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PCM III Exam I > Cardiovascular and Peripheral vascular System - SRS > Flashcards

Cardiovascular and Peripheral vascular System - SRS Flashcards

1
Q

What is the ideal position for the chest exam?

A

Supine with head/chest elevated at 30 degrees.

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2
Q

What interspace do you find the aortic valve sound?

A

2nd right interspace

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3
Q

Where would you find the sound of the pulmonic valve?

A

2nd left interspace

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4
Q

Where would you find the sound of Erb’s point?

A

left of sternum at rib 3

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5
Q

Where should you listen for the tricuspid valve?

A

Lower left sternal border

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6
Q

Where would you listen for the mitral valve?

A

Apex of the heart

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7
Q

What do you use the left lateral decubitus position for?

A

Mitral murmur accentuation

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8
Q

Murmur is defined as?

A

Turbulence across a valve causing a sound

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9
Q

What is a bruit?

A

Similar noise from turbulence within an artery outside the heart itself.

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10
Q

Describe the grading of murmurs from 1/6 to 6/6!!!

A

1/6 Very faint

2/6 Quiet, but can easily be heard if in quiet room

3/6 Moderately loud

4/6 Loud, with palpable thrill

5/6 Very Loud, Thrill, can be heard with stethoscope partially off chest

6/6 Very Loud, Thrill, can be heard with stethoscope

OFF the chest

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11
Q

6/6 murmur?

A

Very Loud, Thrill, can be heard with stethoscope

OFF the chest

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12
Q

4/6 murmur?

A

Loud, with palpable thrill

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13
Q

3/6 murmur?

A

moderately loud

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14
Q

2/6 murmur?

A

quiet, but easily heard if in quite room

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15
Q

1/6 murmur?

A

Very faint

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16
Q

5/6 murmur?

A

Very Loud, Thrill, can be heard with stethoscope partially off chest

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17
Q

What are some common causes of murmurs and bruits?

There’s a lot here.

A
  • Benign or Innocent: Stills
    • typically infants
  • Valvular problems
    • papillary muscle tear or rupture
    • chordae tendoneae rupture
    • congenital malformation
    • fibrosis annulus or leaflet (infection)
  • Patent ductus (Aorta-Pulm A)
  • Septal defects ASD, VSD
  • Artery stenosis
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18
Q

What are some less common causes of murmurs and bruits?

A
  • Tetralogy of Fallot: Pulmonic Stenosis + VSD + Aorta overriding VSD + RVH
  • Abdominal Aneurysm
  • Hyperthyroid state
  • Obstructive Hypertrophic Cardiomyopathy (IHSS)
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19
Q

Any arterial area where a bruit or murmur is heard has?

A

Turbulent blood flow

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20
Q

What are the components of the tetralogy of fallot?

A

Pulmonic Stenosis + VSD + Aorta overriding VSD + RVH

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21
Q

What is the S1 heart sound? What does it signal?

A

—S1 : Mitral and Tricuspid closures. Signals onset of systole

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22
Q

What is the S2 heart sound? What does it signal?

A

—S2: Aortic and Pulmonic closures. Signals onset of diastole

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23
Q

Which heart sound is closely timed with the carotid pulse?

A

S1

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24
Q

Anything that causes a separation in the closure of paired valves is called a?

A

split heart sound

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25
Q

Split S1 may be…

A

may be normal variant or abnormal from RBBB or PVC (premature ventricular contraction)

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26
Q

When would you have a physiologic varient causing a split S2?

How about a pathological variant?

A

Physiological: with inspiration.

Pathological: pulmonic stenosis or RBBB (right bundle branch block)

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27
Q

What valves are S3 and S4 heart sounds associated with?

A

Non-valvular sounds.

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28
Q

During what phase of the heart do S3 and S4 occur?

A

During diastole

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29
Q

When does S3 occur?

A

Early diastole, closely following S2.

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30
Q

When is S3 considered normal up to?

A

age 30 years

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31
Q

S3 heart sound occurs at the transition of rapid to slow ventricular filling. What is the most common pathology associated with this?

A

LV myocardial damage (CHF, MI) causing systolic dysfunction from dilated cardiomyopathy. Due to sudden limitation of normal ventricular relaxation during filling stage in diastole.

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32
Q

S3 is often present in hemodynamically significant chronic mitral regurgitation. Consequently, this is an important finding in?

A

—An important early finding in heart failure due to a dilated myocardium (more often systolic failure)

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33
Q

When does S4 occur?

A

Just before S1, very late diastole just after atrial contraction

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34
Q

What is S4 sound caused by?

A

Vibration of LV from the atrial kick trying to pump the last of the blood but instead hitting less compliant ventricular wall.

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35
Q

What is the most common pathology of S4 heart sounds?

A

Aortic/pulmonic stenosis , HTN (elevated afterload) , wall damage from MI from remodeling or tissue death cause thickening of ventricular walls from a higher work load, and some stiffening. This also leads to non-compliance of the ventricle as the atria pump the last of the blood from the chamber to the ventricle.

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36
Q

What are four things to associate with S4 sounds?

A

—Hypertension
—Aortic valve stenosis
—Pulmonic valve stenosis
—Hypertrophic cardiomyopathy

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37
Q

“Gallop” Rhythm technically refers to either pattern of?

A

S1…S2S3

Or

S4S1…S2

Or

S4S1…S2S3

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38
Q

What is an ejection click?

A

An ejection click is a sound occurring at the moment of maximal pressure with sudden tensing of a valve root. Associated with the annulus.

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39
Q

When does an aortic ejection click occur?

A

Early systolic: at onset of left ventricular ejection, aortic root suddenly stretched. (Second right interspace)

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40
Q

Name some pathological sources of the aortic ejection click!@!

A
  • Dilated aneurysm of aortic root, coarctation of aorta, HTN all can dilate aorta and change the root dimensions.
  • Aortic valve stenosis, and aortic regurgitation also can change the dynamic of the aortic root.
  • Anything that can cause over working of the root of the aortic valve can over-distend it and cause click.
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41
Q

You hear the attached, crescendo-decrescendo pattern of a medium pitch that sounds harsh. It transmits sound to the carotid artery. What is the cause of this?

A

Aortic stenosis

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42
Q

What are the two key findings for aortic stenosis?

A

Systolic crescendo-decrescendo pattern,

medium pitch, typically harsh

Transmits sound to carotid arteries.

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43
Q

What are the pathological causes of aortic stenosis? 3

A
  1. Rheumatic disease (progressive fusion),
  2. congenital bicuspid valve,
  3. calcification of valve.
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44
Q

What are the symptoms of aortic stenosis?

A

None until severe, then dyspnea on exertion, angina and syncope. Left ventricular enlargement can occur, creating hypertrophic, poorly compliant muscle and an S4

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45
Q

You hear an austin-flint murmur during early diastoly, with a high pitch blowing decrescendo murmur. What is this sound d/t?

A

Aortic reguritation

46
Q

What are the pathological causes of aortic regurgitation?

A
  1. Rheumatic disease,
  2. congenital bicuspid valve,
  3. endocarditis (Strep, Staph, Haemophilius..)
47
Q

What are the key aspects of pulmonic ejection click?

A

Sudden root tensioning. Very early systole.

(Second left interspace)

48
Q

What are some pathological causes of pulmonic ejection click?

A

Pulmonary HTN, aneurysm dilating the root

Pulmonary valve stenosis or regurgitation can alter stress on root of valve causing click.

49
Q

You hear a systolic crescendo-decescendo murmur as 2nd left interspace, what might this be?

A

Pulmonic valve stenosis

50
Q

What are three key symptoms of pulmonic valve stenosis? What heart sound might arise with this?

A

exertional dyspnea

chest pain

syncope

S4

51
Q

Describe what you would hear in pulmonary regurgitation

A

Identical to aortic regurg, not as loud. Identify best

by which post it is most clear. Softer diastolic

decrescendo

52
Q

What are some causes of pulmonic regurg?

A

Anything that causes pulmonary HTN: mitral stenosis, LV failure, obstructive sleep apnea, emphysema, idiopathic pulmonary hypertension

53
Q

When would you hear a tricuspid valve stenosis?

A

Diastolic low pitch rumble

54
Q

When and where would you hear tricuspid valve regurg?

A

Early to holosystolic at left sternal border.

55
Q

When does a mitral valve opening snap occur?

A

In diastole

56
Q

A diastolic murmur with an opening snap would likely be related to?

A

mitral valve stenosis

57
Q

What characterizes a mitral valve prolapse?

A

“click and murmur”

58
Q

What is the demographic for mitral valve prolapse?

A

Young women with anxiety

59
Q

What accentuates and diminishes mitral valve prolapse?

A

Accentuated: Valsalva (lowers atrial volume) Standing

Diminishes: Release of Valsalva (increased atrial volume) Squatting

60
Q

What are two common complaints associated with mitral valve prolapse?

A

Unexplained anxiety or panic attacks

palpitations

61
Q

What does “holosystoloc” murmur mean?

A

pansystolic

62
Q

What might a holosystolic murmur that is loud, high pitch and best heard at the apex that audibly radiates to the left axilla be due to?

A

Mitral valve regurgitation

63
Q

Identify the causes of the phonograms shown A-H

A
64
Q

Hypertrophic Obstructive Cardiomyopathy is also known as?

A

IHSS: Idiopathic Hypertrophic Subaortic Stenosis

65
Q

What causes IHSS?

A

Primarily a genetic disorder

Mutations in cardiac sarcomere signal

Hypertrophy of the left ventricle and the interventricular septum

Must consider in FMH of sudden cardiac death, especially among athletes.

66
Q

What are the symptoms of IHSS?

A

Symptoms identical to aortic stenosis: exercise induced dyspnea, angina or syncope.

67
Q

In IHSS there may or may not be a murmur. What can you do in a physical exam to try to catch this condition?

A

Murmur is INTENSIFIED by standing from a squat, or a Valsalva maneuver

68
Q

What kind of murmur would you hear in IHSS?

A

Systolic ejection murmur; best along left sternal border and apex; often with accentuated PMI

69
Q

List all of the systolic ejection murmurs that increase in intensity during valsalva (or standing).

A

IHSS is the only one.

70
Q

Leaning forward accentuates which valve?

A

Aortic

71
Q

Left lateral decubitus accentuates which valve?

A

Mitral

72
Q

How do you perform a valsalva maneuver?

A

Take a deep breath and “push like you’re having a baby”

73
Q

What are three maneuvers to alter murmurs?

A
  1. Valsalva: Take a deep breath and “push like you’re having a baby”
  2. Squatting from a standing position
  3. Standing from a seat or squatting position
74
Q

Squatting momentarily increases volume from more venous return and increases arterial blood pressure. What murmurs are impacted by this and how?

A

Mitral regurgitation murmur is increased

IHSS/Obstructive cardiomyopathy murmur is decreased

75
Q

Standing momentarily decreases volume and therefore right ventricular filling. (less physiologic effect on afterload). What sounds are impacted by this and how?

A

Mitral prolapse sound is increased

IHSS murmur is increased.

76
Q

Valsalva has what impact on what heart sounds?

A

Increase ISHH

Decrease aortic stenosis sounds

77
Q

The only thing we should get a question regarding valsalva maneuver from Dr. Pitcher will be on?

A

IHSS

78
Q

A fistula existing between aorta and pulmonary artery is called?

A

Patent ductus arteriosis (PDA)

79
Q

What might you hear in Graves disease?

A

Thyroid bruit d/t increased blood flow to the thyroid

80
Q

Pericarditis (fluid in the sac) is often assoicated with what?

A

Recent viral infection

MI

Metastasis to pericardium

post cardiac surgery

81
Q

What positioning makes pericarditis feel better? Worse?

A

Leaning forward improves.

Reclining makes worse

82
Q

What are the two noises you hear with pericarditis?

A

Pericardial knock

Rub

83
Q

In pericarditis you may hear a Pericardial knock, which is a diastolic knock heard widely over precordium in constrictive pericarditis. What causes this?

A

Blood coming in to fill RV,LV chambers finds smaller chambers, stops abruptly and vibrates the walls.

84
Q

The rub in pericarditis is from?

A

The two inflamed pericardial surfaces rubbing together when beating.

85
Q

The rub in pericarditis is what-phasic?

A

Triphasic: Atrial systole, ventricular systole, ventricular diastole

86
Q

After finding a murmur or bruit, what should you do to finish the exam?

A

Include periphery: third spacing?

Doppler ultrasound to define bruit

Echocardiogram done with doppler to define murmurs

TTE (transthoracic)

or

TEE (transesophageal)

87
Q

What risk factors would you treat with regard to murmurs or bruits?

A

Smoking, hyperlipidemia, HTN

oxygen +/- CPAP

88
Q

What types of medications might be indicated in murmurs or bruits?

A

Beta Blockers, ACE, ARB, Peripheral vasodilators

(Ca+ Channel Blockers)

89
Q

What are some surgical options related to bruits and murmurs?

A

Valve replacement or repair

Stent

Endarterectomy

90
Q

What are 6 examples of peripheral vascular disease?

A

Intermittent Claudication

Carotid Artery Stenosis

Aneurysm

Raynaud Disease or Phenomenon

Vasculitis

Hypertension (Just FYI)

91
Q

Intermittent claudication is a (not fully) occlysive arterial disease of the limbs. What are the symptoms characterized by?

A

Pain

Tension

weakness of a limb that intensifies with walking and resolves with cessation.

(angina of the periphery essentially)

92
Q

What is charcot syndrome?

A

Compression of the cauda equina, may come with intermittent claudication

93
Q

Intermittent claudication is caused by?

A

ischemia in the peripheral tissue

94
Q

What are some factors of the history to consider in intermittent claudication?

A

oAortic Stenosis: poor perfusion
oAnemia: lowered O2 capacity
oPolycythemia: acts like a traffic jam
oAtherosclerosis: local stenosis
oVolume status: ability to circulate good in, waste out

95
Q

What would you do to detect peripheral artery disease?

A

Ankle brachial index

Systolic of ankle/systolic of brachium - index

96
Q

What are some physical exam clues for intermittent claudication?

A

Poor pedal pulses

Ulcerations

Palor

Cool, shiny, hairless skin

bruit may be present

97
Q

What are the treatment options for intermittent claudication?

A

Meticulous foot care

Smoking cessation!!

Lower lipids

Walk! But not through pain

Cilostazol (Pletal), Pentoxifylline (Trental) can offer limited help

Revascularization procedures

98
Q

How do Cilostazol (Pletal), Pentoxifylline (Trental) help in peripheral artery disease?

A

Makes the wall of the RBC more flexible

99
Q

What are the risk factors for carotid artery stenosis?

A

Older male

Hypertension, Diabetes

Smoking , Hyperlipidemia

Heart Disease

100
Q

What valve disorder will sounds like a carotid bruit?

A

Carotid artery stenosis

101
Q

What are the diagnostics used for carotid artery stenosis?

A

Doppler ultrasound

MRA or CT angiography (100% accurate)

102
Q

What are the treatment options for carotid artery stenosis?

A

Endarterectomy if >69% occluded, soon after CVA if this occurred, only in patients with >5yrs life expectancy.

Elective endarterectomy >50% stenosis

Stents

Risk factor management

Aspirin prophylaxis: 81 to 325mg daily if not contraindicated

103
Q

An aneurysm is a dilation of a segment of a blood vessel. What is a true aneurysm?

How about a pseudoaneurysm?

A
  • True aneurysm involves all three layers of vessel wall and can dissect
  • Pseudoaneurysm is a dilation or hematoma that may or may not involve the layers of the vessel wall which is contained and does not dissect.
104
Q

What are the risk factors for aneurysm?

A

Risk factors include smoking, known atherosclerosis, hypertension, hyperlipidemia, diabetes

105
Q

Vasculitis is a general term characterizing inflammation and damage to vessels, often the lumen, causing stenosis and ischemia to the involved tissue. What are the vessels impacted by takayasu aortitis?

A

Aorta and major branches - known as “pulseless disease”

106
Q

What are the vasculituses associated with medium vessels?

A

Polyarteritis nodosa

Wegener’s granulomatosis

(may be associated with infections/post-infectious insult or circulating immune complex.

107
Q

What vasculitises are associated with small vessels?

A

Henoch-Shonlein Purpura

108
Q

Polyarteritis nodosa is a multisystem necrotizing vasculitis of primarily medium arteries (=arteritis). What does the inflammation in this disease lead to?

A

—Inflammation thickens vessel wall causing stenosis , ischemia and possibly infarct to distal tissues.
—Inflammation also weakens the wall predisposing to aneurysm formation .
—Thrombosis can also occur.

109
Q

What are the ssx assiated with polyarteritis nodosa?

A

—Fatigue, weakness, fever, wt loss, headache, abdominal or other tissue pain occur.

110
Q

What are some common lab values associated with polyarteritis nodosa? How do you confirm the diagnosis?

A

—Invariably an elevated ESR is seen, often with elevated neutrophilic WBC count.

Confirm with biopsy

111
Q

What would you use to treat polyarteritis nodosa?

A

Steroids and immune modulating agents

PCM III Exam I (9 decks)

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