Phys Di 2 Flashcards
1
Q
Where do you listen for aortic valve sounds?
A
right 2nd intercostal space at sternal border
2
Q
Where do you listen for pulmonic valve sounds?
A
left 2nd intercostal space at sternal border
3
Q
Where do you listen for tricuspid valve sounds?
A
4th/5th left intercostal space
4
Q
Where do you listen for mitral valve sounds?
A
left 5th ICS lateral = Apex
5
Q
What do you listen for with the diaphragm?
A
- most sounds
- high pitched murmurs
- clicks
- snaps
6
Q
What do you listen for with the bell?
A
- low pitched
- filling sounds
- such as gallops
- some murmurs
7
Q
S1 sound cause
A
closure of the mitral and tricuspid valves
8
Q
When does S1 occur?
A
- start of systole
- ventricular contraction
9
Q
Is splitting of S1 normal?
A
- no
- asynchrony of mitral and tricuspid closure
10
Q
S2 sound cause
A
closure of the AP valves
11
Q
What does S2 occur?
A
- start of diastole
- ventricular filling
12
Q
Is splitting of S2 normal?
A
- it can be (physiological split)
- related to breathing
- RIGHT ventricular systole is lengthened with deep inspiration
- A closes before P
13
Q
Wide physiological splitting of S2
A
- abnl
- occurs during inspiration and expiration but WIDER on inspiration
- delayed closure of pulmonic valve
- RBBB or pulm. HTN
14
Q
fixed splitting of S2
A
- abnl
- unaffected by respiration
- delayed pulmonic valve closure w/ RV output > LV output
- large ASD; VSD; right heart failure
15
Q
paradoxic splitting
A
- abnl
- audible splitting w/ expiration (disappears during inspiration)
- delayed aortic valve closure (P2 before A2)
- aortic stenosis; LBBB
16
Q
S3 and S4 are best heard:
- what device
- what position
- pt position
A
- bell
- mitral position
- pt in left lateral decubitus position
17
Q
When are S3 and S4 heard? What do they sound like?
A
- heard in diastole
- soft and low pitched
18
Q
What is a loud and intense S3 referred to as?
A
- ventricular gallop
- “ken-TUCK-y”
19
Q
normal causes of S3 gallop
A
can be normal in young people
20
Q
abnormal causes of S3 gallop
A
- when increased vol. leads to exaggerated diastolic filling
- CHF
- regurg
- shunts
21
Q
What is the most common cause of the S3 gallop?
A
CHF
22
Q
specific timing of S3
A
- EARLY diastole
- related to volume overload
23
Q
S4 timing
A
- LATE diastole (just before S1)
- pre-systolic sound
24
Q
S4 is due to?
A
-d/t PRESSURE overload and stiff ventricles
25
Describe the S4 heart sound
- "TEN-ne-see"
- atrial gallop
- NEVER normal
26
conditions causing S4
- when ventricles are stiffened by hypertrophy or fibrosis:
- hypertrophic cardiomyopathy
- aortic stenosis
27
What is an extra valve sound?
- short sound
| - caused by noisy valve
28
Examples of extra valve sounds
- opening sound (mitral_
- ejection click (aortic)
- non-ejection click (mitral)
- prosthetic valve sound
29
Murmurs
- prolonged sound
| - cause is disruption of blood flow
30
murmur causes
- diseased valves
- high output demands
- structural defects (ASD, VSD)
31
misc. extra heart sounds
- overlies heart sounds
- cause is outside the heart
- pericardial friction rub
- precordial knock
32
Characterization of murmurs
1. timing: systolic or diastolic
2. location best heard
3. intensity (grade I-VI)
4. radiation (carotids, axilla?)
5. What does it sound like?
33
Descriptive words for murmur quality
- harsh
- raspy
- machine-like
- vibratory
- musical
- blowing
- grating
- etc
34
other considerations of murmurs
- does it crescendo/decresendo?
| - is the pitch low or high?
35
maneuvers to consider with murmurs
- does it change w/ posture?
- val salva
- respirations
36
heart murmur intensity grading
```
I: barely audible in quiet room
II: quiet but clearly audible
III: moderately loud
IV: loud, associated w/ a thrill
V: very loud, thrill easily palpable
VI: very loud, audible w/o stethoscope, thrill visible
```
37
thrill
- a fine, palpable, rushing vibration (palpable murmur)
| - intensity IV-VI murmurs can be felt
38
What can cause a left sternal border thrill?
severe mitral regurg
39
What can cause a right sternal border thrill?
severe atrial regurg
40
The most common murmurs are systolic murmurs d/t what? (3)
- aortic stenosis
- mitral regurg
- mitral valve prolapse
41
systolic murmur flow chart
slide 52
42
aortic stenosis murmur is best heard:
upright and 2nd right ICS
43
aortic stenosis murmur exam findings
- SYSTOLIC murmur
- harsh, medium pitch, cresc-decrescendo
- radiates to carotids
- +/- ejection click
- like ........ gull ..... or dove........ ??
44
Description of aortic stenosis
calcification of valve cusps restricts forward flow
45
causes of aortic stenosis murmur
- congenital bicuspid valve
- rheumatic fever
- degeneration
46
aortic regurg murmur is best heard:
upright at left sternal border, leaning forward
47
aortic regurg murmur exam findings
- early DIASTOLIC
| - high pitched, soft, blowing, decrescendo
48
aortic regurg description
valve incompetence allows backflow to left ventricle
49
aortic regurg murmur causes
- rheumatic fever
- congenital
- syphilis
- marfan syndrome
50
mitral stenosis murmur best heard:
- left lateral decubitus
| - bell** at apex
51
mitral stenosis murmur exam findings
- opening snap followed by DIASTOLIC rumble
| - low pitch, does not radiate
52
mitral stenosis description
narrowed valve restricts forward flow
53
mitral stenosis murmur causes
- rheumatic fever
- 3:1
- W:M
54
mitral regurg murmur best heard:
- upright at apex
| - increases w/ inspiration
55
mitral regurg murmur exam findings
- holosystolic
- high pitched
- blowing**
- quite loud
- radiates to left axilla (splitting of S2)
56
mitral regurg murmur description
valve incompetence allows backflow from V to A
57
mitral regurg murmur causes
- rheumatic fever
- MI
- myxoma
58
mitral valve prolapse murmur best heard:
-upright at apex and left lower sternal border
59
mitral valve prolapse murmur exam findings
- late SYSTOLIC
- crescendo murmur preceded by **mid-systolic click**
- high pitched, blowing
60
mitral valve prolapse description
redundant valve tissue prolapses into atrium late in systole
61
mitral valve prolapse murmur causes
- congenital
- associated w/ pectus excavatum
- W>M
62
What are the less common heart murmurs?
- tricuspid stenosis
- tricuspid regurg
- pulmonic stenosis (rare)
- ventricular septal defect
- patent ductus arteriosus
63
tricuspid stenosis murmur best heard:
- w/ bell
| - 4th left ICS
64
tricuspid stenosis murmur exam findings
- diastolic rumble
- accentuated early and late
- low pitch, louder on inspiration
- JVP prominent
65
tricuspid stenosis murmur description
calcification of valve cusps restricts forward flow
66
tricuspid stenosis murmur examples of cause
- rheumatic fever
- congenital defect
- right atrial myxoma
67
tricuspid regurg murmur best heard:
- diaphragm
| - left 4th ICS
68
tricuspid regurg murmur exam findings
- holosystolic
- soft
- radiates up left sternal border
- increased on inspiration
69
tricuspid regurg murmur description
valve incompetence backflow to right atrium
70
tricuspid regurg murmur examples of cause
- congenital
| - endocarditis (IVDU)
71
pulmonic stenosis murmur best heard:
-diaphragm at 2nd left ICS
72
pulmonic stenosis murmur exam findings
- systolic ejection murmur
- medium pitch
- coarse
- increased on inspiration
73
pulmonic stenosis murmur description
valve restricts forward flow
74
pulmonic stenosis murmur cause
almost always congenital
75
ventricular septal defect murmur best heard:
diaphragm at left sternal border
76
ventricular septal defect murmur exam findings
- holosystolic
- loud, coarse, high pitched
- does NOT radiate to neck
77
ventricular septal defect murmur description
-regurg of blood through defect
78
ventricular septal defect murmur cause
congenital
79
PDA murmur best heard:
1st-3rd ICSs
80
PDA murmur exam findings
- harsh, loud, continuous murmur
- **machine-like**
- unaltered by posture
81
PDA murmur description
left to right shunt through defects
82
PDA murmur cause
congenital
83
what are the special maneuvers for systolic murmurs
- squatting/leg elevation
- valsalva/standing
- handgrip
- others
84
special maneuvers effect on preload/afterload
- squatting/leg elevation: increases preload
- valsava/standing: decreases preload
- handgrip: increases afterload
85
aortic stenosis murmur changes with special maneuvers
- squatting/elevation: increases
- valsalva/standing: decreases
- handgrip: increases
86
mitral valve prolapse murmur changes with special maneuvers
- squatting: decreases
- valsalva: increases
- handgrip: no change
- other: increases in left lateral decubitus
87
hypertrophic cardiomyopathy murmur changes w/ special maneuvers
- squatting: decreases
- valsalva: increases
- handgrip: decreases
- other: increases in left lateral decubitus
88
mitral regurg murmur changes w/ special maneuvers
- squatting: no change
- valsalva: decreases
- handgrip: increases
- other: increases w/ inspiration
89
VSD murmur changes w/ special maneuvers
- none w/ squatting or valsalva
- handgrip: increases
- other: increases w/ bilateral aterial occulation (BP cuffs inflated)
90
when is a benign murmur best heart?
supine position
91
what is the only change w/ maneuvers for benign murmurs?
it disappears w/ valsalva
92
bruit
unexpected sound of blood moving through narrowed artery
93
bruit info
- can be radiation of heart murmur
- can be caused by local obstruction
- very low pitched and quiet
- use bell
94
Where to auscultate for bruits
- carotid*
- aortic*
- renal*
- iliac*
- temporal
- femoral
95
arterial pulsations
- bounding wave of blood produced by ventricular systole
- diminishes w/ increasing distance from the heart
- reflect blood flow and CO
96
review locations for pulses
slide 63
97
what comparisons should you check for in palpating pulses?
- compare for b/l symmetry
| - compare upper vs lower extremity
98
characteristics of pulse to palpate for
- rhythm/rate (regular or irregular)
- contour
- intensity/amplitude(strength)
99
why does deep inspiration normally increase the pulse rate?
bainbridge reflext
100
bainbridge reflex
1. inspiration increases chest vol.
2. this decreases intra-thoracic pressure
3. venous return to right heart and stretches atra
4. sends message to medulla to decrease PSNS tone
5. heart rate increases
101
pulse amplitude scale
0: absent
1: diminished, barely palpable
2: expected, normal
3: full, increased
4: bounding
102
patterns can vary d/t changes in:
- rate
- rhythm
- intensity/pressure
- contour
103
what arteries are best for evaluating contour?
carotids
104
small and weak pulse description
- barely palpable pulse
- decreased amplitude
- no bounding wave of blood
105
bounding pulse description
- increased pulse pressure
- rapid raise, breif peak, rapid fall
- sign of: atherosclerosis, PDA, anxiety, hyperthyroidism, exercise
106
water-hammer pulse
- aka collapsing pulse
- jerky carotid pulse
- rapid rise, greater amplitude, then quickly collapses
- rapid upstroke: d/y lg. SV and/or vigorous contraction
- steep drop/collapse: d/t rapid runoff of blood from the aorta
107
water-hammer pulse is a sign of what condition?
aortic regurg
108
pulsus bisferiens
- bifid pulse
- 2 systolic peaks "double peak"
- palpable abnormality
- best palpated in carotid a.
109
pulsus bisferiens is associated with what?
-severe aortic regurg +/- aortic stenosis
110
pulsus paradoxus
-exaggerated decrease in pulse amplitude (and BP) on inspiration*
111
pulsus paradoxus is a cardinal sign of what?
**cardiac tamponade
can also be a sign of constrictive pericarditis, lung dz, large PE
112
pulsus alternans
- pulse intensity alternates b/w those of greater and lesser SV
- rhythm is regular
- every other beat is weak
- better felt in distal arteries
113
pulsus alternans is a sign of what?
left ventricular failure**
114
bigeminal pulse
- 2 beats in rapid succession followed by longer interval
- normal beat followed by PVC
- regularly irregular
- every other beat is weak, easily confused w/ alternating pulse
- 2nd beat is weak and early
115
how do you describe a normal pulse?
Rate is 72 bpm and regular, normal intensity and contour, symmetric and synchronous bilaterally. Femoral and radial pulse are synchronous.
116
what to pay special attention to in palpation of edema
- new onset
- unilater or bilateral
- dependent
- pitting or not
117
words to know
anasarca; acites; pitting edema;myxedema; lymphedema
118
signs of venous occlusion
- unilateral swelling
- ruddy
- congested appearance
- warm to touch
119
grading the pitting edema
0+: none
1+: mild, 2 mm
2+: moderate, 4mm; disappears in 10-15 secs
3+: moderately severe, 6mm; may last > 1min
4+: severe, 8mm; can last > 2 min
120
pulsus paradoxus by sphygmomanometer
- taking BP and noting reading as the dsappear w/ inspiration and reappear during inspiration
- postive: if difference b/w 2 systolic measurments is >10mmHg
121
why do pulsus paradoxus by sphygmomanometer?
if JVD is elevated and suspect cardiac tamponade
122
pulsus paradoxus test is very predictive of what?
cardiac tamponade
123
screening test for DVT
- measurement of limb circumference
- proves if unilateral swelling is present
- normal is < 1cm difference
124
homan's sign
- another screening test for DVT
- pt seated, firmly dorsiflex ankle
- produces pain in 35% of pts w/ DVT
- not sensitive, poor predictor
125
ankle-brachial index
- measure systolic pressure in lower leg
- use doppler to hear korotkoff sounds
- compare reading to brachial systolic pressure
- abnl is <1.0
- predictor of peripheral a. dz, arterial occlusion
