Cardiovascular Flashcards by Kyle Campbell

When do you use the diaphragm of the stethoscope? How much pressure is used?

Diaphragm to listen for high-pitched sounds (S1, S2)

- Apply firmly

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When do you use the bell of the stethoscope? How much pressure is used?

Bell to listen for low-pitched sounds (S3, S4)

- Apply lightly

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What are the four key areas that are listened to with cardiac exam?

Aortic valve
Pulmonary valve
Tricuspid valve
Mitral valve

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Where do you listen for the aortic valve?

2nd ICS at RSB

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Where do you listen for the pulmonary valve?

2nd ICS at LSB

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Where do you listen for the tricuspid valve?

4th/5th ICs at LSB

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Where do you listen for the mitral valve?

5th ICS at MCL (apex)

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Where do you listen for the second pulmonic valve?

3rd ICS at LSB

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What is the order in which you listen to the cardiac areas?

Base to apex (top to bottom like a Z?)

Aortic valve
Pulmonary valve
Tricuspid valve
Mitral valve

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What causes the lub sound? Is this during systole or diastole?

Occurs during systole (S1)

- Closure of AV valves

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What causes the dub sound? Is this during systole or diastole?

Occurs during diastole (S2)

- Closure of SL valves

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Where is S1 best heard (louder)? Where is S2 best heard (louder)?

Lub is best heard at apex

- Dub is best heard at base

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What is an accentuated S1 heart sound and why does it occur functionally? What seven conditions might cause this?

Louder S1 sound due to diseased AV valve or more forceful closure of AV valve

Caused by:

Tachycardia
Fever
HTN
Exercise
Anemia
Hyperthyroidism
Mitral stenosis

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What is a diminished S1 heart sound and why does it occur functionally? What two conditions might cause this?

Softer S1 sound due to weak contraction of heart or reduced sound transmission

Caused by:

Thick chest wall (body habitus)
Emphysematous lungs

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Is systole longer or shorter than diastole?

Diastole is longer than systole

- More time between dub (S2) and lub (S1)

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What is physiological splitting of S2? Why does this occur (think what happens first)?

S2 involves two components: A2 and S2

A2 occurs first (aortic valve closes)
S2 occurs second (pulmonary valve closes)

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What three conditions might cause a wider splitting of S2? When is this wider splitting best heard (think respirations)?

Wider = best heard with inspiration

Caused by:

Pulmonary valve stenosis
Mitral valve regurgitation
RBBB

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What two conditions might cause a fixed splitting of S2? When is this wider splitting best heard (think respirations)?

Fixed = same with inspiration or expiration (no change)

Caused by:

Atrial septal defect
RV failure

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What is paradoxical splitting? What condition is this caused by?

Paradoxical splitting is when S2 occurs before A2

Caused by LBBB

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What functionally causes a wide or fixed splitting of S2 heart sound?

Delayed closure of pulmonic valve

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What functionally causes paradoxical splitting of S2 heart sound?

Delayed contraction of LV

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What causes the third heart sound (S3)? Where is this best heard, and with what?

S3: passive, rapid filling of ventricles during diastole

- Best heard with bell at apex

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What causes the fourth heart sound (S4)? Where is this best heard, and with what?

S4: atrial systole/”atrial kick”

- Best heard with bell at apex

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What is the name of the pathological sound associated with S3? What four conditions causes this?

Ventricular gallop (S1 + S2 + S3)

Caused by:

CHF
Anemia
Volume overload of ventricle
Decreased myocardial contractility

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What is the name of the pathological sound associated with S4? What four conditions causes this?

Atrial gallop (S1 + S2 + S4) Caused by: - HTN - CAD - Aortic stenosis - Cardiomyopathy

At what age are pathological gallops typically heard?

Over age 40

In what three populations is S3 normally heard?

- Children - Healthy young adults - Pregnant women

In what two populations is S4 normally heard?

- Trained athletes | - Elderly without heart disease

What is a grade 1/6 murmur?

Barely audible

What is a grade 2/6 murmur?

Quiet but audible

What is a grade 3/6 murmur?

Moderately loud

What is a grade 4/6 murmur?

Loud; associated with thrill

What is a grade 5/6 murmur?

Very loud heard with stethoscope partially off chest; obvious thrill

What is a grade 6/6 murmur?

Very loud heard with stethoscope partially off chest; obvious thrill

What valve abnormality causes a mid-systolic murmur? What is the shape of this murmur?

Mid-systolic: SL valve stenosis | - Usually crescendo-decrescendo

What valve abnormality causes a holosystolic murmur? What is the shape of this murmur?

Holosystolic: AV valve regurgitation | - Usually plateau

What valve abnormality causes a late systolic murmur?

Late systolic: mitral (AV) valve prolapse

What type of murmur is associated with atrial septal defect (ASD)? What is an ASD?

Mid-systolic murmur is associated with ASD | - ASD: LA to RA shunt

What type of murmur is associated with ventricular septal defect (VSD)? What is an VSD?

Holosystolic murmur is associated with VSD | - VSD: LV to RV shunt

Where is a VSD best heard?

Left lower sternal border (LLSB)

In what population are innocent systolic murmurs common? In what four populations would this murmur occur physiologically?

Common in children/young adults | - Physiologically in pregnant women, anemics, fever, or hypothyroidism

What valve abnormality causes an early diastolic murmur? What is the shape of this murmur?

Early diastolic: SL valve regurgitation | - Usually crescendo

What valve abnormality causes a mid-diastolic murmur?

Mid-diastolic: AV valve stenosis

What valve abnormality causes a late diastolic murmur?

Late diastolic: SEVERE AV valve stenosis

What valve abnormality causes an opening snap and diastolic rumble murmur?

Opening snap and diastolic rumble: AV valve stenosis

Which three murmurs are best heard at the apex?

- Mid diastolic (AV valve stenosis) - Late diastolic (AV valve stenosis) - Holosystolic (AV valve regurgitation)

Which murmur is best heard at the 2nd right ICS?

Mid-systolic (SL valve stenosis)

Which murmur is best heard at the 2nd-4th left ICS?

Early diastolic (SL valve regurgitation)

Which two murmurs are best heard when the patient is leaning forward?

AORTIC VALVES: - Mid-systolic (SL valve stenosis) - Early diastolic (SL valve regurgitation)

What type of sound is heard with valve regurgitation?

Blowing

Which murmur involves a high pitch sound?

Early diastolic (aortic OR pulmonary valve regurgitation)

Which two murmurs involves a low pitch sound?

- Mid-diastolic (mitral or tricuspid valve stenosis) | - Late diastolic (mitral or tricuspid valve stenosis)

Which two murmurs involve an opening snap?

- Mid-diastolic (mitral or tricuspid valve stenosis) | - Late diastolic (mitral or tricuspid valve stenosis)

What causes a continuous murmur?

Due to patent ductus arteriosus

What is another name for a "to-and-fro" murmur? What are two causes of this murmur?

Systolic-Diastolic murmur Caused by: - Aortic stenosis WITH regurgitation - Severe aortic regurgitation

What position typically causes a murmur to decrease in intensity? What is the exception to this?

With standing, most murmurs decrease in intensity | - EXCEPTION is HCM (hypertrophic cardiomyopathy) where it increases

What is an aortic or pulmonic ejection click?

Like an opening snap: high-pitched noise associated with valve disease (stenosis), or pulmonary HTN

What is a systolic click due to?

Mitral valve prolapse | - Common and benign

What is venous hum?

Turbulent flow through jugular veins

What is pericardial friction rub and what does it sound like?

Inflammation of pericardial sac | - Sounds scratchy/squeaky

Describe the five characteristics of an internal jugular vein pulsation. How does this differ from the carotid artery?

- Non-palpable - Inward direction - Pulsation eliminated with pressure to vein at sternal end of clavicle - Height of pulsation decreases with upright position - Height of pulsation decreases with inhalation Carotid artery is palpable, outward, pulsation not eliminated with pressure, height of pulsation unchanged with position or breathing

What would cause an elevated JVP? What are four conditions that might cause it?

HYPERvolemia - CHF - Pulmonary HTN - Increased venous vascular tone - Pericardial tamponade

What would cause a decreased JVP? What are two conditions that might cause it?

HYPOvolemia - Blood loss - Decreased venous vascular tone

What is a thrill? What two conditions cause this? What location should these be checked for?

Buzzing or vibratory sensation Caused by: - Aortic stenosis - VSD Checked at LSB and base

What is a lift/heave?

Vigorous cardiac impulse that can be seen/felt through chest wall

What is a bisferiens pulse?

Biphasic pulse: two peaks on one beat

What is Pulsus Alternans?

Strong → weak → strong → weak…

What is bigeminal pulse?

Two beats close together (premature contractions)

What is paradoxical pulse?

Faster with expiration and slower with inspiration

What does a small/thread/weak carotid upstroke indicate?

Cardiogenic shock

What does a bounding carotid upstroke indicate?

Aortic regurgitation

What does a delayed carotid upstroke indicate?

Aortic stenosis

What should a normal carotid upstroke be like?

Brisk, smooth, rapid | - Almost immediately after S1

How do you measure JVP (specialized test)? 4 steps

1. Stand on patient’s right, with patient sitting on exam table set at 30 degree angle (try 60 next) 2. Have patient turn head slightly to left 3. Find highest point of meniscus (oscillation) in right internal jugular vein 4. Measure vertical distance above sternal angle and add 5 cm; sum = JVP

How do you perform cardiac percussion (specialized test)? 2 steps What does this check?

1. Begin at 5th ICS at MAL and percuss lateral to medial 2. Listening for first onset of dullness Estimates heart size

How do you perform cardiac percussion (specialized test)? 5 steps Why would you perform this test?

1. Ask patient to make a tight fist 2. Compress both radial and ulnar arteries 3. Ask patient to open hand (should be pale) 4. Release pressure over ulnar artery 5. If patent (normal), palm flushes within 3-5 seconds Evaluates potency of ulnar artery