is usually unaffected. This error occurs because the total tissue pressure around the artery, that causes it to collapse, represents the sum of both cuff and stethoscope pressure. If the clinician applies 10 mm Hg of stethoscope pressure to the arm of a patient whose intra-arterial diastolic pressure is 80 mm Hg, the diastolic reading will be 70 mm Hg

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9
Q

where is the recommended level of the arm when taking blood pressure?

A

The recommended position of the patient’s elbow is the “level of the heart,” around the fourth intercostal space at the sternum.

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10
Q

what happens if the level of the arm is 6 to 7 cm higher?

A

If the patient’s arm is instead 6 to 7 cm higher (e.g., at the level of the sternomanubrial junction), both the systolic and diastolic readings will be about 5 mm Hg lower.

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11
Q

What happens if the patient’s arm is 7-8 cm lower?

A

If the arm is 7 to 8 cm lower (e.g., at the level of the xiphisternum junction), the pressures will be about 6 mm Hg higher.

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12
Q

What is the ideal blood pressure?

A
  • the pressure which adequately perfuses all the organ systems without causing damage.
  • The minimum acceptable blood pressure allows adequate perfusion of the vital organs without symptoms of hypotension. This is usually more than 90 mm Hg systolic and 60 mm Hg diastolic, although there can be great variation between patients
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13
Q

what is hypotension?

A
  • low blood pressure.
  • (<90/60 mm Hg)
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14
Q

what are the clinical manifestations of low blood pressure?

A

Clinical manifestations of low blood pressure can include fatigue, shortness of breath on exertion, and light-headedness especially on assuming an upright posture.

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15
Q

what are the two most common causes of low blood pressure?

A
  1. dehydration.
  2. decreased cardiac output.
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16
Q

in patients with acute illness and a systolic BP of <90 what is predicted?

A
  • death in those in intensive care units, bacteremia and pneumonia.
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17
Q

what is predicted in those with asystolic BP <80mmHg?

A

predicts death in those with myocardial infarction.

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18
Q

What does the APACHE (Acute physiology and chronic health evaluation) do for those with hypotension?

A
  • assigns more points to severe hypotension than to any other vital sign or laboratory variable.
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19
Q

in those with myocardial infarction with a systolic BP <80mmHg what adverse outcomes are predicted?

A
  • a much higher incidence of congestive heart failure, ventricular tachycardia and fibrillation, and complete heart block.
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20
Q

in hospitalized patients what does hypotension increase the risk of?

A

increases the risk of serious adverse outcomes in the next 24 hours (≤90 mm Hg, LR+ 4.7; ≤85 mm Hg, LR+ 9; ≤80 mm Hg, LR+ 16.7)

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21
Q

what is hypertension?

A

high blood pressure.

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22
Q

what is stage 1 HBP?

A

SBP= 130-139 mmHg.
DBP= 80-89 mmHg.

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23
Q

what is stage 11 HBP?

A

SBP= >/= 140 mmHg.
DBP= >/= 90 mmHg.

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24
Q

what is a hypertensive crisis?

A

SBP = >/= 180 mmHg
DBP= >/= 120 mmHg.

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25
Q

Why should blood pressure be taken in every person even if they are asymptomatic?

A

because essential hypertension is common and treatable and because treatment reduces cardiovascular morbidity and overall mortality rates.

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26
Q

what is the average difference in SBP between arms?

A

6-10 mmHg

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27
Q

what does a difference of 20 mmHg or more between arms indicate?

A
  • obstructive flow in the subclavian artery leading to lower pressure in one arm.
  • significant finding in subclavian steal syndrome and aortic dissection.
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28
Q

what does subclavian steal syndrome present as?

A
  • patient presentation: one weak radial pulse with symptoms of vertebrobasilar ischemia (episodic vertigo, visual complaints, hemiparesis, ataxia, or diplopia).
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29
Q

what does aortic dissection present as?

A

patient presentation of acute chest pain

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30
Q

when is finding the difference between arm and leg pressure valuable?

A
  • Chronic Ischemia of the Lower Extremities and Coarctation of the Aorta
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31
Q

What percentage of patients with Chronic Ischemia of the Lower Extremities and Coarctation of the Aorta has a blood pressure of >140/90 mmHg?

A

96%.

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32
Q

what is associated with patients with Ischemia of the Lower Extremities and Coarctation of the Aorta?

A
  • where in young hypertensive patients, it is hard to obtain blood pressure in the legs or blood pressure that is much lower in the legs than the arms, with hypertension of the arms.
  • femoral pulses that are absent or diminished and delayed (100%)
  • augmented carotid pulsations.
  • various murmurs. (usually a systolic murmur at the sternal border and a continuous murmur posteriorly over the upper spine).
  • visible collateral arteries (usually around the scapula, intercostal spaces, or axilla).
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33
Q

why is temperature tightly regulated?

A

to maintain normal cellular function of vital organs, especially the brain.

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34
Q

When does body temperature produce life-threatening cellular dysfunction?

A
  • Deviation of temperature by more than 4oC above or below normal.
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35
Q

what is fever a fundamental sign of?

A
  • of almost all infectious diseases and many non-infectious disorders.
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36
Q

where can we measure bodily temperature with a thermometer?

A

the patient’s oral cavity, rectum, axilla, tympanic membrane, or forehead (i.e., temporal artery).

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37
Q

which thermometer produces more rapid results than a mercury thermometer?

A

infrared.

38
Q

What are mercury thermometers used to measure?

A

oral, rectal, and axillary measurements

39
Q

what are infrared thermometers used to measure?

A

tympanic or forehead measurements

40
Q

convert these common measurements from Celcius to Fahrenheit;

A

35 C= 95 F
37 C= 98.6 F
40 C= 104 F

41
Q

How do we take the oral temperature using a glass thermometer?

A
  • When using a glass thermometer shake the thermometer down to 350C (96oF) or below, insert it under the tongue, instruct the patient toe close both lips and wait 3-5 minutes. Read the thermometer, reinsert it for a minute and read it again – repeat if the temperature is still rising. Generally, it is better to use an electronic thermometer.
42
Q

How do we take oral temperature using an electronic thermometer?

A

Electronic thermometers – carefully place the disposable cover over the probe and insert the thermometer under the tongue. Ask the patient to close both lips and watch closely for the digital readout. An accurate temperature recording takes about 10 seconds.

43
Q

How do we take tympanic membrane temperature?

A
  • Make sure the external auditory canal is free of cerumen which lowers temperature readings.
  • Position the probe in the canal so that the infrared beam is aimed at the tympanic membrane (otherwise the measurement will be invalid). Wait 2-3 seconds until the digital temperature reading appears. Remove the thermometer and discard the coverslip.
44
Q

does normal body temperature vary depending on the site being measured?

A

yes- this range varies from 36-37.5 C (96.5-99.5F)

45
Q

what is the highest temperature?

A

Rectal readings on average are the highest (about 0.3-0.7oC (0.6-0.9oF)

46
Q

what temperatures are generally the lowest?

A

axillary ones the lowest (about 0.5oC (1.0oF) lower than oral temperature) but take 5-10 minutes to register and are generally considered less accurate than other measurements.

47
Q

What is the most ideal temperature?

A

Tympanic measurements are potentially ideal because they are rapid, convenient, and theoretically best reflect core temperature.

48
Q

What is the core temperature?

A

The core temperature is the temperature of the hypothalamus, which is supplied by the same artery as the tympanic membrane.

49
Q

How much higher is tympanic measurement than oral?

A

approximately 0.8oC (1.4oF) and can be more variable including right and left comparisons in the same person.

50
Q

what do we know about forehead temperature?

A

There is little information on normal forehead measurements in adults and forehead temperature has not been found to be an accurate representation of the standard core temperature.

51
Q

how many variables affect temperature measurment?

A

7.

52
Q

How does eating affect temperature?

A
  • The oral temperature measurement increases about 0.3° C after sustained chewing and stays elevated for up to 20 minutes, likely due to increased blood flow to the muscles of mastication. Drinking hot liquids also increases oral readings by about 0.6° to 0.9° C, for up to 15 to 25 minutes.
  • Drinking ice water causes the oral reading to fall 0.2° to 1.2° C, a reduction lasting about 10 to 15 minutes.
53
Q

How does smoking affect temperature?

A

smoking a cigarette increases oral readings by about 0.2° C for 30 minutes.

54
Q

How does tachypnea (rapid and shallow breathing) influence temperature?

A

Tachypnea reduces the oral temperature reading by about 0.5° C for every 10 breaths/min increase in the respiratory rate.

55
Q

how does cerumen (earwax) influence temperature?

A

Cerumen lowers tympanic temperature readings, simply because it obstructs radiation of heat from the tympanic membrane.

56
Q

How does hemiparesis (weakness) influence temperature?

A
  • In patients with hemiparesis, axillary temperature readings are about 0.5° C lower on the weak side compared with the healthy side which may be attributed to differences in cutaneous blood flow between the two sides.
57
Q

what is the mean oral temperature of a healthy person?

A

oral temperature is 36.5° C (97.7° F).

58
Q

when is the temperature the highest and lowest?

A

There is a diurnal variation where the temperature is usually lowest at 6 am and highest at 4 pm to 6 pm.

59
Q

What is fever defined as?

A
  • Fever is defined as an oral temperature greater than 37.7° C (99.9° F) and a measurement of a temperature of more than 37.8° C (>100° F) at any site.
  • however, a minimum temperature is difficult to define; the oral temperature may drop to 35.0oC (95.0oF) during sleep.
60
Q

are some individuals unable to mount a febrile response to infection?

A
  • Some patients are unable to mount a febrile response to infection, for example, elderly patients and those with renal failure.
61
Q

How is the arterial pulse generated?

A

The arterial pulse is generated by left ventricular systolic contraction ejecting blood into the arterial tree. The pulse wave travels along the arteries at a rate dependent upon the force of ejection and the elastic properties of the arterial wall. The regularity of the pulse wave is determined by the rhythm of cardiac electrical depolarization and subsequent contraction.

62
Q

what three regions is pulse generally taken from?

A
  • radial, brachial and coratid.
63
Q

What is the radial pulse used for?

A
  • commonly used to assess the heart rate
64
Q

what is the carotid pulse used for?

A

carotid pulse most accurately reflects the contour of the aortic pulse wave.

65
Q

what is step 1 of taking a pulse?

A
  1. Apply light pressure along the radial artery with the pads of your index and middle fingers, or the wrist may be encircled by the fingers and hand
66
Q

what is step 1a. of taking a pulse?

A

Compress the radial artery until a maximal pulsation is detected

67
Q

what is step 1b of taking a pulse?

A

If the rhythm is regular and the rate seems normal, count the rate for 30 seconds and multiply by 2. You may also count up to 15 seconds and multiply by 4, however counting less than 15 seconds will provide an incorrect pulse rate.

68
Q

what to do if the rate is unusually fast or slow?

A

then count the beats for 60 seconds.

69
Q

what is the normal pulse rate?

A

60-90 beats/minute

70
Q

what is step 1c. of taking pulse rate?

A

Identify if the rhythm is regular or irregular.

   i.     If irregular, try to identify a pattern – do the early beats appear in a regular rhythm? Does the irregularity vary consistently with respiration? Is the rhythm totally irregular?
71
Q

if the beats that occur earlier and are not detected peripherally, resulting in underestimated heart rate? what can we do to prevent this?

A

check the rhythm again by listening with your stethoscope at the cardiac apex (the point of maximal impulse in the 5th intercostal space on the left side of the chest, at the midaxillary line). The American Heart Association defines the normal sinus heart rate as between 60-100 bpm.

72
Q

what can pulse rate also be taken as part of?

A

Orthostatic/postural vital signs.

73
Q

what is step 2 of taking pulse rate?

A

Try to identify the contour of the pulse wave and its volume, rate, and rhythm. Look for patterns of variability in the pulse volume.

74
Q

What is a normal respiratory rate in adults?

A

At rest the normal respiratory rate in adults is between 12-20 cycles per minute.

75
Q

what is the normal respiratory rate in newborns?

A

In the newborn the rate is about 44, which gradually diminishes until maturity.

76
Q

do men or women have higher RR?

A

women.

77
Q

what is step one of taking RR?

A
  1. In alert patients try to count the respiratory rate without directing attention to their breathing.
78
Q

what is step 2 of taking RR?

A
  1. Stand to the side of the patient and place one hand on the patient’s shoulder. This will allow you to feel the movement of the chest while observing the patient’s respiration
79
Q

what do you want to avoid when taking RR?

A

Avoid staring at the patient’s chest directly because it is generally uncomfortable for the patient, and this may make the patient conscious of their breathing and change their pattern.

80
Q

what is step 3 of taking RR?

A
  1. Observe the rate, rhythm, depth, and effort of breathing.
81
Q

what is step 4 of taking RR?

A
  1. Count the number of respirations in 1 minute. If the rate/rhythm/depth is regular, you can count to 15 seconds and multiply by 4.
82
Q

What is step 5 of taking RR?

A
  1. If the rate is unusually fast or slow, then count the breaths for 60 seconds.
83
Q

what is tachypnea?

A
  • An increase in respiratory rate occurs with central nervous system stimulation and as compensation for respiration problems.
84
Q

what does tachypnea occur with?

A

occurs with exertion, fear, cardiac insufficiency, pain, pulmonary embolism, acute respiratory distress from infections, pleurisy anemia and hyperthyroidism

85
Q

what is bradypnea?

A

Decreased respiratory rate

86
Q

what does bradypnea occur with?

A
  • Occurs with hypothyroidism, respiratory failure, medication and drug use, or brain injuries
87
Q

what is Kussmaul’s breathing (hyperpnea)?

A

respirations are a deep, sighing respiratory pattern

88
Q

why does hyperpnea occur?

A
  • occurs due to increased tidal volume with or without an increased respiratory rate and is a form of hyperventilation that can be seen with any disorder that causes significant acidosis such as uncontrolled diabetes, and toxic ingestion, particularly alcohol.
89
Q

what is Cheyne-Stokes breathing?

A

A pattern of crescendo-decrescendo respirations followed by a period of apnea

90
Q

what does Cheyne-Stoke occur in?

A
  • occurs in patients with heart failure, usually while asleep
91
Q

Can pulse rate and RR be taken at the same time?

A

yes.

foundations of clinical medicine (8 decks)

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