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Clinical Skills I > cardiovascular system > Flashcards

cardiovascular system Flashcards

1
Q

Heart’s Surface Projections:

A
  • Right ventricle = most anterior heart structure
  • left ventricle: left lateral border

Apical pulse/point of maximal impulse:
- Normal: 1 to 2.5 cm diameter; brisk and tapping
- PMI > 2.5 cm suggests LV hypertrophy
- location: 5th intercostal space, 7-9 cm lateral to midsternal line
- Displacement of the PMI indicates LVH, ventricular dilatation, or HF
- dextrocardia: PMI on RIGHT side of chest

Great vessels:
- pulmonary artery
- aorta
- vena cava

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2
Q

PMI palpation

A

palpation:
- Normal: 1 to 2.5 cm diameter; brisk and tapping
- PMI > 2.5 cm suggests LV hypertrophy
- location (supine): 5th intercostal space, 7-9 cm lateral to midsternal line
- duration: during systole
- Displacement of the PMI indicates LVH, ventricular dilatation, or HF
- dextrocardia: PMI on RIGHT side of chest

location:
- if you can’t feel supine -> move pt to LLD

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3
Q

S3 sounds: pathological sounds of HF

A

S3 : abrupt deceleration of inflow across the mitral valve
- can be normal in kids + young adults
- adults: pathological “S3 gallop” -> indicative of SYSTOLIC HF
- Occurs at beginning of diastole following S2
- s3 = Rapid ventricular Filling/Distension
- auscultate: bell in LLD at apex

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4
Q

S4 sounds: pathological sounds of HF

A

S4: increased LV end diastolic stiffness which decreases compliance
- s4 = atrial contraction
- Occurs after atrial contraction at the end of diastole before S1 (active ventricular filling)
- Atrial blood striking ventricle
- Is indicative of DIASTOLIC HF*
- auscultate: bell in LLD at apex

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5
Q

S1 and S2 heart sounds

A

S1:
- Mitral & Tricuspid Valve closure at the beginning of systole
- Represents systolic “LUB”

S2:
- Aortic & Pulmonary Valve closure at the beginning of diastole/end of systole
- Represents diastolic “DUB”

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6
Q

Splitting of S2 sounds

A

normal S2 sound: closure of aortic valve (A2) + closure of pulmonic valve (P2)
- A2 LOUDER due to higher pressure than P2

splitting:
- check LEFT 2nd ICS with bell*
- inspiration: split sound; expiration: fuse together again
- Mechanism: inspiration = increased right heart filling DELAYS the closure of the pulmonic valve (P2) -> audible splitting
- ask pt to breathe quietly and then slightly more deeply than normal

potential causes:
- pulmonic stenosis
- RBBB

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7
Q

Heart Murmurs: definition, stenosis vs regurgitation

A

Definition: heart sounds distinguished by their pitch and LONGER duration
- caused by TURBULENT BLOOD FLOW
- indicate valvular heart ds

Stenosis = abnormally narrow orifice that obstructs blood flow
Regurgitation = improperly closing valves allow blood to flow backward

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8
Q

what corresponds?

A
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9
Q

Pulse: origin and mechanism

A

Origin: LV* pumping blood out through the aorta into the arterial tree

Mechanism:
- pressure wave created by the pumping of blood = pulse felt
- pressure wave travels FASTER than actual movement of blood

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10
Q

Pulse pressure + factors that affect BP

A

PP: systolic BP - diastolic BP

Factors Affecting Blood Pressure:
- LV stroke volume
- Distensibility of the aorta and the large arteries
- PVR: arterioles
- Volume of blood in the arterial system
———-
physical activity; emotional state; pain; noise; environmental temperature; use of coffee, tobacco, and other drugs; and even time of day.

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11
Q

JVP: location to measure + where to estimate; oscillations

A

JVP = crucial indicator of right atrial pressure and cardiac function**
- closely parallels pressure in R atrium/central venous pressure
- related to volume in the venous system**
- point at which the external jugular vein appears collapsed

Location:
- best to measure: pulsations from R INTERNAL jugular vein: direct alignment with R atrium + SVC
- can also use external jugular vein
- lies beneath SCM muscle: can see oscillations at neck surface

Estimation: Measure the highest point of the vein’s oscillation above the sternal angle to estimate JVP
- best at 45 degree incline

Oscillations in the jugular veins during the cardiac cycle represent:
- changes in the right heart during filling and emptying
- atrial contractions

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12
Q

JVP: PE

A

Position: 30-45 degrees (relaxes SCM) and turn pt head so you can look at RIGHT side

Measure:
- find external jugular vein and observe internal jugular venous pulsations
- Identify the highest point of pulsation in the right jugular vein
- measure VERTICAL DISTANCE from sternal angle to the highest point of pulsation
- JVP > 3 cm = ABNORMAL

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13
Q

JVP: when is it increased vs decreased

A

Decreased: BLOOD LOSS

Increased:
- pulmonary HTN (R heart strain)
- acute + chronic HF
- tricuspid stenosis
- AV dissociation
- pericardial effusion/tamponade

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14
Q

pt complains of Chest Pain: DDx

A

MC sx of CAD*

Aortic dissection: Anterior chest pain, often tearing or ripping and radiating into the back or neck

ACS: unstable angina, non-STEMI, and STEMI
- exertional angina
- typical vs atypical chest pain
- nausea/vomit
- pain: upper back, neck, jaw

PE!!!

importantto get a pts baseline level of activity to gauge the severity of the chest pain and guide management
- EKG
- stress test
- echo
- CT angiography

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15
Q

typical chest pain

A

Typical
- Men
- Mid-sternal or left sided
- Squeezing, tightness, pressure
- “elephant sitting on chest”
- Levine sign – clenches fist over sternum
- Radiation: Left arm

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16
Q

atypical chest pain

A

Atypical
- Females
- elderly (over 65)
- diabetes/ immunocompromised
- pain: jaw, back, right shoulder; may not be in chest
- Radiation: Right or bilateral arms
- paroxysmal nocturnal dyspnea

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17
Q

pt complains of palpitations…. define, ddx, next steps

A

Definition: unpleasant awareness of heart beat
- palpitations DOES NOT EQUAL heart ds
- vtach = NO PALPITATIONS

DDX:
- hyperthyroidism
- anxiousness

Next steps:
- have pt describe the palpitation: skipping, racing, fluttering, pounding, stopping, irregular, rapid
- teach pt how to take their pulse* so they know for subsequent episodes
- get an EKG* (afib?)

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18
Q

pt complains of sudden dyspnea

A

PE
spontaneous pneumothorax
anxiety

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19
Q

pt complains of paroxysmal nocturnal dyspnea… characteristics and ddx

A

definition: sudden dyspnea and orthopnea that awakens pt
- occurs 1-2 hrs after going to bed
- pt has to stand up or open up window for air
- +/- wheezing or coughing
- may mimic nocturnal asthma attack

DDx: orthopnea and PND
- LV HF
- mitral stenosis
- obstructive lung ds

20
Q

pt complaining of edema……. definition and next steps

A

Definition: accumulation of excessive fluid in the extravascular INTERSTITIAL space
- up to 5L before pitting edema appears (~10% wt gain)***

next steps:
- ask pt to record their daily morning wt: rapid weight gain (more than 1 to 2 lb/day) will occur prior to visible edema!!!*****
- assess for pitting edema: use thumb and press for 2s

21
Q

Anasarca definition

A
  • severe GENERALIZED edema
  • extending to the sacrum and abdomen
22
Q

pt complains of fainting/syncope

A

Definition: transient loss of consciousness followed by recovery
- blacking out

MCC: vasovagal syncope/neurocardiogenic syncope
- 20%: caused by arrhythmias -> heaert not providing adequate blood flow to the brain

23
Q

Heaves vs thrills

A

Heaves:
- SUSTAINED impulses that LIFT your finger pads
- MC: enlarged ventricles; others: ventricular aneurysm

Thrills: turbulent flow
- BUZZING/VIBRATIONS felt with ball of your hand
- higher grade murmur
- AS: thrills in carotid artery

24
Q

when would you percuss the heart area

A

if you cannot palpate the PMI

25
palpating the heart: RV
RV: 30 degree angle + supine - pt must exhale + hold breath - use tips of fingers on 3-5th ICS - parasternal movement: pulmonary HTN, pulmonic stenosis
26
Appropriate Use of the Stethoscope for the Cardiac Examination: diaphragm vs bell
Diaphragm: HIGH pitched sounds - S1 and S2 heart sounds - murmurs: aortic and mitral regurgitation - pericardial friction rubs - use a TIGHT SEAL****: press down and almost leave an impression -> reduces extra sounds Bell: LOW pitched sounds: - S3 and S4 sounds - murmur: mitral stenosis - LIGHT SEAL start at BASE of heart with diaphragm - check 6 locations -> switch to bell - pt supine 30 degrees
27
Secondary auscultation positions:
LLD: - S3, S4, mitral stenosis - BELL on PMI** Sit up, lean forward, exhale completely, hold breath** - STETHOSCOPE on LLSB and APEX: aortic regurgitation
28
Special maneuvers: standing vs squatting
Standing: - decreases blood return to the heart - decreases PRELOAD Squatting: - increases blood return to the heart - increases PRELOAD Uses: These positions help identify - mitral valve prolapse - differentiate hypertrophic cardiomyopathy from aortic stenosis - AS: squatting will increase murmur - HOCM: standing: increases murmur - MVP: standing louder murmur and earlier onset click
29
special maneuver: valsalva
valsalva: bear down, have pt flex abdomen against hand -initial strain: increases the thoracic pressure -> increases BP = decreased venous return to heart - HOCM: only systolic murmur that increases - DECREASES PRELOAD
30
special maneuver: isometric hand grip
INCREASES AFTERLOAD *** - increases vascular resistance = increase afterload Murmurs: - all stenotic murmurs are quieter EXCEPT MS - regurgitant murmurs LOUDER: mitral regurgitation and aortic regurgitation ***
31
How does inspiration and expiration affect murmurs
Inspiration: - increases RIght sided murmurs Expiration: - increases LEft sided murmurs - increases AS murmurs
32
Grading systolic cardiac murmurs:
Grade 1/6: - Softer in volume than S1 and S2 - very faint - not heart in all positions Grade 2/6: - Equal in volume to S1 and S2 - soft - heard immediately in all positions Grade 3/6: - Louder in volume than S1 and S2 - NO thrill Grade 4/6: - Louder in volume than S1 and S2 - with palpable thrill Grade 5/6: - Louder in volume than S1 and S2 - thrill: heard when the stethoscope is partly off the chest Grade 6/6: - Louder in volume than S1 and S2 - thrill: heard with stethoscope entirely off the chest
33
List the systolic murmurs: midsystolic, holosystolic, late systolic
if DM = MS; then systolic murmurs are MR + opposites (AS + PS) Mitral regurgitation/tricuspid regurgitation opposite: AS + PS Midsystolic: HAPA are MID - HOCM - AS - PS - ASD holosystolic: - MR/TR - VSD late systolic murmur: MVP
34
List the diastolic murmurs: early diastolic, mid-late diastolic, rare
DM = MS (diastolic murmurs = mitral stenosis + the oppoisites (AR + PR) mitral stenosis/tricuspid stenosis (mid-late) aortic regurgitation/pulmonic regurgitation Early diastolic = early didatic wants austin to do APA format: - AR - PR -Austin Flint: low pitched murmur in AR at apex rare: patent ductus arteriosus
35
Murmur summary: Innocent Murmur Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Descriptors: Musical, vibratory Quality: Musical, vibratory Timing: Systolic Location: LSB (Left Sternal Border) Tool: Bell Increases with: Supine position Decreases with: Valsalva maneuver Radiation: N/A; Apex
36
Murmur summary: Hypertrophic Obstructive Cardiomyopathy (HOCM) Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Descriptors: Hypertrophied interventricular septum Quality: Harsh crescendo-decrescendo Timing: Mid-systolic Location: LLSB (Left Lower Sternal Border) Tool: Diaphragm Increases with: Standing, Valsalva Decreases with: Handgrip, Squatting Radiation: No carotid radiation (sounds like AS)
37
Murmur summary: Ventricular Septal Defect (VSD) Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Descriptors: Hole in the ventricular septum, smaller the defect louder the murmur Quality: Loud, high-pitched, harsh Timing: Holosystolic Location: LLSB Tool: Either Increases with: Squatting Decreases with: Standing, Valsalva Radiation: Can be associated with palpable thrill
38
Murmur summary: Mitral Valve Prolapse (MVP) Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Descriptors: Ballooning of part of the mitral valve back into the left atrium Quality: Mid-late systolic ejection click Timing: Systolic Location: Apex Tool: Diaphragm Increases with: Standing (earlier click), valsalva Decreases with: squatting, handgrip (delay the click)
39
Murmur summary: Mitral Regurgitation (MR) Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Descriptors: MV should be closed, but does not fully close causing volume overload Quality: Blowing holosystolic Timing: Pan-systolic Location: Apex Tool: Diaphragm Increases with: LLD (Left Lateral Decubitus), Handgrip, Squatting Decreases with: Standing, Valsalva Radiation: Left axilla
40
Murmur summary: Aortic Stenosis (AS) Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Descriptors: Obstruction of left ventricular outflow of blood Quality: Systolic ejection crescendo-decrescendo Timing: Mid-systolic Location: RUSB (Right Upper Sternal Border) Tool: Diaphragm Increases with: Squatting, exhalation Decreases with: Valsalva, Standing, Sitting up & leaning forward Radiation: Carotid
41
S3 Heart Sound Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Type: S3 (Ventricular Gallop) Quality: "Kentucky"; low-pitched Timing: Diastolic Auscultation Location: Apex Tool Used: Bell Maneuver Increase: Increased with left lateral decubitus (LLD) position
42
S4 Heart Sound Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Type: S4 (Atrial Gallop) Quality: "Tennessee"; low-pitched Timing: Diastolic Auscultation Location: Apex Tool Used: Bell Maneuver Increase: Increase with left lateral decubitus (LLD) position Radiation: N/A
43
Mitral Stenosis (MS) Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Type: Mitral Stenosis (MS) Descriptors: Obstruction of flow from Left Atrium (LA) to Left Ventricle (LV), narrowed mitral orifice Quality: Opening snap***, loud S1, rumble decrescendo Timing: Mid-diastolic Auscultation Location: Apex Tool Used: Bell Maneuver Increase: Squatting, left lateral decubitus (LLD) Maneuver Decrease: Valsalva, standing Radiation: No radiation
44
Aortic Regurgitation (AR) Type: Descriptors: Quality: Timing: Auscultation Location: Bell vs Diaphragm: Maneuver Increase: Maneuver Decrease: Radiation:
Type: Aortic Regurgitation (AR) Descriptors: Aortic valve does not close fully during diastole Quality: Blowing decrescendo Timing: Diastolic Auscultation Location: Left upper sternal border (LUSB), Apex Tool Used: Diaphragm Maneuver Increase: Handgrip, squatting Maneuver Decrease: Valsalva, standing, sitting up & leaning forward Radiation: Left upper sternal border (LUSB)
45
which heart murmurs have radiation
Radiation: PS aortic stenosis: carotid pulmonic stenosis: left shoulder mitral regurgitation: axilla tricuspid regurgitation: xiphoid process

Clinical Skills I (11 decks)

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