Exam 2 - cardiovascular Flashcards
Symptoms of peripheral arterial disease
Fatigue, aching, numbness, pain that limits walking or exertion in legs Erectile dysfunction Poorly healing or non healing wounds of legs or feet Pain present when at rest in lower leg or foot and changes when standing or supine Abdominal pain after meals and associated “food fear” and weight loss
What is claudication?
Exertional calf pain relieved by rest
What are the types of claudication? What do they indicate?
1) Vascular - blood flow that cannot match increased demand of muscles in oxygen during walking
2) Neurogenic - narrowing in the spinal canal (stenosis) creates pressure on the spinal nerves
Vascular claudication
Also referred to as intermittent claudication
Pain or cramping in legs during exertion that is relieved by rest within 10 minutes
Neurogenic claudication
Pain with walking or prolonged standing, radiating from spinal area to butt, thighs, lower legs, or feet
What symptoms and exam findings would you expect in peripheral arterial disease?
Fatigue, numbness, cool dry hairless skin, trophic nail changes, diminished to absent pulses, pallor with elevation, ulceration, gangrene
What symptoms and exam findings would you expect in DVT?
Asymmetric calf diameters, painful calf swelling with erythema, distal
What symptoms and exam findings would you expect in thrombophlebitis?
Pain and tenderness along course of superficial vein
Local swelling, redness, warmth; if palpable nodules or cords, consider superficial or DVT Immobility makes it worse; walking makes it better
What symptoms and exam findings would you expect in cellulitis?
Erythema, edema, warmth Involves deeper dermis, adipose tissue; enlarged tender lymph nodes and fever
What symptoms and exam findings would you expect in lymphangitis?
Commonly found on arm/leg
Red streaks on skin with tenderness; enlarged, tender lymph nodes, and fever
What symptoms and exam findings would you expect in compartment syndrome?
Tight, bursting pain in calf muscles, sometimes with overlying dusky red skin
Tingling, burning sensations in calf, muscles feel tight, full; numbness, paralysis if unrelieved
What symptoms and exam findings would you expect in Buerger disease?
Often digit or toe pain progressing to ischemic ulcerations –> may progress to gangrene at tips of digits Migratory phlebitis and tender nodules along blood vessels, usually involves two limbs
What is Buerger disease?
Inflammatory nonartherosclerotic occlusive disease of small to medium sized arteries and veins (esp in smokers)
What symptoms and exam findings would you expect in Raynaud disease?
Effects distal portions of fingers, pain not prominent unless fingertip ulcers develop
Numbness and tingling common
What is Raynaud disease?
Episodic reversible vasoconstriction in fingers and toes
Triggered by cold temperatures
What is Buerger’s disease also referred to as?
Thromboangiitis obliterans
What is the Allen test?
Compares patency of ulnar and radial arteries
Release pressure over ulnar artery; if ulnar artery is patent, palm floss within 3-5 seconds
What does a negative Allen test indicate?
Patient does not have adequate dual blood supply to the hand (palm still pale)
Negative indication for catheterization, removal of the radial artery, or any procedure which may result in occlusion of the vessel
What are the American Heart Association Cardiovascular Categories for Women - high risk?
>/=1 of these high risks states: existing CHD, CVD, PAD, abdominal aortic aneurysm, DM, end stage or chronic renal disease 10 year predicted risk of >10%
What are the American Heart Association Cardiovascular Categories for Women - at risk?
>/=1 major risk factor: smoking, BP >120/>80 or treated HTN, total cholesterol >200 mg/dL, HDL <50 mg/dL, treated dyslipidemia, obesity, poor diet, physical inactivity, family history of premature CVD Evidence of advanced atherosclerosis, metabolic syndrome, poor exercise capacity on treadmill test Systemic autoimmune collagen vascular disease Hx of preeclampsia, gestational DM, pregnancy induced HTN
What are the American Heart Association Cardiovascular Categories for Women - ideal cardiovascular health?
Total cholesterol <200 mg/dL BP <120/<80 Fasting glucose <100 mg/dL BMI <25 kg/m2 Abstinence from smoking
What type of cardiac screening do athletes require?
History and physical exam
No imaging unless risk factors are present or positive physical exam abnormalities
What are the events of the cardiac cycle?
Systole: ventricular contraction
Diastole: ventricular relaxation
S1: closure of mitral valve
S2: closure of aortic valve
S3/S4: atrial contraction, usually pathologic in adults
How do you calculate cardiac output?
CO = SV x HR
Where would the FNP assess for the aortic, pulmonic, mitral, tricuspid, and Erb’s point?
Aortic: 2nd ICS RSB
Pulmonic: 2nd ICS LSB
Erb’s: 3rd ICS LSB
Tricuspid: 4th ICS LSB
Mitral: 5th ICS MCL
What do heaves and lifts indicate? How would you assess for each?
Use palm and/or finger pads flat or obliquely against chest
Sustained impulses that rhythmically lift fingers; produced by enlarged R/L ventricle or atrium, occasionally ventricular aneurysms
What do thrills indicate? How would you assess for each?
Press ball of hand firmly on chest to check for buzzing or vibratory sensation caused by underlying turbulent flow If present, auscultate same area for murmur
How would you assess for JVP?
1) Raise HOB to 30 degrees, patients head to left side 2) Use tangential lighting, identify internal jugular venous pulsations 3) Identify highest point of pulsation in right jugular vein 4) Extent card horizontally from highest point and ruler vertically from sternal angle (makes exact right angle) 5) Measure vertical distance where horizontal object crosses 6) Add 5cm (distance from sternal angle to center of RA)
What is a normal JVP finding?
JVP >3cm above sternal angle, or more than 8cm in total distance, is ABNORMAL
What does an abnormal JVP finding indicate?
Acute/chronic HF, tricuspid stenosis, pulmonary HTN, SVC obstruction, cardiac tamponade, constrictive pericarditis >95% specific for increased LV end diastolic pressure and low LV EF
How would the FNP evaluate the carotid pulse?
Supine, HOB 30 degrees, inspect for pulsations, index and middle finger on R carotid artery
DON’T palpate both at the same time
How would the FNP evaluate the carotid pulse - amplitude?
Amplitude of pulse correlated with pulse pressure
How would the FNP evaluate the carotid pulse - contour?
Speed of upstroke, duration of summit, speed of downstroke Normal: brisk, smooth, rounded, less abrupt
How would the FNP evaluate the carotid pulse - pulses alternans?
Rhythm of pulse remains regular, but alternating strong vs weak pulse d/t ventricular contractions
Indicates severe left ventricular dysfunction
How would the FNP evaluate the carotid pulse - thrill?
Vibration
How would the FNP evaluate the carotid pulse - bruit?
Murmur like sound
How would the FNP evaluate the carotid pulse - brachial artery?
Assessed in patients with carotid obstruction, kinking, or thrills
What would S3 and S4 indicate?
S3 - abrupt deceleration of inflow across mitral valve (rapid ventricular filling)
S4 - increased LV end diastolic stiffness which decreases compliance (atrial contraction)
How would the FNP elicit murmurs?
Supine with HOB 30 degrees, left lateral decubitus position (listen at lower right sternal border for right sided murmurs with bell)
How are murmurs graded?
What would a systolic click indicate?
Heard in mid and late systole (early systolic ejection sound)
Occur shortly after S1, sudden halting of aortic and pulmonic valves as they open in early systole
Indicates CVD
What are the symptoms of an acute MI?
Dyspnea, N/V, sweating, weakness
What physical exam findings would be associated with heart failure?
Crackles, cyanosis of lips, tongue, oral mucosa, pallor and sweating
Cough, orthpnea, paroxysmal nocturnal dyspnea, sometimes wheezing
Exterion and lying down aggravate
What physical exam findings would be associated with aortic stenosis?
Midsystolic murmur, delayed carotid upstroke, thrills in carotid arteries from suprasternal notch or 2nd ICS, diminished S2, chest pain
What physical exam findings would be associated with pulmonic stenosis?
Wide physiologic splitting of S2, systolic murmur
Aortic stenosis murmur
Location: R 2nd/3rd ICS
Intensity: soft, but often loud with thrill (grade 4/6)
Pitch: medium, harsh, crescendo-descresendo higher at apex
Quality: harsh, may be musical at apex
Manuever: best with patient sitting and leaning forward
Pulmonic stenosis murmur
Normal JVP, R ventricular impulse sustained; if severe, S2 widely split
Location: L 2nd and 3rd ICS
Radiation: if loud, toward L shoulder and neck
Intensity: soft to loud; if loud, associated with thrill
Pitch: medium, crescendo-decresendo
Quality: harsh
What physical exam findings would be associated with mitral regurgitation?
Apical impulse may be diffuse and laterally displaced
Location: apex
Intensity: soft to loud; if loud, associated with apical thrill
Quality: harsh, holosystolic
Maneuver: intensity of murmur does not change with inspriation
What physical exam findings would be associated with tricuspid regurgitation?
Location: lower LSB; if right ventricular pressure is high and ventricle enlarged, murmur is loudest at apex (can be confused with mitral regurgitation)
Radiation: right of sternum, xiphoid, left MCL, NOT axilla
Quality: blowing, holosystolic
Maneuvers: intensity increases with inspiration
What physical exam findings would be associated with Still’s murmur?
Grade 1-2/6 murmur, musical, vibratory
Multiple overtones, early and midsystolic murmur over mid/lower LSB
Mid/lower LSB, can be associated with a carotic bruit
Diminishes from supine to sitting
What physical exam findings would be associated with left ventricular hypertrophy?
Isolated systolic HTN, widened pulse pressure
PMI >2.5cm, displacement of PMI lateral to midclavicular line, sustained high amplitude PMI
What physical exam findings would be associated with coarctation of the aorta?
Lower BP in legs than upper extremities (BP difference of 10mmHg or higher)
Diminished/delayed femoral pulses
Due to narrowing of thoracic aorta
What physical exam findings would be associated with venous hum?
Nonvalvular
Timing: continuous murmur w/o silent interval (loudest in diastole)
Location: above medial third of clavicles (esp R), best heard when patient is sitting, disappears when patient is supine
Intensity: soft to moderate, hum obliterated by pressure on internal jugular vein
Quality: humming, roaring
What physical exam findings would be associated with pericardial friction rub?
Nonvalvular
Timing: coarse grating sound; rubs heard with or without pericardial effusions
Location: heard best in L 3rd ICS with patient sitting and leaning forward with breath held after expiration
Intensity: superficial sound of varying intensity that seems “close to the stethoscope”
Quality: scratchy, scraping, grating
Pitch: high (heard better with diaphragm)
What is paroxysmal nocturnal dyspnea?
Need to sit up at night to ease breathing
Sudden dyspnea and orthopnea that awaken
What does paroxysmal nocturnal dyspnea indicate?
Chest pain, left ventricular failure (left side HF)
What are general physical exam findings in the pediatric patient with congenital heart disease?
Severe acrocyanosis that does not disappear within 8 hours of warming, central cyanosis (tongue/oral mucosa) w/o acute respiratory symptoms
Murmur + central cyanosis
What does split S2 sounds indicate?
Left sided closure of aortic valve and right sided pulmonic valve
What do split S1 sounds indicate?
M1 (cardiac apex) and T1 (lower LSB) - does not vary with respirations
What do the components of an EKG indicate?
P wave: atrial depolarization
QRS complex: ventricular depolarization
Q wave: septal depolarization
R wave: ventricular depolarization
T wave: ventricular repolarization
Cardiac history: swelling (edema)
Interstitial tissue can absorb up to 5L of fluid, 10% weight gain before pitting edema occurs
Obtain daily weights
Causes frequently cardiac
Cardiac history: fainting/syncope
Most common cause is neurocardiogenic (vasovagal syncope)
Causes of aortic stenosis
Bicuspid aortic valve
Causes of pulmonic stenosis
Congenital heart defect
Causes of mitral regurgitation
Structural, mitral valve prolapse, infectious endocarditis, rheumatic heart disease, collagen vascular disease
Functional - ventricular dilation and mitral valve dilation
Causes of tricuspid regurgitation
R ventricular failure and dilation w/ resulting enlargement of tricuspid orifice
Induced by pulmonary HTN or left ventricular failure
Endocarditis
