Cardiovascular and Peripheral vascular System - SRS Flashcards Preview

PCM III Exam I > Cardiovascular and Peripheral vascular System - SRS > Flashcards

Flashcards in Cardiovascular and Peripheral vascular System - SRS Deck (111):
1

What is the ideal position for the chest exam?

Supine with head/chest elevated at 30 degrees.

2

What interspace do you find the aortic valve sound?

2nd right interspace

3

Where would you find the sound of the pulmonic valve?

2nd left interspace

4

Where would you find the sound of Erb's point?

left of sternum at rib 3

5

Where should you listen for the tricuspid valve?

Lower left sternal border

6

Where would you listen for the mitral valve?

Apex of the heart

7

What do you use the left lateral decubitus position for?

Mitral murmur accentuation

8

Murmur is defined as?

Turbulence across a valve causing a sound

9

What is a bruit?

Similar noise from turbulence within an artery outside the heart itself.

10

Describe the grading of murmurs from 1/6 to 6/6!!!

  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

6/6 murmur?

Very Loud, Thrill, can be heard with stethoscope

  OFF the chest

12

4/6 murmur?

Loud, with palpable thrill

13

3/6 murmur?

moderately loud

14

2/6 murmur?

quiet, but easily heard if in quite room

15

1/6 murmur?

Very faint

16

5/6 murmur?

Very Loud, Thrill, can be heard with stethoscope   partially off chest 

17

What are some common causes of murmurs and bruits?

There's a lot here.  

  • 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

What are some less common causes of murmurs and bruits?

  • Tetralogy of Fallot:  Pulmonic Stenosis + VSD + Aorta overriding VSD + RVH
  • Abdominal Aneurysm
  • Hyperthyroid state
  • Obstructive Hypertrophic Cardiomyopathy  (IHSS)

19

Any arterial area where a bruit or murmur is heard has?

Turbulent blood flow

20

What are the components of the tetralogy of fallot?

Pulmonic Stenosis + VSD + Aorta overriding VSD + RVH

21

What is the S1 heart sound? What does it signal?


—S1 :  Mitral and Tricuspid closures. Signals onset of systole 
 

22

What is the S2 heart sound?  What does it signal?


—S2:  Aortic and Pulmonic closures. Signals onset of diastole
 

23

Which heart sound is closely timed with the carotid pulse?

S1

24

Anything that causes a separation in the closure of paired valves is called 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.

A image thumb
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?

Q image thumb

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?

Q image thumb

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?

Q image thumb

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

Q image thumb

A image thumb
64

Hypertrophic Obstructive Cardiomyopathy is also known as?

IHSS: Idiopathic Hypertrophic Subaortic Stenosis

65

What causes IHSS?

Primarily a genetic disorder

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