Cardiac & Vascular Flashcards
What is the PMI? Where is it?
Point of maximum impulse; should be located at about the 7th intercostal space
What is happening during diastole?
Ventricular filling/relaxation
Tricuspid/Mitral valves open
Atrial contraction
What is happening during systole?
Ventricular contraction
Pulmonary/Aortic valves open
Atrial filling/relaxation
The volume of blood ejected in one heartbeat/contraction (70mL is average)
Stroke volume
Functional measurement of stroke volume
Ejection Fraction
The volume of blood ejected from each ventricle in a one minute interval
Cardiac Output
If the EF is below 60% the most likely cause is…
CHF
Factors that effect the stroke volume are…
PRELOAD
MYOCARDIAL CONTRACTILITY
AFTERLOAD
Volume or load that stretches the cardiac muscle prior to contraction
Preload
Increased preload may be associated with…
Increased venous return, reduced HR, ventricular/systolic failure, pathologic valves (aortic or pulmonic)
Decreased preload may be associate with…
Decreased venous return, impaired atrial function, diastolic failure, pathological valves (mitral or tricuspid)
Not all the blood gets pumped out, more blood sitting in the chamber, increased stretching of the chamber when filled
Ventricular/Systolic Failure
The ability of the heart muscle to contract in response to preload
Ionotropy
Increased ionotropy may…
Increase the contractility of the cardiac muscle
How are ionotropy and EF related?
Increased ionotropy = increased EF
The load that the heart must pump against
Afterload
What factors effect the afterload?
Resistance in the arteries/peripheral vascular system & Aortic/Pulmonic valve stenosis
Aortic “zone” of the heart
2nd intercostal space; right sternal border
Pulmonic “zone” of the heart
2nd intercostal space; left sternal border
Erb’s point “zone” of the heart
3rd intercostal space; left sternal border
Tricuspid “zone” of the heart
4-5th intercostal space; left sternal border
Mitral “zone” of the heart
5th intercostal space; left mid-clavicular line
S1 represents…
Closure of AV valves (particularly mitral) at the end of diastole/beginning of systole
S2 represents…
Closure of semilunar valves (particularly aortic) at the end of systole which occurs as ventricular pressure falls below that of aortic pressure
Where is S1 loudest?
At apex (over mitral area)
Intensity of S1 is due to…
The speed that the mitral valve closes
Loud S1 is indicitive of…
Mitral stenosis; Elevated atrial contraction forces the valve open; Early indicator of disease
Soft S1 is indicitive of…
CHF, severely calcified mitral valve
Variable S1 is indicitive of…
Heart block or atrial fibrillation
Where is S2 best heard?
Over the upper sternal border in the Aortic & Pulmonary locations
Closure of the valves that is not simultaneous is called…
Splitting
Splitting can be either…
Physiological (normal) or Pathological
When should physiological splitting be heard? What does it represent?
Should only be present during S2, due to change in pressure in the thoracic cavity during inspiration that causes the right side of the heart a fraction of a second longer to contract than the left side
Wide splitting may be caused by…
Delayed RV contraction
Premature LV contraction
Increased RV afterload
Decreased LV afterload
Fixed splitting may be caused by…
ASD, RV failure
Paradoxical Splitting may be caused by…
Delay in closure of the Aortic valve (LBBB, Aortic, valve disease, LV outflow obstruction)
S3 and S4 are also called…
Gallops
S3 typically occurs…
Early in diastole, low pitched
S3 is best heard at ______ in the _______ position
The apex in left lateral decubitus
S3 is a sign of…
Rapid ventricular filling
S3 may be normal in…
Children and young adults
S3 is typically associated with what condition?
Congestive heart failure
S4 occurs immediately before…
S1 in late diastole
S4 is often considered to be…
“pre-systolic”
S4 marks….
Atrial contraction into a stiff, non-compliant ventricle
S4 is associated with what condition?
LVH due to systemic HTN & aortic stenosis
What sounds may be present with a summation gallop?
S3 & S4
These sounds are high frequency, best heard with the diaphragm, usually indicate valvular stenosis, are difficult to distinguish from S3/S4 sounds, and are brief and crisp
Ejection Clicks and Opening Snaps
Sound that occurs early systole, is heard everywhere, and not affected by standing
Aortic ejection click
Sound that occurs mid systole, is heard best at apex, and will occur earlier with standing
Mitral valve prolapse
Sound that occurs in early diastole, is low pitched, and is due to opening of abnormal valves (AV- usually mitral stenosis)
Opening snap
Murmurs are the result of…
Turbulent blood flow through vessels
The most common type of murmurs are?
Systolic murmurs, Comprise ~95% of all murmurs
The most common cause of murmurs is?
Mitral valve prolapse
Midsystolic murmur is due to…
Aortic/Pulmonic Stenosis
Pansystolic murmur is due to…
Mitral/Tricuspid Regurgitation
Late systolic murmur is due to…
Mitral Valve Prolapse
Early Diastolic murmur is due to…
Aortic Regurgitation
Mid-diastolic murmur is due to…
Mitral/Tricuspid Stenosis
Late Diastolic murmur is due to…
Mitral/Tricuspid Stenosis
Murmurs that start loud and get quieter are…
Decrescendo
Murmurs that get louder then softer are…
Crescendo – Decrescendo
Murmurs that start quiet and get louder are…
Crescendo
Murmurs that remain constant throughout are…
Plateau or uniform
Decrescendo murmurs typically occur in…
Diastole
Crescendo-decrescendo murmurs typically occur in…
Systole
Plateau murmurs typically occur as…
Holosystolic murmurs
Crescendo murmurs may be seen with….
Mitral stenosis
Decrescendo murmurs may be seen with….
Aortic regurgitation
Crescendo-Decrescendo murmurs may be seen with….
Aortic stenosis, Pulmonic stenosis
Plateau murmurs may be seen with….
Mitral regurgitation
Murmu from Aortic Stenosis may radiate to…
The carotids
Mitral regurgitation may radiate to…
The left axillae
Murmurs are graded on a scale of…
1-6
Most murmurs are grade _______
Grade 2
Murmurs accompanied by thrills are graded as…
Grade 4-6
Murmurs that can be heard without assistance are grade _____
Grade 6
A murmur that is blowing may be a sign of…
Aortic/pulmonic regurgitation, mitral regurgitation
A murmur that is harsh may be a sign of…
Aortic/pulmonic stenosis
A murmur that is rumbling may be a sign of…
Mitral/tricuspid stenosis
A murmur that is musical may be a sign of…
Occasionally aortic stenosis, Still’s murmur
A murmur that is machine-like may be a sign of…
PDA
The handgrip maneuver may be usefull to…
Differentiate between mitral regurgitation (increased intensity) and aortic stenosis (decreased intensity)
Leaning forward enhances the murmur associated with…
Aortic regurgitation (lean forward and hold breath in full expiration)
Mitral murmurs are best heard in what position?
Left lateral decubitus position
Mid to late diastolic rumble associated with AR (can mimic MS)
Austin Flint Murmur
PR murmur specifically associated with pulmonary htn; high pitched, blowing
Graham Steell murmur
Mid diastolic murmur heard at the apex during rheumatic fever
Carey Coombs murmur
What pulse has an upward slope that peaks at systole
A normal pulse
In a pulse waveform, the ____________ marks closing of the AV valves and then falls away and diastole begins
Dicrotic notch
What pulse has a much flatter volume and less pronounced dicrotic notch
An anacrotic pulse
An anacrotic pulse is often associated with what conditions?
Aortic stenosis or narrowing over the aortic valve
Aortic stenosis may also cause what type of pulse?
A pulsus parvus et tardus or weak and slow
This pulse is a double-peaked pulse
Bisferiens pulse
With what conditions might you see a Bisferiens pulse?
Occurs with severe aortic regurgitation or floppy aortic valve
When do the two peaks of Bisferiens pulse occur?
During systole or contraction
What are the two peaks of Bisferiens referred to?
First = percussion wave Second = tidal wave
Pulse that occurs when the systemic arterial pressure falls less than 10 mmHg and is not detectable in the peripheral pulses
Pulsus Paradoxus
Pulse where there is cariability of the pulse amplitude from beat-to-beat; thought to be related to changes in the action potential duration during contraction
Pulsus alternans
What condition is Pulsus alternans seen with?
Severe left ventricular systolic failure
What are the 6 P’s of peripheral pulse deficits?
Pain, Pallor, Pulselessness, Poikilothermia, Paresthesias, Paralysis
With the capilly refill test (nail beds), how fast should the color return?
Within 2 seconds
What is a “normal” ratio value for the ankle-brachial index?
Normal = 1.0 - 1.4
Up to ___ % of strokes are caused by carotid artery disease
50%
If you hear bruits while auscultating the carotid arteries (with the bell) then there is a ____ % chance there is an occlusion
60% chance
What are early signs of chronic venous insufficiency?
Varicose veins
Tan/reddish skin changes
Weepy/excoriated skin
Pedal edema
Venous insufficiency that occurs in the superficial veins; becomes red, inflamed, warm, and may be painful; treat with warm compress & NSAIDS
Phlebitis/Thromboplebitis
Upon PE you find calf tenderness, lower leg swelling, palpable cord, and Homan’s sign. What is the pt presenting with?
DVT
Splinter hemorrhages are seen with what condition?
Bacterial endocarditis
Softening of the nail bed that is associated with hypoxic conditions and subacute bacterial endocarditis
Clubbing
Yellow plaques around the eyelids associated with elevated lipid levels
Xanthelasma
Lipid deposits in the anterior sclera; Very uncommon
Corneal arcus
Angular Stomatitis and Conjunctival pallor are associated with what condition?
Anemia
What are the 4 areas/zones/regions of the heart for auscultation?
Aortic, pulmonic, tricuspid, mitral
Strong heart beat, can see the heart beating through the chest; similar to a lift
Heave
S1 best heard at the…
Apex of the heart
S2 best heard at the…
Base of the heart
S2 splitting is best heard at the…
Base with inspiration
S3 best heard at the…
Apex of the heart
Sounds like “KEN-TUC-KY”
S3
Sounds like “TEN-ES-SEE”
S4
What does MS. ARD stand for
Mitral stenosis & Aortic regurgitation = Diastolic murmurs
What does MR. PASS stand for
Mitral regurgitation, Physiologic, & Aortic stenosis = Systolic murmurs
Mitral regurgitation may radiate to the…
Left axial area
Aortic stenosis may radiate up to the…
Carotid area
Veins in the scrotum become varicosed, leads to accumulation of blood in the testes, completely reversible with operation, may lead to infertility in ~50% of men
Varicoscele
You palpate the skin of the leg and it is cold. This is a sign of….
Arterial disease
Edema that does not pit cannot be…
Lymphedema
The most common grade of pitting edema is…
2+ pitting
Generalized edema is called…
Anecarca
Parasitic infiltration of lymphatic system due to a tropical disease, causes severe lymphedema
Elephantiasis
Redness/flushing
Rubor
What is a normal JVD test result
5cm or less
What is a normal pulse graded as?
Normal = 2+
Erectile dysfunction is often the first warning sign of…
PVD & atherosclerotic disease
Vascular disease described as painful, punched out, smaller, pulses are diminished, distal coldness, and nail changes
Chronic arterial ulcer
Vascular disease that is punched out over malleoli and plantar feet, painless, and more common on plantar or side of foot
Diabetic foot ulcer
Pt comes in with suspected DVT however, after exam you don’t think that’s the case. What do you need to rule out the DVT?
2 ultrasounds must be negative
With AAAs when should you increase screening? at what point should intervention occur?
Increased screening once > 3cm
Intervene once > 5cm (5.5 ideal)
