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73 Cards in this Set
- Front
- Back
Blood Flow:
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– SVC –
– RA – – Tricuspid valve – – RV – – Pulmonic valve – – Pulmonary artery – – LA – – Mitral valve – – LV – Aortic valve – – Aorta |
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S1 =
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closing of the mitral/tricuspid valves
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S2 =
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closing of the aortic/pulmonic valves
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P wave =
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atrial depolarization
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P‐R interval
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filling of ventricles
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QRS =
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traveling of impulse thru Bundle of Hiss to R
& L Perkingie fibers |
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HEALTH HISTORY CUES –Child
Cardiac (4) |
Work of breathing
– Pallor – Limited activity – Change in heart rate |
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Cardiac Assessment
HEALTH HISTORY CUES‐Adult: 6 |
SOB with or without exertion
– Chest pain – Syncope – Fatigue – Palpitations – Claudication – Early satiety, abdominal fullness |
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3 Non‐modifiable Cardiac Risk Factors:
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Non‐modifiable
– Age – Gender – Genetics |
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Cardiac Risk Factors:
3 Modifiable |
– HTN
– HLD – DM |
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Cardiac Risk Factors:
• Lifestyle |
Smoking
– Sedentary lifestyle – Obesity Hostility prone behavior (Type A) |
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Cardiac Risk Factors:
Emerging Risk Factors 3 |
- Chlamydia pneumonia
– Homocystinemia – CRP |
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Cardiac Assessment: History
Common Presenting Symptoms 3 |
Fatigue/activity intolerance
• Most prevalent cardiac symptom • Need to ask questions about change • Objective assessment – 6 minute walk – GXT |
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Chest Pain
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Symptom analysis: location, intensity, chronology,
aggravating/alleviating factors, associated – Stable angina ‐ predictable pattern – Rate pressure product (RPP) • Educate pt. to know…..keep below the threshold where pt. experiences physical symptoms |
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Other causes for CP (3)
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– GERD
– Chest wall – Pulmonary |
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Canadian Cardiovascular Society Classification
for CP |
– Class 0: Asymptomatic
– Class 1: Angina with strenuous Exercise – Class 2: Angina with moderate exertion – Class 3: Angina with mild exertion • Walking 1‐2 level blocks at normal pace • Climbing 1 flight of stairs at normal pace – Class 4: Angina at any level of physical exertion |
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Cardiac Assessment: History
Shortness of Breath 5 |
– Dyspnea on exertion (DOE)
– Orthopnea – Paroxysmal Nocturnal Dyspnea (PND) – Talk Test – Use of NYHA Classification scale |
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NY Heart Association Classification for SOB/used in Heart Failure
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I
No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity NY Heart Association Classification for SOB/used in Heart Failure activity. III Marked limitation in activity due to symptoms, even during less‐thanordinary activity, e.g. walking short distances (20–100 m). Comfortable only at rest. IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients. |
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CHADS model
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CHADS score helps to predict how high the
risk is of not using anticoagulation assigns a score from 0 to 6, based on the patient's age and other medical conditions Washington University of Medicine in St. Louis model to determine if anticoagulation therapy is needed based on risk |
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Treatment with Coumadin reduces the risk of
stroke in atrial fibrillation by |
about 2/3 (66%,)
and treatment with aspirin reduces the risk by 1/4 (25%) |
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Developers of the CHADS model recommend
strongly considering therapy with Coumadin for anybody whose CHADS score |
is 1 or higher
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Clubbing
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> 180
‐convex at base & touch w/out space |
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Janeway lesion seen in
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in acute bacterial
Endocardidtis..flat..painless |
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Janeway lesion
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seen in acute bacterial
Endocardidtis flat. painless |
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Osler’s nodes:
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painful erythematous nodules
Associated w/infective carditis |
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Xanthomas..
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Common among older adults
and people with high blood lipids Around the eye called xanthelasma |
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Cardiac Assessment:
Inspection/Palpation Thrill”: fine vibration |
indicates turbulence
in the blood flow |
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Cardiac Assessment:
Inspection/Palpation “Heave”: |
strong outward thrust – may indicate
ventricular hypertrophy |
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Cardiac Assessment:
Inspection/Palpation PMI : |
5th intercostal, MCL
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Location of Thrill
Over the base of the heart at the 2nd intercostal space, just to the right of the sternum, during systole |
Aortic stenosis
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Location of Thrill
At the apex during systole |
Mitral regurgitation
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Location of Thrill
To the left of the sternum at the 2nd intercostal |
Pulmonic stenosis
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Location of Thrill
To the left of the sternum at the 4th intercostal space |
Small muscular
ventricular septal defect (Roger's disease) |
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Infant Normal Heart Rate:
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100 ‐ 130 bpm
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Child Normal Heart Rate:
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80 ‐ 100 bpm
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Adult Normal Heart Rate:
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60 ‐ 100 bpm
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Cardiac Assessment: Grading pulses
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two scales
always stat x/3 or x/4 • 3+ scale – 3/3 =bounding – 2/3 =normal – 1/3= weak • 4+scale – 4/4= bounding – ¾ =normal – 2/4 =weak – 0/3 =absent – ¼ = thready/ intermittent – 0/4 =absent |
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Pulsus magnus –
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bounding
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Pulsus Parvus -
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weak
the pulse is weak/small (parvus), and late (tardus) relative to its usually expected character. It is seen in aortic valve stenosis.[1] With respect to aortic stenosis, "typical findings include a narrow pulse pressure, LVH, a harsh late-peaking systolic murmur heard best at the right second intercostal space with radiation to the carotid arteries, |
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Pulsus Alterans –
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weak/strong alternating
Pulsus alternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis |
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Pulsus paradox
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r/t BP
abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration – normal fall in pressure is less than 10 mm Hg. – excessive decline may be a sign of tamponade, adhesive pericarditis, severe lung disease, advanced heart failure, or other conditions. |
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Allen Test
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If color does not return or returns after 7 seconds, then the
ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely cannulated. |
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5 Risk factors for AAA
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• >65
• Smoking • Male gender • 1st degree relative • Auscultated bruit |
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Pre‐hypertension
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120‐130/80‐89
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Stage 1 HTN
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140‐159/90‐99
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Stage 2 HTN
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160‐179/100‐109
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Clinical Interpretation of ABI
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Normal 1.0 or >
– At risk 0.9 – Borderline ischemia <6.0 to 0.8 – Severe ischemia <0.5 |
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Edema
– Rate the degree of edema |
O= no pitting
• +1 = 0‐1/4” pitting (mild) • +2 = ¼ ‐ ½” pitting (moderate) • +3 = ½ ‐ 1” pitting (severe) • +4 = > 1” (severe |
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Interpretation: Distance between JVP and Sternum Normal: 4 cm or
less (norm) if Increased >4 cm (Jugular Venous Distention) |
Right‐sided Heart Failure (most common)
• Increased right atrial pressure – Constrictive Pericarditis – Tricuspid stenosis – Superior Vena Cava Obstruction – Valsalva phenomenon (laughing, coughing) |
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Provocative: Hepatojugular Reflux
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Apply firm pressure to midabdomen for 30 seconds
• Apply 20‐30 mmHg of pressure – Positive test: >4 cm JVP rise for >10 seconds • Suggests CHF (right or left sided failure) • Falsely positive if Valsalva (abdominal guarding) |
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S1 loudest at
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Associated w/closure of mitral & tricuspid valves
– Loudest at apex‐ mitral & tricuspid areas – Upstroke of pulse , rise of QRS |
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S2
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associated w/closure of aortic & pulmonic valves
– Loudest at base‐aortic & pulmonic areas |
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Auscultation: Diaphragm
Cardiac Assessment: Auscultation |
Diaphragm – S1 & S2
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Auscultation: Bell
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S3, S4, murmurs
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Auscultation:Aortic :
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2nd ICS R, >S2,
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Auscultation:Pulmonic
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2nd ICS, L, >s2
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Auscultation: Erbs
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3rd ICS L, S1 = S2
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Auscultation: Tricuspid :
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5th ICS L, >S1
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Auscultation Mitral :
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5th ICS L, MCL, >S1
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Split sounds:
– Split S2‐ pulmonic area |
Respiratory effect
– Normal – Related to respiration b/c of volume changes you hear both valves splits into A2 and P2 respectively • Paradoxical split – Seen with LBBB • Fixed – Atrial ‐Septal Defect – Right Heart Failure |
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Third Heart Sound S3
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Ventricular gallop
– Heard at apex – Occurs during early diastole – Ken Tuc KY – Pathological seen in CHF, sign of being “wet” – Physiologic seen in increased flow states, under 30 – Blood splashes into stretched ventricle |
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Fourth heart Sound S4
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Atrial gallop
– Occurs w/atrial contraction – Ten Ne See – Always pathological – Found in a stiff heart • Recent MI, HTN |
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Auscultation : Murmurs
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Turbulent flow
– Timing • Diastolic murmurs indicate heart disease • Systolic murmurs can indicate heart disease or can be normal – Shape: intensity overtime‐ crescendo, decrescendo – Location: site of max intensity – Radiation: can you hear it elsewhere – Pitch: high, medium, low |
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Auscultation : Murmurs
Intensity: grade |
I = faint heard only if know 1/6
• II = quiet but heard immediately 2/6 • III = moderately loud 3/6 • IV = loud 4/6 w/palpable thrill • V = very loud heard w/stethoscope partly off chest wall 5/6 • VI = heard w/stethoscope totally off the chest wall |
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Auscultation : Murmurs
Aortic stenosis‐ |
systolic in Aortic area
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Auscultation : Murmurs
Aortic Insufficiency |
diastolic in aortic area
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Auscultation : Murmurs
Aortic insufficiency – w/regurgitation‐ |
systolic &
diastolic components |
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Auscultation
Mitral Murmurs |
diastolic murmur at apex
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Mitral regurge‐
Auscultation |
systolic murmur at apex
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Mitral Valve Prolapse
Auscultation |
Midsystolic click
– Late murmur |
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Pericardial friction rub caused by
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caused by movement of inflammatory adhesions
between visceral and parietal pericardial layers |
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Pericardial friction rub sounds like pieces
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leather squeaking as they
are rubbed together |
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Pericardial friction rub best heard with
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the patient leaning forward or on
hands and knees with breath held in expiration |