Cumulative Exam

Blood circulation pattern

Starting from inferior and superior vena cava to right heart, lungs, and left heart.

Inferior vena cava to superior vena cava

Through right atrium, tricuspid valve to right ventricle, pulmonary valve to pulmonary artery to lungs, then through pulmonary veins back to left atrium through semilunar valves.

From left atrium

Through mitral valve to left ventricle, then through aortic valve to aorta and out to the body.

Exercise termination criteria for implanted defibrillator

Includes ST elevation (>1.0mm) in leads without preexisting Q waves due to prior MI.

Drop in systolic BP

Greater than 10 mmHg despite an increase in workload, when accompanied by other evidence of ischemia.

Moderate to severe angina

A reason for exercise termination in patients with implanted defibrillators.

Central nervous system symptoms

Includes dizziness, ataxia, near syncope as criteria for exercise termination.

Signs of poor perfusion

Includes pallor and cyanosis as criteria for exercise termination.

Sustained ventricular tachycardia

An arrhythmia that interferes with normal maintenance of cardiac output during exercise.

Technical difficulties monitoring

Includes ECG or SBP issues as criteria for exercise termination.

Patient requests to stop

A valid reason for terminating exercise.

85% HRmax or 70% HRR

Threshold for exercise termination.

Sinus bradycardia

Characterized by decrease in SA node automaticity, increased vagal stimulation, or 2nd or 3rd degree block.

Sinus tachycardia

Characterized by increase in SA node automaticity due to fear, emotion, exercise, caffeine, nicotine, amphetamines, or atropine.

Sinus Arrhythmia

Characterized by alternation in vagal stimulation.

Wandering pacemaker

Caused by irritable focus, ischemia or injury to the SA node, congestive heart failure, or increase in vagal firing.

Atrial flutter

Ectopic focus seen in rheumatic disease, mitral valve disease, coronary artery disease or infarction, stress, drugs, renal failure, or hypoemia.

Atrial fibrillation

Caused by multiple ectopic foci.

Junctional rhythms

Caused by sinus node disease, increased vagal tone, digoxin toxicity, or infarction/severe ischemia.

1st degree block

Caused by medication (digoxin, beta blockers), coronary artery disease, rheumatic heart disease, or infarction.

2nd degree Mobitz 1

Transient disturbance in high AV junction, preventing some impulses through AV node.

2nd degree Mobitz 2

Caused by ischemia or infarction of the AV node or digoxin toxicity.

3rd degree block

Caused by acute MI, digoxin toxicity, or degeneration of the conduction system.

Ventricular tachycardia

Caused by ischemia, acute infarction, coronary artery disease, hypertensive heart disease, or reactions to medications (digoxin toxicity).

Ventricular fibrillation

Same causes as ventricular tachycardia and is a sequel to ventricular tachycardia.

PVC

Single ectopic focus from ventricles; multiple indicates different foci.

Cardiac index

Cardiac output divided by body surface area in square meters.

Normal cardiac index

Approximately 3.0 L/min/m2.

Low cardiac index

Less than 2.2 is considered diagnostic of cardiogenic shock.

High cardiac index

May occur in conditions like sepsis, anemia, or hyperthyroidism.

Calcium channel blockers

Indications include coronary artery disease, hypertension, and arrhythmia.

Loop diuretic complications

Indications include hypertension, congestive heart failure, and edema.

Nitroglycerin

Indicated for angina pectoris.

Corticosteroids

Indicated for thromboangitis obliterans and inflammation conditions.

Beta-blockers

Indications include post-MI, hypertension, and arrhythmia.

Digitalis

Indicated for systolic dysfunction in patients with congestive heart failure.

ACE inhibitors

Medications used to treat congestive heart failure and hypertension.

Indications for ACE inhibitors

Congestive heart failure and hypertension.

Mechanism of ACE inhibitors

Removes excess water and sodium while also preventing vasoconstriction.

Adverse effects of ACE inhibitors

Cough (dry hacking), orthostatic hypotension, dizziness, hyperkalemia, hyponatremia.

Echocardiogram

Used to assess pericardial pathologies, muscle pathologies, valve issues, clots, congenital heart disease, ischemia, valve integrity, ventricular size, and ejection fraction.

Holter ECG

Indications include identifying symptoms possibly caused by arrhythmias.

Holter monitoring

Transcutaneous with multiple leads to record heart rhythm for 24 hours.

Cardiac catheterization

Used to measure cardiac output, perform angiography, and assess left and right heart pressures.

ABI grades

Used to assess blood supply; >1.1 indicates arterial calcification, 1.0 indicates adequate blood supply, <1.0 indicates inadequate blood supply.

Heart sounds S1

Heard at the mitral and tricuspid valves; indicates the beginning of systole.

Heart sounds S2

Heard at the aortic and pulmonary valves; indicates the end of systole.

Heart sounds S3

Indicates fluid overload; can be normal in healthy children and young adults.

Heart sounds S4

Indicates ventricular hypertrophy and is associated with conditions like hypertension and diastolic heart failure.

Cheyne-Stokes breathing

Gradual increase in depth of respirations followed by gradual decrease and then a period of apnea.

Kussmaul respirations

Regular but abnormally deep and increased in rate, characterized by distressing dyspnea.

Paradoxical breathing

Chest wall falls in during inspiration, may lead to flattened anterior chest wall.

Diaphragmatic breathing

Deep breathing through the abdomen, slow and deep.

Bronchial breath sounds

Heard near the trachea and mainstream bronchi.

Bronchovesicular breath sounds

Heard near the junction of mainstem bronchi with segmental bronchi.

Vesicular breath sounds

Heard over lung tissue, not near trachea.

Radiopacity

More dense structures hinder x-rays, appearing white on imaging.

Radiolucency

Less dense tissues allow more x-rays to pass through, appearing blacker on imaging.

Intercostal rib space

Normal spaces are even and symmetrical; widened indicates hyperinflation.

Diaphragm position

Normal is dome-shaped; flattened indicates COPD.

Tracheal deviation

Ipsilateral shift indicates atelectasis; shifts away indicate pneumothorax.

Ventilation

Process by which air moves into the lungs.

Perfusion

Total blood in lungs available for gas exchange.

Respiratory acidosis

pH < 7.40 with increased PaCO2.

Metabolic acidosis

pH < 7.40 with decreased HCO3.

Hemoptysis

Coughing up blood; requires immediate cessation of PT and physician notification.

Arterial wound

Anywhere on leg or dorsum of foot or toes; Boney prominences, lateral malleolus; Painful especially with legs elevated; Intermittent claudication; Hair loss; Thin, shiny skin; Ischemia, pale, white skin color; Red-purple mottling; Hypersensitivity to palpation.

Venous wound

Usually above medial malleolus; Shallow, irregular border; White/fibrous slough over granulation tissue; Moderate-heavy drainage; Partial to full thickness; Edema may become hard, woody in chronic cases; Skin often thin, shiny, dry, cyanotic.

Systolic heart failure

Poor ejection fraction; Weak cardiac contractility; High peripheral resistance.

Diastolic heart failure

Poor ventricular filling; Ventricular walls hypertrophy; Chronic hypertension; Myocardial infarction history; Chronic aortic stenosis.

Stable angina

Happens during predicted level of physical activity; Predictable, reproducible pain; Goes away with rest or nitroglycerin; St depression on ECG; Beta blockers, nitroglycerin, statins, antiplatelets for prevention.

Unstable angina

More severe pain; First few hours of rising; Not relieved with activity; Unpredictable, occurs at rest or with minimal exertion; May not be relieved by rest or nitroglycerin; St depression, T wave inversion or even normal ECG during pain; Immediate hospitalization, nitroglycerin, beta blockers, anticoagulants and possible revascularization.

Prinzmetal angina

Less severe; Often relieved with minor activity; Able to perform high levels of work later in the day without discomfort; Often at rest, cyclic, unrelated to exertion; Relieved by rest or nitroglycerin; St elevation on ECG; Nitroglycerin for relief, calcium channel blockers and nitrates for prevention.

Asthma

Lumens of airways narrowed or occluded; Bronchial smooth muscle spasm, mucosa inflammation, overproduction of viscous mucus; Reversible narrowing of airways; Triggered by allergens/exercise; Sudden or intermittent onset; Chronic inflammatory condition of the airways; Increased responsiveness of airway smooth muscle; Lowered threshold of airway smooth muscle reactivity; Symptoms: wheezing, chest tightness, shortness of breath.

Chronic bronchitis

Inflammation accompanied by excessive mucus secretion; Obstructing bronchial tubes; Presence of a chronic productive cough for 3 months in each of 2 consecutive years; Hypersecretion in large airways, progresses to smaller airways; Thickening of the airway wall; Hypertrophy of submucosal glands; Small airway involvement; 'Blue bloater' = cyanosis in later disease.

Emphysema

Loss of pulmonary parenchyma (loss of alveolar septae and walls of airways); Dilation of terminal airways; Airway obstruction allows air to flow into the alveoli during inspiration but impedes the outflow of air during expiration; Symptoms: shortness of breath, high increase in work in breathing, use of accessory muscles, weight loss, minimal cough, decreased breath sounds, 'pink puffer', barrel chest, air trapping.

Pulmonary fibrosis

Inflammatory of the alveolar wall; Progressive lung disease characterized by scarring of lung tissue, including alveolar walls; Scarring leads to thickening of the alveolar capillary membrane; Unknown cause; Some factors contribute: viral, genetic, immune system disorders, or combo; Immunologically mediated disease; Triggered by an initial acute injury or infection; Symptoms: Dyspnea on exertion progresses to dyspnea at rest in late disease, repetitive non-productive cough, weight loss, decrease in appetite, fatigue.

Pneumonia

Caused by bacteria or viral agents; Symptoms: crackles; Bacterial = high fever, chills, dyspnea, tachypnea, productive cough, pleuritic pain; Viral = moderate fever, dyspnea, tachypnea, nonproductive cough, myalgias; Lower lobe pneumonia may refer pain to shoulder; Lying on affected side helps pain, lying on unaffected helps oxygenation.

Pulmonary edema

Two primary causes: Cardiogenic pulmonary edema: increased pulmonary capillary hydrostatic pressure, often secondary to left ventricular failure; Non-cardiogenic pulmonary edema (ARDS): caused by increased alveolar capillary membrane permeability; Symptoms: all signs and symptoms of drop in O2; Cough: pink frothy sputum.

Tidal volume

Volume of air moved during either inhalation or exhalation over a specific period of time; Increased in obstructive; Decreased in restrictive.

Expiratory reserve volume

Extra air you can exhale after a normal exhalation; Decreased in restrictive; Decreased in obstructive.

Inspiratory reserve volume

Extra air you can inhale after a normal inhalation; Decreased in restrictive; Decreased in obstructive because of hyperinflation.

Obstructive lung disease

Posture: tripod, use of accessory muscles = helps expand thorax and improve exhalation; Widened/increased intercostal space = hyperinflated lungs pushes ribs outward = barrel chest; Flattened diaphragm; Pursed lips.

Restrictive lung disease

May lean forward, less accessory muscle use at rest = breathing is shallow, minimal chest expansion; Narrowed intercostal space = stiff lungs or chest wall restrict rib movement; Lung compliance is reduced = no deep breaths.

Ischemic threshold

Used as a strict maximum limit to ensure exercise stays below the point of heart oxygen deprivation; Exercise should be 10 bpm below ischemic threshold from last session.

Arterial insufficiency treatment

PAD - antiplatelet therapy, statins

Patient education for arterial insufficiency

Cardiovascular risk, nutrition and weight control, stop smoking, skin care education

Exercises to avoid with arterial insufficiency

Static exercise, straining, valsalva maneuver

Most effective exercise for arterial insufficiency

Walk until claudication, rest until pain subsides, resume walking, long term program more than 6 months

Preferred position for arterial insufficiency

Upright positions preferred

Chronic venous insufficiency treatment

Provide education and prevention to avoid complications of venous ulceration, chronic wounds, edema management

Gold standard for chronic venous insufficiency

Compression therapy, bandages, compression stocking, compression pumps

Exercise for both arterial and venous insufficiency

Low impact walking or bike

ABI check for exercise progression

Check ABI first, if < 0.5 avoid aggressive exercise

RPE levels for cardiac rehab Phase 1

Below 11

RPE levels for cardiac rehab Phase 2

12-13

RPE levels for cardiac rehab Phase 3

16-17

Exercise termination criteria based on Blood pressure levels

Terminate at 85% HRmax, 70% HRR

Indications for terminating exercise

ST elevation without Q waves, drop in systolic BP > 10 mmHg with other evidence of ischemia, ventricular tachycardia, 2nd or 3rd degree block, SBP > 250 mmHg, DPB > 115 mmHg

Assisted coughs

Manually assisting patient to cough, thrust diaphragm as they cough to help them have more force