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72 Cards in this Set
- Front
- Back
How to take the JVP
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1. patient supine at 30-45º head turned slightly to left
2. lanmark the IJV between 2 heads of SCM 3. measure ht of JVP above sternal angle (>3cm above SA = elevated) 4. adjust patient angle as needed |
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Abdominojugular reflex: when to perform
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perform if unclear which pulsation is JVP, or if the JVP appears normal but you still suspect HF
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How to perform AJ maneuver
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apply 20-30mmHg pressure over abdomen
positive maneuver confirms elevated JVP (can be transient or sustained |
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apex: 3 things to comment on
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1. position: MCL at 5th ICS
2. Size: quarter 3. movement: sustained/not sustained |
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palpation for thrills and heaves
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1. palpate 4 cardinal areas for thrill (= grade IV or more)
2. palpate for RV heave |
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Tamponade: General inspection expected findings
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potential dyspnea, \
reduced LOC if hypotensive peripheral edema |
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Expected vital signs in tamponade
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BP: low, pulsus paradoxus 20-50mmHg
HR: high RR: high Temp: NA Sats: potentially reduced |
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how to measure pulsus paradoxus
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1. note SBP where first Korotkoff sound heard
2. deflate cuff slowly and note pressure at which K sounds remain constant through inspiration and expiration 3. difference btw these two pressures = PP |
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PP in pericarditis vs. tamponade
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pericarditis: PP <20 mmHg
tamponade: PP 20-50mmHg |
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Systematic inspection in tamponade (relevent findings)
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Dyspnea Neck: JVP (NO KUSSMAUL'S, ie should increase with expiration) |
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JVP findings in tamponade 2
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1. absent y descent
2. No Kussmaul's sign (this would be present in constrictive pericarditis) |
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tamponade: palpation findings 2
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1. hepatomegaly
2. edema (palpate lower limbs for pitting edema) |
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auscultation: tamponade 2
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muffled heart sounds at all locations
pericardial rub possible |
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Vitals in LHF
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BP: ±, or decreased
HR: inc RR: inc. Temp: NA Sats: dec. |
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CHF vitals: carotid pulse
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usually normal, reduced if AS is causing their CHF..
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JVP in LHF: ht
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elevated >3cm above SA
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JVP in LHF: Waveform
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prominent outward systolic wave (CV wave)
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JVPin LHF: Kussmaul
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positive Kussmaul can indicate severe LHF
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JVP: AJ test: when to perform?
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when JVP is normal but HF suspected
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LHF: precordial inspection
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SEADS
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LHF: precordial palpation 3
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Apex (size, location, sustained)
Thrills: palpate at 4 cardinal areas Parasternal Heave |
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LHF: auscultation
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1. S1 S2
2. S3 (vol. loaded) 3. Murmurs: AS, AR, MS |
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3 murmurs that can cause LHF
+ Murmur that can result from LHF |
1. AS: systolic ejection murmur
2. AR: early diastolic decrescendo murmur 3. MS: diastolic rumble and MR if LV dilates enough.. |
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Abdo exam in LHF
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pulsatile liver = Tricuspid regurg
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LHF Palpation: extremities
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pitting edema
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Auscultation of lungs in LHF
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crackles in pulmonary edema
absent breath sounds in pleural effusion |
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next prompt: diff't AS from a benign functional murmur
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k
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Vitals in AS
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BP: low pulse pressure
HR: ±, low and slow pulse, comment later RR: ± Temp: ± (35.4-37.8) Sats: ±, low if hypoperfusing |
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Pulse in AS (2 important findings)
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palpate carotid: pulsus parvus et tardis
brachioradial delay or apical carotid delay |
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JVP in AS
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normal, unless the LHF is present and has caused RHF
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precordial inspection in AS
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SEADS
visible impulses respiratory effort |
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Abdo inspection in AS
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ascites, edema
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extrem inspection in AS
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edema
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Palpation of precordium
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1. thrills and pulsations in 4 cardinal areas
2. apical impulse (sustained) 3. RV heave 4. apical-carotid delay or brachioradial delay |
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Auscultation in AS
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1. 4 cardinal areas
2. S1, S2 (s2 diminished if calcified valve) 3. S3, S4. 4. murmurs!! |
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Murmur of AS vs. Functional murmur
location, timing, radiation, Frequency |
1. Location: R base
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description of murmurs: SCRIPT
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A mnemonic to remember what characteristics to look for when listening to murmurs is SCRIPT: Site, Configuration (shape), Radiation, Intensity, Pitch and quality, and Timing in the cardiac cycle.
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Murmur of AS vs. functional murmur
1. site 2. configuration (shape) 3. Radiation 4. Intensity 5. Pitch 6. Timing |
1. site: AS at R base, functional m. over LSB or L base
2. shape: AS = crescendo decrescendo 3. radiation: AS radiates to carotids 4. intensity 5. pitch: AS = high pitch due to large pressure gradient 6. timing: AS = early, mid, late, holosystolic |
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How does AS affect other heart sounds
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notable: softer S2 if calcified valve
others not so important • S3, S4 • reversed S2 splitting • narrow pulse pressure |
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summary: 7 key findings of AS
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1. late peaking systolic murmur over aortic area with broad apical-base radiation
2. sustained impulse 3. delayed carotid artery upstroke 4. absent or diminished S2 5. prolonged murmur 6. apical carotid delay 7. reduced carotid a. volume |
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MR: general appearance
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sick/not sick/distress
quick screen cyanosis plethoric diaphoretic dyspnea |
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MR: vitals
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BP: low in acute MR (query cardiogenic shock)
HR: normal, fast, possibly irregularly irregular RR: fast or normal T: elevated if infectious cause of MR SAO2: normal or low |
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MR: inspection: HEENT
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Central cyanosis
Conjunctival hemorrhage (IE) ROth spots on retina (IE) |
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MR inspection: Neck
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JVP !!
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MR inspection: Hands:
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• peripheral cyanosis
• evidence of IE (janeway lesions: hemorrhagic cutaneous lesions on palms and soles) • splinter hemorrhage (nails) (IE) • osler nodes: painful subQ nodes in distal finger (IE) |
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MR Inspection abdomen
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ascites, pulsatile liver, heart failure stuff
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periphery (MR inspection)
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edema
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MR inspection: Chest
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SEADS, sternal shape
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MR palpation: chest
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thrills, (4 areas)
heave apical impulse |
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MR palpation: abdo
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pulsatile liver
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MR palpation: periphery
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pitting edema
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MR ascultation
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S1, S2 (may have loud S2)
S3 (chronic), S4 (acute); listen with bell comment on regularity Murmurs |
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Murmur of MR (acute and chronic)
SCRIPT + maneuver to bring murmur out. (1. site 2. configuration (shape) 3. Radiation 4. Intensity 5. Pitch 6. Timing) |
High-pitched pansystolic blowing murmur at the apex that radiates to axilla. diastolic flow rumble may be heard in chronic MR
Isometric handgrip increases murmur (due to increased afterload). |
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next prompt: exam of suspected RHF from pulmonary edema
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k
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RHF: gen appearance
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Well/not well
dyspnea pallor diaphoresis, etc. |
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RHF: ask for vitals /offer to assess
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k
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Pulses in RHF 5
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palpate
1. radial 2. femoral 3. popliteal 4. posterior tibial 5. dorsalis pedis |
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RHF: do the JVP!!
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will either be elevated, or can perform Abdominojuglar test if JVP normal but RHF suspected..
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JVP finding in tricuspid regurg
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large V wave that blends with C wave
result = monophasic "CV wave" |
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review: performing the AJ maneuver and commenting on findings
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20-30 mmHg of pressure on abdomen for 10s.
normal response: transient rise in JVP abnormal response (and positive test) = sustained rise in JVP. |
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RHF: inspection
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hands: cyanosis, nail beds, cap refil Neck: JVP if you haven't already Chest: SEADS, hair loss abdomen: pulsatile liver legs: edema |
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Palpation: RHF
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Chest: apical impulse, heaves, thrills
abdomen: pulsatile liver, ascites legs: edema |
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Auscultation RHF
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S1, S2,
S3, S4 (LLSB) murmurs |
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Murmur of TR: SCRIPT + maneuver to bring otu
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Pansystolic murmur heard over the LLSB in 4th interspace
accentuated by incr. venous return (inspiration, lift legs, etc) |
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PVD: GA, vitals, etc same deal
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k
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PVD: inspection of legs 6
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expose legs
1. size, shape, symmetry, color 2. discoloration, swelling, rashes, scars, ulcers, abnormal venous patterns 3. ahir loss 4. nail beds 5. skin temp/difference btw legs 6. wounds and sores |
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PVD: palpation of legs 5
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1. inguinal lymph nodes
2. PULSES: femoral popliteal, dorsalis pedis, posterior tibial pulses: PRESENT or ABSENT 3. pitting edema 4. coolness of foot 5. tenderness, muscle tension (DVT) |
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PVD: auscultation of legs
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ausc. for bruits over femoral segment, iliac segment, over aorta.
bruits = stenosis |
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PVD: special maneuvers: venous filling time
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raise legs 45 deg for 1 minute, then let patient sit up and dangle feet over edge of table.
abnormal test= >20sec for the vein to rise |
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PVD: special maneuvers: cap refill time
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check toes, >5 sec is abnormal
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PVD: special maneuvers:Buerger test
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lift limb 90º till it becomes pale, slowly lower legs and note angle at which color returns to the feet.
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PVD: special maneuvers: ABI
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take BP of brachial a. on both sides. use highest value.
take bp at posterior tibialis and dorsalis pedis using BP cuff and doppler device. use highest systolic of the two. ABI = P(leg)/P(arm) P >0.97 |