Cardiovascular Examination, CV Meds and ECG Basics

Comprehensive vocabulary flashcards covering cardiovascular physical therapy examination techniques, heart sound auscultation, vital sign responses, cardiac pharmacology, and fundamental electrocardiogram (ECG) rhythm analysis.

S1 Heart Sound

The first normal heart sound, characterized by a slightly prolonged "lub" caused by the closure of both atrioventricular (mitral and tricuspid) valves at the onset of ventricular systole.

o Current conditions

o Symptoms

o Medical or surgical hx

o Medications

o Allergies

o Labs, images etc

o Family hx

o Patient goals

o Functional status

o ADL status

o SDOH

o Social history

o General demographic

o Living environment

o Occupational hx

Cardiopulm Patient history

• Diagnosis, date of event, date of surgery : Primary and secondary diagnosis

• Risk factors for heart disease

- HTN, smoking, HLD, DB

- Family hx, stress, sedentary lifestyle, age, obesity

• Other medical or surgical hx

- Precautions? Activity modifications?

• Hospital course

- Review interdisciplinary notes: Case management for SDOH insight

- Lab values, test results, O2 orders, vitals

Previous cardiac history including major events

• Cardiac risk factors

• Other co-morbid conditions

Cardio pulm exam hx: Medical chart review

o Address each level of the ICF

• The foundation of your examination

• Establish rapport with patient and loved ones

• Allow the patient to speak at their own pace

• Reassure your patient that mobility is safe for them

• Ask about:

- Pain and other complaints

- PLOF: ADLs, mobility status, assistance required

- Equipment: AD, O2

- Functional limitations

- Hx of PT

- Goals for PT

cardiopulm exam: Pt history

Chieft complaint

• Source/type of admission (elective or ED admission)

• Demographics

• Signs & Symptoms on initial presentation

• Signs & Symptoms of improvement or decline

History of Present illness

• Symptoms leading up to current/recent admission(s)

• Previous cardiac events and tests leading up to admission

• Demographic and behavioral risk factors

Chart review: Hospital course

• Date of admission

• Dates and outcomes of Important procedures, surgeries, & significant events

• Dx tests, imaging, & lab results

• Referrals & consults

Chart review: medications

During and prior to admission

• Anticipated cardiac effects (and side effects)

Chart review: social hx

• Living situation & environment

• Occupation

• Prior Level of Function, Activity & Participation

• Home equipment & Services Received

Precautions: Red flags

Examples of patients in need of immediate referral and treatment:

Pneumothorax

• Acute onset CP and dyspnea (respiratory distress), cyanosis

Pericarditis (infection of the epicardium aka visceral pericardium)

• Sharp, constant CP

• Coarse rubbing sound (pericardial friction rub) in quiet breathing

• Fever and increased WBC

Acute Coronary Syndromes

• Unstable angina, Small MI (aka NQMI aka NSTEMI), Large MI (aka QMI aka STEMI)

Precautions: Yellow flags

Examples of High-Risk Patients:

• LVEF < 30%

• Survivors of Sudden Cardiac Arrest

• Complex ventricular arrhythmias

• Acute MI complicated by CHF, cardiogenic shock, and/or serious ventricular arrhythmias

• 2nd / 3rd degree AV Block (with a pacemaker), or rapid supraventricular arrhythmias

• Syncope

High-Risk Factors for Sternal Dehiscence:

• Diabetes

• Obesity

• Steroid use

• Osteopenia/osteoporosis

• Re-op median sternotomy

Cardiovascular exam

• PTs play an important role on the cardiopulmonary system in every setting.

• A comprehensive cardiopulmonary exam starts with examination > evaluation > intervention.

• A thorough history is the first part of our cardiopulmonary examination and includes past medical history, extensive chart review, and patient interview.

Review of systems

Pt history, interview asking questions

Systems review

Physical exam and screening

o Inspection and observation

o Vitals

o Pulse and edema assessment

o Additional assessments as needed to ensure the

safety of our patient

Systems review MSK

Strength and ROM

• Avoid resistance in acute

cardiac patient

• Avoid bilateral UE activity

(>90 degrees flexion) in

patients with sternal

precautions

• Screen for brachial plexus

and peroneal nerve injuries

in surgical patient

• Screen for proximal muscle

weakness in transplant

population or any patient on

steroids

System review: integumentary

Skin and Soft Tissue

• Special attention to occiput,

sacrum, and heels

• Examine incisions for

redness, swelling, drainage

• Cyanosis, trophic changes

• Gout not uncommon in

heart failure population

undergoing diuresis

• Bilateral pedal edema

consistent with heart failure

• Unilateral pedal edema

consistent with trauma, DVT,

infection

S2 Heart Sound

The second normal heart sound, characterized by a high-pitched "dub" caused by the closure of both semilunar (aortic and pulmonic) valves immediately following ventricular systole at the onset of ventricular diastole.

S3 Heart Sound (Ventricular Gallop)

An abnormal low-pitched early diastolic sound ("lub dub dub") occurring just after S2, caused by blood rapidly rushing into an overfilled or non-compliant left ventricle; indicative of congestive heart failure or left ventricular dysfunction.

S4 Heart Sound (Atrial Gallop)

An abnormal late diastolic sound ("la lub dub") occurring just prior to S1, generated when the atria contract to force blood into a stiff, non-compliant ventricle; strongly associated with ventricular hypertrophy and chronic hypertension.

Heart Murmur

An abnormal sound resembling a "swoosh" resulting from turbulent blood flow across cardiac valves due to valvular disease such as stenosis (narrowed opening) or regurgitation (incomplete closure).

Pericardial Friction Rub

An abnormal coarse, scratching or creaking sound (resembling two pieces of leather rubbing together) heard during auscultation over the 3rd and 4th intercostal spaces in supine, indicative of pericarditis.

Point of Maximal Impulse (PMI)

The apical pulse point located where cardiac contraction is most distinctly palpated against the anterior chest wall, normally situated in the 4th or 5th left intercostal space near the midclavicular line.

Cardiac Auscultation Sites

The four primary surface chest areas used to assess heart sounds: Aortic (2nd right intercostal space at right sternal border), Pulmonic (2nd left intercostal space at left sternal border), Tricuspid (4th to 5th left intercostal space at lower left sternal border), and Mitral (5th left intercostal space at midclavicular line).

Jugular Venous Distention (JVD)

The abnormal engorgement of the jugular vein examined with the patient recumbent at $>45^\circ$ head elevation and rotated contralaterally; distention greater than $3\text{--}5\,\text{cm}$ above the sternal angle of Louis indicates elevated central venous pressure from congestive heart failure or cor pulmonale.

Digital Clubbing

Fingertip deformity characterized by bulbous swelling and loss of the normal angle between the nail plate and nail bed, commonly caused by chronic systemic hypoxia.

Tripod Position

A compensatory seated posture in which the patient leans forward and braces their hands or elbows on the knees or an adjacent surface to optimize the mechanical advantage of accessory neck and chest muscles during respiratory distress.

Pulse Deficit

The numerical difference between the apical heart rate and the peripheral radial pulse rate when taken simultaneously, indicating inadequate left ventricular stroke volume to produce a palpable peripheral pulse (commonly seen in atrial fibrillation and premature beats).

Orthostatic Hypotension

A reduction in blood pressure occurring within $3\,\text{minutes}$ of standing from a supine position, defined as a decrease in systolic blood pressure of $\ge 20\,\text{mmHg}$ or a decrease in diastolic blood pressure of $\ge 10\,\text{mmHg}$, typically accompanied by a $10\text{--}20\,\%$ increase in heart rate.

Mean Arterial Pressure (MAP)

The average pressure in a patient's arteries during one complete cardiac cycle representing tissue perfusion, calculated as $\text{MAP} = \text{DBP} + \frac{1}{3}(\text{SBP} - \text{DBP})$; values below $60\,\text{mmHg}$ indicate clinical hypotension.

Pulse Quality Scale

A 5-point clinical rating scale assessing arterial pulse volume: Grade 0 (Absent), Grade 1+ (Thready; barely perceptible, easily obliterated), Grade 2+ (Weak; difficult to palpate), Grade 3+ (Normal; requires moderate pressure to obliterate), and Grade 4+ (Bounding; hyperactive, not obliterated with moderate pressure).

P Wave

The electrocardiographic waveform representing electrical depolarization of the atria.

PR Interval

The electrocardiographic interval measured from the onset of the P wave to the beginning of the QRS complex, reflecting the time required for electrical impulses to travel from the atria through the AV node; normal duration is $0.12\text{--}0.20\,\text{s}$ ($3\text{--}5\,\text{small boxes}$).

QRS Complex

The electrocardiographic waveform representing ventricular depolarization, normally narrow with a duration of $< 0.12\,\text{s}$; a width of $\ge 0.12\,\text{s}$ defines a wide QRS complex.

T Wave

The electrocardiographic waveform reflecting ventricular repolarization.

Sinus Bradycardia

A regular cardiac rhythm originating from the sinoatrial node with identical P waves before each narrow QRS complex at a resting rate of $< 60\,\text{beats/min}$.

Sinus Tachycardia

A regular cardiac rhythm originating from the sinoatrial node with a 1:1 P-to-QRS ratio at a rate of $> 100\,\text{beats/min}$.

Atrial Fibrillation

A supraventricular arrhythmia characterized by an irregularly irregular ventricular rhythm, complete absence of distinct P waves, fibrillatory baseline undulations, and variable AV conduction.

Atrial Flutter

A supraventricular tachycardia generated by an atrial reentry circuit, marked by a characteristic "sawtooth" pattern of flutter waves without discrete normal P waves.

Premature Ventricular Contraction (PVC)

An ectopic impulse originating within the ventricles that fires early, interrupting the underlying cardiac rhythm, characterized by the absence of a preceding P wave and a wide, bizarre QRS complex ($\ge 0.12\,\text{s}$).

Ventricular Tachycardia (VT)

A life-threatening cardiac arrhythmia defined by a sequence of $3$ or more consecutive premature ventricular complexes occurring at a rate of $> 100\,\text{beats/min}$, presenting with wide, abnormal QRS complexes.

Ventricular Fibrillation (VF)

A lethal cardiac arrest rhythm characterized by rapid, chaotic electrical quivering without discernible QRS complexes or mechanical pumping action, resulting in an absent pulse and requiring immediate CPR and defibrillation.

First-Degree AV Block

An atrioventricular conduction delay in which every P wave is conducted to the ventricles (1:1 P-to-QRS relationship), but the PR interval remains consistently prolonged at $> 0.20\,\text{s}$.

Second-Degree AV Block: Mobitz I (Wenckebach)

An atrioventricular block characterized by progressive, cyclical prolongation of the PR interval until a single P wave is completely blocked and fails to produce a QRS complex ("longer, longer, drop").

Second-Degree AV Block: Mobitz II

An atrioventricular block characterized by constant PR intervals on conducted beats, with intermittent, unexpected non-conducted P waves and dropped QRS complexes; represents an unstable clinical finding that requires prompt medical escalation.

Third-Degree (Complete) AV Block

A complete cessation of electrical conduction between atria and ventricles (AV dissociation), marked by regular P waves firing independently of an independent, slower ventricular or junctional escape rhythm.

Myocardial Ischemia (ECG Manifestation)

Reduced coronary blood flow to the myocardium evidenced on an electrocardiogram by horizontal or downsloping ST-segment depression and/or T-wave inversion associated with patient symptoms or exertion.

Myocardial Infarction (ECG Manifestation)

Acute myocardial necrosis and cellular death indicated on an ECG by ST-segment elevation and/or the appearance of significant pathological Q waves ($> 1\,\text{small square wide}$ or $> \frac{1}{3}$ the height of the QRS complex).

Digitalis (Cardiac Glycosides)

A cardiovascular drug that enhances myocardial contractility by increasing intracellular calcium and inhibits SNS activity; toxicity can produce visual disturbances, gastrointestinal upset, life-threatening arrhythmias, and scooped ST depression.

Sternal Precautions

Post-surgical movement restrictions designed to prevent sternal dehiscence after a median sternotomy, including avoiding bilateral upper extremity elevation above $90^\circ$ of flexion, resisting heavy lifting, and avoiding pulling up on bed or stair rails.