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H&P #2 > Cardiovascular System > Flashcards

Cardiovascular System Flashcards

1
Q

List the basic anatomical and physiological functions of the heart:

A

Heart sits anterior to esophagus

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2
Q

Heart’s Position in the Body

A

RV makes up most of the anterior heart, ending near the sternum

LV is anterior to the patient’s left beyond sternum, and also posterior to the RV

LV tapers inferiorly to a tip – cardiac apex.
Often creates a point of maximal impulse (PMI) in left 5th ICS just medial to the MCL

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3
Q

Heart Chambers, Valves, and Blood Flow

A
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4
Q

What is systole?

A

ventricular contraction.
Increasing ventricular pressure causes pulmonic and aortic valves to open for ejection of blood.
Increasing ventricular pressure also causes mitral and tricuspid valves to close, preventing blood flow back up to the atria.

mitral valve closing creates the S1 heart sound.
Closure of the tricuspid valve is more quiet because of lower right-sided heart pressures, and generally doesn’t contribute to S1.

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5
Q

What is diastole?

A

ventricular relaxation.
As systole is ending, pressure in the aorta is greater than pressure in the left ventricle, causing the aortic valve to close.
This is the S2 heart sound
At the same time, the pulmonic valve is closing, and the atrioventricular valves are opening.

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6
Q

Splitting of Heart Sounds

A

The left side of the heart has a higher pressure, and sounds occur slightly before the right side of the heart.
During inspiration, the right heart has increased filling time, increased stroke volume, and increased ejection time.
This slows down the pulmonic valve from closing.
S2 may be composed of two distinct sounds
First, and louder, A2.
Second, and softer, P2.
Split sounds will generally merge back to a single sound during expiration.
Splitting can happen of S1, but TV is generally quiet, so we mostly think of this as splitting of S2.
If S1 is split, it will not be affected by inspiration

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7
Q

What are murmurs?

A

Turbulent flow in the heart.
May be “innocent”, or may signify pathology.
When considering valves these will be as either:
Stenosis – a narrowed and less compliant valve that creates turbulence as blood flows through it, when it should be flowing through it.
Regurgitation (or insufficiency) – a valve that hasn’t fully closed and allows blood to leak backwards, when that valve normally should not have blood flowing through it.

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8
Q

List the (4) ROS for the cardiovascular system:

A
  1. Chest Pain
  2. Palpitations
  3. Shortness of Breath
    - Dyspnea
    - Orthopnea
    - Paroxysmal Nocturnal Dyspnea
  4. Edema
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9
Q

At what age should you begin assessing lifetime risk early?

A

20 years old

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10
Q

What global risk factors should you screen for every visit?

A

Family History
Tobacco Use
Diet Choices
Physical Activity
BMI
Blood Pressure
Heart Rhythm (pulse regular or irregular?)

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11
Q

What global risk factors should you screen periodically?

A

Cholesterol
- Every 5 years for low risk people
- Every 2 years for higher risk people

Blood Glucose
- Without risk, every 3 years beginning at age 45
- More frequently and/or earlier for anyone at risk

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12
Q

What is bruit? How do you check for bruit?

A

A bruit is turbulent flow, like a swooshing or rushing.

AUSCULTATE!

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13
Q

Describe proper positioning of the patient for routine examination:

A

When inspecting, palpating, and auscultating…
Table at 30 degrees, PA on the patient’s right side, with adequate lighting!

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14
Q

Define lifts, heaves or thrills:

A

Precordial impulses are VISIBLE (lifts, heaves) or PALPABLE VIBRATION (thrills) pulsations of the chest wall

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15
Q

šList the (6) auscultatory areas for cardiac examination:

A
  1. 2nd Intercostal Space, Right Sternal Border
  2. 2nd Intercostal Space, Left Sternal Border
  3. 3rd Intercostal Space, Left Sternal Border
  4. 4th Intercostal Space, Left Sternal Border
  5. 5th Intercostal Space, Left Sternal Border
  6. Point of Maximal Impulse

Bruit?

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16
Q

Describe the indications for special auscultatory maneuvers as well as techniques employed: S3 and S4 aortic murmur

A

If you suspect an S3 or S4 heart sound, or a mitral murmur, place the patient in the left lateral decubitus position, and auscultate the PMI with the bell of the stethoscope.

If you suspect an aortic murmur, place the patient in a seated position, have them exhale, hold their breath out, lean forward, and auscultate the 4th and 5th ICS, LSB and the apex with the diaphragm of the stethoscope.

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17
Q

Describe the indications for special auscultatory maneuvers as well as techniques employed:

To help differentiate the sounds of hypertrophic cardiomyopathy, aortic stenosis, and mitral valve prolapse, ask the patient to squat and auscultate the precordium to become familiar with the sounds. Then ask the patient to stand and continue auscultating.

A

The murmur of HCM is increased with standing and decreased with squatting.

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18
Q

To help differentiate the sounds of hypertrophic cardiomyopathy, aortic stenosis, and mitral valve prolapse, ask the patient to squat and auscultate the precordium to become familiar with the sounds. Then ask the patient to stand and continue auscultating.

A

In Aortic Stenosis, the murmur is increased with squatting and decreased with standing.

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19
Q

To help differentiate the sounds of hypertrophic cardiomyopathy, aortic stenosis, and mitral valve prolapse, ask the patient to squat and auscultate the precordium to become familiar with the sounds. Then ask the patient to stand and continue auscultating.

A

In MVP, the click is delayed and murmur shortened with squatting; standing moves the click earlier and lengthens the murmur.

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20
Q

List the etiology of normal heart sounds: S1 and S2

A

S1:
You should hear this – “lub”
Mitral valve closing, and the quiet tricuspid valve too.
Best heard at the lower left sternal border, and at the apex
At the apex, S1 is generally louder than S2.

S2:
You should hear this too – “dub”
Closure of the aortic and pulmonic valves.
Best heard at the 2nd intercostal space on the left sternal border, and along the mid left sternal border (3rd and 4th ICSs).
This may be split, especially during inspiration, into A2 and P2.

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21
Q

Describe the maneuver to differentiate physiologic from pathologic splitting of heart sounds:

A

Physiologic splitting is the “expected” split of S2 we find that can disappear with expiration.
Pathologic splitting suggests disease.
A wide-split S2 has the A2 and P2 components far apart during inspiration, but they get closer (although not combined) with expiration.
This might suggest a valve disorder or a conduction disorder.
A fixed-split S2 has a widened split S2 during inspiration that does not shorten at all with expiration.
This can suggest an atrial septal defect, or RV failure.

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22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

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22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

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22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

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22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

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22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

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22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

22
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound

23
Q

Extra Heart Sounds in Systole: “Early ejection sounds”

A

Occur shortly after S1
Coincides with opening of the semilunar valves
High in pitch
Usually indicates CVD
Aortic ejection sound
Pulmonic ejection sound 2nd ics and 3rd ics, high in pitch, position change, at bottom?

24
Q

Extra Heart Sounds in Systole: “Clicks”

A

occurs in Mitral Valve Prolapse
Mid-late systole
Left lower sternal border, apex
High pitched
Associated with late systolic murmur of MR that follows click
Squatting will delay the murmur
Standing will bring it closer to S1

25
Q

Extra Heart Sounds in Diastole: “Opening snap”

A

Early in diastole
High pitch, snapping
Lower left sternal border
Radiates to the apex & pulmonic area
Opening of a stenotic or stiff mitral valve
Heard best with diaphragm

26
Q

Extra Heart Sounds in Diastole: Define S3 heart sounds:

A

S3 Physiologic
< 35-40y/o
Pregnancy
Heard best at the apex in the left lateral decubitus position with the bell

S3 Pathologic
> 40y/o
“Ventricular gallop”
Altered LV compliance
Abrupt deceleration of flow across the mitral valve - delayed filling
CHF, decreased contractility, MI
Heard best at the apex, left lateral decubitus

“Kentucky” “1, 2, 3”

27
Q

Extra Heart Sounds in Diastole: Define S4 heart sounds:

A

Atrial gallop
Occurs just before S1
Low pitched
Heard best with the bell, at the apex in the left lateral position
Usually heard with hypertensive disease, cardiomyopathy
Can be physiologic in athletes

so late in diastole, close to systole, just before S1

“Tennessee, “S4, gallop of 1, 2”

28
Q

Areas of Accentuated Sounds and Murmur Radiation: “APT M”

A

Aoritc valve - 2-3 right interspace

Pulmonic valve - 2-3 left interspace

Tricuspid valve - left sternal border

Mitral valve - apex

29
Q

Systolic murmurs and types:

A

Occur between S1 and S2
Correlate to carotid upstroke
Midsystolic, pansystolic (holosystolic), late systolic

30
Q

Diastolic murmurs and types:

A

Occur between S2 and S1
Early diastolic, middiastolic, late diastolic (attach to S1 but not S2)

31
Q

Continuous murmurs and types:

A

Start in systole and continue past S2 “going straight through systole and diasotle”

32
Q

timing of valvular murmurs

A

Systolic: “MR PASS “
The AV valves should be closed and the semilunar valves should be opened.
Tricuspid Regurgitation
Mitral Regurgitation
Aortic Stenosis
Pulmonic Stenosis

Diastolic: “MS, ARD”
The AV valves should be opened and the semilunar valves should be closed.
Tricuspid Stenosis
Mitral Stenosis
Aortic Regurgitation
Pulmonic Regurgitation

33
Q

What does shape of murmur describe?

A

Shape describes the intensity over time.

Plateau murmurs don’t change shape.

34
Q

WHat does location of murmurs describe?

A

Location describes where the murmur is loudest.
And that might suggest the origin of the sound.

35
Q

Radiation of Murmurs

A

Relates to direction of blood flow and sound transmission.

36
Q

Intensity of Murmurs

A

Intensity is the volume of the murmur, graded on a I-VI scale.
Intensity is affected by chest wall thickness.

37
Q

I/VI

A

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

38
Q

II/VI

A

Quiet, but heard immediately upon placing stethoscope on chest

39
Q

III/VI

A

moderately loud

40
Q

IV/VI

A

loud, with palpable thrill

41
Q

V/VI

A

very loud with a thrill. May be heard with stethoscope partly off the chest

42
Q

VI/VI

A

very loud with a thrill. May be heard with stethoscope entirely off the chest

43
Q

Tricuspid Stenosis

A

Timing – mid-diastolic
Shape – plateau
Location – lower left sternal border
Radiation – right sternal border, or xiphoid area
Intensity – increases with inspiration
Pitch – medium
Quality – scratchy or rumbling following opening snap, wide split S1, “opening snap”

44
Q

Tricuspid Regurgitation

A

Timing – pansystolic
Shape – plateau
Location – lower left sternal border
Radiation – right sternal border, xiphoid area, left midclavicular line (but not axilla)
Intensity – varies
Pitch – medium
Quality – blowing, with associated S3

45
Q

Pulmonic Stenosis

A

Timing – midsystolic
Shape – crescendo-decrescendo
Location – 2nd and 3rd Intercostal Spaces, Left Sternal Border
Radiation – left shoulder and neck
Intensity – may be soft or loud; thrill present if loud
Pitch – medium
Quality – harsh, with pulmonic ejection sound and split S2

46
Q

Pulmonic Regurgitation

A

Timing – early diastolic
Shape – decrescendo
Location – left upper sternal border
Radiation – right sternal border
Intensity – soft to moderate
Pitch – high with pulmonary hypertension, otherwise low
Quality – blowing

47
Q

Mitral Stenosis Common

A

Timing – diastolic
Shape – decrescendo with some crescendo late to S1
Location – apex
Radiation – not common
Intensity – soft to moderate, may have thrill
Pitch – low
Quality – opening snap, followed by rumble

48
Q

Mitral Regurgitation Common

A

Timing – pansystolic
Shape – plateau
Location – apex
Radiation – Left axilla, sometimes left sternal border
Intensity – may be soft of loud; thrill may be present if louder
Pitch – medium to high
Quality – harsh

49
Q

Aortic Stenosis

A

Timing – midsystolic
Shape – crescendo-decrescendo
Location – 2nd Intercostal Space, Right Sternal Border
Radiation – carotids, left sternal border, apex
Intensity – occasionally soft, but generally loud, with a thrill
Pitch – medium
Quality – harsh

50
Q

Aortic Regurgitation

A

Timing – diastolic
Shape – decrescendo
Location – left sternal border
Radiation – apex, and occasionally right sternal border
Intensity – usually soft to moderate
Pitch – high
Quality – blowing, can be mistaken as breath sounds

51
Q

(5) Non-valvular Murmurs:

A
  1. Ventricular Septal Defect
  2. Hypertrophic Cardiomyopathy
  3. Patent Ductus Arteriosus
  4. Innocent Murmurs
  5. Physiologic Murmurs
52
Q

Ventricular Septal Defect

A

VSD is a congenital anomaly where there is a hole connecting the left and right ventricles.

Loud, pansystolic, harsh, high pitched murmur heard loudest on the lower left sternal border with wide radiation.

can live with VSD, but needs to be corrected or left alone

53
Q

Hypertrophic Cardiomyopathy “heart muscle disease enlargment”

A

Myocardial enlargement that prevents appropriate functioning of the heart.

Harsh, medium pitch midsystolic murmur that radiates from the 3rd and 4th left intercostal spaces to the apex and base of the heart. S4 is often added / present.

54
Q

Patent Ductus Arteriosus

A

A vessel connecting the pulmonary arteries to the aorta, that was used to bypass pulmonary circulation in a fetus, that remains opened.

Continuous murmur, often with pause in late diastole. Loudest at 2nd left intercostal space that crescendos during systole and decrescendos in diastole, radiates toward the left clavicle, and had a harsh, machinery-like quality.

55
Q

Innocent and Physiologic Murmurs

A

Soft, low to medium pitch midsystolic murmur heard on the left sternal border and over to the apex, little to no radiation, and usually decreases or disappears with sitting.

Innocent murmur – no other pathology, caused by LV ejecting blood into aorta. Common in children and young adults.

Physiologic murmur – findings with an associated “stressful” condition, like anemia, pregnancy increase demand, fever increase demand, or hyperthyroidism.

H&P #2 (2 decks)

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