Pcm Test 2 Flashcards
(138 cards)
1
Q
Aortic valve heard
A
Right 2nd ICS at SB
2
Q
Where is pulmonic valve heard
A
Left 2nd ICS at SB
3
Q
Tricuspid valve where
A
Left 4th ICS at SB
4
Q
Mitral valve where head
A
Left 5th ICS at MCL
5
Q
Grade 1 murmur
A
Very faint
6
Q
Grade 2 murmur
A
Quiet, soft, easily heard with stethoscope
7
Q
Grade 3 murmur
A
Moderately loud
8
Q
Grade 4murmur
A
Lous with palpable thrill
9
Q
Grade five murmur
A
Very loud with thrill; can hear with stethoscope partly off chest
10
Q
Grade 6 murmur
A
Heard without stethescope
11
Q
Systolic murmur
A
Between S1 and s2
12
Q
Diastolic murmur
A
S2 and s1 between
13
Q
S1
A
Closure of TV and MV
14
Q
S2
A
Closure of AV and PV-may split with inspiration
15
Q
S2
A
Dull, low pitch; best heard with bell
Kentucky
16
Q
S2
A
Physiologic in kids, young adults
Pathological in older adults=HF
Ventricular gallop
17
Q
S4
A
Dull low pitched; best heard with bell
Tennessee
Forceful atrial contraction against stiffened low compliant ventricle
Atrial gallop
18
Q
Systolic murmur
A
MR (MVP), TR, AS, PS, VSD Aortopulmonary shunts (early, mid, late, holosystolic/pansystolic)
19
Q
Diastolic-AR, PR
-MS, TX
Atrial myxoma
A
Ok
20
Q
Continuous murmurs
A
PDA-machinery
AV fistula
ASD with high LA pressure
Coarctation
21
Q
VHD
A
Most common conditions encountered today-degenerative (senile calcification)
Myxomatosis degeneration (MVP) Congenital (bicuspid aortic valve)
Decline in incidence of RHD
22
Q
Mitral regurgitaiton chronic
A
MVP most common MAC (mitral annular calcification)
23
Q
Mitral regurgitaiton acute
A
Rupture of chordal tendineae
Rupture of papillary msucle
Ischemic papillary msucle dysfunction-
CAD/MI : next most common cause f MR
IE; valve perforation
24
Q
MR symptoms
A
Asymptomatic years-> of fatigue , DOE and palpitations
Acute; volume overload/orthopnea, PND, RHF/LHF
25
PE MR
Systolic murmur 9blowing , prominent at apex; radiates into left axilla)
Loudness of murmur correlated with severity
Decreased D1 or normal; may have a systolic click
26
Mitral stenosis
4th decade
DOE, cough, orthopnea, PND< pulmonary edema, hemoptysis, arterial emboli, A fib
Ortner syndrome: hoarseness d/+ compression of left recurrent laryngeal nerve
27
MS PE
Malar flush-ruddy cheeks, blue fancies. Increase D1; opening snap after s2
Rumbling, diastolic murmur-low pitched; bestheard at apex. Use bell
28
Aortic stenosis
Degenerative (calcific, senile, fibrosis or sclerosis) congenital bicuspid aortic valve )BAV)
1% of pop born with BAV)
Rheumatic or post inflammatory scarring
Normal AoV is 4cm^2
29
Symptoms AS
6th decade: exertional dyspnea, angina, syncope, HF
Without treatment prognosis is poor
Without treatment most will die within three years of developing syncope and within two years of onset of HF
30
Pathophysiology AS
Obstruction leads to pressure overload LVH increased LVED pressure
Gradient across valve
Severe AS if AoV <1cm^2
31
PE AS
Narrow pulse pressure; decreased SV and systolic pressure
Delayed pulses-par is (weak-small/tardus-late)
Systolic murmur, harsh 2nd ICS RSB; radiated into suprasternal notch/carotid
Gallavardin phenomenon-murmur radiates to apex (like MR)
32
AR
Causes acute-IE, aortic dissection, BAV
Chronic causes-syphilis, ankylosis spondylitis
33
PE AR
Wide pulse pressure
De musset sign
Corgi ANS pulse
Traduces sign
Durozreys sign
Hills sign
Bisferious pulse
Diastolic , decrescendo murmur 3rd ICS LSB
Systolic murmur usually present , soft
Austin flint murmur; can mimic MS
34
Tricuspid regurgitaiton
Associated with pulmonary HTN, inferior MI/RV infarction and others
Pathophysiology; prominent V wave in JVP
Blowing systolic murmur LSB; increase with inspiration (Corvallis sign)
35
TS
Associated with MS, TR< and RHD
Pathophysiology; prominent A wave in JVP ascites, hepatomegalia (may pulsate)
Diastolic murmur LSB; increase with inspiration (carvallos sign) and decrease with expiration and valsava
36
Pulmonic regurgitation
Most cases are due to pulmonary HTN
Diastolic , blowing murmur 2nd LSB, 2nd ICS (graham steel)
37
Pulmonary stenosis
Atresia
Congenital
Can cause angina and syncope
Auscultation-systolic murmur , ejection click
2nd-3rd ICS, LSB/radiated toward left shoulder and increases on inspiration /RVH
Maybe associated with TOF or TGA
May require balloon commissurotomy if pressure gradient>50 mmHG
38
Electronic health records
Ok
39
Electronic medical records
Digitalized version of the paper charts int he clinicians office but the information int he EMRs doesn’t travel easily out of the practice. Inf act, the patients record might have to be printed and delivered by main/fax to specialists and othe members of the care team
40
Electronic health records
Do allot he EMR things-and more. They are build to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved int he patients care
41
Do EHR talk to another EHR
No
42
2009
Incentives-health informations echnology for economic and clincial health act, which authorizes incentive payments through Medicare and medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clincial care
43
2010
President Obama signed the patient protections nd affordable care act
Physicians and hospitals had to prove that they had met 25 different functional objectives with their use of an EHR product to be considered meaningful userspenalties included cuts to Medicare payments for those not implanting EHR
44
2017
As of 2015, nearly 9 in 10 of office based physicians had adopted EHR
45
Meaningful use (MU)
Stage 1-data capture and sharing 2011
Stage 2-advance clincial processes
Stage 20improved outcomes
46
MU
Refers to the use of certified EHR technologies by health care providers in ways that measurably improve health care quality and efficiency
```
Ultimate goal is to bring about health care that is
Patient centered
Evidence based
Prevention oriented
Efficient
Equitable
```
47
Data
Qualitative, or quantative (discrete, continuous)
48
MU criteria’s 2014
Patient portal-contact provider electronically
| Clinical decision support tools-computerized alerts and reminders to care providers and patients
49
MU report a total of 6 ambulatory clincial quality measures to CMS or states
Adherence to chronic medications
Adherence to statin therapy for individuals with CAD
Adherence to chronic medications for individuals with DM
Adherence to antipsychotic medications for individuals with schizophrenia
INR for individuals taking warfarin and interacting anti infective medication
Lack monthly INR monitoring for individuals on warfarin
50
Premium cost
Higher for unhealthy than healthy
51
As medical costs go up, premiums are raised to ensure resources>cost
What are the costs administrative, medical, other
52
Cost of implementation
1.5 billion Mayo Clinic over next five years EHR
53
What is fee for service
Volume based, not value
Physician is paid when patients is seen
54
What is merit based incentive payment
Standardizes measures (evidence based)
Incentives care that focuses on improved quality outcomes
Increases access to better care
Enhanced coordination through a patient centered approach
Improved results
55
MARCA
Medicare access and CHIP reauthorization act of 2015
CMS stated that MACRA enacts a new payment framework that rewards health care providers for giving better care instead of more service
56
Are doctors happy
No many unsatisfied and very dissatisfied
57
Why don’t we like EHR
Typing-docs become data entry clerks
Average physician gets only 3 hours training in the EHR he/she is expected to use
Inability to capture the interpersonal moments
Too many alerts on most systems
Quantitative data versus free text
Too much time entering data
58
Shortcuts
Scribes
Dictation
Templates
59
Etiquette best practice
Introduce yourself
Sit down
Get intima history then ask if ok to enter stuff on computer
Invite patient to look at screen with you
When appropriate turn away from computer, get close
60
What is the triangle
Computer, provider, patient
61
The quadrangle
The medical student, physician , patient, and computer
62
Why don’t we teach EMR
900 outpatient EMR systems
277 inpatient EMR systems
63
Medical students must
1. Have their own unique login and password to chart on behalf of the preceptor
Contribute meaningful data to EHR with the inclusion of a student note or, at least, the students review.update of the past, family/social history and ROS
A. Enter needed data into he EHR and the rationale for entering clincial information ins tructured data fields versus the challenges of entering free text
B. Search for data within the EHR
C. Review patient care protocols
D. Find and use disease specific templates, reminders and decision support
Enter data into the appropriate fields int he EHR
Have all notes reviewed, edited and signed by the supervising physician with appropriate instructive feedback given
64
Medical students must know
Old system
Redocument HIP and PE
Attending physician can only accept students documentation
Verify in the medical record any student documentation
Physician must verify in the medical record all student documentation
65
Templates
Too easy to leave normal history, ROS, or exam findings pre populated without changing them.
Note cloning-all look same
Increased liability if students document in chart
- juries might be confused
- erroneous info not refuted by attending
- documentat correct info that attending ignores
66
Most important
At this time the NBOME has you develop a SOAP note from thin air for colles so that’s what we do here
67
Old system
Students could not do all soap
Now physician can just verify stuff documented is accurate -makes medical students more important, can do and help physician
Before could just document stuff that nurse could —reduce some of documentation burden to physician , be benefit to physician
68
Pediatric murmurs
Ok
69
At birth things that close
Foramen ovals, ductus arteriosus, ductus venosus
70
Who gets complete heart exam(over four post)
- any heart murmur
- history or history consistent of congenital heart (get sweaty when eat, weight gain, blah blah)
- respiratory symptoms (not thriving, cough, wheezing)
- if blue
- any chest pain that you cant say is MSK (costochondritis)
- anyone who passes out (usually vagovagal in kids and benign)
- fine exercise tolerance and suddenly cant
- family history of sudden death in anyone in family (idiopathic hypertrophy sub aortic stenosis(hypertrophy aortic arch), idiopathic its linked to AD so most get)
71
What is a complete cardiac exam
Four posts, pulses(radial brachial femoral dorsalis pedis posterior tibial), perfusion (cap refill 2 sec), pulse (2/4),
- murmur grade timing, position, if it radiates, where loudest, character (machine, soft)
- know murmur grades
72
Most innocent murmurs
Willl change with position
73
Pathologic murmur
Won’t change with position
| *exception!
74
Pulse top to bottom in kid
Pulses top normal and femoral diminished
-coarctation or aorta
75
Bp higher or lower than legs
Higher in legs than arms
76
Grade 4
Thrill
77
Why s3 normal in kids
Left ventricle so much more compliant-blood suddenly hit super coolant left ventricle
78
S3 in adult
Systolic heart failure
79
Can S1 split
Can
80
S2 split
Inspiration , pulmonic and aortic valve close at different times
Overfilling right heart so
81
Fixed slipt (not just with inspiration)
ASd in systolic
82
S1 inaudible
Holosystolic vsd
Something obscuring it
83
PDA
Continuous
84
Diastolic
Other than venous hum, Changes with turning the neck
Not normal and do workup
85
Diastolic sound ever normal
No
86
What sound in diastolic ok
Venous hum
87
Most common cause of innocent murmur
Stills/IHSS, hypertrophic cardiomyopathy tay
Systolic ejection murmur heard bt lower left sternal borer and apex
Increase if stand, increases with valsava
88
Key features of innocent murmur
```
Sensitive
Short duration
Single
Small
Soft
Sweet
Systolic
```
89
Refer to cardiologist
```
4 or above
Diastolic
Increase when stand
If symptomatic
Obscured, cant hear S1 or s2
Femoral pulse weak (in comparison to UE)
Extra sound
Thin chest wall and hyperactive pericardium
History sudden death
Congenital /genetic
```
90
Stills
APEX and LL bell
Decreased with inspiration, sitting up, standing,
Systolic, ejection, soft or vibratory, grade 1-2
Normal S1 2, no extra sounds
91
Cyanotic congenital heart
One Truncus arteriosus big trunk
Two Interchanged vessels: transposition of the great vessels
Three Tricuspid atresia
Four Tetralogy of fallout
Five Total anomalous pulmonary venous return
92
Diagnosis of congenital heart disease
If close, no connection between right and left
Critical congenital heart disease
So go home, ductus close and they die
93
How determine kids have critical lesions
Baby counts on ductus to stay alive otherwise no right to left
Check oxygen saturation in left arm and left foot
-or right arm and right foot
If same, pass
All about difference, if too much fail and get and echo
94
Check pre and post ductal
If not check for congenital heart condition
95
Surgery
Give anticoagulant so don’t get clots
96
Why stop taking statin
Muscle soreness
97
Where is PMI
5th,
| If not could be normal or not
98
D dimer
Not specific
99
Duplex of popliteal a and v
With knee infection want to look and see what’s there
100
Duplex
Bedside Doppler ultrasound
(Sound waves)
Visualize vasculature and assess for clot
Instant picture arteries don’t compress, veins do
Looking for DVT press transducer to see if vein collapse, if non compressible cord like thrombus forming , DVT
101
Most common use of Doppler
Fetal heart sounds
102
Doppler
Tranducal and doppler, uses both
103
Transthoracic echocardiogram with bubble study
Transesophageal-for endocarditis, thrombus, Camera into esophagus put behind heart and see posterior structures
Transthoracic-limitations in viewing but
104
Bubble study
IV access get syringe with sterile saline and put stop cock on IV attach saline filled syringe and have empty syringe, agitate saline back and forth, cause bubbles but no air
Release saline into IV with bubbles, go to right atrium first
- no defect bubbles go through normal
- if defect bubbles reverse and go right to left atria
105
Bubble
PFO look for -no murmurs there and we don’t know
106
If have bubbles right heat
ASD patent foramen ovale
107
How close PFO
NSAIDS high dose
108
Bubble
Real time assessment of
109
Heart accident
High risk tamponade
110
I AVF
Both up normal
One go down avf up-right axis
One up avf down-left axis
111
Ekg
Rate, rhythm, p wave , Pr prolongation,
112
Chest x ray
Trachea deviation
Bones
Cardiac silhouette (big or small heart)
113
QRS complex different sizes
Electrical alternance
| Badddddd
114
When go to cath lab
MI, need to see electrical conduction issue on ekg
115
FAST exam after car crash
Look for fluid with cardiomegaly
116
Fast exam
Focused bedside US good for rapidly excessive if bleed we need to get immediately
Pericardial-see if tamponade
117
Cardiac tamponade
JVP up
| BP down
118
Transthoracic echocardiogram
Initial test of choice for pericardium , EF, ventricular atrial septa
Diffuse pulmonary disease-obscure views, if fat, bac
119
Bruit
US for stenosis of carotid
120
Baronial aortic US
Dilation-enruysms, occur at INTIMAL layer?
2 cm, anything greater bad
Greater than 5, palpable,
Greater than 3 is aneurysm
121
Greater than 5
Get angiography
| What is thrombus
122
Refer to vascular specialist
If greater than 4 cm
123
Aaa
Tunica media and INTIMAL layers
124
St elevation
Inferior lead 2, 3, avf,
125
Manage acs
CXR, on cardiac monitor, cath lab
126
Cath
Radial of femoral ARTERY into circulation to coronary vascularore , can put contrast in to light up vessels if patent see picture, if blocked wont see follow through
127
Use fluoroscopy to visualize coronary arteries, contrast used
May use stent to decrease likelihood of roaming
128
Risk of coronary angiography
Bruising, bleeding, can have another MI by putting more stress on heart, infection, kidney damage-from contrast (Cr BUN and GFR, if renal disease and CR at 2, lets put on short term dialysis to do this)
129
Faint, irregular rhythm, tachycardia, high bp
Check radial artery pulse to see if difference in pulses wil detect arrhythmia,
130
Ekg a fib
Rate differs! No consistent rate , not really p wave before qrs
131
LONG QT
CAN GO INTO TORSADES
132
Test for a fib
Transesophageal echocardiogram-
Clots can form with atrial quivering with Virchow
A fib-clots!!
133
Fast
Acute trauma
134
Duplex
Arteries, or stroke of carotid
135
Cath
MI
136
Clot
TEE
137
TEE-clot formation
Invasive, thrombus in A fib, prosthetic valve , aortic dissection aortic pathology , US get rapid view
138
How would dissection appear on CXR
Widened mediastinum
