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HA: Mod 3
Abd, Cardiac health assessment
| Question | Answer |
|---|---|
| Abd petechiae, mole, spider veins seen on abd with what disease process? | portal hypertension, liver disease |
| prominent dilated veins on abdomen? | portal hypertension, ascities, cirrhosis |
| Infants with exaggerated potbelly? | malabsorption d/t celiac, CF, constipation, aerophagia |
| Right shoulder referred pain | liver |
| back of left shoulder referred pain | pancreatitis |
| Referred pain from pancreatitis | back of left shoulder, low back pain, RUQ abd |
| back of right shoulder referred pain | perforated duodenal ulcer |
| right axilla referred pain | penetrating duodenal ulcer |
| screening guideline for + family hx of colon ca | colonscopy at 40 yrs or 10 yrs before ca dx in youngest family member |
| screening guideline for hereditary nonpolyposis colorectal ca | colonoscopy q 1-3 yrs, genetic counseling/testing start at 21 yr. |
| screening guideline for familial adenomatous polyposis | flex sig, or colonoscopy q 1-2 yr screen at puberty genetic counseling/testing |
| screening guideline for ulcerative colitis | colonoscopy c biopsy for dysplasia q 1-2 yr, start 7-8 yr p dx of pancolitis; or 12-15 yrs p left sided colitis |
| testing guidelines mortality reduction | FOBT annual: < 15-33% Flex sig q 5 yr: identify ca and poly > 1 cm, < mortality 59-80% DCBE q 5 yr: image entire colon, can detect ca, lg polyp |
| Incidence of colon ca | 3rd most commonly dx ca 2nd leading cause of death 5 yr survival 90% if bowel wall only; 35-60% if lymph node involved; >10% w/mets |
| Risk Factors for colon ca | older age, male, personal hx strong family hx of colorectal ca/polyps (ca in 1st degree relative < 60; or 2 1st degree of any age) hx of ovarian, endometrial, or breast ca, chronic ulcerative colitis, or Crohn's dx |
| Screening recommendations of average risk | at 50: FOBT annual; flex sig q 5 yr; DCBE 5-10yr, or colonoscopy q 10 yr (ACS:sigmoid q yr x 2 then q 3-5 yrs. c annual digital exam at 40) |
| Describe anatomic landmark of the base of the heart | 2 ICS, of the right sternal border |
| What part of the heart is the most anterior cardiac surface? | Right ventricle-under and th right of the sternum |
| Where is the apex of the heart | Left ventricle; PMI (point of maximum impulse) 5th ICS, Left MCL |
| What are controllable risk factors for CAD? | HTN, Hyperlipidemia, DM |
| What is most prevalent cardiac symptom? | fatigue target questions related to change in activity patterns. Objective measures: 6 min walk test, GXT, VO2 max |
| Canadian Classification of chest pain | Class I-extreme high activity Class II-moderate level of activity Class III-low level Class IV-at rest |
| NY Heart Association classification-functional status | Class I-sx at extreme exertion Class II-normal activity Class III-less than normal activity Class IV-at rest |
| What is difference between 3+ and 4+ pulse grading scale? | 3/3 bounding 4/4 bounding 2/3 normal 3/4 normal 1/3 weak 2/4 weak 0/3 absent 1/4 thready 0/4 absent |
| Name two pulse sites on feet | dorsalis pedis-top of foot posterior tibial-behind ankle |
| Average normal BP | 120/80 |
| prehypertension | 120-139/80-89 |
| Stage I HTN | 140-159/90-99 |
| Stage II HTN | 160-179/100-109 |
| What if results of BP reading have mixed categories? | Use higher category if Systolic and Diastolic in different cateogies |
| How do you calculate pulse pressure? | Systolic minus diastolic |
| What is the significance of narrow pulse pressure? | <25% may indicate poor perfusion |
| What is a normal Ankle-Brachial Index? | normal >/= 1.0 LEAD: <= 0.9 Borderline ischemia: |
| Extra cardiac assessment include: | general appearance skin (color/temperature/lesions) nails |
| What is a flat, painless lesion on the plam of the hand? | Janeway lesions |
| Whar are painful erythematous nodules on hands? | Osler's nodes, associated with infective endocarditis |
| What symptoms do the eyes exhibit in HTN? | opthalmic: AV nicking, exudate, hemorrhage, Roth spots |
| What is associated with high arch in the palate? | Mitral valve prolapse |
| What are the sites for chest palpation? | aortic, pulmonic, tricuspid (RV), mitral (LV) |
| What are we assessing for when we palpate the chest? | thrills, heaves (abn) PMI |
| What arteries do we assess for bruit? | carotid, temporal, aorta, renal, iliac |
| What occurs in the heart with the S1 sound? | closure of mitral & tricuspid valve, (loudest at mitral & tricuspid areas) |
| How can you differentiate S1 from S2? | upstroke of pulse; location where loudest (Rise of QRS) |
| What occurs with S2 sound? | closure of aortic and pulmonic valve (loudest at aortic, pulmonic area) |
| Split S2 heard at what area? | pulmonic area |
| What area can the S3 be heard? | at the apex, during early diastole as ventricle fills |
| What is the ventricle gallop? | S3 |
| What is the artial gallop? | S4 |
| Where is the S4 heard? | at apex |
| When is the S3 sound normal? | under 30 yrs of age |
| What is the significance of S4? | pathologic implication of stiff heart assoc. with MI, HTN |
| How do you grade murmurs? | I/VI-soft, barely audible II/VI-clearly audible III-VI-loud IV/VI-loud with thrill V-VI-ausculate with chestpiece partially off chest wall VI/VI-auscultate with chestpiece off chest wall |
| Aortic murmurs: | BASE (2nd ICS, RSB) systolic (stenosis) diastolic (aortic insufficiency) |
| Systolic murmurs: | aortic stenosis mitral regurgitation |
| Mitral murmurs: | At APEX (5th ICS, MCL) diastolic (mitral stenosis) systolic (mitral regurgitation) |
| Mitral valve prolapse | midsystolic (S2) click late murmur |
| What is the systolic heart sound? | S1 ventricular contraction |
| What is the diastolic heart sound? | S2 ventricular filling |
| What are reasons heart sounds would be muffled? | obesity COPD cardiac tamponade |
| What questions must be asked when a patient has heart failure? | congestion at rest (warm) low perfusion at rest(cold) |
| What might be assessed when a patient has wet heart failure? | crackles, S3 gallop, mitral regurg murmur,JVD,edema liver congestion, ascites |
| What might be assessed when a pt has cold heart failure? | pulse pressure decreased, skin temperature, cyanosis |
| Where is the PMI located anatomically on the chest wall? | 5th ICS, MCL |
| Displacement of the PMI could indicate what? | PMI lateral of MCL or > 10cm of midsternal line suggest LVH, or enlargment |
| What is the normal size of the PMI? | 1-2.5cm when pt supine (less than the size of a quarter); brisk & tapping |
| Where is the base of the heart? | superior (TOP) of the heart 2 ICS, R/L sternal borders Right ventricle joins pulmonary artery |
| What is the cardiac apex? | Left ventricle Located at PMI (5ICS, MCL) |
| What patients PMI might be at the xyphoid or epigastric area? | COPD, due to Right ventricle hypertrophy |
| What are the atrioventricular valves? | tricuspid (Rt) and mitral (Lt) valve |
| What occurs in systole? | Ventricular contraction |
| what occurs in diastole? | Ventricular relaxation |
| What valves are open in systole? | aortic valve as blood is pumped to body (mitral valve should be closed) |
| What valve is open in diastole? | Mitral valve |
| What causes S1? | closure of mitral valve (systole) *Think systole is higher # so it is 1st. |
| What causes S2? | closure of aortic valve (beginning of diastole) |
| What usually corresponds with systolic blood pressure? | maximum left ventricle pressure |
| What pathologic condition would cause you to hear the mitral valve opening? | mitral stenosis |
| What causes S3? | ventricular filling in early diastole normal in children < 30 yr old |
| What causes S4? | atrial contraction pathological |
| What causes a split S2? | closure of aortic and pulmonic valve at different times during INSPIRATION. Pulmonic valve closes a little later than aortic valve during inspiration. |
| Where should you listen for a split S2? | 2/3 ICS near sternum Right side-pulmonic Left side-aortic |
| Where can you a hear a split S1? | left lower sternal border (tricuspid) NOT related to inspiration! |
| Where is the sound for the mitral valve located on chest wall? | (loudest S1 segment) cardiac apex (PMI+5th ICS, MCL) |
| What are some causes of murmurs? | innocent turbulent blood flow of young stenotic valve insuffient valve (regurgitation) |
| Where would murmurs of mitral valve occur? | near cardiac apex (PMI) |
| Where would murmurs of tricuspid valve occur? | lower left sternal border |
| Where would murmurs of aortic vavle be heard? | range from 2 ICS to apex |
| Where would murmurs of pulmonic valve be heard? | 2/3rd ICS (but also can be heard at left lower sternal border and apex) |
| What occurs with the p wave on the ECG? | atrial depolarization |
| What occurs with the QRS wave on the ECG? | ventricular depolarization |
| What occurs with the T wave on the ECG? | ventricular repolarization |
| What heart sound correlates with the QRS? | S1 (systole; ventricular cnt, closure of mitral valve) |
| What heart sound correlates with the t wave? | end of T wave is S2 (beginning of diastole; ventricular relaxation; closure of aortic valve) |
| Where would extra heart sounds correlated with the ECG? | S3-between T and P wave S4-before QRS |
| What is pulse pressure? | difference between the systolic and diastolic blood pressure |
| What is arterial pressure? | ventricular contraction |
| What affects arterial pressure? | left ventricle stroke volume distensibility of aorta and lg arteries PVR volume of blood in arterial system |
| What is preload? | volume of blood in right atrium at end of diastole |
| What is afterload? | vascular resistance |
| What vein best estimates CVP(central venous pressure)? | right external jugular vein JVP = right atrial pressure = CVP = RT ventricular end diastolic pressure |
| What increases JVP? | heart failure, pulmonary htn, tricuspid stenosis, cardiac tamponade |
| Where is the sternal angle? | bony ridge adjacent to second rib where manubrium joins body of the sternum |
| How high is the sternal angle from right atrium? | 5 cm (no matter the position of the pt.) |
| What is the normal range of JVP? | > 4cm above sternal angle would be 9cm if add 5 cm (sternal angle above right atrium) |
| What are the characteristics of venous waveform? | signifies right atrium contraction a-atrial cnt (presystolic-before S1) x-atrial relaxation v-venous filling y-atial emptying into ventricle |
| What are the seven attibutes of a symptom? | location (& radiation), quality, quantity (severity-pain scale), timing, setting, remitting/exacerbating factors; assoc. symptoms |
| What kind of cough is associated with left ventricular heart failure or mitral stenosis ? | dry with exertion or at night & may progress to pink frothy sputum/hemoptysis (can also have orthopnea, PND) |
| What characterized angina? | exertional CP, less than 1-3 min (up to 10-20 min) relieved with rest,NTG. (50% have MI) |
| What type of CP assoc with aortic dissection? | anterior CP, tearing, ripping, radiate to back/neck |
| What arrythmia can be reliably identified at bedside? | a fib (irregularly irregular) |
| What is the leading cause of death for men and women in the US? | CVD; 1/3 of deaths |
| When should screening for BP begin? | age 18 |
| What is prehypertension? | 120-139/80-89 |
| What is Stage 1 htn? | 140-159/90-99 |
| What is the BP targe for diabetes & chronic kidney disease? | less than 130/80 |
| What are risk factors for htn? | physical inactivity, microalbuminuria, GFR<60, family hx of premature CVD (<55male, <65women), excess salt intake, insufficient K+ intake, excess alcohol intake |
| When should screening for risk factors of heart disease begin? When should global risk estimate occur? | age 20, according to AHA; global risk estimate at age 40 |
| When should lipoprotein and fasting glucose begin? | AHA: at age 20, every 5 yrs (or q 2 yr if risk factors present) USPSTF: age 35 men/45 women; or age 20 w/risk factors |
| What risk factor assessments should occur at routine visits? | BP, BMI, waist circumference, pulse (smoking, diet, alcohol, physical activity) |
| ATP III high risk means? | 10 year risk is > 20% established CHD or CHD risk equivalents |
| What is the primary target of cholesterol lowering therapy? | LDL < 100 for high risk (newer update <70) |
| What are independent risk factors for CHD? | metabolic syndrome, tryglicerides >150 |
| What indicates metabolic syndrome? | abd obesity (men > 40in, women > 35in) triglycerides >= 150 HDL men <40, women <50 BP >=130/85 fasting glucose >=110 |
| How do you differentiate internal jugular and carotid pulsations? | 2 elevation & 2 troughs (IJ) 1 single outward component of carotid; height does not change with position of carotid, IJ pulsation is positional; carotid not affected by inspiration, IJ height < w/inspiration; can obliterate pulsation of IJ but not carotid |
| What is the significance if venous pressure is elevated on expiration only? | COPD, not CHF |
| What is specificity of > JVP? | 98% for >left ventricular end diastolic pressure and low left ventricular EF, > risk of death from HF |
| What does a prominent a wave of venous pulsation signify? | tricuspid stenosis (resistance to r atrial cnt) 1st degree heart block SVT, junctional rhythm, pulmonary htn, pulmonary stenosis |
| What does an absent a wave mean? | a fib |
| What does a large v wave mean? | tricuspid regurgitation, constrictive pericarditis |
| When should you listen for a bruit in the carotid artery? | routinely and when a thrill is palpable |
| When is it useful to assess the brachial artery? | If carotid artery has obstruction, kinking or thrills |
| How do you differentiate the S1 & S2 heart sound? | location; S1 louder at apex, S2 louder at base timing; HR<100, S1 after long diastole pause assoc with pulse; carotid upstroke w/S1 (systole) |
| What would cause a displacement of PMI? | cardiac enlargement (as well as diffuse PMI > 3cm, and sustained high amplitude-htn: LV hypertrophy) |
| What would cause an increased amplitude of PMI? | hyperkinetic impulse: hyperthyroidism, severe anemia;pressure overload: aortic stenosis; volume overload: mitral regurg (diffuse amplitude) |
| What sounds are best heard with the bell of the stethoscope? | low-pitch sounds: S3, S4, |
| When is the S1 split louder, if present? | with faster HR = shorter PRI left lower sternal border not associated with respirations |
| When does a diastolic murmur occur? | between S2 and S1 vs. systolic murmur that occurs between S1 & S2 *palpate carotid pulse: systolic coincide with carotid upstroke |
| What can cause a presystolic crescendo murmur? | mitral stenosis murmur getting louder before S1 |
| What causes a decresendo early diastolic murmur? | aortic regurgitation murmur getting softer after S2 |
| What causes midsystolic crescendo-decrescendo murmur? | arotic stenosis (rise and fall of murmur in S1) or innocent blood flow |
| What causes a pansystolic plateau murmur? | mitral regurgitation between S1 & S2 |
| What assessment goes with any ausculated murmur? | palpate for a thrill |
| Grade 1-6 murmurs | 1-very faint, 2-quiet, but heard immediately 3-mod loud, 4- loud w/thrill 5-loud, thrill, heard w/steth partially off chest, 6, very loud, thrill, entirely off chest |
| medium-pitch 2/6, decrescendo diastolic murmur in 4th left ICS with radiation to apex | aortic regurgitation |
| harsh 3/6 cresendo-decrescendo murmur in 2nd ICS radiating to neck | aortic stenosis would accompany delay in carotid upstroke |
| What manuevers reduce left ventricular volume | standing; or valsalva manuever while pt supine: (< venous return, < PVR, < LV vol.); squat or release of valsalva (> PVR, > SV, volume in left ventricle) |
| Mitral valve prolapse | late systolic murmur (systolic click often) murmur longer w/standing/straining; shorten with squat or release of valsalvar manuever |
| aortic stenosis | systolic crescendo-decrescendo murmur decrease w/standing, increase with squat |
| hypertrophic cardiomyopathy | ONLY systolic murmur that increases with strain of Valsalva manuever |
| Pericardial tamponade | > JVP, rapid and diminishing pulse, dyspnea |
| paradoxical pulse | > 10mm Hg change in pulse amplitude with respirations; occur w/pericardial tamponade, constrictive pericarditis, COPD |
| When should an ankle-brachial index be performed? | When a pt exhibits symptoms of arterial ischemia-fatigue, aching, numbness or pain that limits walking; poorly healing wound; pain in LL/foot that changes when standing/supine; 1st degree relative with AAA |
| What is the sensitivity & specificity of the ABI? | 90% sensitive 95% specific |
| What constitutes Peripheral arterial dx? | stenosis, occlusion or aneurysm of lower extremity (often underdiagnosed) |
| What assessment finding of the pulse indicates aneurysm? | widening pulse-femoral, popliteal caused by atherosclerosis, NOT common, but occur primarily in men over 50 |
| What are the differences between arterial and venous insufficiency? | arterial aggrevated by elevation of feet, venous relieve w/ feet elevation. aterial < pulse, venous nml pulse. artery pale, rubby; venous-nml to brown. arterial-no edema, venous w/edema. gangrene w/arterial not venous. ulcer medial/venous; trauma/arteria |
| What is a nml ABI? | >0.90 indicate nml blood flow |
| What is the arterial/venous occlusive disorder that occurs with smokers? | thromboangiitis obliterans (Buerger's disease) pain in arch of foot or fingers/toes |
| What organs in the RUQ of the abdomen? | liver(possible palp at right costal margin), gallbladder,duodenum, right kidney, head of pancreas |
| LUQ of abdomen | slpeen, stomach, body of pancreas |
| LLQ | descending & sigmoid colon |
| RLQ | appendix (ascending colon) |
| What is the capacity of the bladder | 400-500 cc |
| What sacral nerves innervate the bladder | S2, S3, S4 (assess perirectal/perineal sensation) |
| Bluish discoloration of umbilicus? | Cullen's sign (intraabd bleeding) |
| What disease is assoc. w/ purple-bluish straie? | Cushing syndrome |
| What is the significance of Sister Mary Joseph Dempsey nodule? | abd nodule-assoc with > intra-abd pressure c abd ca. and increased mortality |
| What is associated with complete stillness of the pt? | peritonitis |
| What is boborygmus? | growling stomach |
| What is nml span of liver? | Male 10.5cm Female 7 cm range 6-12cm |
| Which kidney is higher? | right |
| How enlarged does spleen need to be before it can be palpated? | 3 x's its size, but can palpate in infant/child |
| normal size of aorta | 2.5 - 4 cm > 3cm suggest AAA (p.447) |
| How do we differentiate AWT from organs? | palpate area of tenderness while pt is sitting up, AWT continues whereas deeper areas < due to muscle protection. Not effective w/children, elderly or rigidity |
| McBurny's point | + pain when push down & hold then release at point of appendix |
| Rovsing's sign | pain in RLQ when palpate LLQ |
| (Ilio)psoas sign | + suggest appendicitis; pain when pt raises right thigh against pressure supine or laterally (irritation of psoas) |
| Obturator's sign | + = appendicitis; pain RLQ (right hypogastric) due to irritation of obturator muscle when rotate flexed leg w/bent knee internally |
| cutaneous hyeresthesia | pain to abd when gently pick fold of skin between thumb & index finger |
| dyspepsia | chronic, recurrent pain to upper abd usually young 20-29 |
| GERD | heartburn, acid reflux or regurgitation more than once a week. worsen by food, position; can have atypical respiratory sx |
| GERD Alarm symptoms | dysphagia (diff swallowing) odyophagia (pain with swallowing), recurrent vomiting, GI bleeding, wt loss, anemia, gastric ca risk factors |
| Who should get an endoscopy? | over 55, not respond to GERD tx, alarm sx |
| LLQ abd pain w/ absent BS, firmness, guarding and rebound on palpation | sm/lg bowel obstruction small bowel c vomiting |
| oropharyngeal dysphagia | diff swallowing r/t motor disorder; drooling, regurgitation, cough w/ aspiration |
| esophagial dysphagia | mechanical narrowing (rings, webs, stricture or ca) below sternoclavicle notch |
| motor disorders that cause dysphagia | *difficulty swallowing solids & liquid diffuse esophageal spasm w/CP, scleroderma- other s/sx scleroderma achalasia-at night, nocturnal cough, CP w/eating |
| diarrhea; acute vs chronic | acute-infectious (< 2 wks.) chronic-chron's or colitis (> 4 wks.) |
| steatorrhea | oily, frothy, floating stool celiac sprue, pancreatic insufficiency, sm bowel bacterial overgrowth |
| melena | black, tarry stool + occult blood test < 60 ml/blood in GI tract (ulcers, varices, tear in esophagus from vomiting usually assoc w/alcohol) |
| black, non-sticky stool | iron, bismuth (pepto-bismol), licorice, commercial choc. cookies |
| red blood in stool | colon, rectum or anus. ca-change in bowel habits polyps, diverticula-no other sx usually inflammation w/ diarrhea hemorrhoid-on t.p., surface of stool, drip in toilet anal fissure-on t.p. surface of stool, anal pain. IF upper GI, > 1L blood loss |
| Jaundice-unconjugated cause | > prod of bilirubin, < uptake of bili by liver, < ability of liver to conjugate bili hemolytic anemia Gilbert's syndrome (< enzyme, jaundice w/illness, stress) normal color urine! |
| Jaundice-conjugated causes | < excretion of bili into bile: viral hepatitis, cirrhosis, primary biliary cirrhosis *conjugated is water soluble-dark urine! |
| Bilirubin from breakdown of _____,by the _____,into ______ that is excreted into ______ for breakdown of _______. | heme of RBC, liver, bile, duodenum (to break down fat) |
| acholic stool | light colored stool from obstruction of bile or viral hepatitis |
| caput medusa | collateral pathway of recanalized umbilical veins radiating up abd to decompress portal htn |
| peritoneal inflammation | involuntary rigidity abd pain w/cough, percussion rebound tenderness(w/appendicitis) can be from appendicitis |
| Traube's space | left lower anterior chest wall-left side tympany nml spleen |
| posititve splenic percussion sign | dullness to percussion when pt inspires which causes enlarged spleen to rise into Traube's space |
| Risk factors for AAA | > 65 yr old smoker male 1st degree relative w AAA repair |
| What percussion sounds are expected with ascites? | tympany at top, dullness to side |
| What other signs indicate ascites | dullness to sides fluid wave peripheral edema |
| appendicitis | early:umbilicus, voluntary guarding late: RLQ > w/cough, involuntary rigidity +Rovsing, + rebound tenderness, +psoas, +obturator, + cutaneous hyperesthesia |
| age of gastric & duodenal ulcer | gastric > 50 duodenal 30-60 |
| Pt with abd pain relieved by leaning forward | pancreatitis |
| Patent foramen ovale | fetal circulation of oxygenated blood from placenta between RA to LA (bypassing lungs) closes at birth |
| ductus arteriosus | connects aorta and pulmonary artery closes 10-15 hrs p birth, up to 2 wks of age PDA remains open, causing mixture of unoxygenated blood with oxygenated blood |
| What are general characteristic of physiologic murmurs in children? | Still Murmur: musical, systolic, (S1) at Left lower sternal border, 2-3/6, age 3-7 yr. *assess murmur with color, energy, history, palpate liver (CHF) |
| causes of severe cyanosis of newborn | transposition of great vessels Tetrology of Fallot tricuspid atresia septal defect pulmonic stenosis |
| cyanosis after neonatal period | pulmonic stenosis TOF lg septal defect |
| purplish plethora | polycythemia |
| central cyanosis | congenital heart defect |
| When to refer murmurs | Diastolic! fills systolic Intense beyond 2/3rd day of life radiates widely |
| normal heart rate by age: newborn, 1 yr, 3 yr, 6 yr, 10 yr | nbn: 120-170 1 yr: 80-160 3 yr: 80-120 6 yr: 75-115 10 yr: 70-110 |
| causes of syncope | CANADA cardiac (valve stenosis, stokes-adam attack), arteriovenous, nervous, anemia, drugs, diabetes, ETOH, poison, altitude, acute fever |
| anomalous passage heart defects | atrial septal defect ventral septal defect PDA |
| valvular heart defect | stenosis (valve doesn't open completely, ex: mitral) atresia (failure of valve formation) regurgitation (incompetent-backflow) |
| vessel placement/development heart defect | transposition of great vessels tetrology of fallot (4 defects: pulm valve stenosis, VSD, aorta position btw l/r ventricles), right ventricle hypertrophy |
| heart development defects | mitral atresia (separates l atrium/ventricle) aortic stenosis (seperate l ventricle/aorta) single ventricle |
| What should you check with BP? | capillary refill prolonged cap refill and nml BP-can still crash |
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