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foundations of clinical medicine > Cardiovascular part 2 > Flashcards

Cardiovascular part 2 Flashcards

1
Q

how do we hear low-frequency sounds with a tuneable diaphgram?

A

To hear low-frequency sounds, rest the chestpiece lightly on the patient, so that the bell membrane is applied just enough pressure to create an air seal and block out ambient noise. This allows low-frequency sounds to resonate. Too much pressure causes the bell to act like a diaphragm.

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2
Q

how do we hear high-frequency sounds with the tuneable diaphragm?

A

To hear high-frequency sounds, apply firm contact pressure to the chest piece to restrict the movement of the diaphragm membrane. This blocks (or attenuates) low-frequency sounds which allows you to hear higher-frequency sounds.

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3
Q

what is auscultation?

A

The act of examining a patient by listening to their organs with our stethoscope

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4
Q

what are the two major positions we can put our patient in to listen to heart sounds?

A

Seated, upright: for further evaluation of audible splitting of S2 (also - some pericardial rubs and aortic regurgitation murmur)

Left, lateral decubitus (LLD): the best position to detect 3rd and 4th heart sounds

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5
Q

Where do we auscultate the aortic valve?

A
  • located in the 2nd intercostal space on the right sternal border
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6
Q

where do we auscultate the pulmonic valve?

A

located in the 2nd intercostal space on the left sternal border

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7
Q

Where do we auscultate Erb’s point?

A

(E; no specific valve) - located in the 3rd intercostal space on the left sternal border. It is useful for a quick and general assessment of the heart as all heart sounds are audible here (pathological and physiological). It is also used to compare heart rate to radial pulse to assess if there is a pulse deficit.

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8
Q

Where do we auscultate the tricuspid valve?

A

located in the 4th intercostal space on the left lower sternal border

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9
Q

Where do we auscultate the mitral valve?

A

located in the 5th intercostal space on the midclavicular line

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10
Q

What are the 5 characteristics we focus on when listening to heart sounds?

A

Timing - systolic or diastolic

Intensity - loud or soft (also be aware of what location the sound is loudest at)

Duration - long or short

Pitch - high or low

Quality - musical, harsh, crescendo, decrescendo, etc.

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11
Q

What does the first heart sound mark?

A

marks the beginning of systole and the closure of the mitral and tricuspid valves. S1 will be the sound that just precedes the carotid pulse and is loudest at the apex of the heart (mitral area). It is best heard with the diaphragm.

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12
Q

what can a loud S1 be a result of?

A

a physiologic hyperdynamic state (fever, exercise), but is also increased in the pathology of mitral stenosis.

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13
Q

what does the second heart sound mark?

A

marks the beginning of diastole with the closure of the aortic and pulmonic valves. This sound follows the carotid pulse and is loudest at the base of the heart (aortic or pulmonic areas). It is best heard with the diaphragm.

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14
Q

what is noticed with S2 with deep inspiration?

A

you can hear a normal, physiologic S2 splitting as the pulmonic valve closes more slowly by an amount >30 msec.

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15
Q

Where is S2 splitting best heard?

A

This is best heard over the 2nd or 3rd left intercostal space (pulmonic or Erb’s point), with the patient lying.

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16
Q

When does S2 splitting disappear?

A

It disappears (or more correctly, A2+P2 are perceived as one sound) when the patient is upright and with expiration.

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17
Q

what is wide splitting?

A

pulmonic stenosis, right bundle branch block, mitral regurgitation

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18
Q

what is wide and fixed splitting?

A

atrial septal defect, right ventricular failure/pulmonary hypertension

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19
Q

what is paradoxical splitting?

A

aortic stenosis, ischemic heart disease, left bundle branch block

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20
Q

how do we differentiate pathological S2 splitting from physiologic?

A

Have patient seated, upright: S2 splitting remains in pathological conditions

Listen during expiration: S2 splitting is audible in pathological conditions (but have the patient continue to breathe in and out regularly)

Listen at the apex of the heart: P2 can be audible at the apex in pathological conditions.

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21
Q

when do we see the 3rd heart sound (S3)?

A

appears in early diastole and is sometimes called the ventricular gallop.It is best heard with the bell at the apex (left ventricle) or left lower sternal border (right ventricle) of the heart. It can sometimes only be heard in the left lateral decubitus (LLD) position.
- rapid filling and stretching of chordea tendinae

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22
Q

who is S3 physiological in?

A

S3 can be physiologic in children or athletic young adults (<40yrs).

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23
Q

when is S3 pathological?

A

congestive heart failure and regurgitation/shunts. If S3 is present after surgery, it has a positive likelihood ratio of 14.6 for postoperative pulmonary edema.

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24
Q

when do we see the fourth heart sound?

A

is audible in late diastole and is sometimes called the atrial gallop. It is best heard with the bell at the apex (left ventricle) or left lower sternal border (right ventricle) of the heart. It can best be heard in the LLD position.
- turbulent flow, blood trying to enter the ventricle

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25
Q

when do S4 gallops become louder?

A

right side and inspiration

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26
Q

when do S4 gallops become softer?

A

left side and inspiration

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27
Q

what does greater flow rate result in

A

louder sound.

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28
Q

what does a stiffer ventricle result in?

A

higher frequency sounds.

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29
Q

is S4 always pathological?

A

yes

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30
Q

what pathologies do we see S4 in?

A
  • It occurs in hypertension, ischemic cardiomyopathy, hypertrophic cardiomyopathy and aortic stenosis (basically, cardiac conditions that are characterized by ventricular stiffening, either by hypertrophy or fibrosis).
  • The presence of S4 has a positive likelihood ratio of 3.2 for predicting 5-yr mortality rate in patients after myocardial infarction.
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31
Q

if we hear a murmur what do we do?

A

if we hear a murmur, we then have to assess the sound and determine its 5 characteristics, paying close attention to the quality of the sound.

32
Q

what do we do if S1 and S2 are clear?

A

we are done auscultating the heart.

33
Q

What does the script represent for murmurs?

A

S; site.
C: character.
R: radiation.
I: Intensity
P: pitch
T: timing; diastolic/systemlic.

34
Q

outline atrial regurgitation heart murmur;

A

Location; left upper sternal border (pulmonic) apex.
Quality; Soft, blowing decrescendo (LUB TARRR(.
Pitch: high
Timing: (early) diastolic.
Position increased; hand grip and squatting.
Pathologies: Acute: Infective endocarditis (water hammer pulse), Chronic: bicuspid aortic valve, connective tissue diseases

35
Q

outline mitral stenosis murmur;

A

Location: Apex.
Quality: delayed, rumbling, decrescendo. (LUB! Dub- durrr) open snapping
Pitch: low (bell).
Timing; mid-diastolic.
Position increased; LLD (rolled on the left side) and squatting.
Pathologies; rhematic fever, SLE, RA, vegetation or tumor.

36
Q

outline mitral regurgitation murmur;

A

Location: Apex, radiates to left axilla.
Quality: blowing holosystolic (BURRRRRR!)
Pitch: high.
Timing: pan-systolic.
Positioning increased: LLD, squatting, hand grip.
Pathologies: Degenerative endocarditis, ischemic heart disease, rheumatic fever, pulsus parvus et tardus (weak +delayed carotid upstroke).

37
Q

outline aortic stenosis murmur:

A

Location: aortic, radiates to carotid arteries.
Quality: crescrendo-decrescendo (BURR-dub).
Pitch: high.
Timing: (ejection) mid-systolic
Positioning increased: squatting.
Pathologies: calcification of aortic valve, rheumatic fever, turners syndrome (bicuspid valve), syncope, angina, dyspnea

38
Q

Outline mitral valve prolapse murmur; can progress into MR

A

Location: apex.
Quality: mid-systolic click, crescendo.
Pitch: high.
Timing: mid-late ejection systolic.
Positioning increased: Valsalva maneuver, standing moves click closer to S2.
Pathologies; Connective tissue disorders: Ehlers-Danlos syndrome, Marfan syndrome Polycystic kidney disease, Rheumatic heart disease, Infective endocarditis

39
Q

Outline ventricular septal defect murmur:

A

Location: left lower sternal border (tricuspid, erbs point).
Quality: harsh, loud holosystolic.
Pitch: high.
Timing: pan-systolic.
Positioning increased; squatting.
Pathologies: Genetic abnormalities: Down syndrome, Edward syndrome, Patau syndrome, Cri-du-chat syndrome, TORCH infections ((T)oxoplasmosis, (O)ther Agents, (R)ubella (also known as German Measles), (C)ytomegalovirus, and (H)erpes Simplex.)

40
Q

why do we measure jugular venous pressure?

A

We measure jugular venous pressure (JVP) to estimate the pressure in the right atrium (central venous pressure).

41
Q

what are pathologies that increase diastolic pressure of the right side of the heart and increase the central venous pressure and make the neck veins visibly distend?

A
  • left heart disease, lung disease, primary pulmonary hypertension, pulmonic stenosis
42
Q

what patients is JVP most helpful in measuring?

A

Measuring JVP is most helpful in patients with ascites or edema, where an elevated JVP indicates heart or lung disease as opposed to other causes of increased central venous pressure, such as chronic liver disease.

43
Q

how do we measure JVP?

A
  • using the sternal angle as a reference point or the phlebostatic axis.
44
Q

what is step one of measuring JVP?

A
  1. Examine the right side of the patient’s neck as these veins have a direct route to the heart. Either the external or internal jugular veins may be used to estimate pressure because measurements in both should be similar.
45
Q

what is step 2 of measuring the JVP?

A

Raise the head of the table so that the patient’s head is elevated to the level at which the top of the neck veins are revealed (approx. 30-45 degrees). The top of the neck veins are indicated by either the point above which the external jugular vein disappears or the point above which the bi-phasic pulsations of the internal jugular vein become imperceptible.

46
Q

what is step 3 of measuring the JVP?

A

After locating the top of the internal or external vein, measure the vertical distance from the top of the vein and the sternal angle

47
Q

when is JVP abnormally elevated?

A

The top of the neck veins is more than 3cm above the sternal angle.

The central venous pressure exceeds 8cm H2O using the method of Lewis (i.e. > 3cm above the sternal angle + 5cm (distance to the right atrium from the sternal angle))

48
Q

What three aspects of pulse have to be evaluated?

A
  • rate.
  • rhythm.
  • amplitude.
49
Q

what is the pulse rate?

A

Arterial pulse rate (also called heart rate) counts the contractions of the heart within a period of time and can be palpated in any of the body’s accessible sites (e.g. carotid, brachial, radial, femoral, popliteal, posterior tibial or dorsalis pedis arteries).

50
Q

which location of taking pulse best reflects the central aortic pulse?

A

the carotid pulse. however the radial pulse is is used more frequently because it is more easily accessible.

51
Q

what is a normal pulse rate?

A

the normal range for heart rate is 60 - 100 beats per minute (bpm); however, recent information reveals that 95% of healthy persons have heart rates between 50-95 bpm

52
Q

when do we count the apical rate (listening to heart tones at the apex with a stethoscope)?

A
  • In patients with a fast heart rate (e.g. atrial fibrillation).
  • is more accurate than counting the radial pulse and 60 seconds of observation is more accurate than shorter periods. If the patient has exerted themselves in the last 20 minutes, you will want to have them wait 20 minutes before assessing their pulse to prevent false readings.
53
Q

when is counting for 60 seconds recommended?

A

In patients with an irregular rhythm, 60 seconds of counting heart beats are also recommended to improve accuracy. In children, it is recommended that the pulse is counted for 60 seconds considering that irregularities in rhythm are common.

54
Q

what is the difference between bradycardia and tachycardia?

A

Bradycardia is a heart rate less than 50bpm and tachycardia is a heart rate greater than 100bpm.

55
Q

what is the positive likelihood ratio predicting mortality in patients with pneumonia?

A

2.1 and 3.0 in patients with myocardial infarction, while the absence of tachycardia decreases the probability of hospital mortality in patients with trauma and septic shock.

56
Q

what is a pulse deficit?

A

a difference of 2 bpm or more between the radial pulse rate and the apical pulse rate (the apical rate always being greater).

57
Q

what is a pulse deficit associated with?

A

This has traditionally been associated with atrial fibrillation, but it is commonly found with all extrasystoles or fast heart rates and by itself has little diagnostic significance.

58
Q

what is a normal pulse rhythm?

A

The normal pulse rhythm is regular, meaning that the frequency of the pulsation felt by your fingers follows an even tempo with equal intervals between pulsations.

59
Q

What are irregular pulse rhythms felt with?

A

arrhythmias?

60
Q

what is a regularly irregular pulse?

A

the pattern of missed beats or variation is predictable (e.g. 3 regular beats then one missed beat called a Pause, which is associated with premature contractions).

61
Q

what is an example of a regularly irregular pulse?

A

Sinus arrhythmia involves an irregular pulse rhythm in which the pulse rate varies with the respiratory cycle: the heart rate increases at inspiration and decreases back to normal upon expiration. This is a common condition in children, adolescents and young adults.

62
Q

what is an irregularly irregular pulse?

A

there is no pattern to the irregularity (aka. chaotic rhythm).

63
Q

what is irregularly irregular pulse associated with?

A

Irregularly irregular pulse rhythm is highly specific to atrial fibrillation (LR+ 24.1, LR- 0.5).

64
Q

what is pulse amplitude?

A

The pulse amplitude (also referred to as pulse force or pulse strength) is the strength of the pulsation felt when palpating the pulse.

65
Q

What is stroke volume?

A

Stroke volume refers to the volume of blood pumped with each contraction of the heart. Therefore the strength of the pulse gives practitioners an estimate of this by assessing the volume of blood, the heart’s functioning and cardiac output as well as the arteries’ elastic properties.

66
Q

How is pulse amplitude measured?

A

Pulse amplitude is recorded using a scale. There is a lack of consensus on the scale to use for grading pulses (e.g. 0 to 3 or 0 to 4; possible the former being used in Canada, the latter in the US),
- four-point scale.

67
Q

what does absent, or diminished represent?

A

weak or thready pulse as in conditions such as heart failure, heat exhaustion, or hemorrhagic shock - basically a weakening pulse indicates serious and advancing disease

68
Q

what does normal or bounding represent?

A

in physiologic conditions with increased stroke volume (exercise, stress) or pathological conditions with fluid overload or hypertension

69
Q

what does 0 represent on the 4-point scale?

A

0 absent or not palpable

70
Q

what does 1 represent on the 4-point scale?

A

1+ difficult to palpate, thready, weak or easily obliterated with pressure

71
Q

what does 2 represent on the 4-point scale?

A

2+ easy to palpate or not easily obliterated with pressure (normal)

72
Q

what does 3 represent on the 4-point scale?

A

3+ full, bounding or not obliterated with pressure

73
Q

What is pulse equality?

A

refers to whether the pulse amplitude is similar on both sides of the body.

74
Q

what does pulse equality provide information about?

A

arterial obstructions or aortic coarctation if there is a difference in strength between the sides.

75
Q

what should you never do when measuring carotid pulse?

A

Never palpate the carotid pulses at the same time as this can decrease and/or compromise cerebral blood flow.

foundations of clinical medicine (8 decks)

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