What conditions decrease the righ atrial pressure>?
An "a" wave corresponds to what in the heart cycle?
"a" waves come immediatly before what part of the cardiac cycle?
Increased "a" waves indicate what is happening in the right atria?
there is increased resistance to emptying of the right atria, this is usually due to decresed right ventricular compliance or tricuspid stenosis
What are some pathologica causes of increased "a" waves?
right ventricular hypertrophy, pulmonary valve stenosis, chronic obstructive pulmnoary disease with associated pumonary hypertnesion, restrictive cardiomyopathy, tricuspid stenosis
Absent "a" waves are caused by what?
atrial fibrillation, Jugular/ventricular rhythms
Intermittent or prominent "a" waves or "cannon a" are caused by what?
atrial ventricular dissociation
An "x" decent corresponts to what?
A prominent "x" decent is due to what pathologies? (3)
Decreased or absent "x" decent is due to what pathologies?
severe tricuspid regurgitation
the "C" wave represents what?
bulging of the tricuspid valve during systolic contraction it may or may not be seen in every patient
the "v" wave represents what?
increased atrial pressure as venous return increases after systole
What pathology can produce a prominent "V" wave?
severe tricuspid regurgitation
What is Kussmaul's sign?
A jugular venous pressure that rises with inspiration
What does a "y" decent represent?
the reduced pressure observed with tricuspid valve opening and atrial emptying during diastole
What causes a prominent or rapid y decent?
What causes a slow y decent?
What causes an absent y decent?
why does JVD normally fall with inspiration?
the reduced pressure from the expanding thoracic cavity
What does kussmaul's sign indicate?
impairment of filling of the right ventricle due to either fluid in the pericardial space or a poorly compliant myocardium or pericardium
What happpens in a positive hepatojugular reflex?
pressing on the liver augments the venous return to the right atrium with a right sided heart disease process the right atrium cannot accomodate for this increased flow of blood so the JVP rises and waveforms increasein intensity
How do you tell the difference between the jugular vein and the carotid?
They both have a pulse but the jugular has a double pulse
the jugular is more easily stopped/occluded
The pulse in the jugular is not usually as strong as the pulse in the carotid
If you have a patient with heart failure and their lungs are rapidly filling with fluid what should you give them and why?
Nitroglycerine to dialate blood vessels and promote forward flow insted of backward flow
Normal carotid upstroke follows ___ and preceeds ___ which is important for the timeing of murmers
What is the only way to measure the pressure in the right atria and ventricles
Can you hear a mitral stenosis with the diaphragm?
No, the diaphragm only hears high pitched sounds and will not be able to pick up a mitral stenosis
If upon chest exam you note that the patient is very tall and thin with a wingspan greater than their height, and they have a large chest scar what underlying disease do you expect they have and what heart problems may be corrolated with that?
Stigmata of Marfan's syndrome, aortic route disese, dialation of the aortic route aortic insufficency and aortic dissection- this is due to the connective tissue imperfections that come with marfans
When the sternum heaves it is a ____ ventricular problem when the sternum lifts it is a ___ ventricular problem
Heaves- Right ventricle; Sternum lifts- left ventricle
If the carotid has bruits or thrills use the ___ artery to time the cardiac cycle
Where would you find the PMI (apical pulse)?
5th intercostal space 1cm medial to the midclavicular line
During percussion if the sternum is not the first and last dull note on the right then what is the most likely disease process?
Right sided dialation
S1 is loudest in the __ area
S1 is loudest at the
S2 is loudest in the __ area
What murmurs do you hear in the Aortic space?
What murmurs do you hear in the pulmonic area?
pulmonic insufficency, pulmonic stenosis and S2
what murmurs do you hear in the tricuspid area?
What murmurs do you hear in the mitral area?
S1, S3, stenosis
Where is the Tricuspid area located?
4th intercostal space left sternal boarder
Where is th mitral area located?
5th intercostal space mid clavicular line
What two areas have murmurs that are heard more clearly with the diaphragm?
Aortic space, pulmonic area
In what two areas is it crucial to listen for murmurs with the bell?
Tricuspid and Mitral stenosis is a low sound is only heard with bell
True or false aortic stenosis can radiate sound to the neck
What is the only murmur found in the aortic space?
Where is the Aortic space?
second intercostal right sternal boarder (below the sternal notch)
Where is the pulmonic area?
second intercostal space left sternal boarder
What murmurs/heart sounds do you hear in the pulmonic area?
Abnormally increased diaphragmatic excursion occurs in
atelectasis or diaphragmatic paralysis
Absent diaphragmatic excursion in
phrenic nerve damage
soft intensity sound that is high pitched and short in duration on chest is indicative of pleural effusion
medium intensity sound that is medium pitched and medium duration the liver will make this sound normally but in the chest it is suggestive of fluid or solid mass in the chest replacing normal air spaces
Loud, low sound with a long duration indicative of healthy lung tissue
very loud and lower tahn ressonance with a longer duration indicative of emphysema or pneumothorax
loud high pitched nois indicating gass bubble under the area of tympany in the chest it suggests absense of lung tissue or could be the gastric bubble
the upper boarder of the liver is located in the 5th intercostal space midclavicular, 7th intercostal space midaxillary, and 9th intercostal space scapular line
If there is no cardiac dullness then what might the patient have?
Intrapulmonary pressure is a mean pulmonary pressure of
>25mmHg at rest
>30mmHg during exercise
must be confirmed with a right heart catheter!
A patient presenting with dyspnea on exertion shoudl recieve what type of ultrasound?
ultrasound of the aorta
Axillary nodes are __ until proven otherwise
soft low pitches breath sounds
heard through inspiration and continue through expiration
fade away at 1/3 of expiration
Heart in equal amounts during inspiration and expiration
can be separated by a silent interval
can be heard in the first and second interspaces anteriorly and between the scapula
louder and higher pitched
short silence between inspiratory and expiratory
expiratory can last longer than inspiratory
can be heard over the manubrium
course lung sounds caused by increased disturbance in the normal lung fields
relatively low pitched snoring sound
constrictive issue that is rarely found on its own
continurous musical prolonged like dashes in time
relatively high pitches with hissing or shrill quality
distinct continuous intermittent notn musical like brief dots in time
Pulmonary functioning tests
differentiate sfrom obstructive and restrictive lung diseases
FEV1 is most important in asthma and COPD pts
In right heart failure if your patient has a pressure of 25-30mmHg what would you expect to see in the lungs?
batwings, an hear crackles/rales indicating fluid
On a chest X ray A + B should be what of T?
less than T
A patient with a right heart cath pressure of 18 or over is in what?
Right heart pressure of 30mmHg or more =
pink frothy sputum and death from heart failure
What is the only EKG arrhythmia to stem entirely from lung pathology?