Cardiac Flashcards
HEART FAILURE
Presents
Heart sounds
Dx labs/tests
Meds to be on
Meds NOT to be on
When should pt’s follow up
Presents:
Here is an easy way to remember whether a sign or symptom is from the left or right side of the heart:
**Both left and lung start with the letter L. Symptoms are lung related, such as dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.
**Right-sided heart failure symptoms are GI related (anorexia, nausea, and right upper quadrant abdominal pain)
Presents
Physical exam findings include
-lung crackles, wheezing, tachypnea, tachycardia,
Heart sounds:
-S3 gallop, paradoxical splitting of S2, jugular vein distention (JVD),
-peripheral edema, and hypoxia.
Dx labs/tests:
-BNP
-EKG
-XRAY (check for cardiomegaly)
-ECHO (measure ejc. fraction (+) = <40%)
Meds to be on:
-Diuretic
-ACEi
-ARB
Meds NOT to be on:
-no TZD’s (DM TX, cause edema)
-no NSAIDS
-no CCB
(increase sodium (Na) and fluid retention)
When should pt’s follow up:
-pt gains >2 kilos a day
INFECTIVE ENDOCARDITIS
pressents:
s/s on HEENT?
hands? feet?
Dx text to confirm?
also known as bacterial endocarditis
presents with
-fever and chills that are associated with a new-onset murmur
-anorexia
-weight loss.
- subungual hemorrhages (splinter hemorrhages on the nail bed)
-petechiae on the palate,
-Osler nodes (painful violet-colored nodes on the fingers and toes)
-nontender red spots on the palms/soles (Janeway lesions).
-Funduscopic exam may show Roth spots (retinal hemorrhages). First test done for suspected IE is the transthoracic echocardiogram.
ABDOMINAL AORTIC ANEURYSM
presents:
initial imaging test:
x-ray findings:
Majority of patients with (AAA) are asymptomatic.
If not ruptured but has symptoms, patient complains of abdominal, back, or flank pain.
The person at highest risk is a 70-year-old elderly White male who is a smoker (current or has quit) and has HTN.
The classic initial symptoms of a severe, sharp, excruciating pain in the abdomen, flank, and/or back with a pulsatile abdominal mass occurs in only about half (50%) of patients.
Incidental finding on chest x-ray may show widened mediastinum, tracheal deviation, and obliteration of aortic knob (thoracic aortic dissection).
Initial imaging test is the ultrasound.
Apical impulse:
Located at the fifth intercostal space (ICS) by the midclavicular line on the left side of the chest
Displacement of the Point of Maximal Impulse
occurs during:
1.
2.
left ventricular hypertrophy (LVH) and cardiomyopathy: The point of maximal impulse (PMI) is displaced laterally on the chest and is larger (>3 cm) in size and more prominent.
“to the Left, and Large”
Pregnancy, third trimester: As the uterus grows larger, it pushes up against the diaphragm and causes the heart to shift to the left of the chest anteriorly.
“pushed up and to the Left”
The result is a displaced PMI that is located slightly upward on the left side of the chest. May hear S3 heart sound during pregnancy.
S3 Heart Sound
-Usually indicative of heart failure or congestive heart failure (CHF)
-Occurs during early diastole (also called a “ventricular gallop” or an “S3 gallop”)
-Sounds like “Kentucky”
-Always considered abnormal if it occurs after the age of 40 years
-This can be a normal finding in children, pregnant women, and some athletes (>35 years of age)
S4 Heart Sound
Increased resistance due to a stiff left ventricle; usually indicates LVH
-Considered a normal finding in some elderly (slight stiffness of left ventricle)
Occurs during late diastole (also called an “atrial gallop” or “atrial kick”)
-Sounds like “Tennessee”
-Best heard at the apex (or apical area; mitral area) using the bell of the stethoscope
Benign Variants:
Physiological S2 Split normal if:
S4 in the Elderly
Physiological S2 Split
-Best heard over the pulmonic area (or second ICS on the upper left side of sternum); caused by splitting of the aortic and pulmonic components.
-A normal finding if it appears during inspiration and disappears at expiration.
S4 in the Elderly
-Some healthy elderly patients have an S4 (late diastole) heart sound, also known as the “atrial kick” (the atria have to squeeze harder to overcome resistance of a stiff left ventricle).
-If there are no signs or symptoms of heart/valvular disease, it is considered a normal variant.
-Pathological S4 is associated with LVH due to increased resistance from the left ventricle.
Mitral Area
-The mitral area is also known as the apex (or apical area) of the heart.
-Fifth left ICS is approximately 8 to 9 cm from the midsternal line and slightly medial to the midclavicular line.
-PMI or the apical pulse is located in this area.
Aortic Area
-The aortic area is the second ICS to the right side of the upper border of the sternum.
Erb’s Point
-Erb’s point is located at the third to fourth ICS on the left sternal border.
A louder murmur. First time that a thrill is present. A thrill is like a “palpable murmur.”
Grade IV
(6 grades total)
systolic murmurs
the only murmurs that____
MR PM AS MVP
“MR”: (point to patons armpit)
PM
“AS”: (grabs him behind the neck)
MVP: clic
Diastolic Murmurs
AR MS
diastolic = doom
All murmurs with “mitral” in their names are only described as located:
-On the apex (or apical area) of the heart or
-On the fifth ICS on the left side of the sternum medial to the midclavicular line
If an apical/apex murmur occurs during S1, it is _______. If an apical/apex murmur occurs during S2, it is ______
mitral regurgitation (MR)
mitral stenosis (MS)
S3 is a sign of ____; S4 is a sign of _____.
CHF
LVH (left ventricular hypertrophy)
A physiological split S2 is best heard at t
he pulmonic area (upper left sternum).
Rule out AAA in an older male who has a pulsatile abdominal mass that is more than ______. The next step is to order ______
3 cm in width
an abdominal ultrasound and CT
Atrial Fibrillation:
what 2 meds are these pts on?
describe the EKG rhythm
Patient reports a sudden onset of heart palpitations described as feeling like
- “a fish is flopping in my chest”
-“drums are pounding in my chest”
-accompanied by feelings of weakness, dizziness, and tachycardia
Beta Blockers (metoprolol)
Anticoagulant’s
-AFib high risk for a blood clot
rhythm: irregularly irregular
-no P wave (or very minimal)
Paroxysmal Supraventricular Tachycardia
EKG shows tachycardia with peaked QRS complex with P waves present.
-When having an episode, has regular but rapid heartbeat, which starts and stops abruptly (intermittent episodes).
-Can be misdiagnosed as a panic or anxiety attack.
“feels like fluttering in my chest”
-Rapid heart rate can range from 150 to 250 beats/min. Reports previous episodes that resolved spontaneously.
tx:
Valsalva’s maneuver: Holding one’s breath and straining hard, maintain strain for 10 to 15 seconds, then release it and breath normally.
“aPrOXimatly a SUPR TACHY rythm”
Pulsus Paradoxus
Defined as a fall in systolic BP (SBP) of more than 10 mmHg during the inspiratory phase.
-Also known as a paradoxical pulse.
-It is an important physical sign of cardiac tamponade.
what occurs when there are variances in heart rate upon inspiration (increase) and expiration (decrease)?
what is the common population for this??
Respiratory sinus arrhythmia
a young healthy athlete (no Tx needed)
Anterior Wall Myocardial Infarction
Anterior wall MI or an anterior STEMI is the most common type of MI.
-EKG changes include ST segment elevation and Q waves (Figure 2).
-Wide QRS complex on leads V2 to V4 resembles a “tombstone.”
-This finding is called “tombstoning.”
Sinus Rhythm and Sinus Arrhythmia
Sinus arrythmia is a common variation of normal sinus rhythm.
-It is more common in healthy children and young adults.
-The P waves show uniform morphology, and the PP interval increases and decreases during inspiration and exhalation (Figure 3).
Warfarin pearls
if you suspect bleeding?
how long to see dose change difference?
when to skip a dose:
when to give antidote:
-Order an INR with the PT and PTT if you suspect bleeding.
-It may take up to 3 days after changing the warfarin dose to see a change in the INR.
-Warfarin (Coumadin) is an FDA category X drug. It is teratogenic.
-Goal is INR of 2 to 3. If INR is between 4.01 and 4.99, hold one dose. Do not give vitamin K.
-antidote: Vitamin K
Hypertensive retinopathy with arteriovenous nicking.
Elderly are at higher risk for orthostatic hypotension due to
a less active autonomic nervous system and slower metabolism of drugs by the liver (prolongs half-life of drugs).
4 first line HTN medications?
the elderly?
ACE-I (-prils)
ARB (-sartans)
Thiazide Diuretics (-thia, -tha)
-1st for elderly
Calcium Channel Blockers (CCB)
(-dipines)
ACE-Inhibitors (-pril’s) :
what labs do you want to monitor for?
when do we change to an ARB (-sartan’s)?
what labs do you want to monitor for?
Renal function
-GFR
-BUN
-Creatinine
-potassium level (risk of hyperK)
when do we change to an ARB (-sartan’s)?
-if pt gets angioedema (facial/neck swelling- that can happen at any time)
-sartans have a dry cough side effect
ACE-Inhibitors (-pril’s):
good or bad for the kidney’s??
stage 1-2 = good!
stage 3-4 = bad
Thiazide Diuretics (-thia, -tha)
bad for those with:
good for:
bad for those with:
Hyper:
-triglycerides
-uric acid
-glucose
HCTZ:
H= hyperglycemia
C= crystals
T= triglycerides
Contraindications:
-Gout
-Hypotension
-Hypokalemia
-Renal failure
-Lithium treatment
-Sensitivity to sulfa drugs and thiazides
good for:
-Osteoporosis
Xanthelasma
cholesterol deposites on pts eyelids visually seen during an exam
elderly pop- normal
youngsters= check lipid profile
