Systole: - Tricuspid/Mitral closed - Aortic/Pulmonic open - Ventricular contraction Diastole: - Aortic/Pulmonic closed - Tricuspid/Mitral open - Ventricular relaxation

Final Flashcards by Brian B

Steps to Cardiovascular Exam

Look- Inspection

Feel- Palpation

Tapping- Percussion

Listen- Auscultation

IPPA

Inspect (General Appearance, Shape (barrel chested-think COPD, Pectus carinatum (Pigeon chest-pops out), Pectus excavatum (Funnel chest)
Palpation: locate point of maximum impulse (PMI)- 4th-5th ICS at mid-clavicular line. Used to locate apex/left border
Percussion: to estimate cardiac size when PMI not detectable (start lateral and go medial—-resonance→dullnes). Over heart will have “dullness” to percussion. Establishes whether tissues are: air-filled, fluid-filled, or solid. (hyperextend middle finger and go in ladder-like pattern)
Auscultate: (listening to heart)

How well did you know this?

Not at all

Perfectly

Locations for heart auscultation

“APT-M”..like ‘appointment”

Aortic: Right 2nd intercostal space @ sternal border

Pulmonary: Left 2nd intercostal space @ sternal border

Tricuspid: Left 4th intercostal space @ sternal border

Mitral: Left 5th intercostal space @ mid-clavicular line (right by nipple…at heart apex)

How well did you know this?

Not at all

Perfectly

What makes up S1 heart sound?

“MTc”

Closing of mitral and tricuspid valves (use diaphragm)

Beginning of systole
Loudest at apex

How well did you know this?

Not at all

Perfectly

What makes up S2 heart sound?

Closing of aortic and pulmonary valves

End of systole
Loudest at the base

How well did you know this?

Not at all

Perfectly

What makes up S3 heart sound?

Normal/physiologic in children/young adults

Pathologic x>40 years old = Ken-Tuck-Y (use bell)

Due to high pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase

How well did you know this?

Not at all

Perfectly

What makes up S4 heart sound?

Can be normal in trained athletes, hypertension

“Ten-Nes-See”

Atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle

How well did you know this?

Not at all

Perfectly

Naming and grading of heart murmurs

(Systolic murmurs fall between S1 and S2)
(Diastolic murmurs fall between S2 and S1)
Graded on a scale of 1 to 6

1: very faint
2: Quiet, no thrill (but heard easily with stethoscope)

3: Moderately loud/loud, no thrill
____________________
4: Loud with palpable thrill

5: Very loud with thrill (with stethoscope partially off chest)
6: Loudest, with thrill (Heard with stethoscope entirely off chest)

How well did you know this?

Not at all

Perfectly

How to test Carotid pulse

Asses for thrills and bruit; may use stethoscope BELL. Medial to SCM muscle. Do NOT assess both carotids at the same time…can pass out!!

Listen for turbulence (narrowing of blood flow)

*Graded on 0-4 scale with normal being +2/4

How well did you know this?

Not at all

Perfectly

How to test Peripheral Pulses

Radial (wrist)
Brachial (elbow)
Femoral (not examined during lab)
Popliteal (behind knee)
Dorsalis Pedis (top of foot)
Posterior Tibial (side of foot)

How well did you know this?

Not at all

Perfectly

How are pulses graded?

Pulses are graded on a 0-4 scale with normal being +2/4 (and put in Objective part of SOAP notes)…Radial Pulse: 2/4 bil.

R/R/A= Rate/Rhythm/Amplitude

0= absent
1= Barely palpable
2=Average intensity
3=Strong
4=Bounding

How well did you know this?

Not at all

Perfectly

Systole vs Diastole

Systole:

Tricuspid/Mitral closed
Aortic/Pulmonic open
Ventricular contraction

Diastole:

Aortic/Pulmonic closed
Tricuspid/Mitral open
Ventricular relaxation

How well did you know this?

Not at all

Perfectly

Cap Refill

Normal cap refill x

How well did you know this?

Not at all

Perfectly

Best place to check for Peripheral Edema?

Grading scale?

Top (dorsum) of foot, anterior tibia (shin), behind medial malleolus

Press firmly for 5 sec then release

Grading scale:

0:Absent edema

1+:Barely detectable, non-pitting (2mm)

2+: Slight indentation (4mm), 10-15 sec long

3+: Deeper indentation (6mm), can last x>1 min

4+: Very Marked indentation (8mm), can last 2-5 min

*Document: from 0/4→ +4/4 pitting edema

How well did you know this?

Not at all

Perfectly

Landmarks for needles etc in abdomen

2nd ICS: needle decompression of pneumothorax

4th ICS: chest tube

7th ICS: thoracentesis (remove excess fluid between the lungs and the chest wall. This space is called the pleural space.

T4: lower margin of endotracheal tube on a chest x-ray

How well did you know this?

Not at all

Perfectly

What does intercostal m. retraction signify?

Respiratory distress

How well did you know this?

Not at all

Perfectly

Where do patients with lung disease often have somatic dysfunctions?

T1-6

How well did you know this?

Not at all

Perfectly

Trachea shifts

Shifts from midline=bad. Indicative of atelectasis (collapsed lung) or tension pneumothorax (build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space)

How well did you know this?

Not at all

Perfectly

Tactile Fremitus

“Ninety-nine” or “One-one-one”
Vibrations through air/solids/fluids
Often more prominent in the interscapular area than in lower lung fields and is more prominent on the Right than on the left…more vibration on side of consolidation

If INCREASED → ConSOLIDation of lung tissue: Pneumonia-increased transmission through consolidated tissue

If Decreased/absent fremitus→ Excessive air (Obstructive lung disease-COPD) or fluid (effusion), fibrosis, pneumothorax or an infiltrating tumor, lung disease

How well did you know this?

Not at all

Perfectly

Percussion (“echo”)

More air → COPD

Dull → Solid tissue and fluid (pneumonias, effusions)

Hyperresonance→ COPD and pneumothorax (increased air)

Dull (fluid) vs Flat (solid) vs Tympanic (air)

How well did you know this?

Not at all

Perfectly

Auscultation

ALWAYS have patient cough/clear throat if they’re sick (pneumonia vs mucus)

Pneumonia=crap in lungs

“Ladder like pattern”- allows for direct comparison bilaterally (Right to left, then left to right etc)

How well did you know this?

Not at all

Perfectly

Abnormal Breath Sound

Crackles (rales)=like tissue paper→ fluid in acini

Wheezes: musical tones → narrowed airway (asthma, COPD, bronchitis)

Rhonchi: like snoring, rumbling → excess secretions in bronchi/trachea

Stridor: inspiratory. Obstruction of larynx/trachea- immediate attention needed

*Noisy breathing is obstructed breathing

How well did you know this?

Not at all

Perfectly

Normal Breath Sounds

Bronchial= loud, high pitch, expiration>inspiration

Bronchovesicular (where tree branches out to each lung), intermediate in intensity and pitch, heard equally in inspiration and expiration

Vesicular=low pitch,soft, inspiration>expiration

Tracheal: very loud, high pitched, heard equally in inspiration and expiration

How well did you know this?

Not at all

Perfectly

Vocal sounds

Only when abnormally located sounds are heard

For all: normally indistinct. Increased clarity with tumor, consolidation, pneumonia

Bronchophany: same as TF, but listening instead of feeling….99 becomes louder/clearer (airless lung aka lobar pneumonia)

Egophony: “ee” sounds like “A”→3x likelihood of pneumonia (airless lung aka lobar pneumonia)

Whispered pectorlioquy: whispers are heard loud and clearer during auscultation (airless lung aka lobar pneumonia)

How well did you know this?

Not at all

Perfectly

Subjective

CC: the patient’s words

HPI: OPQRST or OLDCAARTS
Past Medical History (PMH)
Surgeries
Allergies
Medications
Family History (FH)

How well did you know this?

Not at all

Perfectly

Objective

Heart: RRR no murmur Lungs: CTAB OSE: T4-7 N Rr SBl Special tests: (ex. Neers: positive...Leg roll: negative) Assessment: 3 possible causes and from most to least likely Plan: What you did for the patient, What you plan on doing......(Dr.K- when looking at possible answers, always a CT w/o contrast)

How do patients with obstructive lung diseases sit?

They tend to sit leaning forward with shoulders elevated

Fingernails and signs of clubbing

Swelling of soft tissue at nail base. Loss of normal angle (x>180) leading to a spongy or floating feeling. Mechanism unknown but involves vasodilation.... Seen in: congenital heart disease, INTERSTITIAL LUNG DISEASE, lung cancer, cystic fibrosis

(Percussion): Clinical/Pathological examples: Dullness replaces resonance

Dullness replaces resonance when: Fluid or solid tissue replaces air-containing lung - Lobar pneumonia (alveoli filled with fluid and blood cells) - Pleural accumulations: effusion (serous fluid), hemothorax (blood), Empyema (pus), fibrous tissue or tumor

When will hyperresonance be heard over hyperinflated lungs?

COPD | Asthma

Unilateral hyperresonance suggests:

Large pneumothorax | Large air-filled bulla in lung

Diaphragmatic excursion

Determine distance between level of dullness on FULL EXPIRATION and the level of dullness on FULL INSPIRATION by progressive percussion down from resonance (lung parenchyma) to dullness (structures below diagragm) Normal excursion=3-5.5 cm

Kussmauls sign

Venous column (JVP) rises during inspiration, rather than falls Seen in R heart failure, constrictive pericarditis or RV infarction

Valgus stress test (arm)

(IN) pain=MCL (Ulnar collateral ligament)

Varus stress test (arm)

(Away) pain=LCL (Radial collateral ligament)

Tinel test is for testing what?

Ulnar nerve entrapment Tap between olecranon and medial epicondyle in ulnar groove +=tingling sensation → ulnar nerve entrapment, cubital tunnel syndrome

Golfer's Elbow test

Tests: Medial epicondylitis Arm at 90, supinated, flex wrist. Pain around medial epicondyle = +

Tennis Elbow test (Cozen's test)

Tests: Lateral epicondylitis Arm at 90 with palm facing down, extend wrist. Pain around lateral epicondyle= +

Olecranon bursitis

Bony part of elbow. "students elbow" or "miners elbow"

"Little League elbow"

Pain over medial epicondyle, persistent pain. Most common injury during childhood. Can progress as child grows up Apophysitis→avulsion→ligamentous injury

Radial head instability/"Nursemaid's elbow"

From grabbing a child's arm...they'll keep arm pronated and close to body Pain with palpation of radial head , restriction to posterior glide

Coupled motions at elbow

Ulnar aDduction with supination ("add soup") Ulnar aBduction with pronation Radial head anterior glide with supination Radial head Posterior glide with Pronation (P with P)

Anatomical snuff box

Extensor pollicis longus Abductor pollicis longus Extensor pollicis brevis

List the factors that predispose to Renal Cell Carcinoma:

Smoking Obesity Workplace exposures

Where would you put "Hematuria" (blood in urine) in the notes as a sign of possible urinary tract cancer?

Put it in Review of Systems (ROS)

List the areas that transitional cell urinary tract cancers can occur

Kidneys Ureters Urethra *Entire urinary system should be checked

The majority of Renal Cell Carcinomas are what type?

Clear Cell type Often asymptomatic

Compare/Contrast history and physical findings seen w/ pyelonephritis vs cystitis, or gastrointestinal or female reproductive processes

Pyelonephritis: (worse, more serious)-infection of pelvis and kidney, Fever, chills, WBC casts in urine, flank pain, tenderness, no voiding symptoms, blood culture Cystitis can travel up tract → pyelonephritis (E.coli can travel up)

Distinguish between SOAP (Subjective-Objective-Assessment-Plan) note and full (H and P) History and Physical

SOAP=more focused and problem oriented H and P= includes ROS (Review of SYSTEMS- not "symptoms") and is much more detailed (e.g. used when a patient admitted to the hospital or new to an office to establish primary care)

When to use a CT scan

Gives more detail with areas of involvement If BUN/creatinine is normal you can do CONTRAST. Renal cell cancers will ENHANCE on imaging You get a better picture of what vessels are involved

Renal Cell Carcinoma

VHL (Von Hippel Lindau)

Lloyd's punch: when percussing kidneys...assesses CVA tenderness (Costovertebral Angle)- kidney pain (in back)

True

Cyanosis

Bluish skin from poor circulation or inadequate oxygenation of blood

Dyspnea

difficult or labored breathing

Pneumothorax

Abnormal collection of air or ga-->collapsed lung

Patellar Test nerve

Achilles test nerve

Biceps test nerve

Biceps: C5 Brachioradialis: C6 Triceps: C7

What parts of stethoscope to use

Low pitch bruit=BELL..."Lavell" High pitch (heart/lungs): Diaphragm

Emotion mnemonic

NURS Name Understanding statement Respect patient Support

Alcohol mnemonic

CAGE Cut down Annoyed by criticism Guilty feelings Eye opener *2 or more=90% chance alcoholic

SEX mnemonic

5 P's ``` Partners Prevention Protection Practices Past history of STD's ```

Tobacco pack years

yrs smoking x packs/day

Violence mnemonic

SAFE Stress/safety Afraid/Abused Friends/Family Emergency plan

Faith mnemonic

FICA Faith and beliefs Importance Community Address in care *150 min exercise/wk