Cardiovascular and Peripheral Cardiovascular Flashcards
A patient you are seeing complains of severe pain in her right foot. Based on examination findings, you suspect arterial insufficiency. Which of the clinical findings below would suggest arterial insufficiency as the cause of her problem?
A. Brisk posterior tibial and dorsalis pedis pulses
B. Pallor of the foot upon elevation
C. Pitting edema of the lower leg
D. Warmth of the right foot
B.
A patient you are seeing complains of a sore on his lower leg that does not seem to get better. Based on examination findings, you suspect venous insufficiency. Which of the clinical findings below would suggest venous insufficiency as the cause of his problem?
A. Leg discomfort is exacerbated by dependency
B. Hyperpigmentation is present around the lower calf area
C. Ulceration is present on the medial side of the ankle
D. Affected leg feels warm to the touch
E. All the above
E.
the venous system has a much lower systemic pressure than
the arterial system
What is the main purpose of the valves?
to keep blood from flowing backwards
3 determinants of venous blood pressure
- left ventricular contraction
- blood volume
- the capacity of the right heart to eject blood in to the pulmonary arterial system
venous pressure ___ when left ventricular output or blood volume is ___
falls ; reduced
venous pressure ___ when the right heart ___
rises ; fails
Jugular Venous Pressure
a reflection of the pressure in the right atrium or central venous pressure
Normal CVP is
0-8 mm Hg or 3-8 cm of H20
Pressure in the jugular veins reflects
right atrial pressure
JVP is best estimated from the
internal jugular vein on the right side
A JVP more than ____ is considered elevated or abnormal
8-9 cm
Begin to look for the jugular venous pulsations in the
suprasternal notch of the neck
Remember if you measure the external jugular vein, you measure at
the point the vein appears to collapse
What is the difference between preload and after load?
preload: the amount of blood that’s coming to the right side of the heart, stretching the muscle as it dilates
afterload: the amount of pressure that the ventricle needs to get to to open the aortic valve
what happens in left-sided heart failure?
pulmonary edema
what happens in right-sided heart failure?
if they’re overloaded with fluid, it shows up in their legs - will have edema and increased internal jugular pressure/fluid
why do S1 sounds get split?
during inspiration, when blood goes to the lungs to pick up oxygen, we inspire - it remains sequestered there for a little bit, which means we have a little less blood in the left side of the heart and more in the right side
what happens is that the aortic valve, since it has less blood, closes so the pulmonic closes after it, instead of closing together
When would you hear a split S2?
at the apex
mid-systolic click
when mitral valve closes and then it regurgitates blood and pushes the flap backwards
S3 and S4 are
ventricular filling sounds that ALWAYS happen during DIASTOLE
rumbling sound S3
normal in kids but usually go away when child sits up - in adults its the first sign of congestive heart failure
when would you hear the sound for Aortic Stenosis (murmur)
at the apex of the heart
when would you hear the sound for Mitral Regurgitation? (murmur)
at the base of the heart
What happens in S1?
the beginning of systole, which is when the ventricles contract and push blood to the pulmonary artery and through the aorta
P+ A valves contract and OPEN
so that the blood doesn’t go back into the atria, the mitral and tricuspid valves CLOSE
What happens in S2?
diastole of the ventricle
aortic and pulmonic CLOSE (make the noise), tricuspid and mitral OPEN to let blood come down from the atria to the ventricles
orthopnea
dyspnea at night
DOE
dyspnea on exertion
Dyspnea
shortness of breath
Paroxysmal nocturnal dyspnea (PND)
sleep for a couple hours, then get up in the middle of the night and open the window to get a deeper breath
for people in failure, when they lie down, it increases the volume of intrathoracic blood - it makes them feel breathless (fine when they sit up)
3 main signs of pulmonary edema
left-sided heart failure
pink, frothy sputum
fear of impending doom because of the dyspnea
what are heart palpitations?
when the patient is aware of their heart rate and beating, whether it’s fluttering, skipping a beat, or bounding
syncope (definition, causes)
passing out - the kind of fainting we associate with heart
may be caused by emotional stress, pain, pooling of blood in the legs due to sudden changes in body position, overheating, dehydration, heavy sweating or exhaustion
when does edema get worse
in the evening because it’s more dependent
nocturia
fluid resorption and secretion during evening hours
anasarca
means they have edema everywhere (sacral, arms, legs, face) - everything shows they’re having leakage of fluid into the interstitial spaces
can happen with kidney failure but also liver and heart
central cyanosis
skin turning blue or ashen all over – caused by decreased pulmonary venous saturation
peripheral cyanosis
only certain areas, usually around the mouth (perioral cyanosis), etc.
decreased cardiac output or reduce rate of blood flow through capillaries and increased local extraction of oxygen
can be caused by congestive heart failure, shock
Hemoptysis
coughing up of blood
what is the most common cardiac reason for Hemoptysis?
mitral valve stenosis (due to increased pulmonary venous congestion)
When taking blood pressure in both arms, there should be no more than ____ difference on either side
5-10
SBP (systolic blood pressure)
Pressure generated by left ventricle (LV) during systole, when the LV ejects blood into the aorta and the arterial tree
DBP (diastolic blood pressure)
Pressure generated by blood remaining in arterial tree during diastole, when the ventricles are relaxed
Orthostatic hypotension often seen in what 3 kinds of patients?
Parkinson’s
patients who are receiving hypertensive meds
patients who complain of lightheadedness
What is Orthostatic hypotension?
changing from supine to standing, systolic decreases no more than 15 mm Hg- heart rate increases up to 10 beats/min
What is orthostatic hypotension caused by?
vascular volume loss from hemorrhage, diarrhea, vomiting, dehydration or excessive diuresis
Redistribution of blood volume because of antihypertensives (affect preload, affect afterload), antidepressant, alcohol or nitrates
Prolonged bed rest, simple vasovagal fainting
autonomic nervous system dysfunction in diabetic neuropathy, adrenal insufficiency or Parkinson’s disease
3 kinds of upstroke when palpating the carotid arteries
Brisk – normal
diminished – feels small and weak (decreased stroke volume - might be hypervolemic)
Bounding – feels full and strong (did they just exercise or run to the office? otherwise is hyperkinetic states - hyperthyroidism)
ventricular hypertrophy
seeing the chest wall lift with systole
right ventricular lift would be seen at the
sternal border
left ventricular lift would be seen at
the apex (heart placement is the exact opposite of the lungs)
where is the point of maximal impulse?
in the 5th intercostal space in the midclavicular line in adults
Hepatojugular reflux
the distension of the neck veins precipitated by the maneuver of firm pressure over the liver
What are some causes of hepatojugular reflux
tricuspid regurgitation
heart failure due to other non-valvular causes, and other conditions including constrictive pericarditis, cardia tamponade, and inferior vena cava obstruction
Where is Herb’s point?
at the 3rd intercostal space at the sternal border
Tricuspid valve location
5th intercostal space, by sternal border
Aortic valve location
2nd intercostal space, right sternal border
pulmonic valve location
2nd intercostal space, left sternal border
mitral valve location
5th intercostal space, by the apex at the midclavicular line
The diaphragm is best for detecting what kinds of sounds?
high-pitched sounds like S1, S2, and also S4 and most murmurs
The bell is best for detecting what kinds of sounds?
low-pitched sounds like S3 and the rumble of mitral stenosis
What is S1, which valves open and close during S1, and where is it heard the loudest?
The start of systole (when the heart contracts)
aortic and pulmonic are opening, Tricuspid and mitral close
heard loudest at the apex of the heart
What is S2, which valves open and close during S2, and where is it heard the loudest?
S2 is diastole
Aortic and pulmonic are closing (makes the sound), and the tricuspid and mitral are opening (silent)
heard loudest at the base
True or false: At the 3rd intercostal space, S1 and S2 have the same intensity of sound?
True
When can a split S2 only happen?
during inspiration
S3: ventricular gallop
kind of sounds like the word “kentucky” (tap-tap-tap, tap-tap-tap) or distant thunder
usually means that someone is in congestive heart failure - it’s one of the first signs - it occurs both lying down and sitting up in this case (pathological)
can happen normally, to children or with a large cardiac output in pregnancy
S4: atrial gallop
kind of sounds like the word “tennessee” (luuub-dub-dub)
can occur in athletes, but mostly pathological, and it normally means very low compliance in the ventricles either from CHF, aortic stenosis
you’ll hear these mostly in the left ventricle because it’s the higher
early systolic ejection click
happens in systole
if aortic and pulmonic valves are not quiet, they make a systolic click
remember that when valves are open they should be
quiet
opening snap (extra sound during diastole)
normally opening of AV valves is silent (tricuspid and mitral)
In stenosis - opens with noise
Sharp and high pitched
Diaphragm 3 or 4 ICS at sternal border
murmur grading is on a scale of
1-6
grade 1 murmur
barely audible and only heard in a quiet space - not going to happen in ICU
grade 2 murmur
clearly audible but faint
grade 3 murmur
moderately loud and very easy to hear
grade 4 murmur
loud and associated with a thrill on the chest so you can actually feel the valve
grade 5 murmur
very loud, feel a thrill, don’t even have to have stethoscope fully on the chest
grade 6 murmur
you can sometimes hear without a stethoscope at all
what is a stenosed valve?
very tight valve, which occurs when the valve is opening
or a valve that’s regurgitating, when the valve is closing
which are worse, diastolic or systolic murmurs?
diastolic
Midsystolic Ejection Murmurs
Aortic Stenosis
Pulmonic Stenosis
Pansystolic Regurgitant Murmurs
Mitral Regurgitation
Tricuspid Regurgitation
Diastolic Rumbles of AV Valves
Mitral Stenosis
Tricuspid Stenosis
Early Diastolic Murmurs
Aortic Regurgitation
Pulmonic Regurgitation
Pericardial Rub
inflammation of the lining around the heart
Note that the smaller the baby, the higher the
heart rate and respiratory rate,
and inversely, the lower the blood pressure
Acrocyanosis
where the baby is slightly cyanotic in their extremities/lips (this is normal)
PMI in babies is at the
4th ICS
Murmurs occur in ___ % of children
30-50%
Murmurs most often occur in childhood around ___ years of age
3-4
If a murmur is heard in the first 24 hours of life, there’s a ____ risk of it being a congenital heart disease
1:12
the right lymphatic duct only drains
a very small portion of the body
with venous diseases, we see the veins ___ to the surface
closer
Peripheral arterial disease (PAD)
seen often in smokers – heart attack-like pain
What should you ask patients with Intermittent claudication?
“Have you ever had any pain or cramping in the legs when walking or with exercise?” “Does the pain get better with rest?”
Arterial spasm occurs in
fingers and toes
Venous peripheral vascular disease
Swelling of feet and legs - interstitial fluid building up
Ask about ulcers on lower legs, often near ankles
Hodgkins
generalized lymph swelling (in all of the palpable lymph nodes)
Grading Amplitude of pulses
3+ Bounding
2+ Brisk, expected (normal)
1+ Diminished, weaker than expected
0 Absent, unable to palpate
When feeling for the pulsations on the sides of the aorta, they shouldn’t be more than
5 cm
unilateral leg coldness could be a sign of
inadequate arterial circulation
Inguinal lymph nodes and femoral arteries are near
the genitals
varicose veins are best looked at when the patient is
standing
Deep venous thrombosis (DVT)
blood clot in the leg - leg will swell
Lymphedema
anything that might cause lymph edema in the heart will show in the leg
never going to pit, though
Orthostatic edema
edema from standing, lack of movement
Allen Test
occluding both ulnar and radial arteries - when you let go, the blood should return normally in both
Homan’s sign for venous insufficiency
if it feels warm, it’s red, and you can feel inflammation of the vein behind the knee, and the patient feels pain in the calf when they flex the foot
in varicosity, the veins have become so distended that
the valves can’t meet when they close
how do the intraluminal valves ensure unidirectional flow
Each valve opens toward the heart and closes tightly when filled to prevent back flow of blood
The 3 functions of the lymphatic system are:
to conserve fluid and proteins that leak out of the capillaries
to form a major part of the immune system
to absorb lipids from the intestinal tract
What are the 5 great vessels of the heart?
Superior Vena Cava Inferior Vena Cava Aorta Pulmonary arteries Pulmonary veins
Layers of the heart, superficial to deep
Fibrous pericardium Parietal pericardium Pericardial cavity Epicardium Myocardium Endocardium
In which may gangrene develop: chronic arterial insufficiency or chronic venous insufficiency?
Arterial
Main symptoms of chronic arterial insufficiency: pain, pulses, color, temperature, edema
Intermittent claudication progressing to pain at rest
Decreased or absent pulses
Pale color especially on elevation
Cool temperature
Absent or mild edema
Main characteristics of chronic venous insufficiency (pain, pulses, color, temperature, edema)
None to aching pain on dependency
Normal pulses
Normal or cyanosis skin
Normal temp
Edema present, often marked
