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Clin med II exam II Cardio > Murmurs and Shock > Flashcards

Murmurs and Shock Flashcards

1
Q

descrive the 4 heart valves

A

Aortic Valve (three leaflets) – between PV and aorta

Tricuspid Valve (three leaflets) – between RA and RV

  • Pulmonic Valve (three leaflets) – between RV and PA
  • Mitral Valve (two leaflets) – between LA and LV
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2
Q

explain the grades of murmurs

A
  • Grade 1 – very soft heard after careful auscultation
  • Grade 2 – readily heard soft murmur
  • Grade 3 – moderately loud, not associated w/ palpable thrill
  • Grade 4 – Loud, no or intermittent palpable thrill
  • Grade 5 – loud associated w/ palpable pericardial thrill. Murmur not audible when stethoscope is lifted from thoracic wall
  • Grade 6 – loud murmur associated w/ palpable pericardial thrill and heard when stethoscope is lifter from thoracic wall
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3
Q

define sclerosis, stenosis, regurg

A
  • Sclerosis – valve thickening and calcification without significant pressure gradient (<2 m/sec)
  • Stenosis – valve thickening and calcification with significant pressure gradient (>2 m/sec)
  • Regurgitation – inadequate closure of the valve leaflets, causing back flow of blood into the ventricle
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4
Q

thinking symptom wise where will right and left sided heart failures be noted

A
  • RIGHT side of Heart – back up into body
  • Lower extremity edema
  • Ascites
  • LEFT sided – pulmonary associated symptoms à backs up into lungs first
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5
Q

define preload vs after load

A

preload - volume in ventricles at end of diastole

after load - resistance left ventricle must overcome to circulate blood

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6
Q

what causes an increase in preload vs afterload

A

preload

hypervolemia

regurg of cardiac valves

HF

afterload

vasocontriction

HTN

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7
Q

describe effects of special tests on preload and afterload

valsalva

Squatting from standing

Standing from Squatting

Legs raise (passive)

Handgrip exercise

A

INCREASES preload -

quatting from standing

leg raise

DECREASE preload

Standing from Squatting

valsalva

INCREASED afterload - handgrip

DECREASE afterload - valsalva

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8
Q

most common valvular dz?

A

Aortic regurg

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9
Q

most common causes of AR and AS in:

developed countries

developing countries

A

DEVELOPED countries - Calcific disease

developing countries - rheumatic valve disease

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10
Q

valvular dz assoc w/ sx:

  • Exertional dyspnea
  • Exertional angina
  • HF symptoms – orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, lower extremity edema
  • Awareness of heart beats due to dilation**
A

AR

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11
Q

describe physical exam findings for AR vs AS

A

AR

Wide pulse pressure in BP (140/50)

  • Displacement of apical pulse laterally and inferiorly
  • Prominent pulsation/thrill over sternal notch – aortic dilation
  • Bounding pulse due to arterial pulse falling off rapidly

AS

  • Carotid pulse DEC in amplitude
  • Split S2 (pulmonic valve closing prior to aorta) or deceased S2
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12
Q

As has similar si/sx as AR but we more frequently see:

A

•Pre-syncope or syncope

AR: aware of heart beats due to dilation

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13
Q

describe patho of AR vs AS

A

AR

Increases volume overload in LV -> increase in LV capacity to ensure ventricular compliance -> ventricular wall thickness increases in proportion to increase in chamber radius -> eccentric hypertrophy

AS

Increase afterload in LV à LV needs to generate more force to overcome afterload à thickening of LV à less LV compliance and impedes filling à concentric LV hypertrophy

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14
Q

gold standard for dx of valvular dz?

A

Echo – TTE w/ Doppler

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15
Q

tx of AR/AS

A

Limited physical activity

Tx underlying CV dz

HTN tx challenging

HF management - Low dose diuretic w/ ACE

Palliative care

surgical options

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16
Q

surgical tx of AR and AS

A

SURGICAL

AVR or SAVR – open heart surgery

TAVR – done via femoral, axillary artery or directly via aorta –> Originally used for high-risk pts but not approved for all

F/u

•2-4 wks after discharge, then every 3-6 mo eventually transition to 6-12 mo

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17
Q

Asymptomatic pt monitoring: exam + echo in pts w/ AS

A
  • Mild AS w/o calcification 2-3 yrs
  • Mild AS w/ significant calcification – yearly
  • Moderate AS – yearly
  • Severe AS – every 6 mo
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18
Q

Exercise stress tests are used to dx AS/AR in what pt population

A

•pts w/ severe AS who live sedentary life

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19
Q

metabolic dz such as Paget’s, Fabry’s Lupus are assoc w/

A

AS

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20
Q

sx of MS

A
  • Exertional dyspnea/ exercise intolerance
  • Paroxysmal or persistent Afib
  • Chest pain – due to portal HTN
  • Fatigue
  • Ascites

•Lower extremity edema

  • Thromboembolism
  • Hemoptysis – INC pressure in pul. system
  • Hoarseness – increase in L atrial size that compresses recurrent laryngeal n.
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21
Q

sx of MR

A

Asymptomatic –

•sx don’t occur until late in dz –> develop due to LV enlargement, systolic dysfunction, pHTN or Afib

then develop same sx as MS

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22
Q

Most common cause of MR in developed and developing countries

A

developed –MVP and CAD

developing –rheumatic heart disease

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23
Q

MVP is associated w/ an ______ in sudden cardiac death

A

INCREASE in sudden cardiac death

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24
Q

most common cause of MR

A

MVP

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25
Q

Ct disorders such as Marfans, OI and Ehlers Danlos are associated w/ what valvular dz?

A

MVP

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26
Q

describe primary vs secondary causes of mitral valves dz

A

Primary – due to valve dysfunction

  • Degenerative dz
  • Rheumatic heart dz
  • Endocarditis
  • Congenital

Secondary is due to other factors

  • CAD
  • Dilated CM
  • HCM
  • RV pacing
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27
Q

HF symptoms more common in MR / MS / MVP

A

MS

  • Crackles in lungs
  • Peripheral edema
  • Ascites
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28
Q

Mitral facies are associated w?

A

MS

Mitral facies – pinkish/purple patches on cheeks

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29
Q

tx of Mitral dz

A

Asymptomatic – routine monitoring by cardiologist

Medical management of sx – mostly HF sx

ACE, ARB, BB, aldosterone antag

•Diuretics

surgical procedures:

FIRST line – Mitral Valve Balloon valvotomy

  • Asymptomatic to severe MS
  • Severe MS w/out MR

Transcatheter mitral valve clip

  • MR only
  • Femoral vein access w/ transseptal puncture

Surgical repair / replacement

  • Failed balloon valvotomy
  • Other surgical issues MR or MVP
  • MS w/ MR
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30
Q

describe the different procedures assoc w/ MS vs MR

A

FIRST line – Mitral Valve Balloon valvotomy –> MS

  • Asymptomatic to severe MS
  • Severe MS w/out MR

Transcatheter mitral valve clip –> MR only

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31
Q

split S2 is associated w/

A

AS and PS

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32
Q

describe the displacement of apical pulse in MR vs AR

A

AR - laterally and inferiorly

MR - Leftward displacement

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33
Q

Mitral valve dz Non-surgical candidate monitoring:

A

routine echo yearly

  • Mild – echo every 2-3 yrs
  • Moderate – echo every 1-2 yrs
  • Severe – echo every 6-12 mo
34
Q

Non ejection click is assoc w/

A

MVP

35
Q

diagnostic imaging of choice for mitral valve dz?

A

Echo –

  • usually TTE w/ doppler
  • but TEE is suboptimal
36
Q

CXR of valvular dz show?

A

aortic - widened aortic notch

mitral - Nonspecific LA and LV enlargement

tricuspid - Cardiomegaly from RV enlargement & Pleural effusions

pulmonary - Cardiomegaly w/ RV enlargement

37
Q

si/sx of tricuspid dz

A
  • Neck pulsations (JVD)
  • Palpations
  • Edema (peripheral)
  • Ascites
  • Abdominal pain/bloating
  • Sx related to cause

NO LEFT SIDED sx such as pre-syncope or syncope

38
Q

Opening snap can follow murmur in what valvular dz

A

TS

39
Q

JVD- Kussmal’s sign is associated w/

A

TS and TR

•Lack of or decrease or rise in JVP

40
Q

sx associated w/ tricuspid dz

A

Edema - – ascites, peripheral and occasional anasarca

Hepatomegaly

JVD

41
Q

RA and RV dilation (pHTN, chronic PE, severe COPD) are all causes of:

A

TR

42
Q

tx option of choice for most pts w/ tricuspid dz

A

Surgical repair or replacement

43
Q

tx of TS

A

percutaneous balloon valvotomy

44
Q

medical management of tricuspid dz

A

Med management aimed at sx - Diuretics / aldosterone antag

45
Q

sx of??

Asymptomatic

  • Exertional dyspnea
  • Fatigue
  • Syncope
  • Chest pain
  • Right HF sx (edema, abdominal bloating)
A

pulmonary valve dz

46
Q

tx for PS and PR

A

Should undergo annual screening and monitoring

Correct any underlying issues

  • Pulmonary artery vasodilators
  • HF medication

Congenital PS – fixed in infancy w/ surgery or balloon valvotomy

Symptomatic or severe PR –> Surgical intervention tissue or mechanical valve

47
Q

name the systolic murmurs

A

occur b/w S1 and S2

AS

MR

MVP

TR

PS

48
Q

name diastolic murmurs

A

AR

MS

TS

PR

49
Q

what murmurs are heard best over apex

A

MS - held in expiration

MR

MVP

50
Q

what murmur is heard best ar ERb’s

A

AR

51
Q

what murmurs INCREASE w/

squatting and leg raises

A

AR / AS

MR / MS / MVP

52
Q

AR vs MR special test differnetiation

AS vs MS

A

AR - handgrips inc murmur

MR - hangdrips no effect

AS - handgrips decrease

MS - inspiration decreases

53
Q

hangrips have what effect on these 2 murmurs?

A

AR - increase

AS - decrease

54
Q

in a MS murmur (inspiration / expiration) increases murmur while (inspiration / expiration) decreases murmur

A

expiration increases

inspiration decreases

55
Q

inspiration increases and decreases what murmurs

A

increases TS and TR

decreases - MS

56
Q

HOCM vs AS

A

AS

DECREASES

  • Valsalva
  • Standing

HOCM will do opposite

As radiates to carotid, HOCM does not

57
Q

standing or valsalva decreases what murmurs

A

AR and AS

MS and MR

58
Q

what murmurs radiate to axilla

A

MR and MVP

59
Q

murmur that is described as blowing sound

A

AR

descrecendo

early-diastolic

60
Q

murmur described as harsh

A

AS

crescendo-descresendo (soft-loud-soft)

61
Q

murmur described as rumble (3)

A

MS - loud S1 followed by decresc-cresc, low pitched

MR - medium to high pitch, rumble increases twoard end

TS- opening snap may follow, decresc-cresc, low pitched, rumble increases twoard end

62
Q

murmur described as non-ejection click

A

MVP - low pitched

63
Q

murmur described as continuous blowing

A

AR - early diastolic

TR - systolic

64
Q

murmurs heard best on LSB

A

AR - 3rd and 4th ICS

TS - 3rd to 5th ICS (bell)

65
Q

murmur described as pulmonary ejection click

A

PS - systolic, Crescendo-decrescendo

66
Q

murmurs described as

Crescendo-deccrescendo

Decrescendo-Crescendo

A

Crescendo-deccrescendo

AS and PS

Decrescendo-Crescendo

MS and TS

67
Q

what murmur can radiate to neck and carotids

A

AS

68
Q

describe chemoreceptors and their role

A
  • specialized areas in the medulla oblongata, aortic arch, and carotid arteries that are sensitive to concentrations of O2, CO2, and H+ ions (pH) in the blood
  • Decrease in arterial oxygen or pH and/or increase in carbon dioxide → smooth muscles to contract → vasoconstriction → increase in BP
69
Q

describe baroreceptors and their role

A
  • major stretch receptors located in the aorta and carotid
  • Respond to changed in smooth muscle fiber length by altering their rate of discharge
  • Increase in arterial BP → increase rate of baroreceptor firing → travel afferent nerves → medulla → slows the heart rate via vagus nerve → decreases myocardial contractility → increases arteriolar and venous dilation → reduces BP
70
Q

define orthostatic hypotension

Tx?

A

changes in vital signs taken within 3 minutes of position change (supine to sit or sit to stand)

  • Decrease in SBP >20
  • Decrease in DBP >10
  • Increase in HR >20 bpm

give fluids - if resolve ortho hypo!

tx undeerlying dz

Increase salt in diet

Increase fluid in diet

Elevation of head in bed

Medication changes

71
Q

define hypotension

A

Sustained symptomatic systolic blood pressure (SBP) <90 mmHg

•or an acute drop in SBP of >30 mmHg from baseline

72
Q

name 4 types of shock

A

distributive

cardiogenic

hypovolemic

obstructive

73
Q

causes of distributive vs obstrucitve shock

A

distributive -

septic shock

SIRS

  • Neurogenic shock – TBI, spinal cord injury
  • Anaphylactic shock
  • Drug and toxin-induced shock – insect bite
  • Endocrine shock – Addisons, Myxedema

obstructive

Mechanical

  • Tension pnuemo
  • Pericardial tamponade
  • Constrictive pericarditis
  • Restrictive CM

Pulmonary vascular

  • PE
  • Severe pHTN
74
Q

si/sx of shock

A

look sick

hypotension

tachycardia

Oliguria (<30-50cc/hr)

tachypnea - reduce acidosis

Cool, clammy, cyanotic skin

75
Q

Metabolic acidosis – “high ion gap metabolic acidosis

automaticaaly think??

A

shock

76
Q

Hyperlactatemia correlation w/ mortality w shock

A
  • Normal lactate is 0.1-3mmol/L
  • **higher the lactate higher the mortality
77
Q

management of shock

A

recognize

identify probable cause

oxygen >94%

•Maintain IV access at ALL times

give fluids

maintian ABCs

  • Vasopressors – levophed, phenylephrine, vasopressin
  • Inotropic support – dobutamine, epinephrine
  • Mechanical support for cardiogenic shock
  • Intra-aortic balloon pump
  • Advanced cardiac mechanical support
78
Q

appropriate fluid for type of shock

A
  • LV ischemia or depressed EF: 500-1000cc
  • RV ischemia or sepsis: 2-5L à preload dependent, RA need fluid or it will collapse
  • Hemorrhagic shock: 3-5L
79
Q

complications of shock

A
  • Limb ischemia – can lead to dry gangrene which would require amputation
  • Acute respiratory distress syndrome (ARDS)
  • Death – high mortality associated with some causes of shock
  • Permanent organ damage or death
80
Q

Distributive shock is due to

A

due to severe peripheral vasodilation

81
Q

cardiogenic vs hypovolemic shock due to

A

card -due to intra-cardiac causes of cardiac pump failure that results in reduced cardiac output

hypovol -due to reduced intravascular volume, which in turns, reduced CO

82
Q

obstructive shock is due to

A

due to extra-cardiac causes of cardiac pump failure and is often associated with poor RV output

Clin med II exam II Cardio (3 decks)

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