Lecture 4.2 cardiac pt 1 (8% of final)

Question 1

1) What makes up most of the ant. surface of the heart?
2) Where does this structure lead to?
3) Where does that second structure go?

Answer 1

1) Right ventricle (RV)
2) Pulmonary artery at the sternal notch
3) Courses pt. left.

Question 2

Aorta courses along what boarder?

Answer 2

Right upper sternal

Question 3

Where do murmurs heard in the right 2nd interspace originate?

Answer 3

Aortic valve

Question 4

Where do murmurs heard in the left 2nd and 3rd interspaces (and at higher and lower levels) originate?

Answer 4

Pulmonic valve

Question 5

Where do murmurs heard at or near the lower left sternal border originate?

Answer 5

Tricuspid valve

Question 6

Where do murmurs heard at or around the cardiac apex originate?

Answer 6

Mitral valve

Question 7

Trace the path of blood through the heart (12 steps)

Answer 7

1) SVC
2) Right atrium
3) Tricuspid valve
4) Right ventricle
5) Pulmonary SL valve
6) Pulmonary artery to lungs
7) Lungs
8) Pulmonary veins
9) Left atrium
10) Bicuspid/ mitral valve
11) Left ventricle
12) Aortic SL valve

Question 8

What is synonymous with “systole vs diastole”

Answer 8

Constriction vs. rest

Question 9

1) What is happening during systole?
2) What is happening during diastole?

Answer 9

1) Systole: blood flows from pulmonary and aortic SL valves
2) Diastole: blood flows through tricuspid and bicuspid (mitral) valves

Question 10

During what stage is the pulse palpable?

Answer 10

In the middle of systolic, after S1

Question 11

1) What is closing during the S1 sound?
2) What is closing during the S2 sound?

Answer 11

1) S1: mitral and tricuspid
2) S2: aortic and pulmonary

Question 12

1) What is stenosis?
2) What is regurgitation?

Answer 12

1) Valve is disfigured, slightly closed even when supposed to be open, causing turbulent flow of blood through it, causing a murmur
2) Valve is open when supposed to be closed

Question 13

1) When will aortic/ pulmonic stenosis be heard? Why?
2) What does it relate to? What kind of sound?

Answer 13

1) During systole/ S1, because it’s closed when it should be open
2) Carotids; cresendo-decrescendo

Question 14

What is aortic stenosis characterized by?

Answer 14

Crescendo-decrescendo sound (rises in intensity, then falls)

Question 15

When does mitral/ tricuspid stenosis occur?

Answer 15

During diastole, S2

Question 16

When is mitral/ tricuspid regurgitation heard?

Answer 16

Heard throughout

Question 17

1) When would aortic/ pulmonary regurgitation occur?
2) Where would you hear it?

Answer 17

1) Diastole; blood leaks back into ventricle when valve should be closed
2) Left upper sternal boarder

Question 18

1) What is a VSD?
2) Where does this occur?
3) Where is blood moving? What will happen?
4) What kind of murmur does this cause?

Answer 18

1) Ventricular septal defect
2) L 3-5th interspaces
3) To the right ventricle from the left; goes back to the lungs
4) Plateau murmur

Question 19

1) What is PDA?
2) What usually happens?
3) What kind of sound does this cause?

Answer 19

1) Patent ductus arteriosus; aorta and pulmonary artery are linked
2) Usually closes, if it doesn’t it will remain patent
3) Continuous machine-like murmur after both S1 and S2

Question 20

1) Where is hypertrophic cardiomyopathy?
2) When is it decreased?
3) What kind of murmur?
4) What can it cause?

Answer 20

1) L 3-5th interspaces
2) Decreased with squat
3) Systolic murmur (that goes away with squatting)
4) Spontaneous cardiac arrest

Question 21

1) What does an innocent/ physiologic murmur sound like?
2) Where is it?
3) When does it occur?

Answer 21

1) Soft: grade 1-2
2) Left sternal murmur
3) Always in systole

Question 22

List the 6 grades of murmurs. What are most murmurs?

Answer 22

1) Very faint, heard only after listener has “tuned in”; may not be heard in all positions
2) Quiet, but heard immediately after placing stethoscope on the chest
3) Moderately loud
4) Loud, with palpable thrill
5) Very loud, with thrill. May be heard with stethoscope partially off chest.
6) Very loud, with thrill. May be heard with stethoscope entirely off chest.
-Most are 2 or 3

Question 23

1) What do S4 gallops sound like?
2) What do S3 gallops sound like?
3) What is splitting?

Answer 23

1) “Tenne-ssee” (pre S1)
2) Kentucky (post S2)
3) S2 can split, aortic valve and pulmonic valve don’t close at the same time, causing two sounds. Hard to hear.

Question 24

1) What is friction rubbing indicative of?
2) What is a mid-systolic click indicative of? What does it sound like and when do you hear it?

Answer 24

1) Pericarditis; “scratching the surface”
2) Mitral valve prolapse with regurgitation; “lub, pucker, dub”; late systolic murmur

Question 25

1) Define cardiac output 2) What would it depend on?

Answer 25

1) How much your heart pumps in a minute 2) How much it pumps per beat, and how often it beats

Question 26

1) Define preload 2) When does it go up?

Answer 26

1) How much blood you’ve got in the RV before it loads 2) When your venous system dumps a bunch of blood into your heart

Question 27

1) Define afterload 2) When does it go up? (2)

Answer 27

1) The amount of resistance your heart's LV has to overcome as it squeezes blood out 2) When you have a bunch of blood in your system or when your arterial system is all “clamping down”

Question 28

1) Explain jugular venous pressure 2) What is it important in?

Answer 28

1) Atrial contraction produces the “a” wave (“A” for atrial contraction) -Then, filling of the atria from vena cava produces second “V” wave (V for vena cava) 2) Assessing for heart failure

Question 29

Define pulse pressure

Answer 29

The difference between your systolic and diastolic blood pressures

Question 30

What is Pulsus Alternans?

Answer 30

Regular pulse, but it alternates between strong and weak beats

Question 31

1) What is a paradoxical pulse? 2) When is this diagnosis earned? 3) What is it seen in?

Answer 31

1) Decrease in amplitude on inspiration 2) If sys. BP goes down by 10-12 mmHG 3) Pericardial tamponade

Question 32

What are the four grades of pulses?

Answer 32

0+: absent, unable to palpate 1+: diminished, weaker 2+: brisk, normal 3+: bounding

Question 33

List the red flags for heart issues (5)

Answer 33

1) Chest pain 2) Palpitations 3) SOB: dyspnea, orthopnea, paroxysmal nocturnal dyspnea 4) Swelling 5) Fainting

Question 34

Give 3 examples of types of SOB

Answer 34

Dyspnea, orthopnea, paroxysmal nocturnal dyspnea

Question 35

1) What could chest pain always be? 2) What could it also be?

Answer 35

1) MI 2) Aortic dissection, along with the pulmonary complaints of last lecture

Question 36

1) What 4 symptoms correspond with infarction? 2) What type of symptoms are indicative of MI? 3) What questions should you ask the pt? Why?

Answer 36

1) Diaphoresis, SOB, presyncope, and nausea 2) Worse with activity and relieved with rest i 3) Make sure you suss out the pt’s family, social, and medical history: Smoking, diabetes, HTN, dyslipidemia, obesity and early MI in family are all risk factors

Question 37

List risk factors for MI

Answer 37

Smoking, diabetes, HTN, dyslipidemia, obesity and early MI in family

Question 38

List the key components of dissection (first 3 most important)

Answer 38

1) Tearing pain 2) Rapid onset 3) Sharp pain 4) Radiation to the back or neck 5) Diaphoresis 6) Neurological deficit

Question 39

Physical exam findings in dissection include what?

Answer 39

Marked difference in upper extremity blood pressure

Question 40

1) What are palpitations? 2) What words can be used to describe them? 3) Give 3 potential causes

Answer 40

1) Unpleasant awareness of the heartbeat 2) “Skipping, racing, fluttering, pounding, stopping” 3) Anxiety, hyperthyroid, atrial fibrillation

Question 41

Besides the general complaint of dyspnea, what two things point towards HF?

Answer 41

Orthopnea and paroxysmal nocturnal dyspnea

Question 42

1) What kind of weight gain points toward fluid overload? What may this indicate? 2) What should you do next? Give examples

Answer 42

1) Rapid weight gain with confirmed pretibial edema; may indicate heart failure 2) Add to your history and ask the questions that help you to cluster symptoms around this diagnosis (like orthopnea, paroxysmal nocturnal dyspnea)

Question 43

Syncope has many causes, but among them are what two things?

Answer 43

Arrhythmia and sudden cardiac failure

Question 44

1) How do you investigate if syncope has a cardiac origin? 2) What do you need to know to investigate this complaint correctly? 3) Give examples

Answer 44

1) Sussing out the remainder of the history is key 2) Everything about the circumstance of their fainting spell 3) Do they remember it, did anyone see it, did the pt. shake, did they hit their head when they fell, did their vision change, did they feel the fainting coming on, had they just changed position, was their any accompanying chest pain, are they still having any symptoms: dizziness, SOB, difficulty moving, presyncope, confusion, ongoing pain – if so, where???