CP history and exam (lecture 1)

What should you look at in a chart review

symptoms at rest and with activity, prior / current level of function, history of hospital admissions, PMH / PSH, risk factors, tests / imaging / labs.

why is gait speed considered a vital sign

it may be a general indicator that can predict future events and reflect various underlying physiological porcesses

what labs should you look at

Hgb, BNP, creatinine / BUN, electrolytes (K+, NA+, MG+)

Hgb

a key component of oxygen transport

BNP

high levels can indicate HF exacerbation. It is not trended like troponins.

Creatinine / BUN

reflects renal function. Can indicate comorbidities.

echocardiogram can tell us

systolic vs diastolic dysfunction, LVEF and wall motion abnormalities, valvular dysfunction

Chest x-ray can indicate

pulmonary edema, pleural effusion, and heart and lung diseases

what are the meds that can impact decision making

BBs, CCBs, ACEIs, diuretics, digoxin, nitrates

why is it important to get symptoms at rest and exertion

to help judge if there has been improvement or decline. It can also help differentiate between dyspnea and muscular fatigue as the most limiting symptom.

general signs and symptoms of HF

fatigue, SOB, weight gain from fluid retention

signs and symptoms of L HF

pulmonary edema, inspiratory crackles, orthopnea, PND, cough, S3

Signs and symptoms of R HF (and L)

JVD, pleural effusion, hepatomegaly, ascites, LE edema

cardiac aortic auscultation location

2nd intercostal space along the right side of the sternum (below the clavicle)

cardiac pulmonic auscultation location

2nd intercostal space along the left side of the sternum (below the clavicle)

cardiac tricuspid auscultation location

4th intercostal space along the left sternal border

cardiac mitral auscultation location

5th intercostal space at the left midclavicular line

S1 is

AV valves closing during systole

S2 is

semilunar valves closig during diastole

S3

a gallop where there is an extra sound early in diastole and it is the hallmark of acute decompensated heart failure. *can be normal in young people*

S4

a gallop where there is an extra sound late in diastole. It is associated with hypertension, heart disease, history of MI.

systolic murmur

blowing or vibration associated with S1 or between S1 and S2. Can indicated stenosis of aortic or pulmonic valves or regurgitation or mitral or tricuspid valves.

diastolic murmur

blowing or vibrations associated with S2 or just after S2. Can indicated stenosis of mitral or tricuspid valves or regurgitation of aortic or pulmonic valves

friction rub

a rubbing sound throughout the cardiac cycle that is indicative of pericarditis.

bruit

a swooshing sound when listening over an artery that is indicative of vessel stenosis

where is the strongest pulse

more central in locations such as the carotid artery.

tachycardia increases

myocardial oxygen demand and decreases myocardial oxygen supply

how do you know when pulse is abnormal

when there is inappropriate rate, irregular rhythm, abnormal pulse quality, and if it is accompanied by other symptoms

4+ pulse

bounding

3+ pulse

full, increased amplitude

2+ pulse

normal

1+ pulse

weak, thready

0 pulse

absent

excessive change in pulse strength when breathing (pulse paradoxus) is a sign of

pathology such as COPD or pericarditis

pulsus alternans

regularly alternating strength of pulses not associated with breathing. Typically present with left ventricular failure.

low ABI

low ankle artery pressure which indicates low flow

high ABI

more pressure needed to collapse ankle vessels which indicated calcified ankle vessels

when can there be a falsely high ABI

when there is significant PAD along with vessel calcification

BP hypertensive urgency when

BP is 180/120 with or without symptoms

BP hypertensive emergency when

BP is 180/120 with end organ damage such as encephalopathy, stroke, seizure, retinopathy, acute aortic dissection, acute MI, acute HF, pulmonary edema, acute renal failure, anemia, preeclampsia, HELLP syndrome

BP that is too high can impact

pressure on vessel walls, organs, and the left ventricle

BP that is too low can impact

perfusion

High BP and low pulse pressure is indicative of

a cardiac output problem

High BP and High pulse pressure is indicative of

low vascular compliance

hypotension can lead to

arrhythmias, structural disease, hypovolemia, systemic vasodilation, obstructive

how can you help increase venous return with hypotensive patients

compression stockings, physical counter maneuvers, ankle pumps, abdominal binders, water bolus consumption

orthostatic hypotension can result from

immobility, hemodynamic instability, vasoplegia / shock, hypovolemia, antihypertensives, peripheral neuropathy, opioids, autonomic dysfunction.

what BP drop is indicative of ortostatic hypotension

15-20 mmHg drop or 5-15 mmHg with significant rise in HR

BP contraindications

pain, fracture, cast / splint / sling / post-op, CVA, risk of lymphedema, PICC, hemodialysis AV shunt / fistula, blood clot, IV or recent blood

why use the two step method for BP measurement

to determine SBP by palpating when the radial pulse disappears

if the pulse at the radial artery is present what is the minimum SBP

>90 mmHg

if the pulse at the brachial artery is present what is the minimum SBP

>80 mmHg

if the pulse at the carotid artery is present what is the minimum SBP

>60mmHg

what BP should you consider not exercising at

160/100. If 180/110 ensure there is EKG, crash cart, and supportive personel around.

how can you get a falsely high BP

BP taken / cuff inflated too recently, cuff to small, cuff too loose, brachial A. is below the level of the heart

how can you get a falsely low BP

cuff is too big, brachial A. is higher than level of heart

special exam considerations for COPD

expect decreased lung sounds throughout, S/S of R HF, cyanosis, digital clubbing, altered breathing patterns / excessive use of accessory muscles of ventilation

what are some observations of cardiopulmonary impairments

big accessory muscles, propped position, pursed lip breathing, mobility issues, look for LE edema, nail and lip cyanosis

digital clubbing

enlargement of the distal fingers that is found in patients with chronic, poorly or untreated cardiac and pulmonary disease such as cancer and cirrhosis.

normal breathing pattern

abdominal rise, lower chest, then upper chest sightly

paradoxical breathing

fail chest where the rib fragments get sucked inward during inspiration or chest wall retractions in infants / children during respiratory distress.

apnea

a period of no breathing

kussmaul breathing

deep and labored breathing pattern due to neurologic injury characterized by periods of sustained inspiration. Commonly due to diabetic acidosis.

apneustic breathing

irregular breathing pattern due to neurologic injury characterized by periods of sustained inspiration.

cheyne-strokes respirations

characterized by periods of slow, shallow breathing progressing to rapid, deep breathing returning back to slow, shallow breathing followed by a period of apnea.

auscultations are used for

identifying a baseline, areas of lungs with secretions, and evidence for medical referral or consultation.

lung auscultation location for upper lobe apical segment

supraclavicular fossa

lung auscultation location for upper lobe anterior segment

a little below the clavicle

lung auscultation location for upper lobe posterior segment

over the upper traps

lung auscultation location for middle / lingular segment

medial in the nipple area

lung auscultation location for lower lobe superior segment

medial to the base of the scapular spine

lung auscultation location for lower lobe posterior basilar segment

medial and a little inferior to the inferior angle of the scapular

lung auscultation location for lower lobe lateral basilar segment

lateral and just inferior to the inferior ankle of the scapula

lung auscultation location for lower lobe anterior basilar segment

lateral thorax around the 8th rib

vesicular breath sounds

normal. Softer, lower pitched sounds with much longer I than E. Over most of both lungs.

broncovesicular breath sounds

abnormal. Inspiratory and expiratory sounds are about equal. The sound and pitch is intermediate. It can be normal in the 1st and second interspaces anteriorly between the scapulae.

bronchovesicular and bronchial breath sounds are due to

a large area of atelectasis or consolidation (pneumonia)

Bronchial breath sounds

abnormal. Expiratory sounds last longer than inspiratory ones. Loud and high pitched. Can be normal if heard over the manubrium.

decreased or absent breath sounds are due to

reduced airflow from poor neuromuscular effort, decreased airflow, air trapping, airway destruction, or over pleural effusion

adventitious lung sounds are

extraneous sounds that are not normally present such as crackles and wheezes

crackles

popping noise that can be fine or course. Inspiratory crackles can occur with atelectasis, pulmonary edema, or pulmonary fibrosis. Also can occur with pneumonia.

wheezes

high pitched sounds that indicate bronchospasm of smaller airways, usually occurring with expiration.

Wheezing with inspiration can indicate

severe narrowing / bronchoconstriction

I and E wheezes can indicate

secretions

stridor

an audible, tracheal / bronchial sound with breathing that is due to large airway obstriction.

friction rub

a rubbing sound of intrapleural inflammation or neoplasm and is usually painful with breathing.

Voice sounds

increased or distorted sound transmission which indicated pathological increased density. bronchophony, egophony, and whispered pectoriloquy.

mediate percussion confirms

abnormal bronchial sounds and can assess for hypo-density. resonate = sounds will occur over air-filled organs. Dull - sounds will occur over solid organs or areas of atelectasis / consolidation / tumor. Hyper-resonant = sounds will be abnormally low and resonate as in hyper inflated emphysematous lungs.

tactile fremitus

a manual technique to feel vibration over the chest wall generated by voice sounds which can help to confirm abnormal bronchial sounds or assess for hypo density.

lung auscultation results with HF

inspiratory cackles at bases with pulmonary edema or absent breath sounds at the bases with pleural effusion

lung auscultation results with COPD

diminished lung sounds throughout with a pronounced expiratory phase, wheezes and IE crackles may be present depending on bronchoconstriction and secretions.

lung auscultations results with pulmonary fibrosis

inspiratory crackles and short IE phases due to limited lung volumes.

lung auscultation results with pneumonia

bronchia breath sounds, IE crackles, rhonci in the setting of altered vitals, fatigue, malaise, dyspnea.

does average heart rate increase or decrease as you age

decrease. Infants start at 140 bpm which then decreases to 80 bpm by 12-18 years.

what RPE scale can correlate to HR

the 0-20 scale

what RPE should you target for exercise

13-15 / 20

what is normal respiratory rate

12-18 breaths per minute

what does SpO2 measure

oxygen saturation based on how much oxygen is bound to hemoglobin.

A1 AHA risk classification

children, adolescents, men

A2 AHA risk classification

men >45, women >55 with less than 2 CV risk factors