Exam 2 Flashcards
Connective tissue of vessel
Tunica adventitia
Smooth muscle of vessel
Tunica media
Endothelium of vessel
Tunica intima
Put risk factors in…
HPI
Pregnant women’s blood pressure…..during pregnancy
Decreases
Unilateral edema is from…
Peripheral vascular disease
Bilateral edema is…
From the heart
Normal reperfusion for capillary refill is…
Less than 2 seconds
Carotid pulse point
60-70
Radial pulse point
> 80
Femoral pulse point
70-80
Pulses paradoxus
Decrease in SBP and pulse amplified with inspiration
Pulsus biferiens
Biphasic pulse, double peak
Pulsus parvus et tardus
Pulse is weaker and slower than expected
Pulsus alternans
Alternating strong and weak beats
Diaphragm
High frequency, deep pressure
Bell
Low frequency, light pressure
Allen test
Assess patency of the ulnar artery
What is one of the first symptoms with PAD?
Claudication
Arterial ulcers start out…
In the toes
Ulcers from veins are…
Usually in ankles
Arterial occlusion 3 p’s
Pain/paresthesias
Pallor
Pulselessness
Claudication
Walking Cramp/ache/pain Unilateral Constant Atherosclerosis Relief: stop activity/stand still
Pseudoclaudication
Walking or standing Parasthetic pain Bilateral Variable (not constant) Spinal stenosis/herniated disc Relief: sit down/lay down
Debakey 1
60%
Debakey 2
10-15%
Debakey 3
25-30%
Stanford A
Proximal
Stanford B
Distal
Quincke’s pulse
Blanching and flushing of the nail bed related to aortic insufficiency
Change in blanching and flushing is in conjunction with the cardiac cycle
Varicose veins
Dilation of vessel due to incompetent valves, collateral circulation developed, most easy to detect while patient is standing
Preeclampsia
>40 Primagravida Obese Multigestational Hx of HTN or gestational HTN Renal disease/DM
Arterial insufficiency
Pallor with elevation Rumor Intermitten claudication Diminished/absent pulses Thin, shiny, loss of hair Ulceration on toes
Venous insufficiency
No pain Normal pulses Edema Normal color/cyanosis/brown Ulceration medial ankles
Lipodermatosclerosis
Thick skin and fibrotic due to WBC trapped in capillaries from chronic venous insufficiency
Stage 1 mild venous insufficiency
18-22 pressure, mild discomfort, ankle swelling
Stage 2 moderate venous insufficiency
20-30 pressure, hyperpigmentation, edemas
Stage 3 severe chronic venous insufficiency
> 40 pressure, chronic pain, non healing ulceration
Virchow’s triad
Hypercoagulability
Abnormalities
Stasis
PE classic triad
Dyspnea
Chest pain
Hemoptysis
Thromboangiitis obliterans
Arterial obstruction in the upper extremity
20-40
Emboli
Diminished or absent pulses at the wrists
Temporal arteritis
50+ years
Temporal headache, visual disturbances, claudication
Kawasaki disease
Acute vasculitic illness
Males>females
Coronary artery aneurysms complication
Strawberry tongue
Coarctation of the aorta
Narrowing of the aorta distal to the L subclavian artery
Men>women
Disparity in pulses in upper and lower extremities
Severe HTN!
Subclavian steal syndrome
Subclavian artery stenosis
BP differences in arms
Syncope/presyncope
Neuro
Vascular thoracic outlet syndrome
Compression of arteries at clavicle
Arterial or venous
Young active people
Numbness/tingling, arm/hand fatigue, edema, color changes, diminished pulse
Non modifiable risk factors
Age
Family history
Metabolic syndrome
2 out of 5 of the following: Abdominal obesity Triglycerides >150 HDL men <40, women <50 HTN >130/88 Glucose >100
Pericarditis
Inflammation of the pericardium
2-4 days post MI
Worse with deep inspiration
Dressler syndrome
2-10 weeks postinfarct, chest pain, pleuropericarditis, fever
Viral pericarditis MCC
Coxsackie B virus in young adults
Cardiac tamponade
Pulsus paradoxus 75% Impending doom Tachycardia *muffled heart tones Friction rub
Beck’s triad
JVD
Hypotension
Muffled heart sounds
Seen in cardiac tamponade
Cullen’s sign
Peri umbilical cyanosis
AAA
Grey-turner’s sign
Flank cyanosis
AAA
Janeway lesions
Palms of soles, crop up every few hours to daysa
Osler nodes
Painful blue or pink lesions on pads of fingers or toes
Valsalva maneuver
Forced expiration through closed airway, high intrathoracic pressure impeding venous return to the right atria
Aortic area
2nd right intercostal space, right sternal border
Pulmonic area
2nd left intercostal space, left sternal border
2nd pulmonic area
3rd left intercostal space, left sternal border
Tricuspid area
4th and 5th left intercostal space, left sternal border
Apex/mitral area
5th left intercostal space in medial clavicular line
A wave
Right atrial contraction
If absent, a fib
C wave
Closure of tricuspid valve
v wave
Venous filling
Increasing volume and increasing pressure in right atrium
X descent
Low atrial pressure just before passive atrial filling
Y descent
Decrease in pressure after tricuspid valve opens and blood moves from right atria to right ventricle
Absent- tamponade
Increased JVD
Severe right sided ADCHF
Hepatojugular reflux
Tests for right sided heart failure
Describing when auscultating
Timing
Location
Intensity
Pattern/configuration
S1
Closure of AV valves
Ventricular systole
Loudest at apex
S2
Closure of AV and PV valves
Ventricular diastole/relaxation
Loudest at base
Paradoxical split
Appears with expiration
*pathology
Anything that delays closure of aortic valve
Physiological split
Appears with inspiration
*normal
Heard best at base
S3
Early diastole
Over 40, consider LV failure
Best at apex LLD
S4
Presystole
Best at apex
Special test for aortic regurgitation
Pt leans forward, exhales, stops breathing on exhalation
Auscultating along LSB and apex with the diaphragm
Jugular venous distension
Measures estimated right atrial pressures
Hepatojugular reflux
Aids in diagnosing peripheral congestion in CHF
Standing/valsalva
Decrease LV volume
Decrease vascular tone
Squatting
Increase LV volume
Increase vascular tone
Normal central venous pressure in JVD
<9
What is the best location to hear mitral murmurs?
Apex
What is the best location to hear tricuspid murmurs?
LLSB
What is the best location to hear aortic/pulmonic murmurs?
Base
Where does mitral regurgitation radiate?
Axilla
Where does aortic stenosis radiate?
Carotids and down sternal border
High pitch murmurs
MR and AR
Medium pitch murmurs
AS and PS
Low pitch murmurs
MS and TS
What murmurs are blowing?
MR/AR/TR
What murmurs are coarse/harsh?
AS/VSD/ASD
What murmurs are rumbling?
MS and austin flint murmur of AR
What murmurs are machine like?
PDA
What murmurs are intensified with inspiration?
Right sided murmurs (tricuspid stenosis/regurgitation)
What murmurs are intensified with expiration?
Left sided murmurs (mitral stenosis/regurgitation)
Common characteristics of still/innocent murmurs
Usually midsystolic, 1 or 2 grade, young patients, no radiation, brief and blowing, located in the second left intercostal space near left sternal borer
Systolic murmurs
Aortic and pulmonic stenosis
Mitral and tricuspid regurgitation
Murmurs of ventricular and atrial septal defects
Hypertrophic cardiomyopathy
Aortic stenosis murmur
Midsystolic Crescendo/decrescendo Medium pitch Coarse/harsh Ejection sound after S1 Radiates to carotids
Mitral regurgitation murmur
Best heard at apex, transmits to left axilla Holosystolic Plateau Loud High pitch Blowing
Mitral valve prolapse
Late systolic
Apex and left lower sternal border
*easily missed in supine position
Midsystolic click**
Systolic clicks
Usually secondary to mitral valve prolapse
Mid to late systole, heard best at apex
Change position with physical maneuvers
Ejection sounds
Usually AS/PS associated
Heard at base with expiration
Do not change with positional changes
Pulmonic stenosis
Crescendo decrescendo Ejection sound Coarse/harsh Medium pitch Fills systole Radiates to carotids Palpable thrill
Tricuspid regurgitation
Holosystolic Lower left sternal border Blowing Increase on inspiration Widely split S2 and distended jugular veins
Hypertrophic cardiomyopathy
Crescendo decrescendo systolic Harsh Lower left sternal border Bifid carotid pulse Does not radiate to carotids
Ventral septal defect murmur
Holosystolic Very loud High pitch Harsh/coarse Thrill or left on LSB
Most common pathologic murmur in children
Atrial septal defect murmur
Systolic Loud, harsh, high pitched Pulmonic area Wide fixed s2 splitting Rumbling, early diastolic murmur
Diastolic murmurs
Mitral and tricuspid stenosis
Aortic and pulmonic regurgitation
ASD early diastolic rumbling
Mitral stenosis
Heard best at apex LLD
Low pitch rumble
Does not radiate
Opening snap after s2
Tricuspid stenosis
LLSB Mid-late low pitch rumble Louder on inspiration S1 split Jugular venous pulse is prominent (right side of heart)
Aortic insufficiency/regurgitation
Best at LSB with patient sitting forward and exhaling Early diastolic Decrescendo Soft High pitch Blowing Water hammer/corrigan pulse Austin flint M Ejection sound at base
Patent ductus arteriosis murmur
Loudest in late systole, has a loud and harsh machine like quality
Pericardial friction rub
Scratchy, rubbing sound like a rocking chair “to and fro”
Venous hum
Low pitch, low intensity, heard best in supraclavicular fossa
Intensified if patient sits or stands
Pregnant women heart sound change
Audible s1 and s2 splitting
S3 at 20 weeks of gestation
Systolic ejection murmurs in pulmonic area in 90% of pregnant women
Cyanotic congenital heart defects
5 T’s
Tetralogy of fallot Transposition of great arteries Truncus arteriosus Total anomalous pulmonary venous return Tricuspid atresia
Acyanotic congenital heart defects
ASD VSD PDA Coarctation Aortic stenosis Pulmonic stenosis
Transposition of great vessels
Significant cyanosis, not compatible with life without immediate intervention
Tetralogy of fallot
Pulmonary stenosis
Thickened right ventricle wall
Ventricular septal defect
Aorta overrides septal defect
Cor pulmonale
Enlargement of right ventricle secondary to pulmonary malfunction
Crackles, left parasternal systolic heave
Acute rheumatic fever
Connective tissue disease from strep pharyngitis or skin infection
Jones criteria
Stenotic and regurgitant, mitral or aortic regurgitant
Friction rub
Kawasaki disease
Inflammation of walls in medium sized arteries
Common issue is coronary artery aneurysm
Pectins excavatum
Depression in sternum
Pectus carinatum
Outward pointing of the chest wall
Flail chest
Paradoxical breathing
Tachypnea
Fast and shallow breathing
Hyperventilation
Fast and deep breathing
Tactile fremitus
“99”
Decreased- increased air
Increased- consolidation or fluid
Tracheal position toward affected side
Atelectasis, fibrosis, pneumo
Tracheal position away from affected side
Tension pneumo, enlarged thyroid
Crepitus
Crackly or crinkling sensation, air in subcutaneous tissue
Vesicular sounds
Low pitched, low intensity over healthy lung tissue
Bronchovesicular sounds
Over major bronchi, moderate in pitch and intensity
Bronchial sounds
Highest in pitch and intensity, only over the trachea
Amphoric breath sounds
Blowing over the mouth of a bottle
Stiff walled pulmonary cavity
Cavernous breath sound
Hollow, rigid pulmonary wall
Crackles aka rales
Discontinuous sounds
Fine- high pitched, short
Medium- lower, mid stage of inspiration
Coarse- low pitched, long in duration
Rhonchi
Deeper, rumbling
Pronounced during inspiration
Due to passage of air through obstructed airway
Wheezes
Continuous, high pitched musical sounds
Narrowed or obstructed airway (asthma)
Friction rub breath sound
Outside respiratory tree
Dry, crackly, grating, low pitched sound
Inflamed, roughened surfaces rubbing together, pleurisy
Mediastinal crunch (ham man sign)
Mediastinal emphysema
Loud crackles, clicking and gurgling
Synchronous with heartbeat
Bronchophony
Greater clarity and increased loudness of spoken sounds
Whispered pectoriloquy
Extreme bronchophony where even a whisper is clearly heard
Specific for consolidation
Egophony
E’s become a’s
Infants in respiratory exam
Do not percuss
Listen to crying babies when taking a deep breath in
Stridor
High pitched, piercing sound most often during inspiration due to obstruction high in respiratory tree
Respiratory grunting
Expel trapped air/fetal lung fluid
Peripartum cardiomyopathy
9/10th month pregnancy within 5 months post partum, start having heart failure symptoms
SOB, edema, abnormal weight gain
Asthma
Small airways obstruction due to inflammation and hyperreative airways
Worse at night and in the cold
Wheezing, chest tightness, cough
Pleurisy
Very painful, wont take a deep breath in, inflammatory process with visceral and parietal pleura
Pneumonia
Most common cause of consolidation
Cough, fever, dyspnea, chest pain, rigors, sputum, tachypnea, tachycardia, rales/ronchi
Egophony, whispered pect.
Tuberculosis
Upper lobe, coug with blood streaked sputum
Bronchiolitis
Bronciolar inflammating leading to hyperinflation of the lungs, most infants younger than 6 months
Croup
Viral, 1.5 to 3 years
Stridor, barking cough, wheeze
Cystic fibrosis
Cough and sputum less than 5 years old
Emphysema
Alveoli enlarge, barrel chested, non productive cough, smoking hx, overinflated and hyperresonate
Chronic bronchitis
Large airway inflammation, chronic irritant exposure
Cough and sputum, recurrent bacterial infection
Patients older than 40
Bronchiectasis
Chronic dilation of bronchi or bronchioles caused by repeated pulmonary infections and bronchial obstruction
