An increased "a" wave indicates what? (physiologically)
that there is an increased resistance to right atrial emptying which could be due to decreased right ventricular compliance; for example tricuspid stenosis
An "a" wave immediatly preceeds what heart sound in diastole?
S1
An "a" wave corresponts to ____
atrial contraction
How many cm to you add to JVP to accuratly reflect the distance to the right atrium?
5cm
A normal JVP should be ___cm
less than 9cm
Conditions that lower right atrial pressure (1)
Dehydration
Conditions that elevate right atrial pressured (4)
What conditions decrease the righ atrial pressure>?
Dehydration
An "a" wave corresponds to what in the heart cycle?
atrial contraction
"a" waves come immediatly before what part of the cardiac cycle?
S1
Increased "a" waves indicate what is happening in the right atria?
there is increased resistance to emptying of the right atria, this is usually due to decresed right ventricular compliance or tricuspid stenosis
What are some pathologica causes of increased "a" waves?
right ventricular hypertrophy, pulmonary valve stenosis, chronic obstructive pulmnoary disease with associated pumonary hypertnesion, restrictive cardiomyopathy, tricuspid stenosis
Absent "a" waves are caused by what?
atrial fibrillation, Jugular/ventricular rhythms
Intermittent or prominent "a" waves or "cannon a" are caused by what?
atrial ventricular dissociation
ventricular tachycardia
An "x" decent corresponts to what?
atrial relaxation
A prominent "x" decent is due to what pathologies? (3)
constrictive pericarditis
restrictive pericarditis
pericardial tamponade
Decreased or absent "x" decent is due to what pathologies?
severe tricuspid regurgitation
Atrial fibrillation
the "C" wave represents what?
bulging of the tricuspid valve during systolic contraction it may or may not be seen in every patient
the "v" wave represents what?
increased atrial pressure as venous return increases after systole
What pathology can produce a prominent "V" wave?
severe tricuspid regurgitation
What is Kussmaul's sign?
A jugular venous pressure that rises with inspiration
What does a "y" decent represent?
the reduced pressure observed with tricuspid valve opening and atrial emptying during diastole
What causes a prominent or rapid y decent?
constrictive pericarditis
restrictive cardiomyopathy
RV infarctions
ASD
Tricuspid Regurgitation
What causes a slow y decent?
tricuspid stenosis
What causes an absent y decent?
pericardial tamponade
why does JVD normally fall with inspiration?
the reduced pressure from the expanding thoracic cavity
What does kussmaul's sign indicate?
impairment of filling of the right ventricle due to either fluid in the pericardial space or a poorly compliant myocardium or pericardium
What happpens in a positive hepatojugular reflex?
pressing on the liver augments the venous return to the right atrium with a right sided heart disease process the right atrium cannot accomodate for this increased flow of blood so the JVP rises and waveforms increasein intensity
How do you tell the difference between the jugular vein and the carotid?
They both have a pulse but the jugular has a double pulse
the jugular is more easily stopped/occluded
The pulse in the jugular is not usually as strong as the pulse in the carotid
If you have a patient with heart failure and their lungs are rapidly filling with fluid what should you give them and why?
Nitroglycerine to dialate blood vessels and promote forward flow insted of backward flow
Normal carotid upstroke follows ___ and preceeds ___ which is important for the timeing of murmers
S1, S2
What is the only way to measure the pressure in the right atria and ventricles
swann-ganz catheter
Can you hear a mitral stenosis with the diaphragm?
No, the diaphragm only hears high pitched sounds and will not be able to pick up a mitral stenosis
If upon chest exam you note that the patient is very tall and thin with a wingspan greater than their height, and they have a large chest scar what underlying disease do you expect they have and what heart problems may be corrolated with that?
Stigmata of Marfan's syndrome, aortic route disese, dialation of the aortic route aortic insufficency and aortic dissection- this is due to the connective tissue imperfections that come with marfans
When the sternum heaves it is a ____ ventricular problem when the sternum lifts it is a ___ ventricular problem
Heaves- Right ventricle; Sternum lifts- left ventricle
If the carotid has bruits or thrills use the ___ artery to time the cardiac cycle
Brachial
Where would you find the PMI (apical pulse)?
5th intercostal space 1cm medial to the midclavicular line
During percussion if the sternum is not the first and last dull note on the right then what is the most likely disease process?
Right sided dialation
S1 is loudest in the __ area
mitral area
S1 is loudest at the
apex
S2 is loudest in the __ area
pulmonic area
What murmurs do you hear in the Aortic space?
aortic stenosis
What murmurs do you hear in the pulmonic area?
pulmonic insufficency, pulmonic stenosis and S2
what murmurs do you hear in the tricuspid area?
What murmurs do you hear in the mitral area?
S1, S3, stenosis
Where is the Tricuspid area located?
4th intercostal space left sternal boarder
Where is th mitral area located?
5th intercostal space mid clavicular line
What two areas have murmurs that are heard more clearly with the diaphragm?
Aortic space, pulmonic area
In what two areas is it crucial to listen for murmurs with the bell?
Tricuspid and Mitral stenosis is a low sound is only heard with bell
True or false aortic stenosis can radiate sound to the neck
true
What is the only murmur found in the aortic space?
Aortic stenosis
Where is the Aortic space?
second intercostal right sternal boarder (below the sternal notch)
Where is the pulmonic area?
second intercostal space left sternal boarder
What murmurs/heart sounds do you hear in the pulmonic area?
When percussing what are the boarders of the heart?
left anterior axillary line in the 3rd, 4th, 5th and 6th IC spaces and boarder should be the sternum on the right
How would you possition a patient to listen to a diastolic murmur?
Have the patient sitting
put your stethoscope in the third intercostal space on the left sternal boarder
have the patient lean forward and exhale fully
Where do you listen to a splitting of the S2 heart sound?
2nd intercostal space left sternal boarder(pulmonic area)
Where do you listen for Gallops?
Mitral area 5th intercostal space mid axillary in the left lateral decubitus possition
An S1 sound that is greater than the S2 sound can be caused by what?
Tachycardia, Short PR interval, High output, MS
A S2 sound that is greater than an S1 sound can be caused by what?
1st degree AV heart block, Mitral regurgitation, CHF, ischemia
A varying S1 sound can be caused by what?
complete heart block, Afib
What causes a split S1 heart sound?
RBBB, PVC
What organs are found in the RUQ?
part of the pancrease, liver, gall baldder, kidney, adrenal gland, colon, pylorus, duodenum, portiosn of the ascending and transverse colon
What organs are found in the RLQ?
lower pole of the right kidney, cecum and appendix, portions of the ascending colon, right ovary and tube (if uterus is enlarged), right ureter (bladder if distended)
What organs are found in the LUQ?
left lobe of liver
spleen
stomach
body of pancrease
left adrenal gland and upper aspect of the left kidney
splenic flexure of colon
portion of the transverse and decending colon
What organs are found in the LLQ?
lower pole of the left kidney
sigmoid colon
portion of descending colon
left ureter (bladder if distended)
left ovary and tube (uterus if enlarged)
What are some pathologies found in the Left upper quadrant?
if you hear a bruit in the abdomen that is both systolic and diastolic what is it?
Arterial insufficency
large areas of dullness to percussion in the abdomen may indicate
acites, mass, splenomegally, impaction
dullness at flanks
acites
A protuberant belly that has increased tympany
free air in abdomen
How many cm vertically should the kidney be on percussion of an adult patient?
6-12cm its less if you go midstenal and more if you go midaxillary
an abnormally large liver can be part of portal hypertension name some conditions that cause portal hypertension
right heart failure, tricuspid stenosis, pulsitile liver, liver disease, hepatitis, early cirrhosis, fatty liver disease
If the liver is lower than normal but no increased in size what is on your differential?
tumor in the lungs, COPD, diaphragmatic depression
Percussion of the liver reveals a dender liver what are 2 disease processes that can cause this?
hepatic inflammation, portal hypertension
While you are percussing traubs space and you have the patient inhail what finding is indicative of splenomegally?
if traubs space is displaced (if you can percuss to the axillary line then no splenomegally) or if there is dullness without inspiration in traubs space or just to the side of it
What is the only test besides biopsy to tell if a patient has a kidney infection or a bad URI?
CVA tenderness test
What are some causes of visceral pain?
organ pain, hollow organ pain, kidney stone pain,
can the patient localize viceral pain?
no
The patient has tenderness with movement, pain that they can localize to the RUQ hyperasthesis, skin tenderness and rebound tenderness. does this patient have viceral or peritoneal pain?
peritoneal
Rebound tenderness indicates (peritoneal or visceral) tenderness?
Peritoneal
bleed in abdomen pain refers to
the scapula
ectopic pregnancy pain refers to
the shoulder
pancreatitis pain refers to
the back
aortic anyrism refers to
radiating pain up the back
where pain shows up when you palpate is that referred pain or the area of pathology?
area of pathology
You feel an organ on your exam in the left upper quadrant and you cant tell if its the spleen or the kidney you move upward and feel the superior aspect of the organ what do you expect it is?
kidney
you are having trouble deciding if you are feeling the kidney or the spleen the organ in question has a notch that you can sink a finger into which organ is it?
spleen
If the abdominal aorta is more than 3cm or really pulsitile what do you expect it is?
aortic anerysim
what is the gold standard for checking for aortic aneryism?
ultrasound
Central tympany tests for what?
acites
fluid wave test for what? it is a sensitive test?
acites, no
Ballottment
a brief jab to the organ like the liver in a patient with acites the organ will shift downward then rapdily float back up in the abdominal fluid hitting your hand works on liver not spleen
What is under McBurney's point?
appendix
What does rovsing's sign test for?
appendicitis
You have rebound tenderness in the left lower quadrant when pushing on the right lower quadrant this is a positive __ sign and suggests peritonitis where?
Rovsing's sign, RLQ peritonitis ie appendicitis
Psoas sign
extention of the psoas muscle aggravates an appendicitis so if you stretch or flex the psoas then the appendix will be aggravated
Obdurator sign
tests for appendicitis, stretches the internal obdurator muscle hip rotate leg internally
Cutaneous hyperethesia
when you have pain response by just touching the skin in the area of peritoneal pain
Heal tap
tests for appendicitis can also have patient jump off the gurney
Murphy's sign tests for what
cholecystitis
What is murphy's sign
when you are palpating the liver using the hooking method and you have the patient breath in, if they stop inhailing suddenly then they may have cholecystitis
what will a ventral hernia do as the patient does a crunch?
it will sink back into the abdomen
What are some things you are looking for during a rectal exam
Abnormally increased diaphragmatic excursion occurs in
atelectasis or diaphragmatic paralysis
Absent diaphragmatic excursion in
phrenic nerve damage
Flat percussion
soft intensity sound that is high pitched and short in duration on chest is indicative of pleural effusion
Dull percussion
medium intensity sound that is medium pitched and medium duration the liver will make this sound normally but in the chest it is suggestive of fluid or solid mass in the chest replacing normal air spaces
Resonant percussion
Loud, low sound with a long duration indicative of healthy lung tissue
Hyperresonant percussion
very loud and lower tahn ressonance with a longer duration indicative of emphysema or pneumothorax
Tympany
loud high pitched nois indicating gass bubble under the area of tympany in the chest it suggests absense of lung tissue or could be the gastric bubble
579 rule
the upper boarder of the liver is located in the 5th intercostal space midclavicular, 7th intercostal space midaxillary, and 9th intercostal space scapular line
If there is no cardiac dullness then what might the patient have?
emphysema
Intrapulmonary pressure is a mean pulmonary pressure of
>25mmHg at rest
>30mmHg during exercise
must be confirmed with a right heart catheter!
A patient presenting with dyspnea on exertion shoudl recieve what type of ultrasound?
ultrasound of the aorta
Axillary nodes are __ until proven otherwise
cancer
Vesicular sounds
soft low pitches breath sounds
heard through inspiration and continue through expiration
fade away at 1/3 of expiration
Bronchovesicular
Heart in equal amounts during inspiration and expiration
can be separated by a silent interval
can be heard in the first and second interspaces anteriorly and between the scapula
Bronchial
louder and higher pitched
short silence between inspiratory and expiratory
expiratory can last longer than inspiratory
can be heard over the manubrium
Rhonchi
course lung sounds caused by increased disturbance in the normal lung fields
relatively low pitched snoring sound
Wheezing
constrictive issue that is rarely found on its own
continurous musical prolonged like dashes in time
relatively high pitches with hissing or shrill quality
Crackles (rales)
distinct continuous intermittent notn musical like brief dots in time
Pulmonary functioning tests
differentiate sfrom obstructive and restrictive lung diseases
FEV1 is most important in asthma and COPD pts
Decreased FEV1
Obstructive
Increased FEV1
Restrictive
In right heart failure if your patient has a pressure of 25-30mmHg what would you expect to see in the lungs?
batwings, an hear crackles/rales indicating fluid
On a chest X ray A + B should be what of T?
less than T
A patient with a right heart cath pressure of 18 or over is in what?
Heart failure
Right heart pressure of 30mmHg or more =
pink frothy sputum and death from heart failure
What is the only EKG arrhythmia to stem entirely from lung pathology?
