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34 Cards in this Set
- Front
- Back
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How to find PMI:
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PMI: pt in supine position with head elevated 30deg; can visualize PMI. Apical impulse is the pulsation of chest wall created by systole, located btw 4th & 5th intercostal space at the MCL. Easiest to see in kids and thin pts.
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Palpation of PMI:
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palpate PMI: place fingers on pt's chest wall in region of apex of heart. Identify PMI w/ middle finger, should feel a short tapping beat, if cannot find, tell pt to exhale and hold breath, roll pt slightly to the left this brings the heart closer to chest.
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Where is PMI located?
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PMI is located at 4th & 5th intercostal space at or near the MCL and be <3cm in diameter!
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Abnormalities w/PMI
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pts w/ HF – PMI is displaced down and to left and occupies larger area due to LV dilation. May be difficult to palpate in obese pts.
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Percussion in CV?
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Percussion is not used in CV assessment (replaced by palpation).
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Auscultation: normal heart sounds?
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2 normal heart sounds S1, S2
S1 = Lub: closure of mitral and tricuspid valves, begin of systole. S2 = Dub: closure of aortic and pulmonic valves, end of systole. |
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What are 4 additional heart sounds
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S3, S4, Murmurs, Rubs
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Cause of S3 Gallop; sound it makes?
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Created by rapid filling of ventricles during early diastole
"lub-dub-dub" NORMAL IN KIDS! Abnormal in adults --> congestive HF!!! |
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Causes of S4 Gallop; sounds like?
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due to blood hitting a noncompliant ventricle (usually at end of diastole -- before S1). "Da-lub-dub"
NORMAL in kids Abnormal in adults --> LVH (bc ventricles become thick & stiff) or aortic stenosis (narrow vessel --> blood regurgitates) |
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Murmurs; sounds like?
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produced by turbulent blood flow - blowing swooshing sound.
Often result from valvular abnormalities (mitral regurgitation, aortic stenosis) type of murmur depends on location where its best heard: systolic or diastolic. |
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Grade of Murmurs
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Based on how loud it is:
Grade 1 - 6 1. barely audible 2. audible but faint 3. mod. loud 4. loud (condition is serious at this point) 5. very loud 6. loudest; can be heard w/o stethoscope |
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Rubs - cause, sounds like, when does it occur?
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Scratching, high pitched sound caused by rubbing of layers of an inflamed pericardium. Occurs in pericarditis.
Sound presence and intensity will shift with breathing and body position |
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Areas to auscultate
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1. R 2nd interspace close to sternum (aortic valve area)
2. L 2nd & 3rd interspace along left sternal border (pulmonic valve) 3. L 4th interspace along left sternal border (tricuspid valve) 4. Apex L 5th interspace (mitral valve) Listen for rate, rhythm, and any irregular heart sounds |
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How to auscultate w/ steth diaphragm
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Place diaphragm in each of 4 area to auscultate. Press firmly against chest. Good to pick up high pitched sounds.
Base of heart: S2 is louder Apex: S1 louder |
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Using bell of steth to auscultate
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use bell to listen for EXTRA heart sounds. applied lightly against chest. more sensitive to S3 and S4 sounds. Best heard over APEX
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Palpation of Carotid Artery
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palpate only one carotid artery at a time. press gently until pulse is felt.
Weak pulse = decr. CO, mitral stenosis Hyperkinetic pulse = anemia, thyrotoxicosis (excess thyroid hormone in body) |
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Auscultation of Carotid Artery -- sounds like?
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done in elderly or pt w/ CV disease -- for signs of carotid artery disease
Lightly place diaphragm over artery, ask pt to hold their breath briefly and listen for BRUITS sounds like: blowing, murmur like, suggests artery stenosis |
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Jugular Venous Pressure (JVP)
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height of venous column of blood in the internal jugular vein.
Pressure of JV reflects right atrial pressure. Best assessed on pt's R side. Measured in vertical distance above the sternal angle. Sternal angle: bony ridge adjacent to 2nd rib where the manubrium joins the body of sternum |
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Estimating JVP w/ Pt
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Elevate head of bed 30degr.
Turn pt's head away from the side you are inspecting (should inspect R side!) shine light horizontally across side of neck and note external JV, then look for pulsations of internal JV. Then hold a ruler vertically on the sternal angle... align straight edge perpendi. to angle at where the distended JV is seen (at highest oscillation point). note how far up the angle is on the ruler. |
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JVP elevation based on estimation... normal and abnormal values?
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Abnormal: >3cm above sternal angle --> usually seen with R-sided HF
Elevated JVP => JVD(distention) |
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Hepatojugular Reflux (HJR) -- sign of? how to measure?
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useful to assess in pts w/ R-sided HF.
**HJR is a sign of R-sided HF!!!!** Pt in supine position, firmly press palm of R hand on right upper quad (just below rib cage); Firmly compress for 30-60sec, watch rise in JVP. Normal: JVP will DECR after a few beats Abnormal: If JVP continues to be elevated during entire period, Hepatic Venous Congestion is present. |
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LDL-C equation; non-HDL
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LDL-C = TC - (HDL + TG/5)
Only if TG < 400mg/dl!!!! Non-HDL= TC - HDL |
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Desired TC
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<200mg/dl
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HDL
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LOW
<40 men <50 women HIGH > 60 |
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TG normal & very high
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Normal <150
Very high > 500 [cannot calc LDL!!!] |
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Major Risk Factors for Framingham
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Age: M > 45 W> 55
Fam his w/ CHD: M <55 W< 65 Cigarette smoking Hypertension bp > 140/90 or on MED Low HDL < 40 High HDL > 60 (negative risk) |
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When to use Framingham?
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used in pt w/ >2 risk factors!
Not in those with 0 -1risk or those with CHD or CHD risk equiv **RISK OF DEV CHD event in 10yrs |
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Risk cat. for pts w/ 0 - 1risk factor and NO CHD/CHD risk equiv
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LOW RISK
10 yr risk of CHD is likely <10% NO FRAM CALC NEEDED |
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Fram: Mod risk
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pts w/ 2 or more risk factors; no CHD/CHD risk equiv
CALC FRAM! <10% mod risk 10 - 20% mod HIGH risk |
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Fram: High risk
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pt w/ CHD or CHD risk equiv
CHD: MI, angina CHD risk equiv: 1. Peripheral arterial disease 2. ab aortic aneurysm 3. carotid artery disease 4. diabetes 5. stage 5 CKD (GFR<15) 6. pts w/ 2 or more risk factors AND fram score >20% |
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Fram: Very high risk
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Established CVD and 1 of the following:
1. Mult risk factors incl. diabetes 2. severe poorly controlled risk esp smoking 3. mult risk for metabolic syndrome 4. ACS (MI or unstable angina) |
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LDL goals
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High risk <100
Mod High <130 Mod <130 Low <160 pt with ACS should have goal <70!!!! |
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Non-HDL goal
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always 30 higher than LDL goal
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HDL goal
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>40 in men
>50 in women |
