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Cardiology > Week 2 > Flashcards

Week 2 Flashcards

1
Q

Describe the flow of blood through the heart

A

Enters from superior vena cava to the
R Atrium passing through the tricuspad valve into the R ventricle.
It then exits the right side of the heart through the pulmonic valve into the pulmonary artery to perfuse in the lungs. It exits the lungs (now oxygenated) through the pulmonary vein.
It enters the left atrium. It passes through the mitral valve into the left ventricle and it sent to the body by passing through the aortic valve and into the aorta

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2
Q

What is the inherent rates for the follow:

SA Node

AV Junction

Ventricle

A
  • SA Node: 60-100bpm
  • AV Junction: 40-60bpm
  • Ventricle: 20-40bpm
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3
Q

Does parasympathetic stimulation act on both the atrium and ventricles?

A

No.

PSNS stimulates the atrium only

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4
Q

Why would you place leads underneath the scapula? (2)

A

for children (kiddos are R. side heart-dominant)
OR
posterior MI suspected

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5
Q

Do the EKG lead dance

A 
Disco - Direction of the leads for the limbs
LIMB (6)
Lead I - R hand to L hand
Lead II - R hand to L leg
Lead III - L hand to L leg
AVF - left foot pos. electrode
AVR - right arm pos. electrode
AVL - left arm pos. electrode 
For extra learning fun:
CHEST (6)
V1 - aortic auscutation zone
V2 - pulmonic
V3 - erbs
V4 - left of mitral
V5 - mitral
V6 - right of mitral
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6
Q

What does the P wave indicate?

A

atrial depolarization (contraction)

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7
Q

what does the PR Interval indicate?

A

conduction delay through AV node (due to Ca ions)

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8
Q

what does the QRS complex indicate?

A

ventricular depolarization (contraction)

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9
Q

What does the QT Interval signify?

A

mechanical contraction of the ventricles (with repolarization)

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10
Q

What do we know about the T wave?

A

ventricular repolarization

inversion may indicate MI

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11
Q

What is happening with the heart during the ST segment?

A

ventricles depolarized

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12
Q

What is a U wave?

A

Occurs after T wave
caused by
- hypokalemia
- bradycardia

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13
Q

On an EKG strip:

One small box = how many seconds?

One large box = secs?

A
  • Small: 0.04 sec

- Large: 0.20 sec (1 large box = 5 small)

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14
Q

What are examples of irregularly irregular rhythms? (5)

A
  • Sinus arrhythmia
  • PAC
  • PVC
  • Afib
  • Vfib (pulse-less!)
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15
Q

What do you look at to determine rhythm on an EKG?

A

R-R intervals

if it is irregular run a CMP to check electrolytes

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16
Q

Regularly irregular rhythms include:

A
  • PAC

- PVC(bigeminy/tri/quad)

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17
Q

How do you determine the rate on an EKG

A
  • Count small boxes between two R waves
  • 1500 small boxes/minute=BPM
  • count number of beats per 6 second stripx10
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18
Q

Define Tachycardia?

A

> 100bpm

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19
Q

Define Bradycardia?

A

<60bpm

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20
Q

How is rate determined using large box distance between two R waves?

A

300, 150, 100, 75, 60, 50

ONLY WORKS for REGULAR rates*

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21
Q

If a P wave is not present before every beat what 7 things could it be

A 
Junctional rythmn
ventricular rhythm
PJC/PVC
vtach
torsades
vfib
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22
Q

A sinus rhythm consists of what on a ekg

A
  • P before every QRS in 1:1 ratio
  • Same distance between QRS
  • P waves look the same
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23
Q

You know stimulus is coming from the sinus node how?

A

When P waves are normal

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24
Q

What is a normal sinus rhythm

A
  • P before every QRS in 1:1 ratio
  • Same distance between QRS
  • P waves look the same
  • 60-100bpm
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25
Q

Define sinus bradycardia.
When are you concerned?
When would you RX a pacemaker?
What are symptoms of bradycardia?

A

<60bpm with normal P waves
Concerned at <45-50bpm
Pacemaker at 40bpm
Sx: Lightheaded, dizzy, syncope, SOB, chest pain

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26
Q

what is sick sinus syndrome

A

sx of bradycardia with tachycardic episodes

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27
Q

Define sinus tachycardia.
What labs might you run?
What symptoms would you expect to see?

A

> 100-150 bpm w/ normal p wave

  • labs: electrolytes, glucose, tsh, toxicology, cmp/cbc
  • Sx: palpitations, hypoTN, cyanosis, syncope, dizziness, weakness, chest pn, sob, altered mental status
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28
Q

Describe sinus arrythmia:

A

R-R interval shortens with inspiration, widens with expiration

  • pronounced in children, healthy as long as its phasic, hold breath, normalizes=good
  • looks wide..then shortened…then wide again
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29
Q

Premature atrial contraction (PAC)

What are common sequelae for PACs? (3)

what will you feel in the pulse if PAC?

A
  • contraction is in atrium but outside SA node
  • See a randomly early P wave, narrow QRS, may not conduct to ventricles, irregular rhythm

SEQUELAE

  • aflutter
  • afib
  • psvt

palpate pulse: beat will come but will be weaker

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30
Q

What is the most common non-geriatric arrhythmia?

A

PAC

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31
Q

what are potential etiologies of PAC (6)

A
  • emotion
  • fatigue
  • alcohol
  • tobacco
  • coffee
  • stimulants
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32
Q

Define Premature Ventricular Contraction (PVC)

what sx do PVCs cause?
what are common sequelae?
How does the pulse feel?

A

early beat, no p wave, wide bizarre QRS

sx: asx or flip flop palpitations

Seq:

  • can deteriorate into more frequent pvcs (couplet, bigeminy, trigemini),
  • V tach (3 or more beats in a row),
  • V Fib,
  • asystole

pulse: weak contraction, may/may not feel the beat

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33
Q

When do you know the source of stimulus is unifocal

A

identical shapes, a pvs is labeled and isolated

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35
Q

When looking at QRS on EKG, when do you know you’re looking at Multifocal PVC’s?

A

when QRS are more than one shape

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36
Q

What does Bigeminal mean?

A

every other beat is pvc

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37
Q

What does trigeminal mean?

A

every third beat is pvc

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38
Q

What is a triplet?

A

occur in group of three

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39
Q

Three PVCs in a row =?

A

V-tach

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39
Q

What is the acetylcholine protocol

A

OLD: 1,000 mg choline +1,000 mg pantothenic acid mixed in water drank all day..people didnt like this

NEW: SR choline 750mg and SR pantethine 300mg 1q8hs

SR=slow release

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40
Q

Junctional beat is described as what?

A

Upsidedown P wave

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41
Q

What so great about Ach protocol

A

-neurotransmitter released in all pre and post ganglionic parasympathetic neurons

  • induce skeletal muscle contraction
  • inhibit cardiac contraction
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42
Q

What do you add to the Ach protocol if they have a lot of anxiety

A
  • Tyrosine
  • 5HTP
  • cofactors with Lecithin and PA
43
Q

in regards to Ach protocol why would you choose panthethine over pantethenic acid?

A
  • frequent PVC
  • Elevated TG (dual benefit)
  • DM
  • low income
44
Q

What is long QT Syndome and why is it bad?

Tx:?

A

When the QT interval is lengthened it can be bad!

  • Torsade de points
  • SCD
  • Vfib
  • Twave alternans

TX: betablockers, d-fib, electrolytes

45
Q

Torsade de points

tx:
what can it lead to

A

rapid polymorphic ventricular tachycardia with characteristic twist of QRS around isoelectric baseline

tx: IV magnesium
- can degenerate into vfib

46
Q

What is T wave alternans a risk for

A

sudden cardiac death (SCD)

47
Q

Who is at risk for SCD?

A
  • aborted cardiac arrest
  • Fhx unexplained sudden death
  • syncope
  • torsade de points
  • t-wave alternans
  • prolonged QTc
48
Q

What types of drugs can cause prolonged QT

A
  • HTN: furosemide, HCTZ
  • Antimicrobials: sulfa, erythromycin, ketoconazole, azithro, cipro
  • Electrolyte: hypo (kal,cal,mg)
  • Psychotropics: haloperidol, risperidone, thioridazine, tricyclics, citalopram, sertaline
  • Celexa
49
Q

What is the rule about celexa in regards to long QT intervals?

A

Never give doses above 40mg/day

-inhibits fast acting Na channels

50
Q

What is a PCP’s responsibility regarding long QT

A

check prior to drug RX for long QT

  • check again when medication is steady state
  • RUN THE EKG
51
Q

how many half-lives of a medication does it take to reach steady state concentrations?

A

5 half-lives

52
Q

What is normal BP after 5 minutes resting for
Age <60
Age >60

A

<60: under 140/90 mmHg

>60: 150/90mmHg

53
Q

When assessing the PMI what is important to note

A
  • Location: 5th interspace MCL
  • Diameter: 4cm or less
  • Duration: brief, never passes midsystole
  • Amplitude: force
54
Q

If the PMI is laterally displaced or enlarged think what?

A

LCHF

55
Q

What is a thrill?

What is a heave?

A

Thrill: palpable vibration associated with an audible murmur

Heave: sustained apical impulse beyond mid systole

56
Q

Name 5 irregularly irregular rhythms

A
  • PAC
  • PVC
  • Afib
  • AV Block
  • Sinus arrhythmia
57
Q

What are PACs? Can you feel these on the pulse?

A

Early atrial beat
feels normal strength due to normal cardiac output

you can feel this on the pulse!

58
Q

What are PVCs? How does the pulse palpate?

A

Early ventricular beat

pulse feels weak due to decreased cardiac out

59
Q

Tell me about A-Fib, how do you assess HR with A-Fib?

A

completely erractic pulse

must auscultate at apex for 60 seconds to accurately assess HR

60
Q

Tell me about AV Block

A

second/third degree may feel like random dropped beat

61
Q

Does V fib have a pulse

A

NO

cardiac arrest

62
Q

List the three types of premature beats

A

PAC
PJC
PVC

63
Q

What is pulses biferens

A
  • twice as striking, dicrotic pulse, systolic
  • second pulse is during diastole from closure of aortic valve
  • common with AS, AI, HOCM
64
Q

Pulsus alternans:
does it alternate with breath?
What is it a sign of?

A

alternation of strong and weak arterial pulses despite RRR.
BP varies >20mm from one check to the next

DOES NOT alternate with breath

Sign of severe left ventricular dysfunction…
the DEATH RATTLE dun dun dun

65
Q

What is Pulsus Paradoxus?

when is it seen?

A

exaggerated fall in systolic BP during quiet inspiration- cannot palpate pulse on inspiration

  • cardiac tamponade
  • constrictive pericarditits,
  • asthma COPD
  • Restrictive cardiomyopathy,
  • severe PE
  • hypovolemic shock
66
Q

What is Pulses paradoxicus?

what can cause it?

A

increase in pulse strength/BP during inspiration (normally falls)

-PE, COPD, rCHF, emphysema, asthma

67
Q

What is Pulsus parvus?

A

Low volume, small weak pulse

shock, myocardial disease, AS, pericardial dz, cardiac failure, cardiomyopathy

68
Q

What is Pulsus Tardus?

A

delayed systolic peak due to obstruction of left ventricular ejection,
slow rise
escalated under finger

69
Q

Pulses parvus et Tardus Carotid Pulse

A

carotid pulse is reduced and delayed

70
Q

Corrigan’s Pulse

A

bounding and quickly collapsing pulse of aortic regurg, can see in carotids and in bobbing head

71
Q

Define JVD
What is it gold standard for?
What else can JVD be indicative of?

A

the highest point of pulsation for the internal jugular vein is 3-4cm above the sternal angle

Gold standard: cardiac cause of edema (CHF)

  • rCHF
  • Constrictive Pericarditis
  • SVC obstruction
  • Restrictive cardiomyopathy
  • Tricuspid regurgitation
72
Q

Hepatojugular Reflux

how is it preformed

What does it indicate

A

1cm** or more rise in JVD 3-4cm above sternal angle.

Press firmly on partially inflated BP cuff 20-30mmHg for 15-30sec

80% sensitive and specific for Chronic R and L CHF

73
Q

What is S1

What is S2

A

s1: closure of mitral/tricuspad-systole
s2: closure of aortic/ pulmonic valve-Diastole

74
Q

Aortic valve closes before or after the pulmonic valve in S2

A

Aortic valve (L) closes before pulmonic vale (R)

75
Q

What is an S1 split

What is a physiologic S1 split

A

mitral and tricuspad do not close togehter, heard at tricuspid area, as if it is all the time or not.

yes: delay of pulmonic closure
Physiologic :split: does not vary with respiration

76
Q

List the etiology for the following S1 splits:

  • Fixed
  • Intermittent
  • Fixed or Intermittent
A
  • Fixed: #1RBBB, ASD,
  • Intermittent: PVC (ectopic foci–>lack of perfusion-difference in ventricular timing)
  • Fixed or Intermittent: V-tach
77
Q

What is a physiologic S2 split

A

split on inspiration dt delayed pulmonic valve closure

78
Q

Causes of pathologic fixed S2 split

A

ASD, Mitral Regard, Pulmonic Stenosis, RVF

79
Q

If you hear the S2 split more on inspiration than expiration think:

expiration > inspiration:

A

Inspiration > Expiration: RBBB

Expiration > Inspiration: LBBB

80
Q

S3 gallop

A
  • Diastolic heart sound post s2

- Dt rapid filling against a non-compliant ventricle- death rattle

81
Q

s4 gallop

A

diastolic heart sound pre s1

-dt sudden ventricular distention during atrial systolic contraction

82
Q

When would you use the left lateral decubitus position?

A
  • obese patients/difficult to hear murmurs

- Best to hear mitral and extra sounds

83
Q

When would you use sitting forward

A

Aortic stenosis

84
Q

What is QTPILL and what is it used for

A 
Quality
Timing
Pitch
Intensity
Location
Length
85
Q

Describe and associate with the correct murmur

  • Harsh:
  • Blowing:
A

Harsh: high pitched, stenotic murmurs (AS/PS)

Blowing: Low pitch, hollow tunnel=LEAK
TR, MR, AR, PR

86
Q

Describe and associate with the correct murmur

  • Rumbling
  • Musical
A

Rumbling: through stenosis-MS, TS

Musical: MVP

87
Q

Do stenotic valves have higher or lower pitch murmurs

A

Steonic: lower pitch, wider openings

88
Q

High pitch murmurs listen with the (bell/diaphragm)

A

diaphragm

Regurge/S2 murmurs

89
Q

Low pitch murmurs listen with the (bell/diaphragm)

A

Bell: MS/TS, S1,S3, S4

90
Q

medium pitch murmurs include

A

PS/AS

91
Q

List the intensity levels

What is the name of this?

A

Levine System for Grading Intensity of Murmurs

  • 1/6: soft, intermittent, need to concentrate
  • 2/6: audible immediately on every beat
  • 3/6: loud, no thrill
  • 4/6: loud,thrill
  • 5/6: heard by placing edge of diaphragm over chest
  • 6/6: heard with stethoscope above surface
92
Q

Inspiration as an auscultation maneuver creates what?

-Increase intensity of what sounds?

A

Increases RA return, delays pulmonic valve closure, earlier closure of aortic valve

-Increase intensity of R. Heart sounds(PS/TS)

93
Q

Expiration as an auscultation maneuver creates what?

-Increase intensity of what sounds?

A

Increased LA return

Increases L heart sounds

94
Q

Isometric Hand Grip as an auscultation maneuver creates what?

-Increase intensity of what sounds?

A

-Increases peripheral resistance and blood in L. Ventricle

-Increases;
Regurg Murmurs(AR/MR)
-Decreases AS/MVP

95
Q

Valsalva as an auscultation maneuver creates what?

-Increase intensity of what sounds?

A
  • Decrease venous return, left ventricular volume
  • Increases: HOCM+MVP
-Decreases: 
Most murmurs (MS/AS)
96
Q

PLR/Squatas an auscultation maneuver creates what?

-Increase intensity of what sounds?

A
  • increaes venous return to the heart and L.ventricular volume
  • Increases: AS/MS

Decreases: HCOM/MVP

97
Q

Typical Angina

Unstable Angina

“E” triggers of angina

A

Typical: substernal, rest/nitroglycerine <2-15 minutes

Unstable: new unsent,

98
Q

Thin MI when:

A

Associated with diaphoresis N/V, “impending doom”

-Not relieved by rest, intro

99
Q

Sx of :

Aortic Stenosis

Aortic Dissection

Pericarditis

A

Stenosis: severe, syncope, angina, DOE. Crescendo, decrescendo

Dissection: Rapid onset, maximum intensity, “tearing”, radiates to back, urgent referral, order Cxr/D-dimer

Pericarditis: sudden, sharp, pleuritic pain, relieved leaning forward, radiation to neck

100
Q

5 questions to ask all patients with chest pain

A
  1. Worse on exertion?
  2. is it NOT reproducible from palpation
  3. Do you think its from your heart?
  4. Age:
  5. Hx of vascular disease

Each question scores 1 points

101
Q

If they have chest pain + DOE rule out what?

A

CAD, CHF, COPD

see if its better with nitro

102
Q

Central vs Peripheral Cyanosis

A

Central: Altitude sickness, pulmonary edema, COPD, PE

Peripheral: raynauds, chf, shock, outflow tract obstruction (AS/HCOM)

103
Q

DDX for Palpitations with:
Flip/flop:
Flutter:
Tachycardia:

A

Flip Flop: PAC/PVC

Flutter: Aflutter, Afib, frequent PAC/PVC

Tachycardia: sinus tachycardia, PAT, PSVT

104
Q

B/L lower extremity edema

U/L lower extremity edema

A

B/L: CHF or chronic kidney dz

U/L: DVT

Cardiology (8 decks)

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