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Physical Diagnosis > CV abnormal > Flashcards

CV abnormal Flashcards

1
Q

what is pulse pressure

A

systolic pressure - diastolic pressure

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2
Q

what is Bisferiens pulse? What condition causes it?

A
  • significant aortic valve regurgitation
  • double pulse felt due to backflow of blood in early diastole
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3
Q

what are the two pulses felt in Bisferiens pulse

A
  • first carotid pulse is normal systole
  • second pulse early diastolic due to the regurgitating blood
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4
Q

What is pulsus alternans

A

physical finding with aterial pulse waveform showing alternating strong and weak beats

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5
Q

pulsus alternans is almost always indicative of what condition? Describe the pathophysiology

A
  • left ventricular systolic impairment
    1. ejection fraction will decrease -> reduction in stroke volume
      1. increase in end-diastolic volume
    2. next cycle: myocardial muscle will be stretched more than usual
      1. will cause an increase in myocardial contraction
        1. stronger systolic pulse
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6
Q

what is jugular venous distension

A
  • elevated jugular venous pressure (> 7 mmHg)
  • sign of fluid overload
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7
Q

what is jugular venous pressure an indicator of

A

right atrial pressure; elevation suggests fluid overload

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8
Q

how do you measure JVD (specialized exam)

A
  1. elevate head of bed to 30 deg
  2. find internal jugular venous pulsations
    1. locate highest point of pulsation
  3. measure from sternal angle
    1. sternal angle is considered to be 5 cm above right atrium)
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9
Q

what JVD measurement indicates elevated right heart pressure

A

JVP higher than 4 cm above the sternal angle (9 cm above R. atrium) indicates elevated right heart pressure

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10
Q

What is the hepatojugular reflux (specialized exam) testing for?

A
  • a test for fluid overload (heart failure)
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11
Q

how would you perform hepatojugular reflux (specialized exam)

A
  • patient is supine; head at 30 deg angle
  • apply firm and sustained pressure to the abd in the RUQ over the liver for greater than 10 seconds
  • observe the neck for an increase in JVP, followed by a decrease as the hand is released
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12
Q

what indicates a positive hepatojugular reflux (specialized exam)

A
  • JVP will increase in all patients with this maneuver, but it is exaggerated in right heart failure
  • > 3 cm increase is positive
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13
Q

Where would you locate the apical impulse

A

5th intercostal space in Midclavicular line

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14
Q

When you locate the PMI, you should note its size and appearance. What should the PMI not exceed?

A

should not exceed 2.5 cm in diameter, or the width of one intercostal space

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15
Q

what is a thrill

A

a palpable murmur, usually due to vibrations that accompany loud murmurs

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16
Q

what is a lift (or heave)

A

when the cardiac impulse feels more vigorous than normal, and ca be felt or seen through the chest wall

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17
Q

what do lift or heaves usually indicate

A

right ventricle hypertrophy

  • pulmonary HTN
  • coronary heart disease
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18
Q

bell mode allows you to hear what frequency sounds?

A

bell mode = low frequency

  • light contact with chestpiece
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19
Q

diaphragm mode allows you to hear what frequency sounds?

A

diaphragm mode = high frequency

  • use firm pressure
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20
Q

in what two positions do you want the patient to be in to auscultate soft mumurs at the base

A
  • sitting up
  • leaning forward
    • ask patient to lean forward, exhale completely, and hold

* listen at base for possible aortic or pulmonic regurgitation

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21
Q

in what two positions do you want the patient to be in to auscultate low pitched filling sounds

A

left lateral decubitus

  • place bell of stethoscope on the apical impulse
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22
Q

the first heart sound is best heard where?

A

at the apex

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23
Q

what does the first heart sound (S1) correspond to?

A

systole

  • aortic and pulmonic valves are forced open and blood in ejected into arteries
  • closure of mitral and tricuspid valves produce S1 “lub” sound
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24
Q

What does a louder S1 heart sound indicate

A
  • diseased A-V valve or more forceful closure of A-V valve
    • e.g. mitral stenosis, tachycardia, fever
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25
Q

What does a softer S1 heart sound idicate

A
  • weak contraction of heart

OR

  • reduced sound transmission from thick chest wall or emphysematous lung
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26
Q

Where is the second heart sound S2 best heard

A

at the base of the heart (1, 2)

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27
Q

what produces the second heart sound S2

A

Diastole

  • closure of aortic and pulmonic valves produces the S2 sound -> “Dub”
  • during this time, the heart is relaxed, ventricles start to refill and mitral and tricuspid valves are open
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28
Q

There is a normal or physiologic splitting of S2 during what

A

inspiration

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29
Q

what is split during physiologic splitting of S2

A
  • split to hear
    • aortic valve closure
    • pulmonic valve closure
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30
Q

Wide splitting is due to what? What conditions can cause this?

A

Delayed closure of pulmonic valve

  • pulmonary stenosis
  • RBBB
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31
Q

fixed splitting, or splitting of S2 that does not vary with inspiration indicates what

A

atrial septal defect or right ventricular failure

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32
Q

paradoxical splitting present during expiration and gone during inspiration; A2 follows P2 indicates what?

A

delay in contraction of left ventricle due to a left bundle branch block

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33
Q

what creates a third heart sound S3

A
  • created in early diastole by early passive rapid filling of the ventricles with blood from the atria
    • S3 is produced by rapid distension of the ventricular walls, causing vibration
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34
Q

describe third heart sound S3. Where is it best heard?

A
  • low pitched
  • heard best with bell, at apex
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35
Q

what combination of sounds produced what is known as ventricular gallop rhythm

A

S1+ S2+ S3

36
Q

What patient populations can have a non-pathological S3 gallop

A
  • children
  • healthy young adults
  • pregnant women
37
Q

What patient populations can develop a pathological S3 gallop

A
  • > 40 y.o
38
Q

pathological S3 gallop is due to what conditions

A
  • heart failure
  • anemia
  • volume overload of ventricle
  • decreased myocardial contractility
39
Q

what creates the fourth heart sound S4

A
  • sound created by second phase of ventricular filling as the atria contract and eject blood into the ventricles (“atrial kick”
    • S4 may be produced as the rush of blood causes vibration of valves, papillary muscles and ventricular walls
40
Q

what combination of heart sounds are referred to as atrial gallop rhythm

A

S1+ S2+ S4

41
Q

Describe S4 sound? Where is it best heard?

A
  • low pitched
  • best heart with bell, at apex
42
Q

S4 may be normal in what patient population?

A

trained athletes

**but usually uncommon in healthy adults

43
Q

what pathology causes an S4 heart sound

A

resistance of ventricular filling

  • stiffness of heart muscle (reduced compliance)
44
Q

what conditions can cause an S4 heart sound

A
  • coronary artery disease
  • cardiomyopathy
  • atrial stenosis
45
Q

what is an aortic or pulmonic ejection click?

A
  • high pitched; opening sound of valve
  • indicates
    • valve disease
    • dilated aorta
    • pulmonary HTN
46
Q

aortic or pulmonic ejection click are heard best using what aspect of the stethoscope?

A

diaphragm

47
Q

what is mitral prolapse?

A

ballooning of mitral leaflets into the left atrium during systole

48
Q

what audible sounds can be heard from mitral valve prolapse

A
  • mid-late systolic clicks
  • variable pitch
  • mitral regurgitation may also occur, with late systolic murmur
49
Q

In describing and documenting a murmur, you should be able to characterize what 4 properties of an “abnormal” heart sound

A
  1. location
  2. timing
  3. grade or intensity
  4. quality and shape
50
Q

What is a grade 1/6 murmur

A

barely audible in a quiet room

51
Q

what graded murmur is this: quiet but clearly audible

A

grade 2/6 murmur

52
Q

what graded murmur is this: moderately loud

A

Grade 3/6

53
Q

what graded murmur is this: loud, associated with thrill

A

Grade 4/6

54
Q

what graded murmur is this: very loud, heard with stethoscope partially off chest; obvious thrill

A

grade 5/6

55
Q

what graded murmur is this: very loud, heart with stethoscope entirely off the chest, obvious thrill

A

grade 6/6

56
Q

describe shape of systolic ejection murmur

A

usually crescendo decrescendo

57
Q

what causes systolic ejection murmur

A

usually due to blood flow across semilunar valves

58
Q

shape of pansystolic (holosystolic) murmur

A

plateau

59
Q

what causes pansystolic (holosystolic) murmur

A
  • usually regurgitation across A-V valves

Or

  • ventricular septal defect
60
Q

a late systolic murmur is typical of what condition

A

mitral prolapse

61
Q

systolic ejection murmur occurs during when blood flows from what pressure system to what pressure system?

A

from high pressure to high pressure

  • from left ventricle through aortic valve into aorta
  • from right ventricle through pulmonic valve into pulmonary artery
62
Q

where would you best hear a systolic ejection murmur

A

listen at base

  • right and left sternal borders
63
Q

aortic and/or pulmonic stenosis can cause what type of murmur

A

systolic ejection murmur

64
Q

innocent systolic murmur are usually associated with what valve

A

pulmonic

65
Q

innocent systolic murmur usually have what characteristics

A
  • grade 1-2; rarely >3/6
  • medium pitch
  • may decrease or disappear with sitting
  • results from turbulent blood flow without valvular narrowing or obstruction
66
Q

innocent systolic murmur are commonly found in what patient populations

A
  • children and young adults
  • pregnancy
  • anemia
  • fever
  • hyperthyroidism
67
Q

mitral or tricuspid regurgitation commonly results in what type of murmur

A

Pansystolic or holosystolic

68
Q

Pansystolic or holosystolic results when blood flows between what two pressure systems?

A

from high pressure to low pressure system

69
Q

describe the physiology of a high to low pressure pansystolic murmur

A
  • pressure in L and R ventricles is significantly higher than in the atria
  • when ventricles contract, if tricuspid or mitral valves leak, the ventricular pressure remains well above the atrial pressure throughout systole and the blood flow from ventricle into atrium is not slowed, so the murmur does not increase and decrease in intensity, it remains the same
70
Q

what is an atrial septal defect

A
  • congenital anomaly
    • left-to-right shunt of blood (LA ->RA)
    • RV enlargement and increase flow through pulmonic valve
71
Q

atrial septal defect causes what type of murmur

A

systolic ejection murmur

  • fixed splitting of S2
72
Q

Where can you hear a ventricular septal defect?

A
  • Harsh systolic murmur at LLSB
73
Q

ventricular septal defect causes what type of murmur? Why?

A
  • pansystolic murmur
  • there is no resistance to flow in the RV therefore, blood is moving from a high pressure to a low pressure system
74
Q

early diastolic mumurs usually have what shape

A

decrescendo

75
Q

regurgitant flow across leaking semilunar valves (aortic or pulmonic) causes what type of murmur

A

early diastolic murmur

76
Q

mitral/tricuspid stenosis (turbulent flow across atrioventricular valves) causes what type of murmur

A

mid diastolic murmurs

77
Q

mitral stenosis causes what noises

A
  • opening snap
  • diastolic rumble
78
Q

aortic stenosis and aortic insufficiency (regurgitation) causes what shape murmur

A

crescendo-decrescendo murmur

79
Q

identify the two maneuvers to identify systolic murmurs

A
  1. standing or strain phase of valsalva
  2. squatting or release phase of valsalva
80
Q

what does the standing or stain phase of valsalva cause

A
  • decreased left ventricular volume from decreased venous return to heart
  • decreases vascular tone
    • decreased BP
    • decreased pulmonary vascular resistance
81
Q

what does the squatting or release phase of valsalva cause

A
  • increased left ventricular volume from increased venous return to heart
  • increased vascular tone
    • increased BP
    • increased peripheral vascular resistance
82
Q

what is patent ductus arteriosis

A

failure of channel between aorta and pulmonary artery to close after birth

83
Q

Name some causes of “To and Fro” systolic/diastolic murmurs

A
  • severe aortic regurgitation
  • aortic stenosis
84
Q

what does this abbreviation stand for: MSC

A

midsystolic click

85
Q

what does this abbreviation stand for: MRG

A

murmurs, rubs, gallops

Physical Diagnosis (16 decks)

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