Cardiovascular and Peripheral vascular System - SRS Flashcards
(111 cards)
1
Q
What is the ideal position for the chest exam?
A
Supine with head/chest elevated at 30 degrees.
2
Q
What interspace do you find the aortic valve sound?
A
2nd right interspace
3
Q
Where would you find the sound of the pulmonic valve?
A
2nd left interspace
4
Q
Where would you find the sound of Erb’s point?
A
left of sternum at rib 3
5
Q
Where should you listen for the tricuspid valve?
A
Lower left sternal border
6
Q
Where would you listen for the mitral valve?
A
Apex of the heart
7
Q
What do you use the left lateral decubitus position for?
A
Mitral murmur accentuation
8
Q
Murmur is defined as?
A
Turbulence across a valve causing a sound
9
Q
What is a bruit?
A
Similar noise from turbulence within an artery outside the heart itself.
10
Q
Describe the grading of murmurs from 1/6 to 6/6!!!
A
1/6 Very faint
2/6 Quiet, but can easily be heard if in quiet room
3/6 Moderately loud
4/6 Loud, with palpable thrill
5/6 Very Loud, Thrill, can be heard with stethoscope partially off chest
6/6 Very Loud, Thrill, can be heard with stethoscope
OFF the chest
11
Q
6/6 murmur?
A
Very Loud, Thrill, can be heard with stethoscope
OFF the chest
12
Q
4/6 murmur?
A
Loud, with palpable thrill
13
Q
3/6 murmur?
A
moderately loud
14
Q
2/6 murmur?
A
quiet, but easily heard if in quite room
15
Q
1/6 murmur?
A
Very faint
16
Q
5/6 murmur?
A
Very Loud, Thrill, can be heard with stethoscope partially off chest
17
Q
What are some common causes of murmurs and bruits?
There’s a lot here.
A
- Benign or Innocent: Stills
- typically infants
- Valvular problems
- papillary muscle tear or rupture
- chordae tendoneae rupture
- congenital malformation
- fibrosis annulus or leaflet (infection)
- Patent ductus (Aorta-Pulm A)
- Septal defects ASD, VSD
- Artery stenosis
18
Q
What are some less common causes of murmurs and bruits?
A
- Tetralogy of Fallot: Pulmonic Stenosis + VSD + Aorta overriding VSD + RVH
- Abdominal Aneurysm
- Hyperthyroid state
- Obstructive Hypertrophic Cardiomyopathy (IHSS)
19
Q
Any arterial area where a bruit or murmur is heard has?
A
Turbulent blood flow
20
Q
What are the components of the tetralogy of fallot?
A
Pulmonic Stenosis + VSD + Aorta overriding VSD + RVH
21
Q
What is the S1 heart sound? What does it signal?
A
S1 : Mitral and Tricuspid closures. Signals onset of systole
22
Q
What is the S2 heart sound? What does it signal?
A
S2: Aortic and Pulmonic closures. Signals onset of diastole
23
Q
Which heart sound is closely timed with the carotid pulse?
A
S1
24
Q
Anything that causes a separation in the closure of paired valves is called a?
A
split heart sound
25
Split S1 may be...
may be normal variant or abnormal from RBBB or PVC (premature ventricular contraction)
26
When would you have a physiologic varient causing a split S2?
How about a pathological variant?
Physiological: with inspiration.
Pathological: pulmonic stenosis or RBBB (right bundle branch block)
27
What valves are S3 and S4 heart sounds associated with?
Non-valvular sounds.
28
During what phase of the heart do S3 and S4 occur?
During diastole
29
When does S3 occur?
Early diastole, closely following S2.
30
When is S3 considered normal up to?
age 30 years
31
S3 heart sound occurs at the transition of rapid to slow ventricular filling. What is the most common pathology associated with this?
LV myocardial damage (CHF, MI) causing systolic dysfunction from dilated cardiomyopathy. Due to sudden limitation of normal ventricular relaxation during filling stage in diastole.
32
S3 is often present in hemodynamically significant chronic mitral regurgitation. Consequently, this is an important finding in?
An important early finding in heart failure due to a dilated myocardium (more often systolic failure)
33
When does S4 occur?
Just before S1, very late diastole just after atrial contraction
34
What is S4 sound caused by?
Vibration of LV from the atrial kick trying to pump the last of the blood but instead hitting less compliant ventricular wall.
35
What is the most common pathology of S4 heart sounds?
Aortic/pulmonic stenosis , HTN (elevated afterload) , wall damage from MI from remodeling or tissue death cause **thickening of ventricular walls from a higher work load, and some stiffening.** This also leads to non-compliance of the ventricle as the atria pump the last of the blood from the chamber to the ventricle.
36
What are four things to associate with S4 sounds?
Hypertension
Aortic valve stenosis
Pulmonic valve stenosis
Hypertrophic cardiomyopathy
37
“Gallop” Rhythm technically refers to either pattern of?
S1…S2S3
Or
S4S1…S2
Or
S4S1…S2S3
38
What is an ejection click?
An ejection click is a sound occurring at the moment of maximal pressure with sudden tensing of a valve root. Associated with the annulus.
39
When does an aortic ejection click occur?
Early systolic: at onset of left ventricular ejection, aortic root suddenly stretched. (Second right interspace)
40
Name some pathological sources of the aortic ejection click!@!
* Dilated aneurysm of aortic root, coarctation of aorta, HTN all can dilate aorta and change the root dimensions.
* Aortic valve stenosis, and aortic regurgitation also can change the dynamic of the aortic root.
* Anything that can cause over working of the root of the aortic valve can over-distend it and cause click.
41
You hear the attached, crescendo-decrescendo pattern of a medium pitch that sounds harsh. It transmits sound to the carotid artery. What is the cause of this?
Aortic stenosis
42
What are the two key findings for aortic stenosis?
Systolic crescendo-decrescendo pattern,
medium pitch, typically harsh
Transmits sound to carotid arteries.
43
What are the pathological causes of aortic stenosis? 3
1. Rheumatic disease (progressive fusion),
2. congenital bicuspid valve,
3. calcification of valve.
44
What are the symptoms of aortic stenosis?
None until severe, then dyspnea on exertion, angina and syncope. Left ventricular enlargement can occur, creating hypertrophic, poorly compliant muscle and an S4
45
You hear an austin-flint murmur during early diastoly, with a high pitch blowing decrescendo murmur. What is this sound d/t?
Aortic reguritation
46
What are the pathological causes of aortic regurgitation?
1. Rheumatic disease,
2. congenital bicuspid valve,
3. endocarditis (Strep, Staph, Haemophilius..)
47
What are the key aspects of pulmonic ejection click?
Sudden root tensioning. Very early systole.
(Second left interspace)
48
What are some pathological causes of pulmonic ejection click?
Pulmonary HTN, aneurysm dilating the root
Pulmonary valve stenosis or regurgitation can alter stress on root of valve causing click.
49
You hear a systolic crescendo-decescendo murmur as 2nd left interspace, what might this be?
Pulmonic valve stenosis
50
What are three key symptoms of pulmonic valve stenosis? What heart sound might arise with this?
exertional dyspnea
chest pain
syncope
S4
51
Describe what you would hear in pulmonary regurgitation
Identical to aortic regurg, not as loud. Identify best
by which post it is most clear. Softer diastolic
decrescendo
52
What are some causes of pulmonic regurg?
Anything that causes pulmonary HTN: mitral stenosis, LV failure, obstructive sleep apnea, emphysema, idiopathic pulmonary hypertension
53
When would you hear a tricuspid valve stenosis?
Diastolic low pitch rumble
54
When and where would you hear tricuspid valve regurg?
Early to holosystolic at left sternal border.
55
When does a mitral valve opening snap occur?
In diastole
56
A diastolic murmur with an opening snap would likely be related to?
mitral valve stenosis
57
What characterizes a mitral valve prolapse?
"click and murmur"
58
What is the demographic for mitral valve prolapse?
Young women with anxiety
59
What accentuates and diminishes mitral valve prolapse?
Accentuated: Valsalva (lowers atrial volume) Standing
Diminishes: Release of Valsalva (increased atrial volume) Squatting
60
What are two common complaints associated with mitral valve prolapse?
Unexplained anxiety or panic attacks
palpitations
61
What does "holosystoloc" murmur mean?
pansystolic
62
What might a holosystolic murmur that is loud, high pitch and best heard at the apex that audibly radiates to the left axilla be due to?
Mitral valve regurgitation
63
Identify the causes of the phonograms shown A-H
64
Hypertrophic Obstructive Cardiomyopathy is also known as?
IHSS: Idiopathic Hypertrophic Subaortic Stenosis
65
What causes IHSS?
Primarily a genetic disorder
## Footnote
Mutations in cardiac sarcomere signal
Hypertrophy of the left ventricle and the interventricular septum
Must consider in FMH of sudden cardiac death, especially among athletes.
66
What are the symptoms of IHSS?
Symptoms identical to aortic stenosis: exercise induced dyspnea, angina or syncope.
67
In IHSS there may or may not be a murmur. What can you do in a physical exam to try to catch this condition?
Murmur is INTENSIFIED by standing from a squat, or a Valsalva maneuver
68
What kind of murmur would you hear in IHSS?
Systolic ejection murmur; best along left sternal border and apex; often with accentuated PMI
69
List all of the systolic ejection murmurs that increase in intensity during valsalva (or standing).
IHSS is the only one.
70
Leaning forward accentuates which valve?
Aortic
71
Left lateral decubitus accentuates which valve?
Mitral
72
How do you perform a valsalva maneuver?
Take a deep breath and “push like you’re having a baby”
73
What are three maneuvers to alter murmurs?
1. Valsalva: Take a deep breath and “push like you’re having a baby”
2. Squatting from a standing position
3. Standing from a seat or squatting position
74
Squatting momentarily increases volume from more venous return and increases arterial blood pressure. What murmurs are impacted by this and how?
Mitral regurgitation murmur is increased
IHSS/Obstructive cardiomyopathy murmur is decreased
75
Standing momentarily decreases volume and therefore right ventricular filling. (less physiologic effect on afterload). What sounds are impacted by this and how?
Mitral prolapse sound is increased
IHSS murmur is increased.
76
Valsalva has what impact on what heart sounds?
Increase ISHH
Decrease aortic stenosis sounds
77
The only thing we should get a question regarding valsalva maneuver from Dr. Pitcher will be on?
IHSS
78
A fistula existing between aorta and pulmonary artery is called?
Patent ductus arteriosis (PDA)
79
What might you hear in Graves disease?
Thyroid bruit d/t increased blood flow to the thyroid
80
Pericarditis (fluid in the sac) is often assoicated with what?
Recent viral infection
MI
Metastasis to pericardium
post cardiac surgery
81
What positioning makes pericarditis feel better? Worse?
Leaning forward improves.
Reclining makes worse
82
What are the two noises you hear with pericarditis?
Pericardial knock
Rub
83
In pericarditis you may hear a Pericardial knock, which is a diastolic knock heard widely over precordium in constrictive pericarditis. What causes this?
Blood coming in to fill RV,LV chambers finds smaller chambers, stops abruptly and vibrates the walls.
84
The rub in pericarditis is from?
The two inflamed pericardial surfaces rubbing together when beating.
85
The rub in pericarditis is what-phasic?
Triphasic: Atrial systole, ventricular systole, ventricular diastole
86
After finding a murmur or bruit, what should you do to finish the exam?
Include periphery: third spacing?
Doppler ultrasound to define bruit
Echocardiogram done with doppler to define murmurs
TTE (transthoracic)
or
TEE (transesophageal)
87
What risk factors would you treat with regard to murmurs or bruits?
Smoking, hyperlipidemia, HTN
oxygen +/- CPAP
88
What types of medications might be indicated in murmurs or bruits?
Beta Blockers, ACE, ARB, Peripheral vasodilators
(Ca+ Channel Blockers)
89
What are some surgical options related to bruits and murmurs?
Valve replacement or repair
Stent
Endarterectomy
90
What are 6 examples of peripheral vascular disease?
Intermittent Claudication
Carotid Artery Stenosis
Aneurysm
Raynaud Disease or Phenomenon
Vasculitis
Hypertension (Just FYI)
91
Intermittent claudication is a (not fully) occlysive arterial disease of the limbs. What are the symptoms characterized by?
Pain
Tension
weakness of a limb that intensifies with walking and resolves with cessation.
(angina of the periphery essentially)
92
What is charcot syndrome?
Compression of the cauda equina, may come with intermittent claudication
93
Intermittent claudication is caused by?
ischemia in the peripheral tissue
94
What are some factors of the history to consider in intermittent claudication?
oAortic Stenosis: poor perfusion
oAnemia: lowered O2 capacity
oPolycythemia: acts like a traffic jam
oAtherosclerosis: local stenosis
oVolume status: ability to circulate good in, waste out
95
What would you do to detect peripheral artery disease?
Ankle brachial index
Systolic of ankle/systolic of brachium - index
96
What are some physical exam clues for intermittent claudication?
Poor pedal pulses
Ulcerations
Palor
Cool, shiny, hairless skin
bruit may be present
97
What are the treatment options for intermittent claudication?
Meticulous foot care
Smoking cessation!!
Lower lipids
Walk! But not through pain
Cilostazol (Pletal), Pentoxifylline (Trental) can offer limited help
Revascularization procedures
98
How do Cilostazol (Pletal), Pentoxifylline (Trental) help in peripheral artery disease?
Makes the wall of the RBC more flexible
99
What are the risk factors for carotid artery stenosis?
Older male
Hypertension, Diabetes
Smoking , Hyperlipidemia
Heart Disease
100
What valve disorder will sounds like a carotid bruit?
Carotid artery stenosis
101
What are the diagnostics used for carotid artery stenosis?
Doppler ultrasound
MRA or CT angiography (100% accurate)
102
What are the treatment options for carotid artery stenosis?
Endarterectomy if \>69% occluded, soon after CVA if this occurred, only in patients with \>5yrs life expectancy.
Elective endarterectomy \>50% stenosis
Stents
Risk factor management
Aspirin prophylaxis: 81 to 325mg daily if not contraindicated
103
An aneurysm is a dilation of a segment of a blood vessel. What is a true aneurysm?
How about a pseudoaneurysm?
* True aneurysm involves all three layers of vessel wall and can dissect
* Pseudoaneurysm is a dilation or hematoma that may or may not involve the layers of the vessel wall which is contained and does not dissect.
104
What are the risk factors for aneurysm?
Risk factors include smoking, known atherosclerosis, hypertension, hyperlipidemia, diabetes
105
Vasculitis is a general term characterizing inflammation and damage to vessels, often the lumen, causing stenosis and ischemia to the involved tissue. What are the vessels impacted by takayasu aortitis?
Aorta and major branches - known as "pulseless disease"
106
What are the vasculituses associated with medium vessels?
Polyarteritis nodosa
Wegener's granulomatosis
(may be associated with infections/post-infectious insult or circulating immune complex.
107
What vasculitises are associated with small vessels?
Henoch-Shonlein Purpura
108
Polyarteritis nodosa is a multisystem necrotizing vasculitis of primarily medium arteries (=arteritis). What does the inflammation in this disease lead to?
Inflammation thickens vessel wall causing stenosis , ischemia and possibly infarct to distal tissues.
Inflammation also weakens the wall predisposing to aneurysm formation .
Thrombosis can also occur.
109
What are the ssx assiated with polyarteritis nodosa?
Fatigue, weakness, fever, wt loss, headache, abdominal or other tissue pain occur.
110
What are some common lab values associated with polyarteritis nodosa? How do you confirm the diagnosis?
Invariably an elevated ESR is seen, often with elevated neutrophilic WBC count.
Confirm with biopsy
111
What would you use to treat polyarteritis nodosa?
Steroids and immune modulating agents
