H&P Final Exam: Cardio Flashcards
What are palpitations commonly described as?
Skipping, fluttering, pounding, stopping, flip-flopping, and racing.
What is edema?
Accumulation of fluid in the extravascular interstitial space.
How do I know if edema is due to CHF?
It is consistent in when it occurs.
How much weight gain can one get from edema?
up to 10% (5L of fluid can be absorbed by the interstitial space)
Why does edema occur in pregnancy?
Mothers have to increase their blood volume to compensate for the fetus.
Where are the 5 listening posts in terms of intercostal spaces?
Aortic = R 2nd intercostal parasternal
Pulmonic = L 2nd intercostal parasternal
Left sternal = L 3-5th intercostal parasternal
Tricuspid = L 5th intercostal space parasternal
Mitral = L 5th intercostal space (anterior axillary)
What do pulsations indicate?
Increased blood volume and/or pressure.
What are heaves?
Forceful cardiac contractions causing slight to vigorous movement of sternum and ribs and can rhythmically lift your fingers.
What are thrills and what do they indicate?
Buzzing or vibration sensation of loud cardiac murmurs. Occurs in turbulent blood flow.
Note:
Similar to a cat purring.
How does the apex shift if someone has LVH?
The apex will shift left.
What does the base of the heart refer to?
Superior aspect of the heart at the R and L 2nd intercostals near the sternum.
What is another name for PMI?
Apical impulse
Where is the PMI/apical pulse palpated?
5th ICS, 7-9 cm lateral to midsternal or just medial of the L midclavicular.
When can a PMI not be palpable?
Healthy and/or obese people.
How large is a PMI? What makes it larger?
<2.5cm (quarter sized)
Left Lateral Decubitus enlarges it.
What is the amplitude of a PMI?
Small, brisk, tapping.
What is indicated by strong suprasternal/epigastric pulsations?
Increased R ventricular pressure
Ex: Chronic lung disease
What is pulse pressure?
SBP - DBP, so its normally around 40 mm Hg.
What is a dicrotic notch?
A second notch found in between the SBP and DBP that occurs due to transient increases in aortic pressure as the aortic valve closes.
What is JVP used to diagnose?
Right sided heart pressures and cardiac function.
It acts as a barometer to determine the filling pressures of the chambers.
What are two common causes of elevated JVP?
Pulmonary HTN
Long-standing Systolic HF
What does JVP parallel in the body?
R atrium pressure/central venous pressure.
What is elevated JVP commonly correlated with?
Acute and chronic HF.
Describe a jugular waveform.
Multiple peaks,
Note:
See slide 20 for a visual.
R atrium contraction is the highest peak.
R ventricle contraction and R atrium filling are similar heights.
What is Kussmaul’s sign?
Elevated JVP during inspiration, suggestive of constrictive pericarditis.
What is the acronym POLICE for?
Differentiating between carotid and internal jugular pulsations.
What does POLICE stand for?
Palpation
Occlusion
Location
Inspiration
Contour
Erect/Position
What is the POLICE for a jugular vein?
Palpation: rare
Occlusion: eliminated by light pressure
Location: superficial and lateral in neck, between SCM heads.
Inspiration: height falls during inspiration.
Contour: Double impulse, 3 peaks, 2 troughs.
Erect/Position: Height drops as patient becomes more upright.
What is the POLICE for a carotid?
Palpation: palpable
Occlusion: not eliminated by pressure
Location: Deep and medial in neck
Inspiration: no effect
Contour: single thrust
Erect/position: no effect
If I have decreased blood volume, what happens to my JVP?
JVP will fall.
Jugular veins will collapse.
If I have increased blood volume, what happens to my JVP?
JVP will increase
JVD will occur
Note:
Can occur due to impeded flow into R side of heart or impeded diastolic filling.
What is normal JVP?
<3cm below the sternal angle
What is the angle made when measuring JVP?
Angle of Louis
If I anticipate my patient is in hypovolemia, what should I do to the head of the bed?
Lower the head of the bed, because JVP will be lower.
If I anticipate my patient is in hypervolemia, what should I do to the heard of the bed?
Raise the head of the bed, because JVP will be higher.
What sound is a carotid bruit?
Turbulent arterial blood flow.
Sounds like a murmur.
If my patient has a weird carotid, what pulse do I assess instead?
Brachial
Where is S1 heard the loudest?
At the apex.
What are the characteristics of S1?
Closure of AV valves.
Lub sound
Corresponds with pulse
What listening post is best to hear S1 splits?
Left sternal border
What does it mean if S1 is split?
MV closure is significantly preceding TV closure.
Where is S2 heard the loudest?
Base of the heart
What listening post is best to hear S2?
2nd and 3rd ICS.
What are the characteristics of S2?
Closure of semilunar valves.
Physiologically split because AV closure precedes PV valve closure normally.
When is S2 splitting abnormal?
Upon expiration.
Inspiration is normal.
What is S3?
Kentucky/ventricular gallop.
It represents an increased volume of blood hitting a compliant ventricle.
When does S3 occur?
At the beginning of diastole after S2.
When is S3 normal?
Children
Trained athletes
Pregnancy (sometimes)
What is S4?
Tennessee/atrial gallop
Produced by the sound of blood being forced into a stiff/non-compliant/hypertrophic ventricle.
When does S4 occur?
Occurs just after atrial contraction at the end of diastole, prior to S1.
When is S4 normal?
Never!
What is a quadruple gallop?
presence of S3 S4.
Hello-goodybye
What is a summation gallop?
Presence of S3 S4 in tachycardia causes them to merge.
When is the diaphragm used for heart sounds? Bell?
Diaphragm is for S1 and S2. (high-pitch) (S1 and S2 are valves closing, so I imagine a snap, and snaps are high-pitch)
Bell is for S3 and S4. (low-pitch) (They have to do with blood hitting something, which is like a dull splash)
Note:
D = ding which is high pitch.
B = boom which is low pitch.
What do clicks means?
Damaged valves.
What are the common clicks?
Mid-systolic click in MVP
Ejection click in AV and PV stenosis after S1.
When is an opening snap heard?
MV stenosis. It is heard after the A2 component of S2.
AKA heard as part of AV valve opening.
When is a pericardial friction rub heard?
Loudest in systole, but can be heard at the beginning and end of diastole too.
What is a pericardial friction?
A scratching, creaking, high-pitched sound coming from rubbing of inflamed pericardium.
Changes with position and time.
What are the two valve categories that cause murmurs?
Stenotic valves
Insufficiency/regurgitation of valves
What are the two timings for murmurs?
Systolic = just after S1, coincides with carotid upstroke.
Diastolic = just after S2, post carotid upstroke.
What are the murmur shapes?
Crescendo = grows louder
Decrescendo = grows softer
Crescendo-Decrescendo = Slowly increases then slowly decreases.
Plateau = same intensity throughout.
How do we grade heart murmur intensity?
Grade 1-6.
1 = very faint
6 = very loud, might not even need stethoscope to hear.
At what grade do heart murmurs start having thrill?
4
What is left-lateral decubitus used for in terms of heart murmurs?
Brings out left-sided S3, S4, and mitral murmurs. (esp mitral stenosis!!!)
What is a hunched forward position used for in terms of heart murmurs?
Aortic murmurs (esp aortic regurg)
What happens to MVP when a patient squats?
shortens
What happens to venous return in a standing patient?
It decreases.
How do I differentiate hypertrophic cardiomyopathy (HCM) from aortic stenosis? (AS)
HCM increases in intensity when you go from squatting to standing.
Note:
Standing decreases venous return, so Starling’s law must use increased ventricular contraction to compensate is the logic I think of to remember this
What is the valsalva maneuver?
Forcible exhalation against a closed glottis after full inspiration, causing increased intrathoracic pressure.
What happens to my HR in valsalva?
Decreases as aortic pressure increases, then bounces back.
When is a valsalva maneuver used?
Differentiate MVP and HCM from AS.
Mitral valve prolapse
Hypertrophic cardiomyopathy
Aortic stenosis
What is PVD?
Peripheral venous disease
What are the risk factors for PVD?
DM
HTN
HLD
FMHx
Smoking
> 55 yo
Males
What does red indicate for PVD?
Superficial thrombophlebitis
What does brown indicate for PVD?
Venous insufficiency
What is anasarca?
Extreme generalized edema characterized by widespread swelling of skin due to effusion of fluid into extravascular space.
Note:
Looks like a super puffy face :(
What is pitting edema?
Edema that leaves a pit when u press it. Does not rebound fast. Means it is just fluid.
What is claudication?
Pain or cramping in the legs during exertion that is relieved by rest within 10 mins.
How do I grade peripheral pulses?
0-3.
3 is bounding
2 is brisk and normal.
1 is diminished
0 is absent, unable to palpate.
What is the purpose of the Allen test?
Checking for any arterial insufficiency or lack of collateral circulation in the wrist/hand.
What happens with untreated PVD?
Venous stasis dermatitis or varicose veins
Venous stasis ulcers
DVTs
What is Homan’s sign?
Calf pain upon dorsiflexion of foot.
Is Homan’s sign indicative of DVT?
Eh.
It has low sensitivity and low specificity.
