Week 4 - Cardiovascular

Question 1

Cardiovascular examination

Answer 1

• Note general appearance and measure blood pressure and heart rate.
   Color, respiratory rate, level of anxiety, BP, HR
• Estimate the level of jugular venous pressure.
• Auscultate the carotids (bruit) one at a time.
• Palpate the carotid pulse including carotid upstroke (amplitude, contour, timing) and presence of a thrill.
• Inspect the anterior chest wall (apical impulse, precordial movements).
• Palpate the precordium for any heaves, thrills, or palpable heart sounds.
• Palpate and locate the PMI or apical impulse.
• Palpate for a systolic impulse of the right ventricle, pulmonary artery, and aortic outflow tract areas on the chest wall.
• Auscultate S1 and S2 in six positions from the base to the apex.
• Identify physiologic and paradoxical splitting of S2.
• Auscultate and recognize abnormal sounds in early diastole, including an S3 and OS of mitral stenosis and an S4 later in diastole.
• Distinguish systolic and diastolic murmurs, using maneuvers when needed. If present, identify their timing, shape, grade, location, radiation, pitch, and quality

Question 2

Cardiac apex

Answer 2

Has the point of maximal impulse, locates the left lower border of the heart and found at 5th intercostal space

Question 3

S1

Answer 3

closure of mitral and tricuspid valves

Question 4

S2

Answer 4

closure of pulmonic and aortic valves
- Splits into
- A2 (aortic valve closure) and P2 (pulmonic valve closure)
- A2 louder, P2 softer

Question 5

S3

Answer 5

abrupt deceleration of inflow across the mitral valve (systolic HF)

Question 6

S4

Answer 6

increased left ventricular end diastolic stiffness with decreased compliance (diastolic HF)

Question 7

Systole

Answer 7

ventricular contraction (aortic valve is open blood flow from LV into the aorta)

Question 8

Diastole

Answer 8

ventricular relaxation (pulmonic valve open, blood flow from left atrium into relaxed LV)

Question 9

Screening for individual CV risk factors

Answer 9

• Family history
• Smoking
• Unhealthy diet
• Obesity
• Physical activity
• Hypertension
• Dyslipidemias
• DM
• AF

Question 10

When do you do a lipid screening?

Answer 10

Measure lipid levels every 5 years for people 40-75 without existing CVD

Question 11

How do we treat CV disease?

Answer 11

Start low dose statins for patients 40-75 who have one or more risk factors (DM, smoking, HTN, HLD) and have a 10 year calculated risk of greater than 10%

Question 12

Jugular Venous Pressure

Answer 12

• Provides an index of right heart pressures and cardiac function
• Accurately predicts elevations in fluid volume in HF
• JVP falls with loss of blood or decreased venous vascular tone and increases with right or left heart failure, pulmonary hypertension, tricuspid stenosis, AV dissociation, increased venous vascular tone, and pericardial compression or tamponade.
• JVP measured at >3cm above sternal angle considered elevated

Question 13

Assessing the carotid artery

Answer 13

Auscultate for bruit first – narrowing of arteries due to atherosclerosis
- Have the patient hold their breath, listen with the diaphragm

Palpation – could dislodge a plaque resulting in stroke
- Feel for carotid upstroke, amplitude, contour, presence/absence of thrills
- Assessment characteristics of the carotid pulse

Amplitude – correlates with pulse pressure
* Contour of pulse wave – speed of upstroke, duration of summit, speed of downstroke

Thrills – vibrations like a purring cat

Question 14

Pulsus Alternans

Answer 14

force alternates due to strong and weak ventricular contractions
- Indicative of left ventricular dysfunction

Question 15

Paradoxical pulse

Answer 15

greater than normal drop in SBP during inspiration

Question 16

Murmurs

Answer 16

Caused by turbulent blood flow and usually indicate valvular heart disease
- Longer duration and high pitch
- Tips for identifying murmurs
 Systole (between s1-s2)or diastole (between S2-S1)?
 Loudest at sternal border or apex?
 Check in decubitis position
- Sound
 crescendo, decrescendo, holosytolic
- Intensity (1-6), pitch (high, medium, low), quality (blowing, harsh, rumbling, muscial)

Question 17

Midsystolic murmur

Answer 17

begins after s1 stops before s2 (turbulent flow across AV valves)

Question 18

Pansystolic murmur

Answer 18

starts with S1 stops with s2

Question 19

Late systolic murmur

Answer 19

starts in mid or late systole through S2

Question 20

Early diastolic murmur

Answer 20

immediately after s2, fades before s1

Question 21

Mid diastolic murmur

Answer 21

starts after s2 and fades before s1

Question 22

Late diastolic murmur

Answer 22

Starts late in diastole and continues up to S1

Question 23

Peripheral vascular system exam

Answer 23

Arms:
- Inspect the upper extremities (size, symmetry, swelling, venous pattern, color).
- Palpate the upper extremities (radial pulse, brachial pulse, epitrochlear lymph nodes).
Abdomen:
- Palpate the inguinal lymph nodes (size, consistency, discreteness, any tenderness).
- Inspect and palpate the abdomen (aortic width and pulsation).
- Auscultate the abdomen (aortic, renal, and femoral bruits).
Legs:
- Inspect the lower extremities (size, symmetry, swelling, venous pattern, skin color, temperature, ulcers, hair loss).
- Palpate the lower extremities (femoral pulse, popliteal pulse, dorsalis pedis pulse, posterior tibial pulse, temperature, swelling, edema).

Question 24

Allen test

Answer 24

check the patency of hand arteries – have patient squeeze fist, press on the radial and ulnar artery until palm is pale, release ulnar. Perfusion should occur in 3-5 seconds

Question 25

Atherosclerosis

Answer 25

a chronic inflammatory disease initiated by injury (i.e., smoking or hypertension) to vascular endothelial cells, provoking atheromatous plaque formation.

Question 26

Pitting edema scale

Answer 26

1+ barely detectable impression when finger pressed into skin
2+ slight indentation 15 seconds to rebound
3+ deeper indentation 30 seconds to rebound
4+ >30 seconds to rebound

Question 27

Pulse scale

Answer 27

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

Question 28

Pulsus parvus

Answer 28

weak pulses usually seen with atherosclerotic PVD

Question 29

Pulsus tardus

Answer 29

sluggish pulses usually occurring in aortic steonosis or low cardiac output

Question 30

Intermittent claudication

Answer 30

• Pain relieved within 10 minutes of resting
• Usually caused by ischemia due to atherosclerosis

Question 31

Chronic venous insufficiency

Answer 31

o Soft edema with pitting on pressure – may be bilateral
o Skin thickening usually near the ankle
o Ulceration and brownish pigmentation and edema in the feet are common

Color arises from chronic obstruction and incompetent valves of the deep venous system

Question 32

Neurogenic claudication

Answer 32

pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet

Question 33

Acute arterial occlusion

Answer 33

o Embolism or thrombus
o Distal leg pain involving the foot
o Sudden onset w or w/o pain
o Coldness, numbness, weakness, absent distal pulses

Question 34

DVT

Answer 34

Unilateral calf and ankle swelling, and edema suggest venous thromboembolism (VTE) from DVT, chronic venous insufficiency from prior DVT, or incompetent venous valves; or it may be lymphedema