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329 Cards in this Set
- Front
- Back
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abdomen anterior border
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(extends from diaphragm to symphysis pubis)
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Abdomen Posterior border
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(vertebral column & paravertebral muscles)
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Abd. wall muscles join where?
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midline by tendon seam (linea alba=white line)
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exterior abd. muscles
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rectus abdominis and eternal oblique
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underlying muscles
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internal oblique and transversus
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RUQ
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Liver--gallbladder—pylorus—duodenum--head of pancreas--part of right kidney & adrenal gland--hepatic flexure of colon--part of ascending & transverse colon
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LUQ
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Stomach--spleen--left lobe of liver--body of pancreas--part of left kidney & adrenal gland--splenic flexure of colon--part of transverse & descending colon
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RLQ
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Cecum--appendix--part of ascending colon--right ovary & fallopian tube--lower pole of right kidney--right ureter--right spermatic cord--bladder--uterus
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LLQ
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Part of descending colon--sigmoid colon--left ovary & fallopian tube--lower pole of
left kidney--left ureter--left spermatic cord--bladder--uterus |
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Epigastric
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midline, between costal reigons
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umbilical
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around umbilicous
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suprapubic
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above pubic bone
ex. full bladder = suprapubic distention |
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aorta
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slightly left of midline in upper ABD, bifurcates into right and left renal arteries at costal margin, Bifurcates into right & left iliac arteries 2 cm below umbilicus, Branches into femoral arteries at groin
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liver
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(fills RUQ & extends to left MCL) - lower border may be palpable
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spleen
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(normally not palpable)
Lays under diaphragm on postero-lateral ABD wall Lays oblique & parallel with 10th rib, lateral to MAL |
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kidneys
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(retroperitoneal; posterior to ABD at costovertebral angle)
Right kidney is approx 2cm lower than left kidney due to the liver (may be palpable) |
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ovaries
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usually only palpable by bimanual pelvic exam
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hollow organs
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are usually not papable
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stomach
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below left diaphragm behind rib cage
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gallbladder
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under liver, lateral to right MCL
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small intestine
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located in all 4 quads
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colon
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located in all 4 quads
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rib cage protects...
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abd organs
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right rib cage protects..
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liver, gallbladder, right kidney
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left rib cage protects..
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stomach, spleen, left kidney
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newborn umbilical cord
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2 arteries, 1 vein, any deviation may indicate a congenital anomaly
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infant/child liver
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takes up more space in ABD
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infant/child bladder
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lies higher in ABD cavity (between symphysis pubis & umbilicus)
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in general, infant/child organs
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are easier to palpate, b/c they have a less muscular ABD wall
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morning sickness
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(r/t increased HCG [human chorionic gonadotropin] - occurs in 1st trimester
in 50 to 75% of individuals (usually starts in 4th to 6th week) |
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heartburn during pregnancy
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(r/t increased esophageal reflux 2o increased pressure from displaced ABD organs)
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decreased GI motility during pregnancy
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constipation
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increased pressure on venous system during pregnancy may lead to
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hemorrhoids, varicostities
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enlarging uterus
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decreased bowel sounds r/t displacement of intestines upward and posterior
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ABD skin changes
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striae and linea nigra
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aging adult experiences... (7)
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increased fat on abd, decreased salivation/taste, delayed gastric emptying (increasing the risk of aspiration when laying supine), decreased gastric acid (may lead to altered B12 absorption, Fe deficiency anemia, and calcium malabsorption), increased incidence of gallstones, decreased liver size (impaired drug metabolism- "start low, go slow), increased constipation
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diet history, ask about?
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fiber, h2o, laxitive use, exercise
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appetite, assess for...
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anorexia or increased appetite
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weight change
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inc/dec, time period, intentional/unintentional
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dysphagia
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difficultly swallowing indicating a problem with throat or esohpagus
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odynophagia
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pain upon swallowing
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food intolerance
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causes GI symptoms
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lactose intolerance
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gastric bloating r/t decreased lactase, not an alleric response; subsequent exposure will not be harmful
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concerning heartburn ask about use of...
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antiacids
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for location (OLDCART) of abdominal pain
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record the quadrent pain is experienced in
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meds are usually advised to be taken with food in order to prevent what?
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gastric bleeding or gastritis
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N&V with symptoms of fever and chills indicates...
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infection
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blood with N&V
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hematemesis
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melena
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black tarry stool<--UGI bleeding, ex. ulcer
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black stools could be from
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Fe, bismuth (pepto)
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hematochezia
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maroon stools, usually lower GI bleeding, may be UGI bleed if rapid motility is present
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BRBPR
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bright red blood per rectum - lower GI bleed ex. hemorrhoids
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Clay colored stool indicates
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biliary obstruction
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decreased caliber of stool
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pencil thin= obstruction - cancer or not enough fiber
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fissures
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linear cracks in rectal mucosa, may be r/t constipation and hemorrhoids
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Distention (7 F's)
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fluid, feces, flatus, fat, fetus, fibroid, fatal mass
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after abd surgery what is a major cause of small bowl obstruction (SBO)?
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adhesions, scar tissue
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which meds are r/t GI bleeding?
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NSAIDS
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what problems can ETOH cause in the abd
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GI ulcers, liver problems
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what problems can nicotine cause in the abd
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inc. incidence of peptic ulcers
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before doing the objective exam, take these mesasures (6):
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HOB, patient’s arms at side, full exposure of ABD, empty bladder; use good lighting & examiners nails should be short
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if you are the examiner and you are left handed what side of the patient should you do the exam from?
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left
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countour is observed from where to where?
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rib cage to pubic bone
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normal contour
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is flat to rounded
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scaphoid
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dip in abd
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protrubent
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implies nutritional state, african children
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when assessing symmetry check for (3) things
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assymetry, bulges, visible masses
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to check for a hernia have the pt do what?
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a sit up
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belly button
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umbilicus
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on very thin people we may be able to see the... or ...
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aorta or perastalsis
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colicky pain
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restless
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peritoneal pain
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absolute stillness, knees flexed, grimaces, rapid uneven respirations
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everted umbilicus indicates (3 possibilities
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ascites, underlying mass, or pregnancy
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purple striae indicateds
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cushing's syndrome; an excess adencortical hormone
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what is ascites associated with?
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liver disease
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skin lesions r/t liver disease
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petechia, cutaneous angiomas
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prominent dilated veins
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portal HTN [cirrhosis, ascites] or inferior vena cava obstruction
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ausculating abd
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precedes percussion & palpation since these will alter bowel sounds if done first
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Borborygmi
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growling sounds) = hunger
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normal range for frequncy of bowel sounds
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5-30 min
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up until how long should you listen for bowel sounds until heard?
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5 minutes
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hyperactive bowel sounds
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rushing, tinkling (may indicate early bowel obstruction)
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hypoactive/absent bowel sounds is caused by possible (4) things
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Abdominal surgery results in a paralytic ileus (absence of GI motility & BS) – may take 48 hours for BS to return
peritonitis bowel obstruction hypokalemia |
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what part of the stethoscope should you use to check vascular sounds?
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bell
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brutis (swooshing vascular sound) is seen with..
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peripheral artery disease (i.e., stenosis of an artery)
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check for brutis at the aorta
-location -indication |
-left midline
-aneurysm |
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check for brutis at the renal-location
-indication |
-at costal margin on each side of abdomen
-renal artery stenosis (RAS) |
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check for brutis at the iliac-location
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2 cm below umbilicus on each side of abdomen
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check for brutis at the femoral arteries -location
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in groin over femoral arteries
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percussion detects (3) things
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distention, fluid, masses
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usually what sound (percussion) perdominates all 4 quads and r/t what?
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tympany r/t gas in small and large intestines
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there should be dullness over what ? (6)
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liver, distended bladder, adipose tissue, fluid, feces, mass
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hyperresonance will be present with..
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gaseous distention
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liver span RMCL range (5th ICS to right costal margin)
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6-12cm
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liver span mid sternal line
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4-8cm *usually not mesasured
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heptamegaly
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enlargment of the liver >12cm at the RMCL
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what disease displaces the liver downwards
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COPD
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spleen is usally obscured by.. and can be found by a dull note where?
normal legnth of spleen |
stomach contents
found at Dull note 9th to 11th ICS & posterior to left MAL -<7cm |
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an enlarged speen extending anterious to MAL could be caused by (3)
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mononucleosis, trauma, leukemia
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CVAT tenderness found by doing what, and indicates what?
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direct or indirect percussion over 12th rib elicits pain [may indicate kidney infection]
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before palpation have pt
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bend knees, relax abd
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light palpation
-depress how deep -*watch for |
depress ~ 1 cm
*Watch for involuntary guarding (board-like hardness) |
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deep palpation
-depress how deep -if palpable mass is found describe.. (8) |
depress (> 1 cm)
describe location, size, shape, consistency, surface, mobility, pulsatility, tenderness |
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how does on palpate the liver border?
is it usally palpable? |
feel edge at RUQ with deep inspiration; usually non-palpable
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inferior liver border should be..
is is abnormal if the liver border is greater than how many cm below right costal margin? |
1-2cm
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function of spleen (3)
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Forms monocytes & lymphocytes
Stores RBC & releases into circulation if needed Filters old RBCs from blood |
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a spleen has to be enlarged how many times its size to palpable
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3
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where do you feel for pulsations of the the aorta?
-prominent lateral pulsation may indicate what? |
-left of the midline
-indicate an abdominal aortic aneurysm (AAA) |
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what lymph nodes should you palpate
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inquinal lymph nodes
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roubound tenderness tests for what?
how is it done? how do you know if it's positive? |
- tests for peritoneal inflammation ex. ruptured appendix
-done by a Deep palpation with quick withdrawal (hand at 90o angle) -positive when there is pain with the quick release |
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murphy's sign (cholecystitis)
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Positive test (inspiratory arrest with deep palpation under liver)
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children usually have a protubent contour until the age of
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4
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an infant may have an umblica hernia
- it will appear with in how many wks? -reaches max size by when ? how big? -dissapears with how many yrs? |
-2-3wks
-1 mnth, 2.5 cm -1 yr |
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Diastasis recti found in children/infants
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separation of rectus ABD muscles causing bulge along midline
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up until age ? it is normal for c children to breath abdominally
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7yo
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in the first 24 hrs of life infant stool is
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sticky, greenish black meconium
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1.by the 4th day if a baby is breast fed their stool will be..
2.by the 4th day if a baby is formula fed their stool will be.. |
1. golden/yellow, pasty
2. brown-yellow, firmer |
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splenomegaly
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enlarged spleen
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sternum parts (3)
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manubrium, body & xiphoid process
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suprasternal notch of sternum
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ridged top of manubrium
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Manubriosternal Angle (Angle of Louis, Sternal angle)
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Bony ridge (articulation of manubrium & body of sternum)
• Continuous with 2nd rib (count ribs & ICS from this point) - ICS numbered by rib • Site of tracheal bifurcation into right & left main bronchi • Corresponds with upper border of atria |
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Ribs (12 pairs)
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• Costochondral junction
• Intercostal spaces • Floating ribs (11-12) - attached to spinal column only; 12th rib tip palpable midway between spine & side |
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Costal Angle
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• Normal (≤ 90o)
• Abnormal (angle increases [flattens] with hyperinflation) |
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Vertebral Prominens (C 7)
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palpate with head flexed
• If 2 bumps (then C7 & T1) |
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Thoracic Vertebrae (12)
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Spinous Process (knobs on vertebrae)
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Scapula
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Lower tip (inferior border) at 7th - 8th rib
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Reference lines
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verticle lines used to document physical findings)
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Anterior Reference lines
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Midsternal
Midclavicular (MCL) |
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Posterior Reference lines
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Vertebral (midspinal)
Scapular |
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Lateral Reference lines
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Anterior axillary line (AAL) - at anterior axillary fold
(MAL) - midway between AAL & PAL Posterior axillary line (PAL) - at post axillary fold |
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Mediastinum contains..
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heart & great vessels, esophagus, trachea)
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apex of lungs located
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3 - 4 cm above 1st rib)
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base of lungs rests
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(rests on diaphragm)
Right side (at 5th ICS, MCL) Lt side (at 6th ICS, MCL) |
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lateral border of lungs runs from where to where
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from apex of axilla to 7th - 8th ribs
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posterior border of lungs
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C7 to T10 [or T12 with inspiration])
Upper lobes T1 to T3/T4 Lower lobes T3 to T10 (expiration) or T12 (inspiration) |
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right lobes
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3 lobes: upper/middle/lower) - shorter due to liver
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left lobes
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(2 lobes: upper/lower) - narrower due to heart border
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horizantle fissure
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Right side only) - 4th rib right sternal border to 5th rib MAL
Separates upper & middle lobe |
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Anterior Oblique Fissures (bilateral)
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5th rib MAL to 6th rib MCL
Right (separates middle & lower lobes) Left (separates upper & lower lobes) |
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Costodiaphragmatic recess
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(pleura extend 3 cm below level of lung) - potential space
for fluid/air which may compress lung |
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trachea
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Trachea anterior to esophagus
• Starts at cricoid (10 - 11 cm long) • Bifurcates at manubriosternal angle (anteriorly) • Bifurcates at T4 (posteriorly) |
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acinus
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(functional respiratory unit) - bronchioles, alveolar ducts, alveolar sacs & alveoli
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goblet cells lining bronchial tree
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secrete mucus that entrap particles which are sweeped upwards by cilia
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b/c smoking paralyzes cilia
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the result is mucous pooling
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broncial tree
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Right Main Stem Bronchus (shorter & straighter)
• Dead space (trachea & bronchi) |
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Respiratory acidosis
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retained CO2
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Respiratory alkalosis
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excessive excretion of CO2 through respirations
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chronic hypoxia
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desensitzes CO2 receptors in the brain; thus low O2 levels
become the stimulus to breath |
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apnea r/t
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(delivery of high O2 concentrations
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normal stiumulus to breathe
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increased CO2
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hacking cough indicates
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mycoplasm, pneumonia
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dry, non productive cough inidcates
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early CHF, allergies, meds (ACEI)
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clear/white septum
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viral bronchitis/pneumonia
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translucent white/gray septum
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noninfectious, chronic bronchits, smoker
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green/yellow septum
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bacterial bronchitis/pneumonia)
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rust septum
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pneumococcal pneumonia) – blood mixed with yellow sputum
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blood septum (hemoptysis)
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cancer, TB
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foul odor septum
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bacterial
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orthopnea
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difficulty breathing supine - 2 pillow, etc.)
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Paroxysmal nocturnal dyspnea (PND) -
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awakens from sleep with SOB
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Dyspnea
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difficult, labored breathing)
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Diaphoresis
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night sweats
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Pleurisy (
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chest pain with breathing
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Histoplasmosis
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inhaled fungus
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gran/pesticide inhalation common in what occupation
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farmers
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Coccidioidomycosis or “Valley fever
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inhaled fungus) - San Joaquin Valley
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Silicosis common in what occupation
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stone cutters, miners, potters
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pneumoconiosis common in what occupation?
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coal miners
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Asbestos common in what occupation?
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(plumbers) - Abestos exposure + smoking increases lung CA risk (≥ 10x)
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upper respriatory infections are common children from what ages
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4-6yo
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aging adult respiratory problems
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• SOB/fatigue with daily activities (decreased vital capacity [exhaled air after maximum inspiration] as measured by spirometry)
• Lung disease • Chest pain with breathing (rib fractures - spontaneous or r/t trauma/abuse/falls) |
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start physical exam of posterior thorax by having Pt
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undress down to waist to compare sides
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when inspecting respirations look for three things:
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rate, rhythm, effort
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normal shape and symmetry of chest wall
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AP diameter < transverse; 1-2 to 5:7 (increases with age)
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scoliosis
-more common in who? -asses for .. -observe... -severe curvature (<45 degrees) may... |
more common in girls, adolescents
assess uneven shoulder, scapular, hip heights observe gait severe curvature may decrease lung volumes |
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a tripod position is..
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abnormal
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symmetric chest expansion
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(at level of T9 or T10) – may be uneven with atelectasis, pneumothorax, pleural effusion, phrenic nerve damage, etc.
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Tactile fremitus (vocal fremitus) - repeat "99"
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Palpable vibrations (use base of fingers at MCP joint or ulnar surface)
• Start at lung apices (symmetry is most important) • Most prominent between scapulae & sternum; progressively decreases down thorax • Greater in thin persons (due to decreased thickness of chest wall) |
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increased fremitus
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consolidation extending to lung surface
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decreased fremitus (transmission of vibration blocked) r/t (4) problems
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Bronchial obstruction
Pneumothorax Pleural effusion COPD (emphysema) |
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Crepitus (sub-q emphysema)
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• Course crackling sensation
• R/T air entering sub-q tissue (open thoracic injury, chest surgery, tracheostomy) |
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when percussing start where? and continue side to side down back
avoid what two areas? |
start at the apices (above clavicle)
avoid scapula and ribs |
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hyperresonant sounds from percussing ICS
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emphysema, pneumothorax
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dull sounds from percussing ICS
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increased density) - atelectasis, pneumonia, pleural effusion
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auscultation technique
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Lean forward; breathe deeply through mouth
• Use diaphragm of stethoscope • Progress from top to bottom & side to side; listen at each location for a full respiratory cycle (inspiration & expiration) |
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bronchial normal and abnormal sounds
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normal to hear loud, harsh sounds over neck (trachea and larynx)
it's abnormal to hear loud, harsh sounds over peripheral lung fields (indicates consolidation) |
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bronchovesicular sounds
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Moderately loud/harsh
• Norm over midsternum & between scapula in back (major bronchi) |
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vesicular sounds
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Low, soft
• Norm over peripheral lung fields • Absent (mucus plug, collapsed lung) - report immediately! |
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Adventitious Sounds (added sounds; not normally present)
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It may be difficult to differentiate crackles from rhonchi.
• Generally rhonchi clear with coughing & crackles do not • Rhonchi are deeper, more prolonged, more rumbling, more pronounced during expiration |
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Crackles (previously called rales) – sounds like Velcro opening
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Produced when there is fluid inside a bronchus causing a collapse of the distal (smaller) airways and alveoli. Crackles occur when there is a sudden equalization of pressure causing some of the airways to pop open. Heard on inspiration; doesn’t clear with
coughing. |
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fine crackles
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high-pitched, short duration, cracking & popping sounds)
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coarse crackles
-what are they -what are they caused by? |
(low-pitched, longer duration, bubbling & gurgling sounds)
• Causes (atelectasis, pneumonia, fibrosis, heart failure, pulmonary edema) |
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rhonchi
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• Airflow through an airway obstructed by thick secretions, spasm, or tumor (e.g,, bronchitis, decreased cough reflex, etc.)
• Loud, low, coarse sounds (like a snore or rumble) most often heard continuously during inspiration or expiration • Often clears with coughing or suctioning |
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wheeze
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Airflow through a constricted airway (bronchospasm associcated with asthma; acute or chronic bronchitis)
• High-pitched squeaking sound (like a whistle) • Primarily heard on expiration, but, may also be heard on inspiration • Assess breath sounds with forced expiration in an asthma patient to check for bronchoconstriction |
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Stridor (a sign of respiratory distress)
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• r/t partial airway obstruction
• Characterized by an inspiratory wheeze • Louder in the neck than chest |
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Pleural Friction Rub
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Caused by inflammation of pleural surfaces (pleurisy)
• Coarse, rubbing or grating sound during inspiration or expiration (disappears with breath holding) |
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voice sounds
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assess if breath sounds are abnormal
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Bronchophony
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(repeat "99" or “blue moon”)
• Norm ("99" muffled & indistinct) • ABN (clear "99") - increased lung density |
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egophony
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repeat “E”)
• Norm ("EEE" sound) • ABN ("E" to "A" changes) - consolidation |
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whispered pectoriloquy (whisper 1-2-3)
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• Norm (sounds faint, muffled, almost inaudible)
• ABN (sounds clear & distinct) - consolidation |
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inspecting anterior thorax
Pursed lips (seen in obstructive disease) |
prolongs expiration to allow for exhalation of trapped air
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clubbing of nails
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r/t chronic fibrotic lung changes
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Tension pneumothorax
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trachea shifts to the opposite side of lung collapse
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splinting
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shallow breaths to control pain
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Pectus excavatum
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sunken sternum, funnel chest)
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Pectus carinatum
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forward protrusion, pigeon chest)
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Barrel chest
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increased AP diameter) - associated with aging, emphysema, asthma
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costal angle
|
<90 degrees
|
|
|
barrel chest
|
>90 degrees
|
|
|
Retraction or bulging of ICS – unilateral vs bilateral
|
Retraction (obstruction or increased respiratory effort)
• Bulging (trapped air - emphysema) |
|
|
Use of accessory neck muscles to lift sternum & rib cage
|
(SCM, scaleni [below SCM] &
trapezius |
|
|
normal rate of respiration
|
(rate 10 - 20/min [adult] with occasional sigh [expands alveoli])
|
|
|
Tachypnea
|
rapid, shallow breathing; > 20/min) - fear, fever, anxiety, exercise,
respiratory insufficiency, pneumonia, alkalosis, pleurisy, lesions in the pons |
|
|
Hyperventilation (rapid, deep breathing)
|
extreme exertion, fear, anxiety, diabetic ketoacidosis (DKA)
CO2 is excreted thru respirations (thus increasing the alkalinity of the blood) |
|
|
Bradypnea (regular, slow breathing; < 10/min)
|
depressant drugs, increased intracranial pressure (ICP), diabetic coma
|
|
|
Hypoventilation (irregular, shallow)
|
narcotic OD, anesthetics, prolonged bedrest, splinting with pain
• CO2 is retained (may cause acidosis) |
|
|
Cheyne-stokes
|
regular, cyclic; breathe 30 - 40 sec, then apnea x 20sec) - CHF & other causes
|
|
|
Biots (ataxic
|
irregular, deep, slow with periods of apnea (precedes Cheyne Stokes)
|
|
|
Stertorous
|
snoring
|
|
|
stridor
|
croup, foreign body, growth on vocal cords, high pitched on inspiration
|
|
|
anterior Symmetric chest expansion
|
palpate thumbs on xyphoid process
|
|
|
tactile fremitus
|
chest wall vibrations while repeating “99”) - start at apices & work down; avoid breast tissue
|
|
|
percussion of anterior thorax
|
• Start at apices
• Percuss interspaces for resonance • Compare sides • Avoid breasts • Note cardiac dullness • Border of liver (dullness at 5th ICS MCL) • Gastric bubble on left (tympanic) |
|
|
auscultation of anterior thorax
|
Start at supraclavicular space & progress down to 6th rib
• Follow same pattern as with percussion |
|
|
atelectasis
|
collapsed alveoli; predisposes to pneumonia
|
|
|
bronchitis
|
inflammation of bronchi acute or chronic
|
|
|
emphysema
|
destruction of alveoli; decreased gas exchange
|
|
|
asthma
|
intermittent bronchospasm/constriction) - may lead to chronic lung disease
|
|
|
pleural effusion
|
fluid in pleural space
|
|
|
pneumothorax
|
air in pleural space; collapsed lung
|
|
|
hemothorax
|
blood in pleural space
|
|
|
Surfactant produced at 32 weeks gestation
|
problems with collapse of alveoli if born before this
|
|
|
special considerations for the physical exam of a thorax for infant/child
|
Count RR for 60 sec
• ≤ 3 months old (obligatory nose breathers) - nasal obstruction can cause death • ≤ 5 - 6 yo (bronchovesicular breath sounds normal in peripheral lung fields) |
|
|
Precordium
|
area on anterior chest overlying the heart & great vessels
|
|
|
Mediastinum
|
Midthoracic cavity that contains the heart & great vessels
Location: 2nd to 5th ICS, right sternal border to left MCL |
|
|
Apex
|
5th ICS, 7 to 9 cm left of midsternal line (approximately at MCL) - the heart is rotated
so that the right side is anterior & the left side is posterior |
|
|
Pericardium
|
Attached to vessels, esophagus, sternum & pleura; anchored to the diaphragm
|
|
|
Valves
|
Unidirectional
Open & close passively |
|
|
Atrioventricular Valves
|
Left = Mitral
Right= Tricuspid • Chordae tendinea attach the AV valves to the papillary muscles & provide stability to valves during systole (rupture of the chordae tendinea may be life threatening) |
|
|
Semilunar Valves
|
• Right = Pulmonic
• Left = Aortic |
|
|
Conduction system
|
the electrical system that initiates and conducts the heart beat
|
|
|
SA node
|
the intrinsic pacemaker. It works like a spark that starts the heart beat & then it
is transmitted across atria to the AV node, then to the Bundle of His and finally to the Perkinje fibers in the ventricles. |
|
|
Electrocardiogram (ECG)
|
reflects the electrical conduction through the heart
|
|
|
P wave
|
depolarization of atria) – spread of stimuli through atria
If the SA node isn’t firing properly or doesn’t fire at all, then the P wave will look abnormal or be absent. The SA node should fire at a rate of 60-100 bpm If a lower pacemaker takes over (e.g., AV node), then the rate will be slower |
|
|
PR interval
|
time from stimulation of atria to stimulation of ventricles
|
|
|
QRS complex
|
depolarization of ventricles) – spread of stimuli through ventricles
|
|
|
T wave
|
(repolarization of ventricles) – resting phase
|
|
|
U wave
|
(final venricular repolarization) – not always seen on EKG
|
|
|
Hemodynamic system
|
moves blood through the heart & vessels)
|
|
|
lower body blood flow
|
Lower body → inferior vena cava → RA
|
|
|
upper body blood flow
|
Head & Neck → superior vena cava → RA
↓ • RA → tricuspid valve → RV → pulmonary semilunar valve → pulmonary arteries→ lungs/alveoli → pulmonary veins → LA → mitral valve → LV → aortic semilunar valve → aorta → body |
|
|
Vessels
|
lie at base of heart)
• Venous blood • Arterial blood |
|
|
Flow of Blood
|
blood flows from higher to lower pressure gradients)
|
|
|
Backward Flow
|
Blood moves by pressure gradients. You can get a backflow of blood when atrial
pressures are excessively high. |
|
|
Backward Flow- Right heart
|
No valves between right atrium & vena cava
• If pressure in the right atrium is greater than the vena cava, then blood back flows to the veins of the neck & PV system & results in distended neck veins & peripheral edema - r/t valve disease, lung disease, etc. |
|
|
Backward Flow- Left Heart
|
No valves between left atrium & pulmonary veins
• If pressure in the left atrium is greater than the pulmonary veins, then blood back flows to the lungs & results in pulmonary congestion (e.g., crackles/rales) - r/t valve disease, HTN, etc. |
|
|
Preload (Left Ventricular End Diastolic Volume)
|
Increased left ventricular volume causes more stretch on the myocardial muscle fibers at the
end of diastole • Frank Starling Law (the greater the stretch of muscle fibers, the stronger the contraction) • The goal is to maximize preload (volume) in order to maximize left ventricular contraction & cardiac output • However, excessive preload leads to decreased C.O and heart failure |
|
|
Afterload (also known as SVR or PVR)
|
The opposing pressure the ventricle must generate to open the aortic valve during systole
• increased SVR (afterload) causes increased aortic pressures • Excessive afterload increases myocardial workload & O2 consumption • may be caused by arteriosclerosis, HTN, sympathetic nervous system stimulation (e.g., stress), excessive alcohol intake |
|
|
Cardiac Output
|
CO = HR X SV
• Normal (4 - 6 L/ min) |
|
|
Heart Sounds
|
• Heart sounds are produced by closure of the valves
• Valve sounds are louder on the left side (e.g. mitral valve closure is louder than tricuspid and aortic valve closure is louder than pulmonic) |
|
|
Valve Sites
|
Listen to all sites with the diaphragm and bell of the stethoscope
• Listen for aortic murmurs (sitting and leaning forward is best) • Listen for extra heart sounds (left lateral decubitus position is best) |
|
|
S1
|
• Mitral/tricuspid valves close → creates S1
• Aortic/pulmonic valves open (when ventricular pressure exceeds aortic) → ventricles contract and blood is ejected from ventricles • Ends diastole; begins systole |
|
|
S2
|
Aortic/pulmonic valves close → creates S2
• Mitral/tricuspid valves open • Rapid filling phase (passive initial filling of ventricles) • Atrial kick (atrial contraction ejects last 25% of SV into ventricles) • Ends systole; begins diastole |
|
|
S3
|
(S1------S2, S3) “Ken------tucky”
• Indicates ventricular resistance to early passive filling • Occurs in early diastole (immediately after S2) • Causes • Decreased ventricular compliance (early sign of HF) • High output conditions such as hyperthyroid, pregnancy, etc. |
|
|
S4
|
(S4, S1------S2) “Tenness------ee”
• Indicates ventricular resistance to filling during the atrial kick • Occurs in late diastole (immediately before S1) • Causes |
|
|
Summation Gallop
|
( S3 & S4)
|
|
|
Split S1
|
mitral valve closing before the tricuspid valve due to higher pressures on the left)
• uncommon since closure of tricuspid is usually too faint to hear • may be mistaken for an S4 |
|
|
Split S2
|
aortic valve closing before pulmonic during deep inspiration)
• common • changes in intrathoracic pressure with deep inspiration causes asynchronous valve closure • may be mistaken for an S3 although an S3 is not affected by breathing patterns • Most prominent at 2nd ICS, left sternal border at peak inspiration (in contrast to an S3 which is best heard at the apex) |
|
|
murmurs
|
blowing/swooshing sound that occurs with turbulent flow through valves or great
vessels) |
|
|
causes of murmurs
|
increased velocity (exercise)
• decreased viscosity (thin) • decreased volume (anemia) • defective valves (forward or backward flow) • septal defects (ABN openings between chambers) |
|
|
Stenotic murmurs
|
occurs when a valve is open)
• Prevents adequate forward flow through thick, stiff valves • Causes harsh murmurs |
|
|
Regurgitant murmurs
|
(occurs when a valve is closed)
• Also referred to as insufficiency • Results in backward flow due to poor valve closure • Causes turbulent sound |
|
|
Systolic Murmurs
|
heard in systole after S1)
• Aortic/pulmonic stenosis - when semilunar valves are open • Mitral/tricuspid insufficiency - when A-V valves are closed |
|
|
Diastolic Murmurs
|
heard in diastole after S2)
• Mitral/tricuspid stenosis - when A-V valves are open • Aortic/pulmonic insufficiency - when semilunar valves are closed |
|
|
In summary, to determine what type of murmur you are hearing you must:
|
1. know if you are in systole or diastole
• One way to tell if you are in systole or diastole is to palpate the carotid pulse while listening to the heart sounds; if you feel the pulse immediately after you hear the heart sound, then you are in systole. 2. identify at which valve site the murmur is loudest 3. know which valves are open & closed to determine if it is a stenotic or regurgitant murmur |
|
|
timing of murmurs
|
Systolic versus diastolic
• Early, mid or late cycle • Entire cycle • Holodiastolic (between S2 & S1) • Holosystolic (between S1 & S2) |
|
|
intensity of murmurs
|
graded 1 [soft] through 6 [loud])
|
|
|
location of murmurs
|
valve site
|
|
|
Innocent Murmur
|
functional murmur)
• No valve, cardiac or other pathology • Common in childhood (usually due to increased blood flow) |
|
|
Chest Pain Etiology
|
• Cardiac (angina, MI, mitral valve prolapse)
• Pulmonary (pneumonia, pleurisy, embolis) • Pericardial (pericarditis) • Musculoskeletal/chest wall (costochondritis, arthritis) – hurts with palpation • Gastrointestinal (may mimic MI) - ulcer, hiatal hernia, esophagitis, indigestion • Neurotic - anxiety |
|
|
Describe SXS (OLD CART)
|
Onset (at rest, with activity, after eating, etc.)
• Location (substernal, localized versus radiating) • Duration • Character (burning, sharp/stabbing, crushing, pressure, etc.) |
|
|
Angina (myocardial ischemia) - imbalance between O2 supply & demand (thus, more common
with exercise) |
SX: chest discomfort with or without radiation, SOB
• Should resolve in a couple of minutes with rest &/or treatment (NTG) → may progress to an MI if not treated • Prolonged symptoms may indicate an MI |
|
|
Myocardial Infarction (heart attack)
|
SX: similar to angina; may also have diaphoresis, N/V, palpitations, sense of
impending doom |
|
|
Atypical symptoms of CAD
|
• SOB
• sharp chest pain • fatigue |
|
|
• Risk Factors for CAD
|
Age (male ≥ 45; female ≥ 55, or postmenopausal)
• HTN or hypertensive treatment • Smoking • Hyperlipidemia • Diabetes • Family history of premature CAD in 1st degree relative (male < 55; female < 65) |
|
|
Shortness of Breath
|
Dyspnea
• DOE • PND • HF (lying down increases venous return & myocardial workload) • Orthopnea |
|
|
Edema & Nocturia
|
endent edema
• Nocturia (recumbent position increases venous return to heart → increases renal blood flow → increases U/O) |
|
|
Past HX
|
Cholesterol level, murmurs, congenital heart disease, rheumatic fever, swollen joints,
heart surgery, last EKG, stress test (ETT) results, etc. |
|
|
Family HX
|
HTN, CAD, DM, obesity, congenital heart disease, genetically transmitted disease
(e.g., hypertrophic cardiomyopathy is the leading cause of death in young athletes) |
|
|
Personal Habits
|
Diet (high fat, sodium)
• Smoking (vasoconstricts) - increases heart rate, myocardial workload and O2 consumption • ETOH (increases afterload) – cardiac depressant causing sympathetic compensatory response • Exercise (increases HDL, myocardial muscle tone) • Medications (digitalis, diuretics, beta blockers, calcium channel blockers, etc.) |
|
|
Carotid Arteries
|
Visualized at top of neck near mandible
• Palpate in lower 1/3 of neck between trachea & SCM muscle (avoids carotid sinus which slows HR) • Palpate one artery at a time • Pulse strength 2+ (diminished with decreased stroke volume) • Auscultate for bruits |
|
|
Jugular Veins
|
Indirect measure of RA pressure
• Jugular veins reflect changes in filling pressures • No valves between jugular veins & RT atrium • Increased RT atrial pressure = increased JVD • External jugular vein (lies over SCM) • Internal jugular vein (IJV) - underneath & medial to SCM • More reliable than external jugular vein for measuring RA pressure (attached directly to SVC) • Can't see IJV (can only see waves or fluctuations) • Slightly rotate head to side (look for pulsations at the RIGHT base of the neck (caused by the IJ moving the SCM) • Differentiate carotids from internal jugular veins • Internal Jugular Veins • Pulsation visible but not palpable • Two undulating waves or fluctuations • Carotids • Palpable pulsation (one brisk pulsation wave) |
|
|
Assessing Jugular Venous Distention and Jugular Venous Pressure
|
• Raise HOB 30-45 degrees and locate the top of the IJ pulsation in the Right neck
• Jugular Venous Distention • Norms: 3-4 cm above sternal angle • Jugular Venous Pressure (estimate of RA pressure) • JVP = JVD + 5 cm (distance of R atrium from sternal angle) • Norms: ≤ 9 cm H20 |
|
|
Hepatojugular reflex
|
Normal (when pressure is applied to the liver border, the jugular vein on
the right side of the neck will distend for a few seconds, then return to normal) • Abnormal (jugular veins will remain elevated as long as pressure is applied to liver) - suggestive of CHF |
|
|
Precordium
• Inspect & palpate |
Apical impulse (aka PMI)
• Located at 4th or 5th ICS, left MCL) - palpable in 1/2 of adults (decreased with obesity & thick chest walls) • If shifted farther to the left, this may indicated cardiomegaly (enlarged heart) • Heaves (lifts) • sustained forceful thrusting of ventricle during systole • visualized & palpated at the apex • Thrill (palpable vibrations) • Associated with loud harsh murmurs • Palpate across precordium |
|
|
Precordium
• • Ausculate |
• Rate (norm 60 - 100)
• Rhythm (regular; regular - irregular; irregular) • Heart sounds – listen to each valve with the diaphragm & bell • S1 (loudest at apex) • Corresponds with R wave on ECG • Diminished sounds (pericardial effusion, obesity, emphysema) • S2 (loudest at base) • Aortic valve sounds are best heard with the patient sitting & leaning forward • Split Sounds • Gallops (S3, S4) – turn patient to left side; often more pronounced over apex • Rubs and clicks • Murmurs – listen over the valve sites and note any radiation across the precordium |
|
|
ARTERIES
|
carry oxygenated blood to peripheral tissues
|
|
|
Partial arterial occlusion
|
leads to decreased 02 delivery to distal tissues & tissue ischemia)
|
|
|
Untreated total occlusion
|
may result in tissue death and loss of limb)
|
|
|
exercise
|
aggravates ischemia due to increased O2 needs)
|
|
|
VEINS
|
consist of superficial & deep veins
• Return venous blood to the heart |
|
|
Venous return depends on:
|
skeletal muscle contraction (moves blood proximally) – BR decreases return
• functional valves to prevent backflow (valves open towards the heart) • a patent lumen (to keep maximum forward flow) • respirations (help flow by decreasing thoracic pressure & increasing abdominal pressure) |
|
|
Legs
Deep veins |
(deep veins are responsible for most venous return) (femoral & popliteal veins)
|
|
|
Legs
Superficial Veins |
g., great saphenous vein (medial surface) – site for CABG
• Removal does not significantly compromise venous return since the deep veins return most blood to the heart |
|
|
perforators
|
connect the veins
|
|
|
General Questions
|
Past history of vascular problems, inflammatory conditions, heart disease
• Enlarged lymph nodes (painful, chronic, acute) |
|
|
Arterial Insufficiency
|
decreased arterial blood supply to the tissues)
|
|
|
• Intermittent claudication
|
muscle ischemia) - usually affects gastrocnemius muscle
• Classic symptoms (calf pain with exercise; relieved by rest) • High occlusive disease may manifest as pain in thigh or buttock |
|
|
Venous Insufficiency
|
decreased venous return)
|
|
|
• Swelling
|
• Unilateral versus bilateral
• unilateral (e.g., venous occlusion) • bilateral (e.g., heart failure) • Precipitating factors (prolonged standing/sitting, travel (e.g., airplanes) • Associated symptoms (SOB, nocturia) – may be HF • Nutritional status (hypoalbuminemia may lead to edema) |
|
|
Hormonal contraceptives
|
increase risk of venous thrombosis
|
|
|
Assess all palpable pulses
|
• Head & Neck (temporal, carotid) – covered in other lectures
• Arms (brachial, radial, ulnar) • Legs (femoral, popliteal, posterior tibial, dorsalis pedis) |
|
|
Grade Pulses
|
4+ (bounding)
3+ (full/increased; may be normal) 2+ (normal) 1+ (weak, barely palpable) 0 (absent) |
|
|
Use doppler as needed
|
to detect weak pulses
|
|
|
Assess bruits
|
temporal, carotid aortic, renal, iliac, femoral)
|
|
|
Assess capillary refill
|
Normal = CRT <2 sec)
• apply pressure to fingernail or toenail for a few seconds and assess blanch response of nailbed • color should return in less then 2 sec • color return in greater than 2 sec indicates: • arterial occlusion • hypothermia • hypovolemic shock |
|
|
Typical Changes of Arterial Insufficiency
|
Decreased or absent pulses
• Pallor of extremity • Cool skin • Thin, shiny, atrophic skin • Thick ridged nails • Loss of hair (check dorsum of toes) • Ulcers & gangrene • Note. An occluded artery does NOT cause swelling |
|
|
test arterial patency
Leg Elevation |
With patient supine, raise the leg until it blanches
• Then have patient sit and dangle legs (note the time of color return) • Arterial occlusion = delay in color return of many seconds or minutes • Severe disease = delay in color return of ≥ 2 minutes |
|
|
test arterial patency
Ankle-Brachial Index |
The ratio of B/P in lower legs compared to arms.
• A lower B/P in the leg is a sign of arterial occlusion |
|
|
test arterial patency
Allen Test |
(assess patency of the radial & ulnar arteries)
• hold hand up & clench fist • occlude radial & ulnar arteries • release pressure on radial artery (should pink up immediately * repeat procedure to test ulnar artery |
|
|
Edema
|
accumulation of fluid in extracellular [interstitial] spaces)
|
|
|
assessing edema
|
• Pedal (foot)
• Pretibial (anterior leg along tibia) – press directly over the bone • Dependent (feet, sacrum, etc.) • Anasarca (entire body) • Pitting versus non pitting • Edema Scale |
|
|
edema scale
|
1+ 2 mm pit disappears rapidly
2+ 4 mm pit disappears in 10-15 sec 3+ 6 mm pit may last more than 1 minute 4+ 8 mm pit lasts 2-5 minutes |
|
|
skin changes with venous stasis
|
redness (rubor) or brown discoloration, leg ulcers
|
|
|
Superficial Thrombophlebitis
|
Redness, thickening, tenderness along a superficial vein
|
|
|
Deep Vein Thrombosis
S/S |
may be life threatening; predisposes to a pulmonary embolis*
Pain, warmth, tenderness & swelling over a vein • Asymmetric calf size • Homan's sign (calf pain on dorsiflexion of foot) – UNRELIABLE; It is better to assess with a venous doppler |
|
|
Risks for Deep Vein Thrombosis
|
Bedrest or immobility (e.g., casted leg) - increased risk because of decreased skeletal muscle activity
• Trauma • Hypercoagulable state (Increased clotting) • Varicosities (genetic, obesity, pregnancy) - creates incompetent valves • Hormonal contraceptives (increased risk with smoking) – especially after age 35 |
|
|
Varicose veins
|
dilated and swollen vessels d/t incompetent venous valves or proximal vein
obstruction) |
|
|
Lymph Node Assessment (generally not palpable)
|
Palpate the epitrochlear nodes
• Palpate inguinal lymph nodes |
