CV integration lab

Question 1

Venous return to the RV _____ during normal inspiration and a ____ in venous return to the LV.

Answer 1

Venous return to the RV increases during normal inspiration (increases in vol) and decreases in venous return to the left ventricle (reduction of vol)

These changes in venous return can alter intensity of murmurs and heart sounds, primarily those that

Question 2

During inspiration, there is an increase in the splitting of:

Answer 2

S2 as A2 and P2 are separated (due to longer RV ejection time compared to LV ejection time during inspo)

Question 3

Describe S3 and S4 heart sounds of RV origin w/ inspo and expo:

Answer 3

decrease with expo

increase with inspo

Question 4

Describe S3 and S4 from left side of heart with inspo and expo:

Answer 4

increase with expo

decrease with inspo

Question 5

Describe tricuspid stenosis with inspo and expo:

Answer 5

opening snap decreases with expo

opening snap increases with inspo

Question 6

Describe mitral stenosis with inspo and expo:

Answer 6

opposite of tricuspid

opening snap increase wit expo

opening snap decreases with inspo

Question 7

Pulmonary ejection sounds with inspo and expo:

Answer 7

decrease in inspo

Question 8

Inspiration increases the intensity of murmurs originating from the ___ of the heart.

What are they also?

Answer 8

R side of the heart

Murmurs= tricuspid stenosis, pulmonary regurg, systolic murmur of tricuspid regurg (cavallo’s sign) and presystolic murmur of ebsteins anomaly)

Question 9

What happens in MVP?

Answer 9

inspiratory decrease in venous return to the left side of heart reduces LV volume

Question 10

In what pathological heart issue does murmur and click occur earlier and may diminish?

Answer 10

Mitral valve prolapse

Question 11

When might a loud first heart sound be heard?

Answer 11

fever or exercise (hyperdynamic)

mitral stenosis

atrial myxoma

Question 12

When might a soft first heart sound be heard?

Answer 12

low CO @ rest, HF

tachy

severe mitral reflux (caused by destruction of valve)

Question 13

What would produce a variable intensity in the first heart sound?

Answer 13

atrial fibrillation

complete heart block

Question 14

What is a second heart sound?

Answer 14

audible expiratory spitting means >30 msec difference in timing of the aortic (A2) and pulmonic (P2) components of the second heart sound

Question 15

Where is splitting of S2 best heard over?

Answer 15

over 2nd left ICS

Question 16

normal P2 is often softer than which sound? where is it rarely audible

Answer 16

normal P2 is often softer than A2

rarely audible at apex

Question 17

If P2 is audible over apex what is the diff dx?

Answer 17

significant pulmonary HTN

Atrial septal defect

Question 18

Second heart sound findings should always be present in what positions?

Answer 18

upright and supine

normal subjects may have expiratory splitting when recumbant that disappears when upright

Question 19

When can you hear a loud aortic component of second second?

Answer 19

systemic HTN

dilated aortic root

Question 20

When can you hear a soft aortic component of second second?

Answer 20

calcific aortic stenosis

Question 21

What kind of second heart sound would you hear with pulmonary htn?

Answer 21

loud pulmonary component of second sound

Question 22

What shock is caused by failure of the heart as a pump to deliver adequate perfusion to peripheral tissues

Answer 22

cardiogenic shock

Question 23

What shock is caused by failure of arterial circulatory bed to maintain adequate perfusing pressure to peripheral tissues?

Answer 23

distributive shock

Question 24

What shock is caused by significant reduction in cicrculating vascular volume, resulting in reduced perfusing pressure to peripheral tissues

Answer 24

hypovolemic shock

Question 25

What regulates HR?

Answer 25

autonomic NS

Question 26

what influences stroke volume?

Answer 26

LV preload, afterload, and myocardial contractility

Question 27

Systemic Vascular resistance is governed by:

Answer 27

arterial tone, arterial volume, and structural integrity of vessels themselves

Question 28

Example of someone running up hill and CV performance of what happens:

Answer 28

runner experiences ruge in serum catecholamines--> increased SNS output--> increased HR--> increased myocardial contractility--> increased CO; arteriolar tone will increase as result of VC effects of catecholamines--> increase in perfusion pressure--> adequate blood flow to joggers LE and diaphragm

Question 29

When does shock typically occur?

Answer 29

when there is a massive perturbation of one or more of the processes (HR/ stroke vol/SVR, etc.) that cannot be compensated for by adoptions in other areas

Question 30

What components are the main ones that go into tissue perfusion pressure?

Answer 30

CO (HRx SV) SVR (arterial tone/volume/integrity)

Question 31

A patient presents with unexplained sinus tachy and a BP of 90/75 (hypotensive BP), what would the main differential that you would think about be?

Answer 31

shock | could also consider cardiac tamponade..

Question 32

If you see a pt with shock who has bradychardia (or lower than expected HR), what should you consider doing next?

Answer 32

ways to increase HR

Question 33

In a patient with suspected shock, it is critical to check what early?

Answer 33

arterial blood gases and lactate levels

Question 34

What is associated with better outcome in a patient with cardiogenic shock and what should you exclude immediately?

Answer 34

exclude acute MI immediately EARLY revascularization is assoc with better outcomes!

Question 35

What would be a cause of a wide, fixed splitting S2

Answer 35

atrial septal defect

Question 36

What would be a cause of wide split S2, varying with inspo

Answer 36

pulmonary stenosis, RBBB

Question 37

What would be the cause of paradoxical splitting of S2

Answer 37

hypertrophic cardiomyopathy

Question 38

If you see diffuse ST elevations on all leads(and/or sometimes PR depression), what should you suspect?

Answer 38

acute pericarditis

Question 39

How would you describe a pericardial friction rub?

Answer 39

a three component scratchy rub that is loudest over the left sternal border

Question 40

The dx of acute pericarditis requres presence of at least 2 of the following criteria:

Answer 40

typical chest pain pericardial friction rub widespread ST segment elevation new or worsening pericardial effusion

Question 41

Common clinical features of cardiac tamponade include:

Answer 41

``` Dyspnea Hypotension Tachy Jugular venous distention Pulsus pardoxus of >10 mmHg ```

Question 42

Constrictive pericarditis can complicate any pericardial dz (acute pericarditis or cardiac surgery). How do these pts typically present?

Answer 42

progressive dyspnea edema ascites cachexia elevated JVP, pulsus paradoxus, Kussmauls sign, and/or pericardial knock

Question 43

In a pt with acute pericarditis, the sharp pleuritic chest pain typically IMPROVES when the pt:

Answer 43

sits up and leans fwd

Question 44

Where is pericardial friction rub heard best upon auscultation?

Answer 44

scratchy sound best heard with diaphragm and loudest over left sternal border

Question 45

Pts with suspected pericardial dz should undergo initial evaluation with:

Answer 45

ECG, CXR, and Echo

Question 46

Pericardial effusion and cardiac tamponade on ECG:

Answer 46

low QRS voltage (bc fluid in bw heart and ECG leads) and sometimes electrical alternans (QRS reflecting swinging in heart in pericardial fluid)

Question 47

What ECG findings would you find in constrictive pericarditis?

Answer 47

no specific findings nonspecific ST and T waves changes are common

Question 48

What is the CXR in acute pericarditis? Pericardial effusion ? constrictive pericarditis?

Answer 48

acute pericarditis= typically NORMAL Pericardial effusion (with or w/out tamponade) = cardiomegaly with clear lung fields Constrictive pericarditis= pericardial calcification (uncommon)

Question 49

What test should you perform rapidly if you suspect tamponade?

Answer 49

echocardiography | normal in acute pericarditis unless assoc. with pericardial effusion

Question 50

What test has a major role in IDENTIFICATION of a pericardial effusion and in assessing its hemodynamic significance?

Answer 50

Echocardiography

Question 51

What is the treatment for cardiac tamponade?

Answer 51

immediate removal of pericardial fluid