cardio + pulm exam (combined)

What is the normal % of blood ejected from the ventricle per beat (EF)?

55-70%

What is contractility?

force of myocardial contraction

What is rate product pressure (RPP, or double product pressure [DPP])?

What is it used for?

HR x SBP

• to measure myocardial workload & O2 demand of the heart

What does a higher and lower RPP indicate?

• higher RPP = more O2 demand on the heart

• lower RPP = lower stress & demand on the heart

What happens with incremental exercise in terms of HR, Q, & BP?

HR, Q, & MAP increases linearly w/ increasing work rate

• HR & Q plateaus at 100% VO2max or HRmax

• SBP increases, DBP remains fairly intact

What is the new AHA/ACC High BP Guidelines?

• normal: <120/80

• elevated: SBP 120-129 AND DBP <80

  • Tx: healthy lifestyle & diet

• stage 1: SBP 130-139 OR DBP 80-89

  • Tx: same as above, and meds in case of high risk

• stage 2: SBP ≥140 OR DBP ≥90

  • Tx: meds

• hypertensive crisis: SBP >180 AND/OR DBP >120

  • need prompt ∆s in meds or immediate hospitalization if Sx’s present

  • Sx’s: chest pain, back pain, SOB, numbness, weakness, vision ∆s, difficulty speaking

  • medical emergency

What is hypotension?

What can cause this?

SBP <90 OR DBP <60, inadequate blood flow to heart, brain, & other organs

• bed rest, drugs, arrhythmia, blood loss or shock, MI

What is orthostatic hypotension?

How can you assess this?

drop in SBP >20 or DBP >10

• assess BP & HR when pt has been supine for 5 min

• then have pt stand up, then reassess BP & HR after 3 min of standing

• if pt is symptomatic, have them sit down and maybe w/ legs elevated to a reclined position

What are the effects of altitude initially & after acclimatization?

• initial: increased HR, Q, BP, normal SV

• acclimatization: increased HR, normal Q & BP, reduced SV

What are the CV effects of aquatic therapy?

• decreased HR, BP, VO2

• increased SV, Q

• increased venous return & preload d/t increased hydrostatic pressure

• cephalad redistribution of blood flow

What are the respiratory effects of aquatic therapy?

challenges chest expansion

• decreased IRV, VC

• increased WOB

What are the MSK effects of aquatic therapy?

• decreased WB, edema d/t hydrostatic pressure exerted by water

• increased mm strength & endurance d/t water resistance

What are the % WB with immersion of C7, xiphoid process, & ASIS?

• C7 = 10% BW

• xiphoid process = 33%

• ASIS = 50%

What are the effects of warm water & cold water with aquatic therapy?

• warm: relaxation

• cold: reduce pain & inflammation

What are beta blockers?

What does it do and who is it used for?

beta-adrenergic blocking drugs (-olol)

• compete w/ epinephrine & norepinephrine for beta adrenergic receptors in the heart

• reduce HR & contractility (lower myocardial O2 demand)

  • will blunt HR during exercise

• for pts w/ CAD & HTN

Mnemonic for Borg RPE rating?

13 SHVEM

• 13 = somewhat hard

• 15 = hard

• 17 = very hard

• 19 = extremely hard

• 20 = maximal exertion

What is preload?

L ventricular end-diastolic pressure (LVEDP); the amt. of ventricular stretch at the end of diastole

What is afterload?

systemic vascular resistance (SVR); the amt. of resistance the heart must overcome to open the aortic valve and push blood out

• higher afterload is not good for us

What are the 5 auscultation landmarks and their locations?

• aortic: 2nd IC space, R sternal border

• pulmonic: 2nd IC space, L sternal border

• Erb point: 3rd IC space, L sternal border

  • heart murmurs

• tricuspid: 4th IC space, L sternal border

• mitral (apical): 5th IC space, L midclavicular line

  • best site if S3 present

  • point of maximal impulse

What are the S1, S2, S3, S4 heart sounds?

• S1: lub, closure of tricuspid & mitral valves (AV valves) → onset of systole

• S2: dub, closure of pulmonary & aortic valves (semilunar valves) → onset of diastole

• S3: ventricular gallop (S1-S2-S3), ventricular filling into overloaded ventricle after AV valves open

  • low-frequency turbulence, heard during early diastole

  • hallmark sign of CHF

• S4: atrial gallop (S4-S1-S2), ventricular filling & atrial contraction into stiff ventricle

  • low-frequency turbulence, heard during late diastole

  • common in HTN, pulmonary HTN, MI, LV hypertrophy, increased LVEDP, aortic or pulmonary stenosis

What are heart murmurs?

What are the grades?

whooshing or swishing sounds of turbulent blood flow d/t valve disorders

• grade 1 = softest

• grade 6 = audible w/o stethoscope

What are systolic murmurs?

“lush” instead of “lub”; turbulence b/w S1-S2

• d/t valve disease (mitral valve prolapse), aortic stenosis, or may be normal

What are diastolic murmurs?

turbulence b/w S2-S1

• d/t aortic & pulmonary regurgitation, mitral stenosis

What is thrill?

abnormal, palpable tremor w/ vascular or cardiac murmur

What is the difference b/w stenotic valve & regurgitant valve?

• stenotic valve: impaired opening

• regurgitant valve: impaired closing

What is bruit?

Where is this most commonly found?

adventitious sound or murmur (blowing sound) of arterial or venous origin

• turbulent blood flow d/t atherosclerosis or partially blocked artery

• common in carotid or femoral arteries

What is pericardial friction rub?

high-pitched heartbeat, leathery, scratchy quality

• d/t inflammation of the pericardial sac

• post-MI pericarditis (Dressler syndrome)

How do you grade pulses?

• 0 = absent, not palpable

• 1+ = diminished, barely palpable: reduced SV, cardiogenic shock, increased peripheral resistance, severe CHF

• 2+ = normal, easily palpable

• 3+ = full pulse, increased strength

• 4+ = bounding pulse: increased SV, shortened ventricular systole, reduced peripheral pressure, aortic insufficiency, HTN, exercise

How much is IRV relative to TV?

IRV = 5x of TV

How much is ERV relative to TV?

ERV = 2-2.5x of TV

What is inspiratory capacity (IC)?

TV + IRV

What is functional residual capacity (FRC)?

RV + ERV

What is vital capacity (VC)?

TV + IRV + ERV

• all the air going in & out

What is forced expiratory volume in 1 sec (FEV1)?

the volume of air exhaled in the first second under force after max inhalation

What is forced vital capacity (FVC)?

the total volume of air that can exhaled during a max forced expiration effort

What are pulmonary function tests (PFTs)?

series of breathing tests to evaluate lung function

• helps dx & manage lung conditions like COPD & restrictive lung disease

What are the characteristics of obstructive diseases?

What are some common conditions?

• no problems inhaling, but air does not come out when exhaling (air trapping)

• increased RV, FRC, TLC

• decreased IRV, ERV, IC, VC FVC, FEV1

• TV remains normal

• cystic fibrosis, bronchitis, asthma, bronchiectasis, emphysema (CBABE)

What is the GOLD classification for COPD?

• FEV1/FVC for all is <70%

• mild COPD:

  • FEV1: ≥80% predicted

  • w/ or w/o production of cough & sputum

• moderate COPD:

  • FEV1: 50-80% predicted

  • SOB w/ exertion

  • w/ or w/o production of cough & sputum

• severe COPD:

  • FEV1: 30-50% predicted

  • greater SOB w/ exertion, reduced exercise capacity, fatigue

  • repeated exacerbation of their disease

• very severe COPD:

  • FEV1: <30% predicted, or <50% predicted + chronic respiratory failure

  • respiratory failure

  • signs of R HF (cor-pulmonale)

How can you treat pts w/ obstructive lung disease?

improve airflow clearance and avoid early airway closure:

• pursed lip breathing

• huffing instead of coughing

What are the characteristics of restrictive diseases?

What are some common conditions?

• less air coming in & out

• decreased everything, except for FEV1 which stays normal

• interstitial lung disease (ILD), sarcoidosis, lung fibrosis, scoliosis, kyphosis, ankylosing spondylitis, ALS, obesity, burns, PNA, pneumothorax, hemothorax, pulmonary effusion

How can you treat pts w/ restrictive lung disease?

address underlying cause:

• ventilatory support

• respiratory mm training/chest expansion exercises

What are the normal breath sounds?

• vesicular

• broncho-vesicular

• bronchial

• tracheal

• the further down the lungs you go, the lower the sound

What are the characteristics of vesicular breath sounds?

Where can it be found?

• softest intensity, lowest pitch of expiration

• inspiratory longer than expiratory

• over most of the lungs

What are the characteristics of broncho-vesicular breath sounds?

Where can it be found?

• medium intensity & pitch of expiration

• inspiratory & expiratory sounds equal in length (similar to tracheal)

• b/w 1st & 2nd IC spaces anteriorly, b/w scapulae posteriorly

What are the characteristics of bronchial breath sounds?

Where can it be found?

• loud intensity, high pitch of expiration

• expiratory longer than inspiratory

• over manubrium

What are the characteristics of tracheal breath sounds?

Where can it be found?

• loudest intensity, relatively high pitch of expiration

• inspiratory & expiratory sounds equal in length (similar to broncho-vesicular)

• over trachea in the neck

What are the abnormal breath sounds?

• rhonchi

• wheeze

• crackles (rales)

• pleural rub

What are the characteristics of rhonchi?

Which conditions are associated with this?

• continuous, low-pitched, rattling sound, like snoring

• COPD, cystic fibrosis, chronic bronchitis, bronchiectasis, PNA

What are the characteristics of wheeze?

Which conditions are associated with this?

• high-pitched, heard in expiration d/t airway obstruction (can be heard in inspiration in severe cases)

• asthma, COPD, or aspiration of any foreign body

What are the characteristics of crackles (rales)?

What condition does this indicate?

• brief, discontinuous, high-pitched, popping sounds heard in both inspiration & expiration

• pulmonary edema

What are the characteristics of pleural rub?

What condition does this indicate?

auscultation of lower lateral chest w/ each inspiration & expiration

• pleural inflammation

What is bronchophony?

What causes this?

increased vocal resonance w/ greater clarity & loudness of spoken words

• secretions in lungs

What is egophony?

What causes this?

long “E” sounds ∆ to a long, nasal-sounding “A” sound

• secretions in lungs

What is whispered pectoriloquy?

What would you have the pt say to test this?

increased loudness of whispering

• recognition of the whispered words “one, two, three”