CMR wk 2 Flashcards
what sign does clubbing look for?
Schamroth’s sign (diamond window between touching posterior fingers) = no clubbing if present
what can cause clubbing
-chronic low O2
-disease not related to O2 (IBD, cirrhosis)
how to inspect for peripheral cyanosis
hands/toes distally, blue discoloration
causes of peripheral cyanosis
-cold
-poor circulation
-sepsis
-COPD
-DVT
-PVD
-Raynaud’s
how to inspect for central cyanosis
inner mucous membranes of mouth + inner eyelids, blue discoloration (can be entire body)
what happens in the blood during central cyanosis
deoxyhemoglobin (deoxy Hb) increases in blood
deoxy Hb = hemoglobin with no oxygen
-normal oxygenated blood has <80-85% oxygenated blood
what is hair loss in LE concerning for
PAD (peripheral artery disease)
symptoms of chronic venous insufficiency in LE
-ankle swelling
-flaking/itchy skin
-stasis ulcers
-skin color xs
-friable skin
PE findings for chronic venous insufficiency in LE
-edema
-skin pigmentation (brown/red)
-varicosities
causes of chronic venous insufficiency in LE
-smoking
-lack of exercise
-obesity
-aging
-female
-DVTs
chronic venous insufficiency in LE can lead to
venous stasis ulcers
why does distal extremity muscle atrophy occur
can be from CHF causing muscle loss from degeneration + lack of use
distal extremity muscle atrophy can lead to
cachexia (loss of body fat, muscle, bone)
2 types of lesions and where they occur
Janeway lesions (non-tender) on palms/soles
Osler’s nodes (tender) on palms/soles
what are Janeway lesions and Osler’s nodes concerning for
infective endocarditis (valve infections)
nail changes that occur with PAD
hypertrophic, brittle nails
why do you test capillary refill
check state of peripheral perfusion
when do you test capillary refill
with dyspnea, cold extremities, cyanosis
how to test capillary refill
-squeeze distal fingertip + blanch nailbed
-normal if pink returns < 2 sec.
where does fluid accumulate with edema
interstitial space
4 questions to ask about edema
-Chronic / acute
-Unilateral / bilateral
-Painful ?
-Pitting ?
when do you test for edema
leg pain / swelling
how do you test for edema
push on distal anterior medial tibia b/l (on bone) for > 5 sec.
depression stays > 10 sec. = pitting present
what should you rule out if pitting edema present
DVT
CHF
nephrotic syndrome
grading pitting edema
+1 (2mm, mild)
+2 (4mm)
+3 (6mm)
+4 (8mm, severe)
what does JVP+/JVD indicate
edema, CHF (volume overload)
low JVP best seen in what pt position
supine
high JVP best seen in what pt position
90 degrees (sitting upright)
steps to find JVP
-raise pt’s head 30-45 degrees
-pt turns head to left
-use a light, find right IJV + EJV pulsations (flutters) [top of IJV pulsation = meniscus]
-place ruler upright on sternal angle
-make 90 degree angle with ruler and straight edge to the meniscus
central venous pressure/JVP = ruler measurement + 5 cm
where is right IJV usually located
triangle between SCM muscle + clavicle
where is right EJV usually located
over top of SCM muscle, more superior to IJV
what distance does central venous pressure/JVP measure
right atrium -> chest wall, chest wall -> meniscus
elevated JVP =
> 8 cm above right atrium
or
3 cm above sternal angle
when do you measure ABI (ankle brachial index)
if concerns for PAD
why do you do a neuro exam w cardiac complaint
bc vessel disease can cause vision loss, stroke risk, peripheral neuropathy
what neuro test result do you expect w Acute Limb Ischemia? why?
decreased motor strength + sensation (can indicate acute arterial occlusion present)
OMM results expected with cardiac complaint
TART changes T1-T5
if HTN present, what eye exam do you perform
check optic nerve w fundoscopic exam
why do you check throat if chest pain present
concerned for GERD/acid reflux
what dental disease is a marker for chronic inflammation
gingivitis
why do you check the neck if palpitations present
thyroid exam for goiter/Grave’s disease
what is PAD (peripheral arterial disease) synonymous with
PVD (peripheral vascular disease)
what is PAD
narrowing of blood vessels in extremities, causes less blood flow to musculature relative to its metabolism
risk factors for PAD
-old age
-smoking
-HTN
-male
-HLD
-DM
5 Ps of PAD
-claudication (Pain in legs w walking)
-Pulselessness (in DP or PT pulses)
-Pallor (in distal extremities)
-Paresthesia (numbness) - w severe ischemia
-Paralysis (weakness) - w severe ischemia
Claudia Parks, Partly Pulls Pals
additional symptoms of PAD
-smooth shiny skin
-decreased toenail growth
-cool/numb LE
-non-healing ulcers
-muscle atrophy
what does highest BP between both brachial arteries tell you
non-invasive estimate of BP exiting the heart
how to find ABI
compare highest BP from brachial a. of arm -> to each leg individually
what does ABI tell you
if pathways between heart and respective ankles (arteries) interfere w blood flow
equation to find ABI
systolic BP at ankle of concern
_____(divided by)_____
highest systolic BP from either arm
what can ABI tell you besides diagnose PAD
predicts mortality + adverse cardiac events independent of traditional CV risk factors
who should ABI test
everyone age 70+
everyone age 50+ w hx of DM or smoking
everyone w sxs concerning for PAD
what order should you find systolic BPs of all extremities? why?
- right arm
- right leg
- left leg
- left arm
BP may drift during exam, arm at beginning and end = some quality control
abnormal systolic BP differences between arms + what this means? common in what pts?
> 10 mmHg
subclavian / axillary arterial stenosis, common if at risk for atherosclerosis
ABI result values
< 0.90 = PAD diagnosis
0.90 - 1.40 = normal
> 1.40 = non-compressible, calcified vessel
PAD classifications + outcomes
< 0.5 = severe PAD -> refer to vascular specialist
0.5 - 0.8 = moderate PAD -> refer to vascular specialist
0.8 - 0.9 = mild PAD -> treat risk factors
what is happening during moderate PAD
moderate arterial obstruction + associated claudication
what is happening during severe PAD
-likely multi-vessel disease
-nonhealing ulcerations
-ischemic rest pain
-pedal gangrene
how long should pt rest prior to ankle BP
15-30 min.
define JVP
(jugular venous pressure) in cm H2O
an estimate of right atrial pressure using height of the right IJV (internal jugular vein) in relation to angle of Louis (sternal angle)
define JVD
(jugular venous distension)
when JVP is 3-4 cm above sternal angle with head elevated to 30-45 degrees, or >8 cm total distance above right atrium
what condition does JVP evaluate for
heart failure
elevated right heart pressure is usually caused by what condition
left heart failure
why is the IJV (internal jugular vein) used to determine JVP (jugular venous pressure)
-IJV is more in line w right atrium than EJV
-EJV can be occluded in sicker pts
EJV vs IJV in size, location, route to heart
EJV
-smaller
-superficial
-indirect route, has 2 right angles
IJV
-larger
-deep
-direct
vein pulsations
-movement
-number of pulses / per cardiac cycle
-inspiration effect
-soft + diffuse
-2 pulses / per cardiac cycle
-respirophasic
artery pulsations
-movement
-number of pulses / per cardiac cycle
-inspiration effect
-discrete + robust
-1 pulse / per cardiac cycle
-no change w inspiration
question you’re answering when measuring JVP/checking for JVD
is increased right atrium pressure present?
classic triad of sxs seen with Cardiac Tamponade
JVD
muffled heart sounds
hypotension
components of a CBC
WBC count
WBC differential count
RBC count
Hematocrit (Hct)
Hemoglobin (Hb)
Mean corpuscular volume (MCV)
Mean corpuscular hemoglobin (MCH)
Mean corpuscular hemoglobin concentration (MCHC)
Red cell distribution width (RDW)
Reticulocyte count
Platelet count
define WBC count
number of leukocytes per volume of blood
define WBC differential count
% of different types of WBCs in blood
meaning of + neutrophils in WBC differential count
bacterial infection
meaning of + lymphocytes in WBC differential count
viral infection
inflammation
lymphoma
meaning of + basophils in WBC differential count
allergies
inflammation
meaning of + eosinophils in WBC differential count
allergies
parasites
malignancy
meaning of + monocytes in WBC differential count
chronic / sub-acute infection
leukemia
lymphoma
autoimmune
define RBC count
number of RBCs per volume of blood (these cells carry oxygen to rest of body)
when to test WBC count
infection
physiological stress
when to test RBC count
congenital heart disease
anemia
polycythemia vera
COPD
bone marrow pathology
define Hematocrit (Hct)
% of whole blood occupied by RBCs
when to test Hematocrit (Hct)
CHF
fluid xs
hemorrhage
define Hemoglobin (Hb)
amount of hemoglobin molecules per volume of blood (these cells carry oxygen to rest of body)
when to test Hemoglobin (Hb)
polycythemia vera
smoking
high altitude
menorrhagia
hemorrhage
malignancy
iron deficiency anemia
define Mean corpuscular volume (MCV)
average size of RBCs in blood sample
high MCV =
low MCV =
high MCV = RBCs LARGER than normal
low MCV = RBCs SMALLER than normal
when to test Mean corpuscular volume (MCV)
*FIRST step in anemia workup
define Mean corpuscular hemoglobin (MCH)
amount of hemoglobin per RBC
when to test Mean corpuscular hemoglobin (MCH)
anemia workup
alcoholism
liver pathology
define Mean corpuscular hemoglobin concentration (MCHC)
average hemoglobin concentration per volume of blood, but includes size of RBC
when to test Mean corpuscular hemoglobin concentration (MCHC)
anemia workup (spherocytosis)
define Red cell distribution width (RDW)
range of variation in RBCs size + shape
when to test Red cell distribution width (RDW)
anemia workup (thalassemia)
alcoholism
liver pathology
multiple blood transfusions
define Reticulocyte count
number of immature RBCs per volume of blood
define Platelet count
number of platelets per volume of blood
when to test Reticulocyte count
anemia workup
sickle cell disease
systemic inflammation
malignancy
what question are you answering with Reticulocyte count
if new RBCs are being released into circulation
when to test platelet count
essential thrombocythemia
malignancy
HIV
at what level of Platelet count can spontaneous bruising / bleeding occur
below 20k
what does CBC screen for
anemia
leukemia
what symptoms would you order CBC for
weakness
fatigue
fever
inflammation
infections
bruising / bleeding
what does CBC monitor
blood dyscrasias
HIV
chemotherapy
any treatment that xs blood cell counts
leuko-
white
cyto-
cell
-osis
abnormal process
-penia
lack / deficiency
poly-
many
-emia
blood
thrombo-
lump / clot
if anemia is on a CBC, what lab do you look at next? why?
MCV
to see if it is microcytic, macrocytic, normocytic
3 things pts should not do prior to BP reading
exercise
caffeine
smoking
how is arm positioned during BP reading
antecubital fossa is level with the heart
BP cuff position on arm
2.5 cm above antecubital fossa
bell or diaphragm to take BP
bell
what rate do you deflate BP cuff at
2-3 mmHg / sec
how far apart are 2 high BP readings to make HTN diagnosis? what’s the exception?
a few weeks
exception if hypertensive emergency w BP 180/110 +
what is “gold standard” for measuring out of office BP
ambulatory blood pressure monitoring (ABPM)
draw JNC 7 vs ACC/AHA chart
6 lifestyle modifications from JNC 8 to lower BP
-DASH diet
-weight loss
-reduce sodium < 2.4 gm daily
-30+ min. aerobic exercise almost daily
-alcohol < 2 drinks daily (men), < 1 drink daily (women)
-quit smoking
HTN urgency vs emergency
HTN urgency = 180+/110+
HTN emergency = end stage organ damage
define lipids
a group of fats + fat-like substances
2 important types of lipids
cholesterol + triglycerides
how are lipids transported in the blood
transported by lipoprotein particles
each particle = combination of protein / cholesterol / triglyceride / phospholipid
3 types of lipoproteins
HDL (high-density lipoproteins)
LDL (low-density lipoproteins)
VLDL (very low-density lipoproteins)
2 sources of cholesterol
-produced by body
-diet
where is excess cholesterol deposited in body
becomes plaques on the walls of blood vessels
define atherosclerosis
hardening of the arteries
NCEP III recommendation for lipid panel age
healthy adults: > 20 years of age
ACP + USPSTF recommendation for lipid panel age
healthy adult males: by age 35
healthy adult females: by age 45
lipid panel retesting guidelines
-every 5 years if normal results
-every year if abnormal
should pt fast for lipid panel test
yes, should be fasting
4 lipid parameters in a lipid panel
total cholesterol
LDL
HDL
triglycerides
3 parts total cholesterol is made up of
HDL (good) cholesterol
LDL (bad) cholesterol
triglycerides
main target of interventions for cardiovascular disease
lowering LDL (bad cholesterol) is the goal
total cholesterol
normal
borderline
high
normal: < 200 mg/dL
borderline: 201-240 mg/dL
high: > 240 mg/dL
HDL (good cholesterol)
optimal
normal
low
(higher is better)
optimal: > 60 mg/dL
normal: 40-59 mg/dL
low: < 40 mg/dL
LDL (bad cholesterol)
ideal
normal
borderline high
high
very high
(lower is better)
ideal: < 100 mg/dL
normal: 100-129 mg/dL
borderline high: 130-159 mg/dL
high: 160-189 mg/dL
very high: > 190 mg/dL
triglycerides
normal
borderline
high
very high
(lower is better)
normal: < 150 mg/dL
borderline: 150-199 mg/dL
high: 200-499 mg/dL
very high: > 500 mg/dL
cardiac risk ratio
elevated risk for coronary heart disease
normal risk for coronary heart disease
low risk for coronary heart disease
risk ratio = total cholesterol / HDL
elevated: > 5.0
normal: < 5.0
low: < 3.5
