Pcm Test 2 Flashcards
Aortic valve heard
Right 2nd ICS at SB
Where is pulmonic valve heard
Left 2nd ICS at SB
Tricuspid valve where
Left 4th ICS at SB
Mitral valve where head
Left 5th ICS at MCL
Grade 1 murmur
Very faint
Grade 2 murmur
Quiet, soft, easily heard with stethoscope
Grade 3 murmur
Moderately loud
Grade 4murmur
Lous with palpable thrill
Grade five murmur
Very loud with thrill; can hear with stethoscope partly off chest
Grade 6 murmur
Heard without stethescope
Systolic murmur
Between S1 and s2
Diastolic murmur
S2 and s1 between
S1
Closure of TV and MV
S2
Closure of AV and PV-may split with inspiration
S2
Dull, low pitch; best heard with bell
Kentucky
S2
Physiologic in kids, young adults
Pathological in older adults=HF
Ventricular gallop
S4
Dull low pitched; best heard with bell
Tennessee
Forceful atrial contraction against stiffened low compliant ventricle
Atrial gallop
Systolic murmur
MR (MVP), TR, AS, PS, VSD Aortopulmonary shunts (early, mid, late, holosystolic/pansystolic)
Diastolic-AR, PR
-MS, TX
Atrial myxoma
Ok
Continuous murmurs
PDA-machinery
AV fistula
ASD with high LA pressure
Coarctation
VHD
Most common conditions encountered today-degenerative (senile calcification)
Myxomatosis degeneration (MVP) Congenital (bicuspid aortic valve)
Decline in incidence of RHD
Mitral regurgitaiton chronic
MVP most common MAC (mitral annular calcification)
Mitral regurgitaiton acute
Rupture of chordal tendineae
Rupture of papillary msucle
Ischemic papillary msucle dysfunction-
CAD/MI : next most common cause f MR
IE; valve perforation
MR symptoms
Asymptomatic years-> of fatigue , DOE and palpitations
Acute; volume overload/orthopnea, PND, RHF/LHF
PE MR
Systolic murmur 9blowing , prominent at apex; radiates into left axilla)
Loudness of murmur correlated with severity
Decreased D1 or normal; may have a systolic click
Mitral stenosis
4th decade
DOE, cough, orthopnea, PND< pulmonary edema, hemoptysis, arterial emboli, A fib
Ortner syndrome: hoarseness d/+ compression of left recurrent laryngeal nerve
MS PE
Malar flush-ruddy cheeks, blue fancies. Increase D1; opening snap after s2
Rumbling, diastolic murmur-low pitched; bestheard at apex. Use bell
Aortic stenosis
Degenerative (calcific, senile, fibrosis or sclerosis) congenital bicuspid aortic valve )BAV)
1% of pop born with BAV)
Rheumatic or post inflammatory scarring
Normal AoV is 4cm^2
Symptoms AS
6th decade: exertional dyspnea, angina, syncope, HF
Without treatment prognosis is poor
Without treatment most will die within three years of developing syncope and within two years of onset of HF
Pathophysiology AS
Obstruction leads to pressure overload LVH increased LVED pressure
Gradient across valve
Severe AS if AoV <1cm^2
PE AS
Narrow pulse pressure; decreased SV and systolic pressure
Delayed pulses-par is (weak-small/tardus-late)
Systolic murmur, harsh 2nd ICS RSB; radiated into suprasternal notch/carotid
Gallavardin phenomenon-murmur radiates to apex (like MR)
AR
Causes acute-IE, aortic dissection, BAV
Chronic causes-syphilis, ankylosis spondylitis
PE AR
Wide pulse pressure
De musset sign
Corgi ANS pulse
Traduces sign
Durozreys sign
Hills sign
Bisferious pulse
Diastolic , decrescendo murmur 3rd ICS LSB
Systolic murmur usually present , soft
Austin flint murmur; can mimic MS
Tricuspid regurgitaiton
Associated with pulmonary HTN, inferior MI/RV infarction and others
Pathophysiology; prominent V wave in JVP
Blowing systolic murmur LSB; increase with inspiration (Corvallis sign)
TS
Associated with MS, TR< and RHD
Pathophysiology; prominent A wave in JVP ascites, hepatomegalia (may pulsate)
Diastolic murmur LSB; increase with inspiration (carvallos sign) and decrease with expiration and valsava
Pulmonic regurgitation
Most cases are due to pulmonary HTN
Diastolic , blowing murmur 2nd LSB, 2nd ICS (graham steel)
Pulmonary stenosis
Atresia
Congenital
Can cause angina and syncope
Auscultation-systolic murmur , ejection click
2nd-3rd ICS, LSB/radiated toward left shoulder and increases on inspiration /RVH
Maybe associated with TOF or TGA
May require balloon commissurotomy if pressure gradient>50 mmHG
Electronic health records
Ok
Electronic medical records
Digitalized version of the paper charts int he clinicians office but the information int he EMRs doesn’t travel easily out of the practice. Inf act, the patients record might have to be printed and delivered by main/fax to specialists and othe members of the care team
Electronic health records
Do allot he EMR things-and more. They are build to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved int he patients care
Do EHR talk to another EHR
No
2009
Incentives-health informations echnology for economic and clincial health act, which authorizes incentive payments through Medicare and medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clincial care
2010
President Obama signed the patient protections nd affordable care act
Physicians and hospitals had to prove that they had met 25 different functional objectives with their use of an EHR product to be considered meaningful userspenalties included cuts to Medicare payments for those not implanting EHR
2017
As of 2015, nearly 9 in 10 of office based physicians had adopted EHR
Meaningful use (MU)
Stage 1-data capture and sharing 2011
Stage 2-advance clincial processes
Stage 20improved outcomes
MU
Refers to the use of certified EHR technologies by health care providers in ways that measurably improve health care quality and efficiency
Ultimate goal is to bring about health care that is Patient centered Evidence based Prevention oriented Efficient Equitable
Data
Qualitative, or quantative (discrete, continuous)
MU criteria’s 2014
Patient portal-contact provider electronically
Clinical decision support tools-computerized alerts and reminders to care providers and patients
MU report a total of 6 ambulatory clincial quality measures to CMS or states
Adherence to chronic medications
Adherence to statin therapy for individuals with CAD
Adherence to chronic medications for individuals with DM
Adherence to antipsychotic medications for individuals with schizophrenia
INR for individuals taking warfarin and interacting anti infective medication
Lack monthly INR monitoring for individuals on warfarin
Premium cost
Higher for unhealthy than healthy
As medical costs go up, premiums are raised to ensure resources>cost
What are the costs administrative, medical, other
Cost of implementation
1.5 billion Mayo Clinic over next five years EHR
What is fee for service
Volume based, not value
Physician is paid when patients is seen
What is merit based incentive payment
Standardizes measures (evidence based)
Incentives care that focuses on improved quality outcomes
Increases access to better care
Enhanced coordination through a patient centered approach
Improved results
MARCA
Medicare access and CHIP reauthorization act of 2015
CMS stated that MACRA enacts a new payment framework that rewards health care providers for giving better care instead of more service
Are doctors happy
No many unsatisfied and very dissatisfied
Why don’t we like EHR
Typing-docs become data entry clerks
Average physician gets only 3 hours training in the EHR he/she is expected to use
Inability to capture the interpersonal moments
Too many alerts on most systems
Quantitative data versus free text
Too much time entering data
Shortcuts
Scribes
Dictation
Templates
Etiquette best practice
Introduce yourself
Sit down
Get intima history then ask if ok to enter stuff on computer
Invite patient to look at screen with you
When appropriate turn away from computer, get close
What is the triangle
Computer, provider, patient
The quadrangle
The medical student, physician , patient, and computer
Why don’t we teach EMR
900 outpatient EMR systems
277 inpatient EMR systems
Medical students must
- Have their own unique login and password to chart on behalf of the preceptor
Contribute meaningful data to EHR with the inclusion of a student note or, at least, the students review.update of the past, family/social history and ROS
A. Enter needed data into he EHR and the rationale for entering clincial information ins tructured data fields versus the challenges of entering free text
B. Search for data within the EHR
C. Review patient care protocols
D. Find and use disease specific templates, reminders and decision support
Enter data into the appropriate fields int he EHR
Have all notes reviewed, edited and signed by the supervising physician with appropriate instructive feedback given
Medical students must know
Old system
Redocument HIP and PE
Attending physician can only accept students documentation
Verify in the medical record any student documentation
Physician must verify in the medical record all student documentation
Templates
Too easy to leave normal history, ROS, or exam findings pre populated without changing them.
Note cloning-all look same
Increased liability if students document in chart
- juries might be confused
- erroneous info not refuted by attending
- documentat correct info that attending ignores
Most important
At this time the NBOME has you develop a SOAP note from thin air for colles so that’s what we do here
Old system
Students could not do all soap
Now physician can just verify stuff documented is accurate -makes medical students more important, can do and help physician
Before could just document stuff that nurse could —reduce some of documentation burden to physician , be benefit to physician
Pediatric murmurs
Ok
At birth things that close
Foramen ovals, ductus arteriosus, ductus venosus
Who gets complete heart exam(over four post)
- any heart murmur
- history or history consistent of congenital heart (get sweaty when eat, weight gain, blah blah)
- respiratory symptoms (not thriving, cough, wheezing)
- if blue
- any chest pain that you cant say is MSK (costochondritis)
- anyone who passes out (usually vagovagal in kids and benign)
- fine exercise tolerance and suddenly cant
- family history of sudden death in anyone in family (idiopathic hypertrophy sub aortic stenosis(hypertrophy aortic arch), idiopathic its linked to AD so most get)
What is a complete cardiac exam
Four posts, pulses(radial brachial femoral dorsalis pedis posterior tibial), perfusion (cap refill 2 sec), pulse (2/4),
- murmur grade timing, position, if it radiates, where loudest, character (machine, soft)
- know murmur grades
Most innocent murmurs
Willl change with position
Pathologic murmur
Won’t change with position
*exception!
Pulse top to bottom in kid
Pulses top normal and femoral diminished
-coarctation or aorta
Bp higher or lower than legs
Higher in legs than arms
Grade 4
Thrill
Why s3 normal in kids
Left ventricle so much more compliant-blood suddenly hit super coolant left ventricle
S3 in adult
Systolic heart failure
Can S1 split
Can
S2 split
Inspiration , pulmonic and aortic valve close at different times
Overfilling right heart so
Fixed slipt (not just with inspiration)
ASd in systolic
S1 inaudible
Holosystolic vsd
Something obscuring it
PDA
Continuous
Diastolic
Other than venous hum, Changes with turning the neck
Not normal and do workup
Diastolic sound ever normal
No
What sound in diastolic ok
Venous hum
Most common cause of innocent murmur
Stills/IHSS, hypertrophic cardiomyopathy tay
Systolic ejection murmur heard bt lower left sternal borer and apex
Increase if stand, increases with valsava
Key features of innocent murmur
Sensitive Short duration Single Small Soft Sweet Systolic
Refer to cardiologist
4 or above Diastolic Increase when stand If symptomatic Obscured, cant hear S1 or s2 Femoral pulse weak (in comparison to UE) Extra sound Thin chest wall and hyperactive pericardium History sudden death Congenital /genetic
Stills
APEX and LL bell
Decreased with inspiration, sitting up, standing,
Systolic, ejection, soft or vibratory, grade 1-2
Normal S1 2, no extra sounds
Cyanotic congenital heart
One Truncus arteriosus big trunk
Two Interchanged vessels: transposition of the great vessels
Three Tricuspid atresia
Four Tetralogy of fallout
Five Total anomalous pulmonary venous return
Diagnosis of congenital heart disease
If close, no connection between right and left
Critical congenital heart disease
So go home, ductus close and they die
How determine kids have critical lesions
Baby counts on ductus to stay alive otherwise no right to left
Check oxygen saturation in left arm and left foot
-or right arm and right foot
If same, pass
All about difference, if too much fail and get and echo
Check pre and post ductal
If not check for congenital heart condition
Surgery
Give anticoagulant so don’t get clots
Why stop taking statin
Muscle soreness
Where is PMI
5th,
If not could be normal or not
D dimer
Not specific
Duplex of popliteal a and v
With knee infection want to look and see what’s there
Duplex
Bedside Doppler ultrasound
(Sound waves)
Visualize vasculature and assess for clot
Instant picture arteries don’t compress, veins do
Looking for DVT press transducer to see if vein collapse, if non compressible cord like thrombus forming , DVT
Most common use of Doppler
Fetal heart sounds
Doppler
Tranducal and doppler, uses both
Transthoracic echocardiogram with bubble study
Transesophageal-for endocarditis, thrombus, Camera into esophagus put behind heart and see posterior structures
Transthoracic-limitations in viewing but
Bubble study
IV access get syringe with sterile saline and put stop cock on IV attach saline filled syringe and have empty syringe, agitate saline back and forth, cause bubbles but no air
Release saline into IV with bubbles, go to right atrium first
- no defect bubbles go through normal
- if defect bubbles reverse and go right to left atria
Bubble
PFO look for -no murmurs there and we don’t know
If have bubbles right heat
ASD patent foramen ovale
How close PFO
NSAIDS high dose
Bubble
Real time assessment of
Heart accident
High risk tamponade
I AVF
Both up normal
One go down avf up-right axis
One up avf down-left axis
Ekg
Rate, rhythm, p wave , Pr prolongation,
Chest x ray
Trachea deviation
Bones
Cardiac silhouette (big or small heart)
QRS complex different sizes
Electrical alternance
Badddddd
When go to cath lab
MI, need to see electrical conduction issue on ekg
FAST exam after car crash
Look for fluid with cardiomegaly
Fast exam
Focused bedside US good for rapidly excessive if bleed we need to get immediately
Pericardial-see if tamponade
Cardiac tamponade
JVP up
BP down
Transthoracic echocardiogram
Initial test of choice for pericardium , EF, ventricular atrial septa
Diffuse pulmonary disease-obscure views, if fat, bac
Bruit
US for stenosis of carotid
Baronial aortic US
Dilation-enruysms, occur at INTIMAL layer?
2 cm, anything greater bad
Greater than 5, palpable,
Greater than 3 is aneurysm
Greater than 5
Get angiography
What is thrombus
Refer to vascular specialist
If greater than 4 cm
Aaa
Tunica media and INTIMAL layers
St elevation
Inferior lead 2, 3, avf,
Manage acs
CXR, on cardiac monitor, cath lab
Cath
Radial of femoral ARTERY into circulation to coronary vascularore , can put contrast in to light up vessels if patent see picture, if blocked wont see follow through
Use fluoroscopy to visualize coronary arteries, contrast used
May use stent to decrease likelihood of roaming
Risk of coronary angiography
Bruising, bleeding, can have another MI by putting more stress on heart, infection, kidney damage-from contrast (Cr BUN and GFR, if renal disease and CR at 2, lets put on short term dialysis to do this)
Faint, irregular rhythm, tachycardia, high bp
Check radial artery pulse to see if difference in pulses wil detect arrhythmia,
Ekg a fib
Rate differs! No consistent rate , not really p wave before qrs
LONG QT
CAN GO INTO TORSADES
Test for a fib
Transesophageal echocardiogram-
Clots can form with atrial quivering with Virchow
A fib-clots!!
Fast
Acute trauma
Duplex
Arteries, or stroke of carotid
Cath
MI
Clot
TEE
TEE-clot formation
Invasive, thrombus in A fib, prosthetic valve , aortic dissection aortic pathology , US get rapid view
How would dissection appear on CXR
Widened mediastinum
