Cardiac

Question 1

What is the mediastinum?

Answer 1

a connective tissue–lined compartment located centrally in the thoracic cavity. It is bordered by the lungs on either side, the sternum anteriorly, and the thoracic vertebral bodies posteriorly. The mediastinum houses the heart and its great vessels—the aorta, pulmonary artery, and superior and inferior vena cavae—as well the esophagus, trachea, thoracic duct, and thoracic lymph nodes.

Question 2

What is the most anterior structure of the heart?

Answer 2

Right atrium

Question 3

Where is the PMI of the heart found?

Answer 3

At the cardiac apex, the tapered inferior tip of the left ventricle. It is typically located at the 5th intercostal space at the left midclavicular line

Question 4

Where is the PMI located in dextrocardia?

Answer 4

On the right side of the chest

Question 5

What is a PMI >2.5cm evidence of?

Answer 5

left ventricular hypertrophy

Question 6

If the patient’s PMI is not at the apex, but rather at the xyphoid process or epigastric area, what might be causing this?

Answer 6

COPD, or right ventricular hypertrophy

Question 7

What would cause the PMI to move laterally, placing it 10 cm or more lateral to the midsternal line?

Answer 7

left ventricular hypertrophy or ventricular dilation from myocardial infarction or heart failure

Question 8

What are the two atrioventricular valves?

Answer 8

The mitral and tricuspid

Question 9

What are the two semi lunar valves called?

Answer 9

aortic and pulmonic

Question 10

what are s3 and s4 heart sounds? Are they normal? What do they indicate?

Answer 10

In most adults, the diastolic sounds of S3 (kentucky) and S4 (Tennessee) are pathologic, and are correlated with systolic and diastolic heart failure, respectively.

Question 11

What does an s3 heart sound correspond with?

Answer 11

An S3 corresponds to an abrupt deceleration of inflow across the mitral valve.

Question 12

What does an s4 heart sound correspond with?

Answer 12

An S4 corresponds to increased left ventricular end diastolic stiffness which decreases compliance.

Question 13

What is the period of ventricular contraction called?

Answer 13

systole

Question 14

what is the period of ventricular relaxation called?

Answer 14

diastole

Question 15

What does the s1 sound correspond with?

Answer 15

Closure of the mitral valve and the tricuspid valve in the right side of the heart

Question 16

What does the sound of s2 correspond with?

Answer 16

aortic valve closure, as well as closure of the pulmonic valves

Question 17

When might you hear an audible “opening snap” of the mitral valve?

Answer 17

In restricted valve motion, as in mitral stenosis.

Question 18

Where on the chest would you ascultate the aortic valve?

Answer 18

Right second intercostal space or cardiac apex

Question 19

Where on the chest would you ascultate the sounds of the pulmonic valce?

Answer 19

Left second and third intercostal spaces close to the sternum, but also at higher or lower levels

Question 20

Where on the chest would you ascultate the tricuspid valve?

Answer 20

At or near the lower left sternal border

Question 20

Where on the chest would you ascultate the tricuspid valve?

Answer 20

At or near the lower left sternal border

Question 21

Where on the chest would you ascultate the mitral valve?

Answer 21

At and around the cardiac apex

Question 22

Where does the cardiac electrical impulse orginate?

Answer 22

the sinus node in the right atrium, near the junction of the vena cava

Question 23

Explain ejection fraction

Answer 23

EF is the percentage of ventricular blood volume that is ejected with each heart beat, and is normally 60%

Question 24

Explain stroke volume

Answer 24

The volume of blood ejected with each heart beat

Question 25

What is cardiac output defined as?

Answer 25

Cardiac output, the volume of blood ejected from each ventricle in 1 minute, is the product of heart rate and stroke volume.

Question 26

What are the two common manifestations of heart failure?

Answer 26

Heart failure with preserved ejection fraction and heart failure with reduced ejection fraction

Question 27

What is preload?

Answer 27

The amount of blood that stretches the cardiac muscle before contraction. The volume of blood in the RV at the end of diastole is its preload for the next heartbeat.

Question 28

What are some causes of increased preload?

Answer 28

Physiologic causes include inspiration and the increased volume of blood flow from exercising muscles. The increased blood volume of a dilated RV in heart failure also increases preload.

Question 29

What are some causes of decreased right ventricular preload?

Answer 29

Causes of decreased right ventricular preload include exhalation, dehydration, and pooling of blood in the capillary bed or the venous system

Question 30

What is myocardial contractility?

Answer 30

Myocardial contractility refers to the ability of the cardiac muscle, when given a load, to shorten. Contractility increases when stimulated by action of the sympathetic nervous system and decreases when blood flow or oxygen delivery to the myocardium is impaired, as occurs in MI.

Question 31

What is afterload?

Answer 31

Afterload refers to the degree of vascular resistance to ventricular contraction.

Question 32

What are four factors that affect blood pressure?

Answer 32

Left ventricular stroke volume
Distensibility of the aorta and the large arteries
Peripheral vascular resistance, particularly at the arteriolar level
Volume of blood in the arterial system

Question 33

What does jugular venous pressure (JVP) reflect?

Answer 33

Right atrial pressure

Question 34

What do absent A waves represent on an EKG?

Answer 34

atrial fibrillation

Question 35

What are concerning symptoms that would trigger you to do a cardiac exam?

Answer 35

Chest pain
Palpitations
Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea
Swelling (edema)
Fainting (syncope)

Question 36

How is the pain of aortic dissection commonly described?

Answer 36

Anterior chest pain, often tearing or ripping and radiating into the back or neck

Question 37

True of false: Women with acute coronary syndrome can present with atypical symptoms such as upper back or jaw pain, shortness of breath, nausea or fatigue

Answer 37

Both men and women with acute coronary syndrome usually present with the classic symptoms of exertional angina; however, women, particularly those over age 65, are more likely to report atypical symptoms that may go unrecognized, such as upper back, neck, or jaw pain; shortness of breath; paroxysmal nocturnal dyspnea; nausea or vomiting; and fatigue, making careful history-taking especially important.

Question 38

What might be the cause of a sudden onset of dyspnea

Answer 38

Sudden dyspnea occurs in pulmonary embolus, spontaneous pneumothorax, and anxiety.

Question 39

What is orthopnea?

Answer 39

Shortness of breath when the patient is supine that improves when the patient sits up

Question 40

How much fluid can interstitial tissue absorb before pitting edema appears?

Answer 40

Up to 5L

Question 41

Other than cardiac or pulmonary causes, what might cause pitting edema?

Answer 41

Causes are frequently cardiac (right or left ventricular dysfunction; pulmonary hypertension) or pulmonary (obstructive lung disease)20 but can also be nutritional (hypoalbuminemia), and/or positional.

Question 42

How can you help a patient with a risk of fluid retention to monitor fluid accumulation?

Answer 42

Consider asking patients who retain fluid to record daily morning weights because edema may not be obvious until several liters of extra fluid have accumulated; however, rapid weight gain (more than 1 to 2 lb/day) will occur prior to visible edema.

Question 43

How old would a patient have to be to have a JVP that is visible and accurate enough to give a reliable assessment?

Answer 43

12 year old

Question 44

What measurement of JVP would be considered “elevated above normal”?

Answer 44

> 3cm above the sternal angle, or 8cm in total distance above the right atrium

Question 45

Why is it important to ascultate the carotid artery prior to palpation?

Answer 45

As the presence of carotid atherosclerosis could potentially narrow the carotid arteries, it is important to auscultate the carotid arteries prior to palpating the carotid pulse.

The most feared complication of carotid artery palpation is the dislodgment of an atherosclerotic plaque, which could result in stroke.

Question 46

When palpating the carotid pulse, what finding might indicate aortic stenosis?

Answer 46

Delayed carotid upstroke

Question 47

When might the carotid pulse be weaky/thready? When might it be bounding?

Answer 47

The carotid pulse is small, thready (barely detectable), or weak in cardiogenic shock; the pulse is bounding in aortic regurgitation.

Question 48

What is pulsus alternans? What does it indicate?

Answer 48

Pulsus Alternans. In pulsus alternans, the rhythm of the pulse remains regular, but the force of the arterial pulse alternates because of alternating strong and weak ventricular contractions. Pulsus alternans almost always indicates severe left ventricular dysfunction.

Question 49

How can you assess for a paradoxical pulse?

Answer 49

As the patient breathes quietly, lower the cuff pressure to the systolic level. Note the pressure level at which the first sounds can be heard. Then drop the pressure very slowly until sounds can be heard throughout the respiratory cycle. Again, note the pressure level. The difference between these two levels is normally no greater than 3 or 4 mm Hg.

Question 50

How can you easily differentiate between paradoxical pulse and pulsus alternans?

Answer 50

Pulsus alternans and a bigeminal pulse vary beat to beat; a paradoxical pulse varies with respiration.

Question 51

How can palpation of the carotid artery help in the assessment of cardiac murmurs?

Answer 51

Palpation of the carotid artery during auscultation is an invaluable aid to the timing of sounds and murmurs. Since the carotid upstroke always occurs in systole immediately after S1, sounds or murmurs coinciding with the upstroke are systolic; sounds or murmurs following the carotid upstroke are diastolic.

Question 52

In what patients might palpation of the chest wall be less useful?

Answer 52

Palpation is less useful in patients with a thickened chest wall (obesity) or increased AP diameter (obstructive lung disease).

Question 53

When palpating the chest wall- what is a heave? What might it indicate?

Answer 53

To palpate heaves, use your palm and/or hold your fingerpads flat or obliquely against the chest. Heaves are sustained impulses that rhythmically lift your fingers, usually produced by an enlarged right or left ventricle (depending on the location of the heave) and occasionally by ventricular aneurysms.

Question 54

True or false: the presence of a thrill changes the grading of a murmur

Answer 54

True

Question 55

How might an apical impulse be shifted in a pregnant patient?

Answer 55

Upward and left

Question 56

How might a patient with atrial stenosis present?

Answer 56

Patients with an atrial septal defect often experience dyspnea as well as atrial arrhythmias. Fixed splitting of the second heart sound occurs in atrial septal defects and right heart failure and does not vary with respiration

Question 57

True or false: Tricuspid stenosis causes a splitting of the S2 heart sound

Answer 57

False. Tricuspid stenosis would not usually affect the second heart sound as it is a component of S1.

Question 58

How long is a normal QRS complex? How would a left bundle branch block effect the QRS complex?

Answer 58

The QRS complex is the duration of ventricular depolarization and is normally less than 100 milliseconds. A left bundle branch block would extend ventricular depolarization and cause lengthening of the QRS complex and its duration.

Question 59

What does the QRS wave correspond to? The P wave? T wave?

Answer 59

The P wave is the result of atrial depolarization and would therefore have changes associated with atrial enlargement. The QRS complex, R wave, and S wave are a result of ventricular depolarization, whereas the T wave is a result of ventricular repolarization.

Question 60

If heart rate reduces by 20%, with no change in stroke volume, how would the cardiac output change?

Answer 60

Cardiac output is the product of heart rate and stroke volume. Therefore, if the heart rate decreases by 20%, the cardiac output would decrease by 20% if the stroke volume did not change.

Question 61

How can you assess for splitting of S2?

Answer 61

Listen for splitting of this sound in the second and third left intercostal spaces. Ask the patient to breathe quietly and then slightly more deeply than normal.

Question 62

True or False: murmurs are a common, normal finding in pregnant patients.

Answer 62

False. Murmurs detected during pregnancy should be promptly evaluated for possible risk to the mother and fetus, especially those of aortic stenosis or pulmonary hypertension.

Question 63

what is the intima and why is it significant in cardiovascular disease?

Answer 63

The innermost layer of all blood vessels is the intima, a single continuous lining of endothelial cells with remarkable metabolic properties.1 Atherosclerotic plaque formation begins in the intima

Question 64

What is an anastamoses?

Answer 64

If an artery is obstructed, anastomoses between branching networks of smaller arteries can increase in size over time to form collateral circulation that perfuses structures distal to the occlusion.

Question 65

What are the three arteries of the upper limbs?

Answer 65

Ulnar, Radial and Brachial

Question 66

What are the three arteries that stem from the femoral artery?

Answer 66

the popiteal, posterior tibial and dorsalis pedis

Question 67

How can you differentiate between edema and lymphedema?

Answer 67

Edema is typically compressable, while lymphedema (from obstructed lymphatic drainage) is usually not compressable.

Question 68

Why are upper extremity DVTs more common in recent years?

Answer 68

increased placement of central venous catheters, cardiac pacemakers, and defibrillators.19 Most patients present with unilateral or asymmetric swelling of the extremities.

Question 69

Differentiate between pulses tardus and pulses parves

Answer 69

Pulsus parvus refers to weak pulses, usually seen with atherosclerotic PVD, while pulsus tardus refers to sluggish pulses, usually occurring in the setting of aortic stenosis or low cardiac output.