Cardiovascular Flashcards
Should normal valves make a sound when opening?
No - silent
Where do normal heart sounds come from?
closing
What is S1?
closure of mitral valve
What is S2?
closure of aortic valve
What is systole?
period of ventricular contraction, aortic valve is open, mitral valve is closed
What is diastole?
period of ventricular relaxation, fills with blood; aortic valve is closed, mitral valve is open
In a healthy patient, which part of the heart has the strongest contraction?
left ventricle
How can you remember the diastolic murmurs?
ArMsPT
Aortic regurgitation
Mitral stenosis
Pulmonic regurgitation
Tricupsid stenosis
What is stenosis?
stenotic open valve
What is regurgitation?
regurgitant closed valve
What is the Ar for ArMSPT?
aortic regurgitation
What is the M in ARMSPT?
mitral stenosis
What is the P in ARMSPT?
pulmonic regurgitation
What is the T in ARMSPT?
tricupsid stenosis
What are the systolic murmurs?
aortic stenosis
mitral regurg
pulmonic stenosis
tricupsid regurg
ventricular septal defect
What is S3?
when mitral valve pops open again to begin a new diastole right after S2. Healthy in young people <40 and pregnancy, athletes
When is S3 concerning?
pathologic/concerning in elderly in which it means heart failure issue
Where can you hear S3 best?
using bell at the apex in left lateral decubitus position
How is split S2 different from S3?
high pitched (diaphragm) and heard best at the pulmonic valve. Split s2 is common in inspiration while s3 is abnormal.
What is S4?
atrial contraction at the end of diastole right before S1; which reflects a pathological change in compliance
Where can you hear S4?
low pitched (bell) and heard at the apex with patient in left lateral decubitus
When is a split S2 normal?
during inspiration only
What is split S2 made up of?
aortic and pulmonic valve closure; split is when they do not close at the same time
What is the most common murmur?
midsystolic ejection murmur, with no associated pathology, just temporary changes in metabolism from pregnancy, fever, hyperthyroidism, anemia
Where can you hear a midsystolic ejection?
2nd and 4th ICS
What does a midsystolic ejection sound like?
crescendo-decresendo, no radiation; loud with a thrill
Where can you hear aortic stenosis?
2nd intercostal space in midsystolic timing
How would you describe aortic stenosis?
crescendo-decrescendo, often loud with a thrill, ejection click, harsh, medium, radiating to the carotids
What helps you hear an aortic stenosis better?
sitting and leaning forward
Where can you hear hypertrophic cardiomyopathy?
3rd and 4th intercostal space in midsystolic timing
How would you describe hypertrophic cardiomyopathy?
crescendo-decrescendo with radiation down left sternal border to the apex; harsh, medium
How can you maneuver to hear hypertrophic cardiomyopathy?
decreases with any increase in venous return (squatting)
increases with any decrease in venous return (standing)
Where can you hear a pulmonic stenosis?
2nd and 3rd intercostal space with midsystolic timing
How would you describe a pulmonic stenosis?
crescendo-decrescendo soft to loud, loud with a thrill; medium pitch, radiating to left shoulder and neck
Where can you hear mitral regurgitation?
apex in holosystolic timing
How would you describe mitral regurgitation?
soft to loud if loud, apical thrill with high pitched blowing; radiation to left axilla and left sternal border
Where can you hear a mitral valve prolapse?
apex
How would you describe a mitral valve prolapse?
mid systolic click in holosystolic; soft to loud with apical thrill and high pitched blowing w/ click.
Radiates to left axilla and left sternal border
Where can you hear tricupsid regurgitation?
lower left sternal border (possibly apex) in the holosystolic timing
How can you describe a tricuspid regurgitation?
soft to loud with medium blowing; tap and blow, tap and drag, radiating to right of sternum to xiphoid
What do we all have a little bit of?
tricupsid regurgitation
What can you do to hear a tricuspid regurgitation better?
intensity increases with inspiration
Where can you hear VSD?
3rd, 4th, 5th intercostal spaces in holosystolic; high pitched (smaller the hole the higher the pitch), HARSH; radiation wide and all over
Which murmurs are considered worse?
diastolic
Where can you hear aortic regurgitation?
left 2nd and 4th intercostal spaces in diastolic
How would you describe aortic regurgitation?
decrescendo with HIGH pitch (diaphragm) hit and drag, radiation to the apex
How can you hear aortic regurgitation better?
sitting and leaning forward
Where can you hear a mitral stenosis?
apex in diastolic
How would you describe mitral stenosis?
decrescendo with a low pitched rumble and “presystolic accentuation” often described as an opening snap and “snapping in and out”
How can you hear a mitral stenosis better?
left lateral decubitus position at PMI, or hand grip and during exhalation
What would a venous hum sound like?
continuous humming roaring and low-pitched above middle third of clavicles bilaterally
What would a pericardial friction rub sound like?
coarse grating sound, scratchy, scraping, high pitched in the left 3rd intercostal spaces
What would help you hear a pericardial friction rub better?
sitting and leaning forward, breath held after forced expiration
What can cause a pericardial friction rub?
pericarditis, inflammation of visceral and parietal pericardium
what does the JVP help tell us?
index for right heart pressure, hydration, and cardiac function
What does the JVP reflect?
atrial pressure, central venous pressure, right end diastolic pressure
What is at the sternal angle of Louis?
RATPLANT
2nd rib
aorta
trachea
pulmonary trunk
left recurrent laryngeal nerve
azygos vein
nerves (cardiac plexus)
thoracic duct
What increases JVP?
heart failure, pulmonary HTN, tricuspid stenosis, pericardial compression
What is a normal value for jugular vein measurement?
<4
What other test can you utilize to see if there is increased venous pressure?
hepatojugular reflux test
What is the hepatojugular reflux test?
placing hands on RUQ, press firmly upward under RCM, 15 seconds of pressure, see if anything happens at jugular veins
abnormal = >3cm rise
What is important ROS for cardio?
chest pain, palpitations, SOB, edema, claudication, syncope
What’s important to ask patients when referring to their shortness of breath?
their baseline activity and how it’s changed after symptoms onset
What are classic symptoms of CHD?
exertional CP, chest pressure, heaviness, discomfort
how can women present differently in an MI?
upper back pain, neck or jaw pain, dyspnea, PND, N/V, fatigue
Does ventricular fibrillation or ventricular tachycardia produce palpations?
no…scary
What is a specific SOB complaint common in heart and lung problems?
paroxysmal nocturnal dyspnea
How much can the interstitial space absorb of fluid before observant peripheral pitting edema?
5L of fluid (10% of weight)
What is the most common cause of synocpe?
neurocardiogenic; pure cardiac is only 20% of the time
What are the three general techniques of cardiac exam?
inspect, palpate, auscultate
(no percussion)
What side can you not take BP for?
anything with mastectomy or AV fistula
How will you have to adjust the bed with JVP abnormalities?
low JVP = lower HOB
high JVP = raise HOB to see it
What’s the difference between a carotid thrill and carotid bruit?
thrill = felt as vibration during palpation
bruit = HEARD during auscultation
What is pulsus alternans?
rhythm is regular but force alternates
What is a paradoxical pulse?
pulse that varies in amplitude with respiration
What are you looking for in a cardiac inspection?
shape of thorax, symmetry, scars, bruising, pacemaker, pale or cyanotic; look for PMI (lighting helps)
How do you palpate in the cardiac exam?
palm, ball, fingerpads in all places! APETM
What are you palpating for?
lifts/heaves (sustained palpable impulses by enlarged ventricles or atriums) felt by FINGERPADS and thrills (buzzing or vibratory sensation) felt by PALM and apical impulse/location of PMI
What can help locate the PMI?
left lateral decubitus position
What should you always note when finding an abnormality?
location, diameter, amplitude, duration
When can a PMI migration occur?
pregnancy, heart failure, cardiomyopathy, ischemic heart disease
What does displacement laterally to the MCL mean?
enlarged heart, heart failure
What’s the order of auscultation?
diaphragm then bell
Where can you hear S1&S2 equally?
erb’s point, and where you can hear aortic regurgitation and mitral stenosis (we think this is wrong)
What are the grades of murmurs?
1-6, with 6 you can hear with no stethoscope, and 1 being very faint
What are characteristics of murmurs?
timing, location, manuever matching, shape, grade, associated features, radiation
What is valsalva?
blowing through a straw
What are you looking for in left lateral decubitus?
S3 and S4, mitral murmurs especially mitral stenosis
What are you looking for in sitting up and leaning the pt forward?
aortic regurgitation
What are you looking for in standing and squatting?
mitral valve prolapse, hypertrophic cardiomypathy vs aortic stenosis
What are you looking for with an isometric hand grip?
MR, AR, VSD, also pulmonic and mitral stenosis
What are you looking for with transient arterial occlusion?
enhancing mitral regurg, aortic regurg, and VSD
What is the only murmur that increases with strain in valsava and confirm your diagnosis?
hypertrophic cardiomyopathy
What are common murmurs in children?
jugular venous hum, cervical systolic murmur, patent ductus arteriosis (loud, harsh, machinery-like, associated thrill), innocent/still’s murmur
What are the four possible valvular systolic murmurs?
aortic stenosis, mitral regurgitation, pulmonic stenosis, tricuspid regurgitation
What are the four possible diastolic murmurs?
aortic regurgitation, mitral stenosis, pulmonary regurgitation, tricuspid stenosis
