PD Block 2 Flashcards
a. pericardium
double-walled fibrous sac that holds the heart; contains heart, roots of the great vessels, and pericardial fluid; protects, lubricates, and fixes heart in place
b. right and left ventricles
ventricles receive blood from the atria and then strongly pump it out during systole
thick-walled, muscular, provides the “oomph” of the heart, most of the heart’s mass
RV receives blood from RA, pumps to lungs via pulmonary artery LV receives blood from LA, pumps to aorta/body
d. aortic valve
semilunar valve
between LV and ascending aorta
forced open in systole
one-way valve: prevents blood from flowing backward from the aorta into the LV
Trileaflet (comprised of three leaves that come together when the valve is closed)
c. right and left atria
atria receive blood from the circulation (body and lungs) and drain into ventricles
relatively thin-walled, reservoirs
RA receives deoxygenated blood from the body/vena cavae
LA receives oxygenated blood from the pulmonary circulation via pulmonary veins
e. pulmonic valve (AKA pulmonary valve)
semilunar valve between RV and pulmonary artery forced open in systole
one-way valve:
Trileaflet
f. the great vessels
collectively, the large vessels that route blood to and from the heart:
j. tricuspid valve
AKA right atrioventricular valve
between RA and RV
open in diastole
one-way valve: prevents blood from flowing backward from the RV into the RA
Trileaflet (comprised of three leaves that come together when the valve is closed)
k. mitral valve
AKA left atrioventricular valve, AKA bicuspid valve
between LA and LV
open in diastole
one-way valve: prevents blood from flowing backward from the LV into the LA
Bileaflet (comprised of two leaves that come together when the valve is closed)
A. Preload:
the initial stretching of the cardiac myocytes prior to contraction
B. Afterload:
can be thought of as the “load” that the heart must eject blood against, closely related to aortic pressure
C. Systole:
The part of the cardiac cycle during which the heart contracts, particularly the ventricles, resulting in a forceful flow of blood into both the systemic and pulmonary circulations. (M)
D. Diastole:
That time between two contractions of the heart when the muscles relax, allowing the chambers to fill with blood; diastole of the atria precedes that of the ventricles; diastole alternates, usually in a regular rhythm, with systole. (M)
S1:
produced by the closure of the mitral and tricuspid valves (CE)
S2:
produced by the closure of the aortic and pulmonic valves (CE)
S3 (S3 Gallop):
The first stage of diastole is a period of rapid ventricular filling. At the end of this stage of rapid filling, an S3 may be heard if the volume of blood that has been transferred is abnormally large, as in mitral regurgitation. The S3 gallop is thought to be the sound the ventricle makes when it is forced to dilate beyond its normal range due to volume overload in the atria (ex: heart failure). Conditions of high cardiac output (ex: thyrotoxicosis, severe anemia) can also cause an S3 gallop. (HS)
S4 (S4 gallop):
The late stage of diastole is marked by atrial contraction. If the ventricle is stiff and non-compliant (ex: left ventricular hypertrophy secondary to longstanding severe hypertension, MI, or cardiomyopathies) then the pressure wave gradient generated as the atria contract generates an S4 sound. Ex of right sided S4: pulmonary hypertension, pulmonary stenosis (HS)
Superior Vena Cava
routes deoxygenated blood from the head/neck/upper extremities (upper body) into the RA
Inferior Vena Cava
routes deoxygenated blood from the abdomen/pelvis/lower extremities (lower body) into the RA
Pulmonary Artery
routes deoxygenated blood from the RV to the lungs
Aorta
routes blood from the LV to the body; ascending – arch – descending – thoracic – abdominal
Pulmonary Veins
routes oxygenated blood from the lungs to the LA
a. physiologic splitting
The pressure of the right side of the heart and left side of the heart are not the same. The right atrium, right ventricle, and pulmonary artery have a lower pressure than the left side of the heart. This results in sounds occurring at different times. For example, the aortic valve found on the left side will close before the pulmonic valve on the right side. This creates a split in S2 which can be broken down as sounds A2 and P2.
b. pathologic
fixed splitting-
A splitting of sounds A2 (aortic component of 2nd heart sound) and P2 (pulmonic component of 2nd heart sound) that is wide and there is no variation between respirations. This could be heard in atrial septal defect and right ventricular failure.
pathologic splitting
ii. paradoxic splitting-
During respiration there is a delay in the closure of the aortic valve (A2) creating an inconsistent movement of A2 and P2. The sounds are separate during expiration and sound closer together during inspiration. This could be heard with a left bundle branch block.
electrical cycle in heart
SA node - contraction of atria, filling of ventricles (diastole)
AV node — purkinje fibers — contraction of ventricles (systole)
SA Node
natural pace maker
auscultation position: aortic area
R 2 ICS
aortic valve and S2
auscultation position: pulmonic area
L 2 ICS
pulmonic valve
auscultation position: Erb’s point
L 3 ICS
pulmonary artery - best for S2
auscultation position: Tricuspid (apex)
L 4/5 ICS
Tricuspid
auscultation position: Mitral
Lateral L 5/6 ICS
S1
Cardiac Exam Inspection acute
GA: signs of acute cardiac distress:
Cyanosis, diaphoresis, pallor, cool temp, difficulty breathing, anxiety, Levine’s sign (clutching fist over chest)
Apical impulse: beating of LV during systole at 4th or 5th LICS at midclavicular line. Not normally seen while supine. May need light.
Cardiac Exam Inspection chronic
GA: signs of chronic heart conditions:
Clubbing fingernails, xanthelasma (yellow waxy deposits on extremities & around eyes, d/t increase cholesterol)
Obesity or coarction (underdeveloped lower extremities)
Cardiac Exam Palpation
Patient elevated 30 degrees
Use carotid pulse to detect timing of systole
Palpate for PMI (apical impulse)
If elsewhere than apex = abnormality
Provides estimation of size of heart
Assess location, diameter (should be one ICS or 1 cm), amplitude (should be gentle), duration
palpable cardiac abnormalities
lift, heave, thrill
For thrills, palpate over areas corresponding to valves
Cardiac Exam: auscultation
Listen to all areas with pt. upright, supine & left lateral recumbent
Upright leaning forward best to hear S2 & aortic murmurs
LL recumbent best to hear S1, mitral murmurs, & low-pitched diastole filling sounds
Listen to all areas with bell and diaphragm
Skin contact!
Listening for: Normal & abnormal heart sounds, rate & rhythm
5 Locations of cardiac exam
Aortic, Pulmonic, Erb’s, Tri, Mitral
S1 heart sound
S1:
Produced by closure of mitral and tricuspid valves
Indicates beginning of systole
Loudest over the apex of the heart; best heard with diaphragm of stethoscope
S2 heart sound
S2:
Produced by the closure of aortic and pulmonic valves
Indicates beginning of diastole
Loudest at left and right intercostal spaces (left for pulmonic valve, right for aortic valve); best heard with diaphragm of stethoscope
Can sometimes hear physiologic splitting of S2 on deep inspiration
chest pain sx
levine’s sign, fist on chest, uncomfortable look
fatigue sx
can’t maintain normal activities
can’t keep up with contemporaries
sleeping more
unusual or persistent
dyspnea sx
aggravated by exertion
difficult breathing
looking uncomfortable
diaphoresis
excessive sweating
syncope sx
associated with palpitations
change in posture
happen with looking up or turning head
unusual exertion
cyanosis sx
found in periphery first
blue/pallor color
decreased OX, decrease bloodflow
cough sx
onset/duration?
dry/wet
increased when laying down
orthopnea sx
SOB while laying flat
LV failure
fixed by sitting up
Claudication sx
pain during exercise from decreased blood flow
mostly in legs, can be arms
paroxysmal nocturnal dyspnea sx
SOB at night
coughing
awakens pt from sleep
xanthelasma sx
waxy yellow deposits on skin
around eye/extensor surfaces
increased cholesterol in blood
other organ systems evaluated with CV complaint
EKG diaphragm lungs PVS musculoskeletal complaints - shoulder pain/jaw pain/xyphoidynia GI distrubances - heartburn, uclers anxiety
hypotension
low BP
postural/ orthostatic hypotension
abnormal decrease in BP from sitting to standing
hypertension
> 140/90
normotension
<120/80
heart murmur intensity grade 1
Grade 1: faint, intermittent
heart murmur intensity grade 2
Grade 2: quiet but easy to hear
heart murmur intensity grade 3
Grade 3: moderately loud, no palpable thrill
heart murmur intensity grade 4
Grade 4: loud, palpable thrill
heart murmur intensity grade 5
Grade 5: loud, palpable thrill; can hear with stethoscope barely touching chest
heart murmur intensity grade 6
Grade 6: very loud, palpable thrill; can hear with stethoscope off chest
seven dimensions of a heart murmur
timing/duration pitch intensity (grading scale) pattern location radiation respiratory phase variations
b. pitch: (murmur)
high, medium, or low? Bell or diaphragm?
a. timing and duration (murmur)
between S1 and S2, or S2 and S1? Short or prolonged?
MURMUR d. pattern: crescendo
: increased blood velocity; decresendo: decreased blood velocity; square/plateau: constant intensity
e. location MURMUR
: where is it auscultated best?
MURMUR f. radiation:
do you hear it only over the specific valve or elsewhere? sound generally transmitted in direction of blood flow
g. respiratory phase variations: MURMUR
impacted by inspiration/expiration? variation of intensity, quality, timing? if venous return issue, increase with insp, decrease with
external cues to peripheral health
Hair pattern on extremities Skin color: o Cyanosis at extremities, lips and nose o Rubor o Pallor o mottling Capillary refill time <2seconds Temperature of skin Pulse strength and regularity Dependent edema
List the sequence of blood flow through the systemic circulatory system.
LV - aorta - brain/lower body/liver/mesentery - through cap beds - exchange of OX - leaves brain/liver/lower body/mesentery – SVC/IVC – RA — RV —- Lungs — reOX – LA — LV
arterial pulse
pressure wave through system from ventricular contraction
arterial BP
force exerted by blood against wall of artery as ventricles contract and relax
Variable in arterial pulse
blood volume
distensibility of aorta
viscosity of blood
peripheral arterial resistance
characteristics of jugular venous pressure (JVP)
Jugular veins reflect activity/competency of the right side of the heart
Visibility of jugular venous pulsations/fluttering indicates right atrial pressure
normal range for JVP
The vertical distance from the sternal angle to the straight edge is the JVP value
Normal range is < 3 cm
Normal range for CVP
CVP (central venous pressure) can be approximated:
5cm + JVP = CVP
Normal CVP is 7 cm, upper limit is 9 cm
carotid -
just below angle of jaw
abdominal aorta -
left lateral and superior to umbilicus
Ausculate before palpating!
Only pulse where both hands needed to apply deep pressure
Pulsations should be less than 2.5 cm apart
femoral -
crease of groin
brachial -
medial antecubital fossa of elbow
radial -
thumb side of wrist where it creases
ulnar
- pinky side of wrist where it creases
dorsalis pedis
- top of foot, between metatarsals 1 and 2
popliteal
- directly behind (flexed) knee
most difficult pulse to find of people
If non-palpable, ensure dosalis pedis and posterior tibialis are symmetrical with good amplitude
posterior tibialis
- posterior to medial malleolus of ankle
Amplitude’s for Pulses 0-4
0=no palpable pulse 1=diminished 2=normal / expected 3=full / increased 4=bounding
a. pulsus alternans
- PE findings:
Pulse has constant rate and rhythm but amplitude (force) alternates between a smaller amplitude and larger amplitude
a. pulsus alternans - Clinical significance:
Can be due to left ventricular dysfunction/failure
b. pulsus bigeminus - Clinical significance:
Can be due to heart disease, digitalis toxicity, or a temporary benign finding.
b. pulsus bigeminus
- PE findings:
Normal pulse beat followed by a premature beat (due to premature ventricular contraction) and a pause. Premature beat’s amplitude (force) is less than the amplitude of the normal beat.
c. pulsus bisferiens
- PE findings:
Pulse has two peaks during systole-the first is the “normal” pulse that occurs during ventricular contraction, but the second is an early diastole due to a backflow of blood; best noticed with palpation of carotid artery
-c. pulsus bisferiens Clinical significance:
Can be due to severe aortic regurgitation or aortic stenosis (narrowing) coupled with aortic insufficiency.
d. pulsus paradoxus
- PE findings:
Atypical decrease in systolic arterial blood pressure (>10 mm Hg) and amplitude (force) during inspiration (breathing in). Normally there is a slight decrease in BP with inspiration, but it’s less than 10 mm Hg. May be detected with palpation, but much easier to detect by taking pt’s BP.
d. pulsus paradoxus - Clinical significance:
Can be due to emphysema, asthma, premature heart contraction, tracheobronchal obstruction, or pericardial effusion (fluid around the heart).
e. pulse deficit
- PE findings:
difference between the rates in pulse when auscultating the heart’s apex (assessing the pulse using stethoscope over apex of heart) versus palpating a peripheral artery (e.g. taking someone’s radial pulse)
e. pulse deficit - Clinical significance:
Occurs when ventricular contraction doesn’t eject a sufficient amount of blood to produce a pulse wave in the arteries. Often associated with premature beats, pulsus bigeminus, and atrial fibrillation.
a. venous insufficiency (chronic)
Assess:
IPPA of lower extremities, Trendelenberg retrograde filling test, Hx of phlebitis, leg injury
a. venous insufficiency (chronic) Findings:
Brawny ankle edema and induration, stasis pigmentations, varicosities, ankle ulcerations, pitting edema, cyanosis/erythema
b. venous obstruction
Assess:
IPPA of lower extremities, pain and swelling in ankle, Homan’s sign; calf measurement
b. venous obstruction Findings:
DVT –> PE, unilateral pitting edema, acute superficial thrombophlebitis
c. arterial insufficiency (chronic)
Assess:
IPPA of lower extremities; postural color changes
c. arterial insufficiency (chronic) Findings:
Cool, pale (upon elevation), thin, shiny atrophic skin around ankle/lower leg. Loss of hair over foot and toes; thickened toenails; gangrene; pain that goes away upon resting
d. arterial obstruction
Assess:
IPPA of upper and lower extremities; Allen test;
d. arterial obstruction Findings:
Pain, numbness, tingling, weakness, pallor –> Acute Arterial Occlusion;
e. varicosities
Assess:
Inspection of lower limbs, palpate for increased venous pressure.
e. varicosities Findings:
Dilated, tortuous, visibly blue/purple veins. Sometimes painful. Indicative of chronic venous insufficiency.
f. dependent edema / pitting and nonpitting
Assess:
Firmly over bony prominence comparing like areas and recording topographic areas. Please refer to lecture slides for picture.
f. dependent edema / pitting and nonpitting Findings:
Bilateral indicates systemic. Unilateral indicates local. “4+ pitting edema from _______ to _______.” CHF —> Edema go higher and higher on Lower Ext.
g. claudication
Assess:
Hx of pain caused by too little blood flow during exercise. Generally affects the blood vessels in the legs, but claudication can affect the arms, too.
g. claudication
Findings:
Sx of peripheral vascular disease
h. capillary refill
Assess:
Pinch fingernails or toenails and observe for capillary refill < 2 seconds.
h. capillary refill Findings:
Greater than 2 seconds indicative of arterial inefficiency
bruits and where to look
turbulent bloodflow through vessels - may be an obstruction/stenosis/restriction
using diaphragm listen for bruits over carotids femoral iliac renal aortic
a. paraphimosis:
foreskin becomes trapped behind the glans penis
o. cryptorchidism:
undescended testicle
n. femoral hernia:
bulging of intestines through the femoral ring
m. direct inguinal hernia:
doesn’t go through internal inguinal ring; through external right; hernia bulges anteriorly, pushes against side of finger
l. indirect inguinal hérnia:
through internal ring; most common type of hernia, pts often young males; pain on straining; touches fingertip on exam
k. epispadias:
urethral deformity; can open on top, side, or be open along length of penis
j. testicular tumor:
câncer that develops in the testicles
b. hypospadias:
urethral opening is on underside of the penis
i. epididymitis:
inflammation of infection of the epididymis; generally caused by chlamydia, gonorrhea, or E. Coli
h. varicocele:
enlargement of the veins within the scrotum
g. spermatocele:
benign, sperm-filled cyst at the head of the epiddidymis
f. hydrocele:
collection of fluid in the scrotum
e. peyronie disease:
connective tissue disorder; chronic inflammation and scar tissue formation in the túnica albugínea
d. condyloma:
presence of warts caused by HPV
c. chancre:
painless ulceration formed during primary stage of syphilis
techniques used to minimize patient anxiety associated with a genital examination
chaperone answers all questions before examination positions they will be in equipment instruction
Male genital self exam (GSE)
Step 1:
Patient should hold penis in hand
Inspect head of penis for lesions or masses (if not circumcised, pull back foreskin)
Palpate head of penis feeling for bumps, sores, warts or blisters.
Step 2: Male genital self exam (GSE)
Inspect urethral meatus, squeeze to see if there is any
discharge.
Step 3: Male genital self exam (GSE)
Patient should examine entire shaft.
Evaluate for any lesions, sores or masses.
Use a mirror to visualize the underside.
Step 4: Male genital self exam (GSE)
Patient should then examine the base of the penis by moving pubic hair out of the way.
Step 5: Male genital self exam (GSE)
Scrotum evaluation
Patient should hold each testicle gently while inspecting and palpating using lighter then firmer pressure.
sequence and examination techniques for male GU Adult
Inspection
lesions, chancres, pubic hair patterns, note circumcised or uncircumcised, position, meatus position/stenosis, phimosis and paraphimosis
sequence and examination techniques for male GU Adult Palpation:
tenderness/nodularities/lesions -
palpate top to bottom
side to side
strip the urethra looking for any abnormal discharge or blood at urethral meatus.
Open meatus to inspect for discharge, lesions.
Scrotum:
Inspection
extreme asymmetry - skin (rashes/redness), separate hair to look at skin,
Scrotum:
Palpation
P: cremasteric reflex - tongue blade stroked on inside of thigh - testicle on that side should rise voluntarily - tests T12-L1-L2 nerves
Testis:
isolate one testicle at a time -
can ask pt to hold penis out of the way,
roll testicle around in fingers - smooth - not overly tender - note contours during palpation -
Hernia:
follow spermatacord up to pelvis, toothpick feeling is the vas defrens, find the external inguinal ring - place tip of finger here and have pt cough/bear down. ,
indirect hernia
If bulge felt on tip of finger =
direct hernia
if bulge felt on side of finger =
Adolescent: GU male
allay anxiety, protect privacy, inspect/palpate - Tanner stage
Child GU Male
lesions, malformations, discharge, masses, hernias
Infant GU Male
Mostly looking for congenital abnormalities, urethral placement, retractability of foreskin, descent of testicles (1-2 months) masses (transilluminate)
male erection
two corpora cavernosa become engorged with blood via arterial dilation and decreased venous flow
autonomic nervous system
local synthesis of nitric oxide
male ejaculation
emission of secretions from vas defrens, epididimides, prostate and seminal vesicles
male orgasm
constriction of vessels supplying blood to corpora cavernosa and gradual subsiding of sexual arousal
