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91 Cards in this Set
- Front
- Back
Base vs. Apex of heart
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Base - top
Apex - bottom |
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Layers of the pericardium
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Fibrous (outer) - connected to diaphragm and sternum, limits stretching of myocardial muscle
Serous (inner) -parietal - close to fibrous tissues -visceral (epicardium) - lies against heart muscle |
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Purpose and amount of pericardial fluid
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20-50mL
facilitates movement of heart muscle and protects it with lubricant |
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AV Valves
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Right - tricuspid
Left - bicuspid (mitral) |
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Semilunar valves
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Pulmonic (RV)
Aortic (LV) |
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Ischemia
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local and temporary lack of blood supply to the heart (reversible)
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Cardiac injury
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beyond ischemia but still reversible
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Infarction
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necrosis of heart muscle
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Coronary circulation
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sinus of valsalva -> left and right main coronary arteries -> (L) left anterior descending coronary artery and left circumflex artery
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Where does LAD supply blood?
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anterior wall and apex of left ventricle, anterior portion of interventricular septum
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Where does LCX branch supply arterial blood?
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left atrium
lateral and posterior portions of the ventricle (sometimes AV and SA nodes) |
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Where does the RCA supply blood?
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right atrium, right ventricle, inferior wall of LV, usually AV and SA nodes, posterior portion of interventricular septum
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What carries venous drainage from the myocardium?
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coronary sinus, anterior cardiac veins, thebesian veins
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where is venous blood from coronary system taken?
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75% RA via coronary sinus
25% in all 4 chambers via thebesian veins |
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Layers of arterial walls
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tunica intima (endothelium +CT)
tunica media (smooth muscle, CT) tunica externa (fibrous CT) |
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most common reason for hospitalization in older patients
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CHF
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amount of patients hospitalized annually for MI over 65
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more than half
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most common cause of death for patients >65
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coronary artery disease
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leasing cause of death in women >65
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heart disease
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What is CHF?
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severe progressive decreased ventricular contractility, decreased CO, decreased tissue perfusion, metabolic needs not being met, volume overload
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Left sided heart failure
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left ventricle cannot pump effectively enough to meet the body's needs (can't move preload, high volume of afterload)
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Right sided heart failure
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RV cannot pump effectively enough to circulate blood to the lungs to be oxygenated, venous distention
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Effects of high afterload in CHF
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blood and fluid back up into lungs and organs and cause edema
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Symptoms of CHF
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cough or crackles (fluid in lungs)
peripheral edema weight gain fatigue SOB, chest pain, tightness possible decreased urination dilated pupils skin pale, grey, or cyanotic orthopnea cough - frothy pink or white sputum decreased BP nausea and vomiting ascites enlarged spleen and liver anxiety falling O2 confusion jugular vein distention infarct s2 gallop, tachycardia weak pulse cool, moist skin |
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Angina
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partial occlusion of vessels supplying blood to heart muscle
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CHF compensation
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1) ventricular dilation - muscle stretch, contractility, CO eventually fails
2) ventricular hypertrophy - increased muscle mass, contractility, CO 3) increased sympathetic activity - increased HR, contractility, CO (increased workload) 4) neurohormonal responses - low CO, low RBF - renin-angiotensin system conserve H2O to increase blood volume |
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MI
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complete occlusion of vessels supplying blood to heart muscle
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Symptoms of MI AND Angina
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pain - squeezing, may radiate to shoulders, arms, neck, jaw, back, may feel like indigestion
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Symptoms of angina
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may be relieved with rest or medication if stable
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MI symptoms in women
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pain, pressure or chest discomfort
neck, shoulder, upper back or abdominal discomfort nausea and vomiting lightheadedness or diziness unusual fatigue |
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Non-modifiable risk factors for CV disease
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family hx
age race gender |
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modifiable risk factors for CV disease
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hyperlipidemia
Low sat. fats, cholesterol, sodium learn to manage stress inactivity HTN, DM abdominal obesity depression |
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Triggers for angina and MI in at risk persons
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exertion
heavy meal emotions, mental stress cigarette smoking stimulants temperature extremes |
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Gerontological variations
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decreased size of heart muscle
atria and ventricles become fibrotic and sclerotic - decreased CO vessels become fibrotic and rigid - increase BP skeletal changes can alter heart position |
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Health history: age
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childhood
-rheumatic fever adult onset -HTN -CAD -MI -CVA -AAA -Raynaud's -Mitral valve prolapse -valve stenosis or regurgitation -dilated or congestive cardiomyopathy -arteriosclerosis |
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Health history: gender
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Women
-higher mortality rate after severe MI -rise in CAD after menopause -ASD -Raynauds Men -predisposition to CAD, VSD |
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Health history: Ethnicity
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European, S. Asian
-CVD Chinese -low rates CVD Black and aboriginal -CVD |
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Health history: chief complaints
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chest pain
syncope palpitations peripheral edema extremity pain orthopnea |
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Health history: common medications
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-antianginals or vasodilators
-antidysrhythmics -anticoagulants -antihypertensives (diuretics, calcium channel blockers, ACE inhibitors) -cholesterol lowering -inotropics - influence contractility of muscle tissue -thrombolytics |
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Health history: communicable diseases
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rheumatic fever (valves)
syphilis (aorta) viral myocarditis |
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Health history: allergies
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aspirin
seafood imaging dyes latex betadine |
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Health history: Family hx
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aneurysm
CVA CAD HTN MI or sudden death MVP |
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Characteristics of Cardiac Ischemia pain
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-pain is burning, squeezing, heaviness, smothering
-not reproducible by palpation, may be relieved with rest or O2, may or may not be accompanied by ECG changes |
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Characteristics of aortic dissection pain
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-pain: sharp, sudden, tearing, radiates to shoulders, neck, back, abdomen
-neurological complications: hemiplagia, sensory deficits -may present with new murmur, bruits, or unequal BP in upper extremities |
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Characteristics of pericarditis pain
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pain: positional ache, dyspnea
may also have pericardial friction rub or distended neck veins |
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Characteristics of pulmonary embolus pain
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pain: sudden onset, sharp or stabbing, varies with respiration
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Characteristics of pneumothorax pain
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-sudden onset, tearing or pleuritic, worsened by breathing
-may also have dyspnea, tachycardia, decreased breath sounds, deviated trachea |
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Characteristics of pneumonia chest pain
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pain: stabbing, exacerbated by coughing and deep breathing
-fever, chills, productive cough, tachypnea |
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Characteristics of esophageal rupture chest pain
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pain: sudden onset upon swallowing or constant retrosternal, epigastric pain
-may mimic signs of pneumothorax -consider when patient has experienced penetrating trauma, severe epigastric blow, first or second rib fracture |
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Characteristics of MSK chest pain
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pain reproducible by chest palpation
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Characteristics of recreational drug use chest pain
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cardiac ishemia pain
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Cardiac landmarks
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aortic area (R2)
pulmonic area (L2) Erb`s point (L3) Tricuspid area (L5) Mitral area (L5, midclavicular) |
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Inspection of precordium
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assess all landmarks for pulsations, apical impulse, point of maximal impulse
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Where might the apical impulse be inspected?
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mitral area
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Where is the tricuspid area in infants?
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4th ICS
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What do you palpate for? (precordium)
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masses
pulsations heaves thrills |
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What hand surface is used to palpate for pulsation
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fingerpads
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What hand surface is used to palpate for thrills
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palmar surface of hand
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What hand surface is used to palpate for heaves
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palmar surface of hand
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Where might apical impulse be palpable?
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mitral area
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Auscultation normal findings at aortic area
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s2 (dub)
s2>s1 |
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Auscultation normal findings at pulmonic area
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listening for s2
s2>s1 (softer than aortic) may be splitting of S2 |
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Auscultation normal findings at tricuspid area
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s1>s2
s1 softer than in mitral s1 may be split but disappears when patient holds breath |
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Auscultation normal findings at mitral area
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s1>s2
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Auscultation for S3
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mitral and tricuspid areas
ventricular diastolic gallop occurs just after s2 use bell ausculate for 10-15s normal in children and young adults, 3rd trimester of pregnancy, abnormal after 30 kentucky rapid ventricular filling |
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Auscultation for s4
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mitral and tricuspid
use bell 10-15s usually louder on expiration (L) and inspiration (R) occurs just before s1 tennessee may occur with or without evidence of decompensation |
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Auscultating for murmurs
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use diaphragm over aortic, pulmonic, mitral, tricuspid
use bell over mitral and tricuspid |
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Auscultation components
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S1, S2, S3, S4
murmurs pericardial friction rub prosthetic heart valves |
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murmur characteristics
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location
radiation timing intensity quality pitch configuration |
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Causes of murmurs
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flow across a partial obstruction
increased flow through normal structures flow into a dilated chamber backward or regurgitant flow across incompetent valves shunting of blood out of a high-pressure chamber or artery through an abnormal passageway |
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Auscultating for pericardial friction rub
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from sternum (3rd-5th ICS) to apex (mitral area) with diaphragm
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Assessment of peripheral vasculature components
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inspection of JVP
inspection of hepatojugular reflex palpation and auscultation of arterial pulses inspection and palpation of peripheral perfusion |
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head elevation during inspection of JVP
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30 - 45 deg
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normal JVP reading
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less than 4cm
most distended when patient is flat 1-2cm above sternal angle when head of bed elevated 30-45 absent when head of bed at 90 deg |
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Calculating CVP, normal range
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add 5 to JVP
normal:3-8cm |
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What does a JVP of >4cm suggest?
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increased RV pressure, increased blood volume or obstruction of RV flow
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Cause of increase in JVP during hepatojugular reflex
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right-sided CHF
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Characteristics of arterial pulses
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rate
rhythm amplitude symmetry |
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Warning signs of potential CV problems
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pallor, cyanosis
chest pain diaphoresis, cool dyspnea dizziness or syncope edema fatigue feeling of impending doom palpitations tingling in extremities pain that limits self care pain or numbness in extremities |
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which arterial pulses should be auscultated? how?
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temporal, carotid, femoral
use bell, ask patient to hold breath |
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Assessment of peripheral perfusion
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arterial
-pallor -allen test venous -homan's sign colour return and venous filling |
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venous and arterial indications of peripheral perfusion
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arterial pulses
colour clubbing cap refill edema skin temperature ulcerations hair distribution |
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assessing orthostatic hypertension
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assess BP supine, sitting, standing (+HR for second 2)
assess weakness or dizziness from position change |
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abnormal findings: orthostatic hypertension pathologies
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hypovolemic
neurological dysfunction side effects from medications |
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Performing Homan's sign and possible indication
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bend knee slightly and sharply dorsiflex foot
pain may indicate DVT |
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normal findings: pallor
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no pallor develops in 60s
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CR and VFT normal findings
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CR 10s
VFT 15s |
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what is a positive allen test?
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radial and ulnar arteries can compensate for one another and maintain colour in hand
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where should peripheral edema be evaluated?
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dorsum of foot, medial malleolus, shin
bilateral comparison starting at malleolus and check how far up the leg the edema goes |
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where are venous ulcerations common?
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around ankles
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characteristics of arterial insufficiency in lower limbs
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intermittent claudication - pain in calf with exercise
pulses may be decreased or absent leg colour: dusky red when dependent skin: thin, shiny, loss of hair over foot and toe, thick ridged nails ulcers near toes or points of trauma |