Cardiovascular

Question 1

Describe the flow of blood through the heart

Answer 1

1. Blood flows from the superior & inferior vena cava into the right atrium
2. Then it passes through the tricuspid valve into the right ventricule
3. Then it goes from the right ventricule through the pulmonic valves and into the pulmonary arteries
4. From the pulmonary arteries it goes into the lungs and flows back toward the heart through the pulmonary veins.
5. Blood flows from the pulmonary veins into the left atrium
6. Then from the left atrium through the mitral valve and into the left ventricle
7. Finally blood flows out of the left ventricule, through the aortic valve, into the aorta, and out to the rest of the body

Question 2

What happens in the heart during systole and what heart sound do you hear?

Answer 2

• the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial pressure, closing the mitral valve.
• Closure of the mitral valve produces the first heart sound, S1
• S1 is louder than S2 at the apex

Question 3

What happens during diastole and what heart sound do you heart?

Answer 3

• As the left ventricle ejects most of its blood, ventricular pressure begins to fall. When left ventricular pressure drops below aortic pressure, the aortic valve closes.
• Aortic valve closure produces the second heart sound, S2, and another diastole begins.
• The second heart sound, S2, and its two components, A2 and P2, are caused primarily by closure of the aortic and pulmonic valves, respectively
• S2 is usually louder than S1 at the base

Question 4

What causes an S3 heart sound?

Answer 4

1. S3 sound is produced During ventricular filling when a large amount of blood strikes a very compliant left ventricle
2. After age 40, a third heart sound is usually abnormal and correlates with dysfunction or volume overload of the ventricles.
3. Associated with heart failure and: hypertrophic cardiomyopathy, myocarditis, cor pulmonale, or acute valvular regurgitation

Question 5

What causes an S4 heart sound?

Answer 5

• S4 is caused by the atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle. This causes abnormal turbulence in the flow of blood that can be detected by a stethoscope.
• It immediately precedes S1 of the next beat and is associated with cardiomyopathy and heart failure

Question 6

What causes a split S2 and where is this best heard?

Answer 6

• S2 heart sound is composed of 2 components: the aortic valve A2 closing and the pulmonic valve closing P2. Since the aortic valve has higher pressure in the valve due to it carrying arterial blood, it is usually louder.
• To hear the pulmonic valve close during the S2 heart sound, it is best heard between the 2nd & 3rd intercostal spaces AND it is heard only on inspiration

Question 7

In what area should you listen to the aortic area?

Answer 7

2nd right intercostal space

Question 8

In what area should you listen to the pulmonic area?

Answer 8

2nd right intercostal space

Question 9

In what area should you listen to the tricuspid area area?

Answer 9

4th intercostal space at the left sternal border

Question 10

In what area should you listen to the mitral area?

Answer 10

5th intercostal space, midclavicular line

Question 11

What is the diaphragm of your stethoscope used for?

Answer 11

The diaphragm is better for:

• High pitched sounds of S1 and S2
• The murmurs of aortic and mitral regurgitation, and pericardial friction rubs.

Question 12

What is the bell of your stethoscope used for?

Answer 12

• The bell is more sensitive to the low-pitched sounds of S3 and S4
• Is used to detect the murmur of mitral stenosis.

Question 13

What are some characteristics of mitral stenosis (location, type, grade, and pitch)?

Answer 13

• Location: left lateral decubitus position over the mitral area using the bell
• Type: Diastolic murmur
• Grade: 1-4
• Pitch: Decrescendo low-pitched rumble with presystolic accentuation.

Question 14

What causes the sound heard in mitral stenosis?

Answer 14

The stiffened mitral valve leaflets move into the left
atrium in midsystole and narrow the valve opening,
causing turbulence. The resulting murmur has
two components: (1) middiastolic (during rapid
ventricular filling) and (2) presystolic accentuation,
possibly related to ventricular contraction.

Question 15

What are some associated findings with mitral stenosis?

Answer 15

• S1 is loud and may be palpable at the apex. An OS often follows S2 and initiates the murmur
• Atrial fibrillation occurs in about a third of symptomatic
  patients, with ensuing risks of thromboembolism.
• The most common cause worldwide is rheumatic
  fever, which causes fibrosis, calcification, and
  thickening of the leaflets

Question 16

What are some characteristics of aortic regurgitation (location, type, grade, and pitch)?

Answer 16

• Location: Left 2nd to 4th intercostal spaces
• Type: Diastolic murmur
• Grade: 1-3
• Pitch: High.
• Quality: Blowing decrescendo; may be mistaken for breath sounds
• Murmur is best heart when the pt. is sitting, leaning forward, with breath held after exhalation.

Question 17

What causes the sound heard in aortic regurgitation?

Answer 17

• The aortic valve leaflets fail to close completely during diastole, causing regurgitation from the aorta back into the left ventricle and left ventricular overload.
• The associated midsystolic flow murmur results from the ejection of this increased stroke volume across the aortic valve.

Question 18

What are some associated findings with aortic regurgitation?

Answer 18

• With advancing severity, the diastolic pressure drops to as low as 50 mm Hg; the pulse pressure can widen by >80 mm Hg.

Question 19

What are some characteristics of mitral regurgitation (location, type, pitch, quality)?

Answer 19

• Location: Best heard in apex
• Type: Pansystolic (Holosystolic) murmur
• Pitch: Medium to high
• Quality: Harsh, holosystolic

Question 20

What causes the sound heard in mitral regurgitation?

Answer 20

• When the mitral valve fails to close fully in systole, blood regurgitates from left ventricle to left atrium, causing the murmur and increasing left ventricular preload, ultimately leading to left ventricular dilatation
• Causes can be structural or functional

Question 21

What are some associated findings in mitral regurgitation?

Answer 21

• The apical impulse may be diffuse and laterally displaced
• S1 normal (75%), loud (12%), soft (12%)

Question 22

What type of murmurs are the most common kind of heart murmurs and what are some characteristics of these type of murmurs?

Answer 22

• Midsystolic ejection murmurs
• They are best heard in the L. 2nd to 4th intercostal spaces
• These heart sounds usually decrease or disappears when sitting
• No underlying CVD caused by turbulent blood flow, probably generated by
  ventricular ejection of blood into the aorta from the left and occasionally the right ventricle.

Question 23

What does a grade 1 murmur sound like?

Answer 23

Very faint, heard only after listener has “tuned in”; may not be
heard in all positions

Question 24

What does a grade 2 murmur sound like?

Answer 24

Quiet, but heard immediately after placing the stethoscope on
the chest

Question 25

What does a grade 3 murmur sound like?

Answer 25

Moderately loud

Question 26

What does a grade 4 murmur sound like?

Answer 26

• Loud, with palpable thrill
• **Note that grades 4 through 6 require the added presence of a palpable
  thrill. **

Question 27

What does a grade 5 murmur sound like?

Answer 27

• Very loud, with thrill. May be heard when the stethoscope is partly off the chest
• **Note that grades 4 through 6 require the added presence of a palpable
  thrill. **

Question 28

What does a grade 6 murmur sound like?

Answer 28

• Very loud, with thrill. May be heard with stethoscope entirely off the chest
• **Note that grades 4 through 6 require the added presence of a palpable
  thrill. **

Question 29

What is the importance of measuring JVP?

Answer 29

• The JVP closely parallels pressure in the right atrium, or central venous pressure, related primarily to volume in the venous system.
• These pulses are rarely palpable, are eliminated by light pressure, and the height of the internal jugular pulsation changes with position changes.

Question 30

What is the best position to assess JVP?

Answer 30

The JVP is best assessed from pulsations in the right internal jugular vein, which is directly in line with the superior vena cava and right atrium

Question 31

How do you externally measure the JVP?

Answer 31

1. 1. Make the patient comfortable. Raise the head slightly on a pillow to relax the SCM muscles.
2. Raise the head of the bed or examining table to about 30°. Turn the patient’s head slightly away from the side you are inspecting.
3. Use tangential lighting and examine both sides of the neck. Identify the external jugular vein on each side, then find the internal jugular venous pulsations.
4. If necessary, raise or lower the head of the bed until you can see the oscillation point or meniscus of the internal jugular venous pulsations in the lower half of the neck.
5. Focus on the right internal jugular vein. Look for pulsations in the suprasternal notch, between the attachments of the SCM muscle on the sternum and clavicle, or just posterior to the SCM. Distinguish the pulsations of the internal jugular vein from those of the carotid artery (see box below).
6. Identify the highest point of pulsation in the right jugular vein. Extend a long rectangular object or card horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right angle. Measure the vertical distance in centimeters above the sternal angle where the horizontal object crosses the ruler and add to this distance 5 cm, the distance from the sternal angle to the center of the right atrium. The sum is the JVP.

Question 32

What is a normal JVP measurement?

Answer 32

• Normal is 3-4cm above the sternal angle w/ HOB @ 30 degrees