Block I: approach to CV Pt. Flashcards
describe the order of blood flow
- deoxygenated blood from body
- sup/inf. VC
- R atrium
- tri-cupsid valve
- R ventricle
- semi-lunar pulmonary valve
- Pulmonary arteries
- lung for oxygenation
- Pulmonary veins
- L atria
- bicuspid valve
- L ventricle
- aorta
- systemic circulation
- becomes doexygenated at capillary beds, returns via venous flow to sup/inf VC and cycle restarts
blood is supplied to heart tissue via coronary arteries during what phase of the cardiac cycle?
diastole (resting/filling phase)
the [] of the aorta supplies the heart with the L and R coronary arteries
first 2 branches of aorta
what major artery branches from the L coronary artery
Left Anterior Descending (LAD)
[]% of flow from the atria to the ventricles is passive
70, addtl. 30% from atrial contraction/atrial kick
outflowing systemic arteries function on a [] pressure system
high, need to perfuse tissue to oxygenate
there is a [] pressure system in systemic venous return
low
outflowing pulmonary arteries function on a [] pressure system
high
there is a [] pressure system on pulmonary venous return
low
as systole begins, ventricular contraction [] pressure in ventricles
raises pressure
as [] begins, ventricular contraction increases pressure in ventricles
raises
the increase in ventricular pressure during systole causes [] on the valves
forces mitral and tricupsid valves CLOSED to prevent backflow into atria during high pressure
what is happening at the moment where the S1 sound is being made
“lub”
Mitral and tricuspid valves are being forced shut during ventricular contraction
-prevents backflow of blood into atria during contraction
what does S1/lubb indicate
beginning systole
what are the two components of the S1 sound?
- mitral vavle closing
2. closure of tricuspid valve
what happens after ventricular systole?
as blood leaves ventricles, the preassure in ventricles falls BELOW that of pulomary and aortic artery
-allows aortic and pulmonic valves to close , causing the S2 sound
what is happening during S2
pressure in ventricles falls below aorta and pulmonic arteries
which forces the two semilunar valves (aortic, pulmonic) shut
what are the two components of the S2 sound
- A2: aortic semu lunar valve closing
2. P2: pulmonic semi lunar valve closing
the S2 sound indicates what
end of systole, beginning of diastole
what happens as ventricular pressure falls below atrial pressure in diastole
mitral and tricuspid valves open to allow blood blow back intro ventricles (diastole)
what is between S1 and S2
systole
what is between S2 and S1
diastole
filling of ventricles sometimes produces an [] sound
S3
[] may be the first clinical sign of congestive heart failure
S3 sound (of ventricular filling)
the [] can sometimes be heard as a 4th heart sound
atrial kick
what is happening during atrial diastole
all heart relaxed, atrial fill with blood from sup/inf CV and pulmonary arteries
what is happening during atrial systole
after 70% passive fillling, atria contract to push remaining 30% into ventricles “atrial kick” [sometimes S4 sound]
M1 and T1 valves open
what is happening during ventricular systole
- pressure builds in ventricles
- M1,T1 closure due to pressure build up (prevents back flow) [S1]
- ventricles contract
- semi lunar (aortic, pulmonary) valves open
what is happening during ventricular diastole
- pressure falls in ventricles
- pulmonic and aortic valves close (S2: A2, P2)
- M1, T1 valves open for passive filling of ventricles (can prod. S3 if CHF, or S4 if atrial kick)
what is another name for EDV
pre-load
[] is the fiber length of ventricles prior to the onset of the contraction, i.e. the amount of stretch during diastole
EDV, pre-load
*think balloon getting filled with air
[] is the resistance of L ventricular ejection and outflow i.e. stress of ventricular wall at the end of systole
after load
*think squeezing mouthpiece of balloon while letting air out
what is the P wave on an EKG
atrial contraction (kick, sometimes S4 sound)
what is the QRS complex on EKG
ventricular contraction
what is the T wave on EKG
diastole, recovery
where is the apical impulse best felt
lower L chest, can be palpated
how is a vigorous apical impulse described
heave, lift
what might a sustained/enlarged apical impulse indicate
myocardial hypertrophy/dysfunction
if an apical impulse is very prominent and NOT sustained, what might this indicate
volume overload or high output states
additional pulsations in apical impulse may reflect []
regional abrnomalities of L ventricular contraction
a parasternal lift indicates []
R ventricular hypertrophy, pulmonary HTN, L atrial enlargement
what is the PMI, where is it best felt?
Point of Maximum impulse: point at which apical impulse is most readily seen/felt
5th intercostal space in around mid-clavicular line
[] is a fine, palpable rushing vibration felt over the precordium
thrill
[] is likened to putting your hand on a purring cat
thrill
[] has the same significance as murmurs
thrills
thrills have the same significance as []
murmurs
[] is a result of eddies from blood coursing through abnormal heart or arteries and leads to a vibration transmitted to peripheral structures
thrill/murmur
[] is more sensitive to vibrations
ear
most murmurs are accompanied by []
thrills
valve sounds are best heard in the area [] the direction of blood flow
away
specific heart sounds are best heart over areas where [] in relation to the valve
over ares where blood flows after it passes through a valve
where is the aortic valvue auscultated
2nd intercostal space, along R sternal border
where is the pulmonic valve auscultated
2nd intercostal space, along L sternal border
where is the 2nd pulmonic sound auscultated
3rd intercoatal space along L sternal border
“erb’s point”
where is the tricuspid valve best heard
4th L intercostal space, lower L sternal border
there is the mitral valve best heard
5th L intercostal space, mid-clavicular line
similar to PMI
describe Lub/S1 sound
- indicates systole
2. is sound of M1, T1 being forced closed by increasing ventricular pressure as ventricles contract
S1 correlates to the [] on EKG
QRS complex
where is S1 best heart
apex of heart
[] occurs simultaneously with carotid pulse
S1
[] is usually louder than S2
S1
S2/dubb description
is the sound of pulmonic and aortic valves (A2, P2) closing, marks end of systole and begining diastole
can sometimes be split
-A2 closes slightly before P2
why might an S2 be split
normal, because pressures are higher and depolarization occurs earlier in L heart
where is S2 best heard?
erb’s point
3rd IC space along LSB
when might S2 sounds be accentruated
conditions that cause abnormal delay in pulmonic valve closure
- increased vol. in R ventricle
- ventricular septal defect
- atrial septal defect - chronic R ventricular outflow obstruction
- pulmonic stenosis - acute/chronic dilation of R ventricle due to sudden rise in pressure
- PE
period between S1-S2 is []
systole
S2-S1 is []
diastole
events occur slightly later in [] side of heart
R
-pressure lower
what is an S3 sound
ventricular filling
-quiet difficult to hear
when does S3 occur
right after S2
in intesnt S3 sound may be described as a []
gallop
S3 occurs during what phase of cardiac cycle?
diastole, heart in early diastole after S2
[] is caused by deceleration of blood flowing into ventricles when ventricles reaches its final stage of filling
S3 “atrial kick”
where is S3 best heard
apex of heart, with patient laying on L side
when may an S3 sound be heard in a patient (disease states)
- pregnancy
- CHF
- MI
- myocardial contusion
- volume overload of ventricle
- mitral valve regurgitation
what is an S4 sound
- second phase of ventricular filling
2. vibration in valves, papillae, and ventricular walls
an intense S4 sound may be galled a []
gallop
when does S4 occur
before S1, at the end of diastole
[] is caused by vibrations of L ventricular muscle of mitral valve & left ventricular flow tracts as a result of forceful atrial contraction into distended ventricle
S4
when might an S4 be heard in a patient? (disease states)
- decreased vascular compliance due to HTN
- CAD
- aortic stenosis
- cardiomyopathy
- profond anemia
- pregnancy
- thyrotoxicosis
what is the most common cause of an S4 gallop
decreased ventricular compliance due to HTN
cardiac valves generally open []
noiselessly, unless thickened, roughed or altered
a snap sound indicates []
MITRAL valvular stenosis
a click sound indicates []
SEMILUNAR valve stenosis
mid-to-late non-ejection systolic clicks may indicate []
mitral valve prolapse
[] is a high frequency sound that occurs shortly after S1 in mid, early, late systole
click
what are clicks and when are they best heard?
- high frequency sound that
- shortly after S1
- mid-late systole
clicks indicate []
mitral valve prolapse
[] is a sustained noise that is audible during times of systole, diastole or both
murmur
a systole murmur occurs when
between S1 and S2
-when ventricles are contracting
what causes a systolic murmur
forward flow across aortic of pulmonic valve
regurgitant flow from mitral/tricuspid valve
what is holosystolic?
systolic murmur merges with first sound
what is pansytolic?
systolic murmur that occurs throughout entire systolie
when does a diastolic murmur occur
between S2-S1
when ventricles are relaxed and filling during diastole
what are some abnormalities that may cause a diastolic murmur
- aortic reguritation
- pulmonic regurgitation
- mitral stenosis
- tricuspid stenosis
diastolic murmus are [] pathologic
ALWAYS
why are diastolic murmurs always pathologic
- include mitral valve stenosis and aortic valve regurgitation
murmurs with thrills are [] significant
ALWAYS
[] begins after S1 and ends before S2 with a peak in early-mid systole
ejection
when does ejection peak?
occurs after S1 and ends before S2, peaks in early-mid systole
what causes an ejection
aortic/pulmonic valve stenosis
happens as blood leaving/ejecting from heart
what is a grade 1 murmur
very faint
what is a grade 2 murmur
quiet
what is a grade 3 murmur
moderately loud
what is a grade 4 murmur
loud with palpable thrill
what is a grade 5 murmur
very loud, easily pablpable
what is a grade 6 murmur
very loud, audible with stethescope off chest
a very faint murmur is grade []
1
a quiet murmur is grade []
2
a moderately loud murmur is grade []
3
a loud murmur with palpable thrill is grade []
4
a very loud murmur that is easily palpable is grade []
5
a very loud murmur that is audible with stethescope off chest is a grade [] murmur
6
