PRE WEEK Flashcards
Below are the following abbreviations for RoA, state what each stands for:
(i) IV (ii) SL (iii) NG (iv)PV (v) TOP (vi) IM (vii) SC (viii) PR (ix) INH
(i) intravenous
(ii) sublingual
(iii) nasogastric
(iv) per vagina
(v) topical
(vi) intramuscular
(vii) subcutaneous
(viii) per rectum
(ix) inhalation
Why is oral always written out in full?
as “O” could lead to ambiguities as if it is misread as a zero & placed too close to the dose this could increase the dose tenfold!
How must quantities less than 1g be written?
In milligrams
What is recorded if a pt has no known drug allergies?
NKDA
If thromboprophylaxis was required, what is the usual low molecular weight heparin (LMWH) used in NHS Fife?
Dalteparin injection
What does the Symptomatic Relief policy in NHS fife allow nurses to do?
To administer from a specified list of medicines which are used for minor symptom relief of pain, constipation, indigestion etc. This list does not include any “Prescription Only Medicines”
What are the (i) modifiable and (ii) non modifiable risk factors for establishing cardiovascular risk? (HINT: there’s 6 modifiable & 5 non-modifiable)
(i) hypertension, hyperlipidaemia, diabetes, obesity, smoking, sedentary lifestyle
(ii) age, ethnicity, gender (males more than females), personal/family history of CVD, low birth weight
When taking PMH for CVD, what are the points to consider?
- History of vascular disease (coronary artery, cerebrovascular, peripheral vascular)
- Diabetes
- Hyperthyroidism
- Renal disease
- Hypertension
- Hypercholesterolaemia
When taking Family History for CVD, what are the points to consider?
- Other family members:
- health problems?
- deceased? - History of CVD at a young age?
- 1st degree male relative
What are the various causes of chest pain?
- CV causes: stable angina, acute coronary syndromes, pericarditis, coronary artery spasm, aortic aneurysm/dissection
- RESPIRATORY causes: pulmonary embolus, pneumothorax, pneumonia, lung cancer, mesothelioma
- UPPER GI causes: oesophageal disease
- MS causes: trauma, muscular or rib injury, costochondritis
- OTHER causes e.g. herpes zoster
What is angina?
A clinical syndrome of chest pain or pressure precipitated by activities such as exercise or emotional stress which increase myocardial
oxygen demand
What are the 3 key features of classical, stable angina?
- Predictable in onset
- Reproducible
- Relieved by rest or GTN (glyceryl trinitrate)
What are the types of acute coronary syndromes?
unstable angina
acute MI - non ST elevation MI (NSTEMI) - ST elevation MI (STEMI)
What are 2 other CVD causes?
- Pericarditis
- viral/MI/TB/uraemia/malignancy etc
- sharp/retrosternal pain that is relieved by sitting forwards - Aortic dissection
- sudden & severe, is a tearing & deep pain that radiates to the left shoulder/back
What is an ST segment?
The ST segment is an electrical measurement recorded by an ECG. It corresponds to the level of damage inflicted on the heart.
The higher the ST segment, the greater the likely damage.
Describe the difference between NSTEMI & STEMI.
A STEMI is the most serious type of heart attack, where there is a long interruption to the blood supply. This is caused by a total blockage of the coronary artery, which can cause extensive damage to a large area of the heart.
An NSTEMI can be less serious than a STEMI. This is because the supply of blood to the heart is only partially, rather than completely, blocked.
As a result, a smaller section of the heart is damaged
What is dyspnoea? What are 2 types of dyspnoea? What are the causes?
Shortness of breath
Orthopnoea, Paroxysmal nocturnal dyspnea (PND)
1. CARDIAC causes: cardiac failure, associated with angina or MI
2. RESPIRATORY causes: asthma, COPD, pneumothorax, pneumonia, bronchitis, bronchiectasis, pulmonary fibrosis etc
3. OTHER causes: anaemia, obesity, hyperventilation, anxiety, metabolic acidosis
Describe the various arrhythmias listed below (i) ventrical or atrial extrasystoles (ii) atrial fibrillation (iii) supraventricular tachycardia (iv) ventricular tachycardia
(i) heart misses a beat or jumps/flutters
(ii) may be unnoticed, heart jumping about or racing
associated breathlessness
(iii) heart ‘racing’ or ‘fluttering’, associated polyuria
(iv) heart racing or fluttering, associated breathlessness, may present as syncope rather than palpitations
What is syncope?
a temporary loss in consciousness caused by a fall in BP
What are the causes of (i) bilateral (ii) unilateral oedema?
(i) cardiac failure, chronic venous insufficiency, hepatic/renal pathology, medication side effect, pelvic mass, immobility etc
(ii) DVT, soft tissue infection, trauma, lymphatic obstruction etc
Describe the origin, insertion & action of (i) pectoralis major (ii) pectoralis minor (iii) latissimus dorsi (iv) serratus anterior
(i) clavicle, costal cartilages & sternum to humerus
- shoulder flexion & adduction
(ii) ribs 3,4 and 5 to coracoid
- stabilises scapula & is a landmark for axillary artery & brachial plexus
(iii) iliac crest, lower thoracic & lumbar vertebrae to humerus
- shoulder extension & adduction
(iv) upper (8) ribs to medial border of scapula
- scapular protraction & rotation in shoulder abduction
What is the blood supply & lymph drainage of the breast?
BS = axillary & internal thoracic arteries lymph = axillary & int thoracic nodes
What are the 3 levels used to describe the severity of tumour spread in the axillary nodes?
LEVEL 1 anterior/pectoral group (lateral to pec minor)
LEVEL 2 central group (deep to pec minor)
LEVEL 3 apical group (medial to pec minor)
What organs does the thoracic wall “protect”?
heart & great vessels Lungs & major airways Liver Stomach Spleen Kidneys
Describe the (i) pump-handle movement (ii) Bucket-handle movement.
(i) rib elevation to push the sternum up & forward to increase thoracic A-P diameter
(ii) additional increase in lateral diameter caused by rub eversion
What accessory muscles are used & when are the used for respiration?
Big muscles that attach to the head & ULs, as well as the abdominal wall muscles
Used when more power is required
What is the inlet & outlet of the thorax & abdomen?
THORAX inlet = neck outlet = diaphragm ABDOMEN inlet = diaphragm outlet = pelvic diaphragm
Describe the thoracic inlet.
a ring of bone & cartilage
T1, 1st ribs & CCs
manubrium
- it slopes antero-inferiroly to T2/3
Where does the apex of the lung extend to?
upwards to the level of T1 & the neck of the 1st rib
i.e. 2-3cm above the anterior part of the 1st rib & clavicle
From anterior to posterior, list the structures that pass between the thorax & UL that lie on the 1st rib.
subclavian vein
scalenus anterior
subclavian artery
inferior trunk of the brachial plexus
What structures pass between the thorax & neck?
vessels that supply & drain the head & neck
trachea
oesophagus
nerves (R&L vagus, R&L phrenic)
What does the thoracic outlet consist of?
T12
12th and 11th ribs
costal cartilages of ribs 10 9 8 7
xiphoid cartilage (roughly opposite T9/10)
What structures pass through the diaphragm & at what level?
T8 CAVAL OPENING - IVC - R.phrenic nerve T10 OESOPHAGEAL OPENING - oesophagus - vagal trunks - left gastric vessels T12 aortic hiatus - aorta - azygos vein - thoracic duct
When do the lungs not reach the lower parts of the pleural cavities?
in quiet respiration
Where do the 4 corners of the heart lie?
3rd Right costal cartilage
2nd Left costal cartilage
6th Right costal cartilage
Left 5th interspace, mid-clavicular line
What is the mediastinum?
structures in the midline of the thorax, between the L and R pleural cavities
Where is the (i) superior (ii) inferior mediastinum?
(i) lies between the inlet & the plane between the sternal angle & T4/5, behind manubrium
(ii) lies inferior to the plane between the sternal angle & T4/5 & the thoracic outlet (i.e. diaphragm)
Where is the sternal Angle located?
2nd costal cartilage
T4/5
Where is the anterior mediastinum located? What does it contain?
behind the manubrium & sternum
anterior to the superior mediastinum & the upper part of the inferior mediastinum
- contains the thymus which is active in children & atrophies with age (fatty remnant)
What structures are found within the superior mediastinum?
SVC (formed by L & R brachiocephalic veins & with azygous vein entering)
Trachea & oesophagus
Aortic arch
Phrenic & vagus nerves
NOTE: the bifurcation of the pulmonary trunk is just inferior to the superior mediastinum
What are the 2(3) further subdivisions of the inferior mediastinum? What do they contain?
MIDDLE MEDIASTINUM
- pericardium & its contents (heart; asc ao, SVC)
POSTERIOR MEDIASTINUM
- structures behind heart & pericardium
- desc ao, azygous vein, thoracic duct, oesophagus
ANTERIOR MEDIASTINUM
- containing the thymus
What are the 5 functions of the CVS?
- Bulk flow of materials (e.g. gases, nutrients, hormones, waste)
- Temp regulation
- Homeostasis
- Host defence
- Reproduction
How much (as a percentage) does the blood make up the (i) heart (ii) pulmonary circulation (iii) systemic circulation?
(i) 7%
(ii) 9%
(iii) 84%
What are the 6 ways in which blood vessels vary?
number diameter wall thickness smooth muscle elastic tissue fibrous tissue
What are all blood vessels lined by?
Endothelial cells
At rest what is the rate of blood flow?
About 5L/min
Describe the features of (i) arterioles (ii) precapillary sphincters (iii) capillaries (iv) venules.
(i) smallest diameter muscular walled arteries
(ii) rings of smooth muscle that control entry of blood from arteriole into each capillary
(iii) smallest diameter BV: simple tube, one cell thick, of flattened endothelial cells
it allows for the diffusion of nutrients, waste etc in/out tissues
(iv) smallest diameter vessels which drain blood back to the larger true veins
What is the main (ultimate function of the CVS?
to ensure adequate blood flow through the capillaries of various organs
How are blood vessels arranged & what does this allow?
In a parallel arrangement
- allows independent regulation of blood flow to different organs
- allows for adaptation to the metabolic demands of the tissues
What do atrioventricular valves attach to?
Chordae tendinae
Describe the 2 semilunar valves of the heart.
Aortic & pulmonary valve
- both tricuspid
- more ‘heavy duty’
- have smaller openings, higher pressure & therefore more stress & physical abrasion
Cardiac muscle; how are they connected & what is the purpose of said connections?
They are connected by desmosomes at the junction between cells (intercalated discs)
- these discs also contain gap junctions that directly connect the cytoplasm & permit the easy transfer of ions between cells
What are the 4 main features of cardiac muscle? Describe said features.
- STRIATED
- similar to skeletal muscle
- thick & thin filaments of A&M
- smaller fibres with individual nucleus’ - CONNECTED VIA INTERCALATED DISCS
- “branching” of individual cells connected into a network - ELECTRICAL CONNECTIONS THROUGH GAP JUNCTIONS
- allow passage of ions permitting action potentials to spread
- functional syncitium - DESMOSOMES
- strong, cell-to-cell adhesion molecules
- junctional complexes
Describe the fibrous & serous pericardium
FIBROUS: defines the middle mediastinum, it surrounds the heart & great vessels
- it’s a closed sac attached superiorly to the roots of the great vessels (apex) & attaches inferiorly to the central tendon of the diaphragm (base)
- phrenic nerves lie on either side of sac & provide its sensory innervation
SEROUS: is the parietal & visceral layers, there’s a minuscule film of lubrication fluid between said layers
What are the clinical conditions that affect the pericardium? Describe them.
Cardiac tamponade
Pericarditis
What is the position of the transverse & oblique sinuses of the serous pericardium
OBLIQUE lies posterior to the heart (potential space) , behind the LA
TRANSVERSE separates the great arteries & veins. Ant = ao & PT
pos = SVC & left auricular appendage of LA
Name the (i) surfaces (ii) borders of the heart & what chambers are represented on said surfaces.
(i) RA, RV & LV form the anterior STERNOCOSTAL surface, but mainly the RV
Inferior, DIAPHRAGMATIC surface = LV & RV
Posterior surface/base = the LA
(ii) RIGHT border = RA
LEFT border = LV & left auricle
APEX = LV, palpable in the 5th left intercostal space, mid-clavicular line
Relate the “corners” of the heart to surface anatomy and diagnostic images (bony landmarks)
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What are the major relations of the heart?
Pleura, lungs & phrenic nerves lie either side
Oesophagus & descending aorta lie behind
What is the course & distribution of the right & left phrenic nerve?
Arise from C3, 4, 5
- enter the sup mediastinum between the venous & arterial veins (post to BCVs)
- they pass between the fibrous pericardium & the parietal pleura
RIGHT: related to veins; right side of SVC, RA anterior to the lung root, R side of IVC to underside of diaphragm (T8)
LEFT: related to arteries between LCC & LSC; arch of ao anterior (&lat) to vagus, ant to the L lung root on pericardium over LV
Why would irritation of the phrenic nerve result in referred pain to the shoulder? (eg from pericardium or gall bladder)
Phrenic Nerve: C 3, 4, 5 (keeps the diaphragm alive) Supraclavicular Nerves: C 3, 4
The lateral supraclavicular nerve supplies skin over shoulder, which is the C4 dermatome
Therefore, structures with a sensory supply via the phrenic may refer pain to the shoulder tip e.g. gall bladder to right shoulder
What do the phrenic nerves innervate?
R&L phrenic nerves:
- Are the sole motor supply to diaphragm
- sensory from the central tendon of diaphragm & its parietal pleura & underlying peritoneum
- sensory from the mediastinal parietal pleura
- sensory from the pericardium
Describe the functional anatomy of each of the chambers of the heart
RA receives de-oxygenated blood from body; sends it to RV; and then to lungs for oxygenation (pulmonary)
LA receives oxygenated blood from lungs; sends it to LV; and then to the body (systemic)
Atria are thin-walled and ventricles thick (esp. left)
Describe the tricuspid valve.
It opens & closes due to BP differences
The papillary muscles & chordae tendinae prevent cusp eversion during systole
3 Cusps (anterior, posterior & septal)
- are attached to a fibrous ring which is part of the fibrous skeleton of the heart
- closes during ventricular contraction (systole), prevent back-flow to the RA
What does valve competence require?
functional papillary muscles
What are the features of the Right Ventricle?
De-ox blood in through the tricuspid valve from RA & out through infundibulum & PT
It forms most of the sternocostal surface & some of the inf/diaphragmatic surface.
- Inflow tract forwards and medially through tricuspid valve. Outflow tract up and back via smooth (laminar flow) infundibulum to pulmonary valve & trunk.
Walls are trabeculated:
- trabeculae carneae (course)
- 3 papillary muscles with chordae tendineae
- Septomarginal trabecula (moderator band)
RV is crescentic in cross section because the interventricular septum bulges from the left
What does each papillary muscle provide?
It send chordae tendinae to 2 cusps
Describe the pulmonary valve.
3 cusps at the root of the pulmonary trunk (Right, Left and Anterior)
- Attached to a fibrous ring which is part of the skeleton of the heart
- Closes during ventricular relaxation (diastole), prevents backflow to the ventricle
Give a summary of the ventricles.
Trabeculae carneae = the muscular ridges in the ventricles that give power of contraction without taking up space. They also give rise to papillary muscles, each of which sends chordae tendineae to the edges of 2 valve cusps.
- The papillary muscles and chordae tendineae prevent cusp eversion into the atrium during ventricular contraction.
- MI may affect papillary muscles and cause valve incompetence.
- The wall of each ventricle becomes smooth near its outflow to create laminar blood flow into the pulmonary trunk and aorta.
Give a summary of the ventricles.
Trabeculae carneae = the muscular ridges in the ventricles that give power of contraction without taking up space. They also give rise to papillary muscles, each of which sends chordae tendineae to the edges of 2 valve cusps.
- The papillary muscles and chordae tendineae prevent cusp eversion into the atrium during ventricular contraction.
- MI may affect papillary muscles and cause valve incompetence.
- The wall of each ventricle becomes smooth near its outflow to create laminar blood flow into the PT and Ao.
Give a summary of the ventricles.
Trabeculae carneae = the muscular ridges in the ventricles that give power of contraction without taking up space. They also give rise to papillary muscles, each of which sends chordae tendineae to the edges of 2 valve cusps.
- The papillary muscles and chordae tendineae prevent cusp eversion into the atrium during ventricular contraction.
- MI may affect papillary muscles and cause valve incompetence.
- The wall of each ventricle becomes smooth near its outflow to create laminar blood flow into the PT and Ao.
How is the PT linked to the Ao?
Via the ligamentum arteriosum
What are the features of the Left Atrium?
IN: pulmonary veins (4)
OUT: bicuspid (mitral) valve to LV
- Interatrial wall smooth, possibly with a slight depression equivalent to the fossa ovalis (ASD)
- has a long tubular auricle, visible on the left cardiac border
- posterior to the LA are oesophagus & desc thoracic Ao
What are the features of the Left Ventricle?
IN: anteriorly through mitral valve towards the apex
OUT: up & back, posterior to pulmonary valve & trunk
Walls are trabeculated:
- trabeculae carnae (fine & numerous compared to RV)
- 2 papillary muscles with chrodae tendinae
- Interventricular wall consists of membranous and muscular portions from 4 embryological origins (Ventricular Septal Defects VSD)
Describe the mitral/bicuspid valve.
It closes during ventricular contraction & prevents backflow into the LA
- 2 cusps (anterior, posterior), attached to the fibrous ring which is part of the skeleton of the heart
Describe the aortic valve.
3 semi-lunar cusps at the apex of the aortic vestibule (R, L, P)
Attached to the fibrous ring which is part of the skeleton of the heart
- closes during ventricular relaxation, prevents backflow from aorta to LV
What is the purpose of the cardiac (fibrous) skeleton?
It supports valves & myocardium
Electrically separates atria & ventricles
The atrioventricular bundle of His should be the only conduction between them
Which sinus of the aortic valve is non-coronary?
posterior
What are the 4 domains of the duties of a Dr?
- Knowledge, skills & performance
– Make the care of your patient your first concern - Safety and quality
- Communication, partnership and teamwork
- Maintaining trust
What are the 4 quadrants? Describe them.
- Medical indications:
Consider each medical condition and its proposed treatment: i.Does it fulfil any of the goals of medicine?
ii.With what likelihood?
iii.If not, is the proposed treatment futile? - Pt Preferences
What does the patient want? Does the patient have the capacity to decide? If not, can anyone advocate for the patient? Do the patient’s wishes reflect a process that is: informed? understood? voluntary? continuing? - Quality of Life
Describe the patient’s quality of life in the patient’s terms and from the care providers’ perspectives. - Contextual Features
Circumstances that can either influence the decision or be influenced by the decision.
