Lecture Two (Adult heart)-Exam 2 Flashcards
(124 cards)
1
Q
What is the overview of the cardiovascular system: examining the heart and blood vessels? (7)
A
- Anatomy of the heart and great vessels
- The heart as a pump; blood pressure
- Beginning the examination with the vital signs: blood pressure and heart rate
- Jugular venous pressure (JVP) and pulsations; carotid pulse
- Chest wall and apical impulse/PMI
- Auscultation: S1 and S2; S3 and S4
- Auscultation:describing cardiac murmurs
2
Q
What are the surface landmarks do we need to know?
A
Count interspaces: Identify your …
o Midsternal line
o Midclavicular line
o Anterior axillary line
o Midaxillary line
3
Q
Identify different lines
A
4
Q
What are the different interspaces?
A
5
Q
Heart Murmurs
- Distinct heart sounds distinguished by what?
- Attributed to turbulent blood flow and usually indicate what?
A
- Distinct heart sounds distinguished by their pitch and their longer duration
- Attributed to turbulent blood flow and usually indicate VALVULAR HEART DISEASE
6
Q
Heart murmurs: What may be represented in young adults?
A
may represent “innocent” flow murmur, especially young adults
7
Q
What is stenosis and regurgitation?
A
- Stenosis: stenotic valve has abnormally narrowed orifice that obstructs blood flow; such as aortic stenosis
- Regurgitation: Valves closing abnormally, result in regurgitation. Blood leaks backward in a retrograde direction and produces a regurgitant murmur
8
Q
What must you do to identify murmurs accurately?
A
- Learn where they are heard best on the chest wall
- Their timing in systole or diastole
- Their descriptive qualities (machine like, etc)
9
Q
Fill in
A
10
Q
What does jugular veins provide?
A
provide index of right heart pressures and cardiac function
11
Q
What are common or concerning symptoms of CVS? (5)
A
*Chest Pain
* Palpitations
*Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea
*Swelling (edema)
*Fainting (syncope)
12
Q
For chest pain, what is the range of causes?
A
- Range of causes
- Cardiac
- Pulmonary
- MSK: see if you can reproduce it
- Outside of the thoracic cavity
13
Q
For Chest pain-OLD CARTS:
What is the onset and duration?
A
14
Q
For Chest pain-OLD CARTS: Character?
A
15
Q
For Chest pain-OLD CARTS: Location and radiation?
A
- Location: Substernal, precordial, epigastric (if locatized then less serious)
- Radiation: Jaw, teeth, down arms, into back, scapula or neck
16
Q
What are the associated symptoms of chest pain (OLD CARTS)
A
17
Q
What occurs in aortic dissection?
A
*Anterior chest pain, often tearing or ripping and radiating into the back or neck, occurs in acute aortic dissection
*Tearing, ripping = aortic dissection
18
Q
What are palpitations? What are various descriptions?
A
An unpleasant awareness of the heartbeat.
Various descriptions
* Rapid beating, skipping, stopping, extra beating, flip-flop
* Regular or irregular?
* Fast or slow?
* Precipitating factors? (SVT)
* Associated with fainting, dizziness, CP, dyspnea or anxiety?
* Duration?
19
Q
What can palpitations be associated with? (not heart disease)
A
- Anxiety
- Hyperthyroid (women over 40)
- Electrolyte imbalance (high or low potassium)
- Drug or stimulant
20
Q
What is dyspnea? What are causes?
A
Dyspnea is an uncomfortable awareness of breathing that is inappropriate to a given level of exertion.
* Cardiac or pulmonary
* Sudden dyspnea occurs in pulmonary embolus,
spontaneous pneumothorax, and anxiety
21
Q
What is orthopnea? How is it quantified?
A
Orthopnea is dyspnea that occurs when the pt is supine and improves when sits up
* Quantified by the number of pillows pt uses for sleeping or by the fact that the pt needs to sleep sitting up (recliner)
22
Q
What is Paroxysmal Nocturnal Dyspnea(PND)
A
awakens pt suddenly about 1-2 hours after falling asleep due SOB
23
Q
Orthopnea and PND can be caused by what?
A
caused LV heart failure, mitral stenosis, obstructive lung disease
24
Q
What is edema?
A
Accumulation of excessive fluid in the extravascular interstitial space
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Interstitial tissue can absorb how much before pitting edema appears?
Interstitial tissue can absorb up to 5 L of fluid, accommodating up to a 10% weight gain, before pitting edema appears
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* Edema can be what?
* What are associated symptoms?
Can be systemic to local
Location, timing, and setting of the swelling and any
associated symptoms:
* Rings tight on fingers?
* Eylids puffy or swollen in morning?
* Have to let belt out?
* Rapid weight changes? (>2 lb rapid wt gain will occur prior to visible edema)
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If a patient is swollen in the morning or the swelling is pass the ankle, do you need to look at?
Cardiac
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What are edema casues?
* Cardiac: right or left ventricular dysfunction, pulmonary hypertension
* Pulmonary: obstructive lung disease
* Nutrition: hypoalbuminemia
* Nephrotic syndrome (rings and eyes)
* Positional: dependent edema
* Anasarca: severe generalized edema extending to the sacrum and abdomen
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What do you need to know about past medical history with CVS?
Prior Cardiac
* Previous hospitalizations and Rx.
* Myocardial infarctions/angina
* Arrhythmias, bradycardia, pacemaker insertion
* Heart Failure
* Syncope or new seizures
* Cardiac Surgery
* Congenital heart disease
* Rheumatic Fever
* Valvular heart disease /MVP
* Heart Murmurs diagnosed in past
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For PMH, what are some other vascular diseases?
* Carotid Artery disease: common and stenosis in carotid artery
* Peripheral Vascular Disease
* Embolic or Thrombotic CVA
* Abdominal or Thoracic Aneurysms
* Varicose veins
* Previous Deep Venous Thrombosis-> emergency, onset of calf pain, worst when pushing on calf
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What are some chronic illnesses you need to know about for PMH?
* Chronic Illnesses * HTN
* DM
* Hyperlipidemia
* Thyroid Disease
* Neoplastic disease
* Chronic lung disease
* Chronic renal (need dialysis) or hepatic disease
* Pulmonary Hypertension
* Pulmonary Emboli
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What should we know about for family history (CVS)?
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What are the key components of the CV examination? (big overview)
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# Key components of the CV exam
* What do you need to note and measure?
* What do you estimate?
* What do you auscultate?
* What do you need to palpate?
* Note general appearance and measure blood pressure and heart rate.
* Estimate the level of jugular venous pressure.
* Auscultate the carotids (bruit) one at a time. (BEFORE PALPATE to not dislodge anything)
* Palpate the carotid pulse including carotid upstroke (amplitude, contour, timing) and presence of a thrill.
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# Key components of the CV exam
* What do you need to inspect?
* What do you need to palpate (not carotid)?
* 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
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# Key components of the CV exam
* What do you need to auscultate (not carotid)?
* What do you need to distinguish?
* Auscultate S1 and S2 in five positions from the base to the apex.
* 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.
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* How is the JVP best assessed?
* When does it fall and increase?
JVP best assessed from the pulsations in the right internal jugular vein
* JVP falls with loss of blood or decreased venous vascular tone
* JVP increases with right or left heart failure, pulmonary hypertension, tricuspid stenosis, AV dissociation, increased venous vascular tone, and pericardial compression or tamponade
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For measuring the JVP: what do you need to find and how is it measured?
* Find the highest point of oscillation of the IJV
* JVP is measured in vertical distance above the sternal angle
* Bony ridge located around T4 adjacent to the second rib
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What are the steps for measuring the JVP?
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How does JVP change with differing angles of bed?
Not much
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What are we looking for with JVP?
JVP measured at >3 cm above the sternal angle, or more than 8 cm in total distance above the right atrium, is considered elevated above normal.
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What is this?
distended neck vein
* common with increase JVP in heart disease
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Carotid arteries: What is the order? How do you perform the exam?
* Auscultation BEFORE palpating
* Auscultate both the carotid arteries to listen for a
bruit
* Bruit is a murmur-like sound from turbulent arterial blood flow
* Ask the patient to stop breathing for about 10 seconds
* Listen near upper end of the thyroid cartilage below the angle of the jaw
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What is a bruit?
Bruit is a murmur-like sound from turbulent arterial blood flow
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* How should you palpate the carotid arteries?
* What do we need to note and avoid doing?
* Pt should be at 30 degrees
* Palpate the carotid, medial to relaxed SCM, roughly level of cricoid cartilage
* Note carotid upstroke, its amplitude and contour, and the presence or absence of thrills
* Avoid pressing on the carotid sinus, adjacent to the top of the thyroid cartilage
* NEVER PALPATE BOTH CAROTID ARTERIES AT THE SAME TIME
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* What are you inspecting?
* What can you do to help you?
* Inspect the anterior chest for apical impulse or PMI
* Shine a tangential light across the chest wall over the cardiac apex to make more visible
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What are you feeling for in palpations? (precordium)
* Heave
* Thrill
* Apical impulse and PMI
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What are heaves and thrills? What causes them?
.
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* Apical impulse represents what?
* In most, the apical impulse is what?
* What happens if you cannot find the apical impulse?
* Apical impulse represents the brief early pulsation of the LV as it moves anteriorly during systole
* In most, the apical impulse is the PMI
* If you cannot find the apical impulse, ask pt to exhale fully
and stop breathing for a few seconds
* For woman, may need to displace the left breast
* If you cannot identify apical impulse with the pt supine, ask to roll partly onto left side into left lateral decubitus position
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How should you palpate the Apical Impulse
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For the Point of Maximal Impulse (PMI), What do you locate and describe?
* Locate two points: intercostal spaces (usually 5th, maybe 4th) and distance in cm from the midclavicular line or midsternal line
* Describe the PMI in relation to the midsternal or midclavicular line, or anterior axillary line if displaced
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How do you auscult a patient for heart?
* Pt at 30 degrees
* Start at base with diaphragm and
“inch” towards apex
* Listen in 5 areas
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What are the ausculatatory areas on the chest wall?
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For heart murmurs: what do you need to do?
* Time the murmur – Systole or diastole? Duration?
* Murmurs that coincide with the carotid upstroke are systolic
* Location on the precordium the murmur is loudest – at the base, along the sternal border, at the apex? Does it radiate?
* Conduct any necessary maneuvers, such as lean forward and exhale or turn to the left lateral decubitus position to accentuate the murmurs
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What are systolic murmurs?
Murmurs that coincide with the carotid upstroke are systolic
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* What murmurs radiate widely?
* What should you use instead?
* Heart sounds and murmurs that originate in the four valves radiate widely.
* Use anatomical location rather than valve area to describe findings
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What should you do for mitral stenosis in the left lateral decubitus?
* Brings LV closer to the chest wall
* Place the **bell** (if you have a bell) of your stethoscope lightly on the apical impulse
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What do you do for Aortic Regurgitation with pt leaning forward?
* Ask the patient to sit up, lean forward, exhale completely, and stop breathing
* Use **diaphragm**, listen along the left sternal border and at the apex
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For identifying and describing any murmurs, how do you do that?
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How do you describe the shape and intensity of murmurs (overview)
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Crescendo, decrescendo, or both (sometimes called diamond-shaped), is an example of what?
Systolic Murmur of aortic stenosis
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For a plateu shape, what is an example?
holosystolic murmur of mitral regurgitation
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What are murmur graded on intensity?
Intensity: grade the murmur on a scale of 1 to 6
* Grades 4 through 6 must have accompanying **thrill**
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How do you describe heart murmurs with quality, pitch and location?
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What does a mitral and aortic regurgitation sound like?
* Harsh 2/6 medium-pitched holosystolic murmur best heard at the apex describes **mitral regurgitation**
* Soft, blowing 3/6 decrescendo diastolic murmur best heard at the lower left sternal border describes **aortic regurgitation**
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Arterial pulses are palpable when?
Artery lies close to body surface
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What are the arterial pulses in arms (3)
o Brachial: at bend of elbow just medial to biceps tendon
o Radial: lateral flexor surface at wrist
o Ulnar: medial flexor surface (overlying tissues may obscure)
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What are the arterial pulses in the legs (4)?
o Femoral: below inguinal ligament
o Popliteal: passes medially behind the femur; palpable behind knee
o Dorsalis pedis: dorsum of foot; lateral to extensor tendon of big toe
o Posterior tibial: behind medial malleolus of ankle
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* What is the lymphatic system?
* What are LN and what do they vary in?
* What is the lymphatic system important in?
* What LNs are accessible to physical exam?
Extensive vascular network that drains lymph from body tissues and returns it to venous circulation
Lymph nodes
* Round, oval, or bean-shaped structures
* Vary in size according to location
Important role in body’s immune system
* Cells in lymph nodes engulf cellular debris/bacteria
and produce antibodies
Only superficial lymph nodes accessible to physical examination
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What are common or concerning symptoms for perpherial vascular exam
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# Health history
For PAD, what do you ask? Arterial spasm? Venous peripheral vascular disease?
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For OLDCART: how do you do onset and duration for leg pain or cramps?
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For OLDCART: how do you do Character for leg pain or cramps?
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For OLDCART: how do you do skin changes for leg pain or cramps?
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For OLDCART: how do you do onset and duration for swlloen ankles or pedal edema?
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For HPI: how do you do related circumstances for swollen ankles or pedal edema?
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For HPI: how do you do associated symptoms for swollen ankles or pedal edema?
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For HPI: how do you do Rx attempted for swollen ankles or pedal edema?
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# Health promotion and counseling
* Most patients with peripheral arterial disease (PAD) have what?
* What can happen in only 10% of affected patients?
* Most patients with peripheral arterial disease (PAD) have no symptoms or non-specific symptoms
* Triad of exercise-induced calf pain that causes patient to stop exercise and experience relief of pain in 10 minutes is present in only 10% of affected patients
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What do you need do to the arms and legs for perpherial vas. exam
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When you inspect both arms from fingertips to shoulders, what do you need to note?
o Size, symmetry, and any swelling
o Venous pattern for prominent veins
o Color of skin and nail beds; texture of skin
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How do you palpate the radial pulse?
* Use finger pads on flexor surface of wrist
* Partially flex patient’s wrist
* Compare pulse in both arms
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How do you palpate brachial pulse?
* Flex elbow slightly
* Palpate artery
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How do you find the epitrochlear nodes?
* Flex elbow 90°
* Support forearm
* Feel in groove between biceps and triceps muscle, 3 cm above medial epicondyle
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Where are the epitrochlear nodes?
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What are these?
Epitrochlear nodes
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For examining the legs:
* Patient should be where?
* Must remove what?
* Inspect both what?
* What do you need to note?
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For the leg exam, What do you need to palpate? What do note?
Palpate superficial inguinal nodes (Gloves)
* Horizontal/vertical groups
* Note size, consistency, and discreteness and tenderness
* Nontender, discrete nodes up to 1-2 cm are palpable in normal people
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What are the palpatable pulses in the leg? (explain where you would find them)
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What is the grading amplitude of the arterial pulses?
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For edema, what do you need compare in the leg? What do you need to note?
Compare one foot and leg with the other
* Note relative size and prominence of veins, tendons, and bones
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How do you check for pitting edema?
* Press firmly with thumb for 5 seconds over dorsum of each foot, behind medial malleolus and shins
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How you do grade edema?
* 1+ Slight pitting, no visible distortion, disappears rapidly
* 2+ Somewhat deeper pit than in 1+, but again no readily detectable distortion, & disappears in 10 to 15 seconds
* 3+ Pit is noticeably deep & may last more than a minute; the dependent extremity looks fuller & swollen
* 4+ Pit is very deep, lasts as long as 2-5 min, & dependent extremity is grossly distorted
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* If edema is present, look for what?
* What do you need to note?
If edema is present, look for causes
* Recent deep venous thrombosis
* Chronic venous insufficiency
* Lymphedema
Note color of skin
* Local area of redness
* Brownish areas near ankles
* Ulcers and where
* Thickness of skin
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What should you suspect if the edema is unilateral? bilateral? Edema without pitting?
* If edema unilateral, suspect occlusion of a major vein
* If edema bilateral, consider CHF
* If edema occurs without pitting, suspect arterial disease & occlusion
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What is the allen test?
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Not only you need to compare left and right symmetry, but also what? Give example
Compare bilaterally, between upper & lower extremities
* Femoral pulse as strong or stronger than radial pulse
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Lack of symmetry between right & left extremities suggest what?
Lack of symmetry between right & left extremities suggest **impaired circulation**
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If femoral pulse weak or absent, what is suspected?
coarctation of aorta or AAA
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What is this?
Emboli to Feet with Impairment of Circulation & Gangrene
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What are reasons for bounding pulse?
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When do you seen marked vasodilatation?
Sun/heat stroke
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What should be auscultated for the perphial vascular exam during abdomen exam?
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Assessment for Venous Obstruction & Insufficiency:
* What do you inspect for?
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What are signs of venous insufficiency?
* Thrombosis
* Varicose veins
* Edema
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What are signs of DVT?
Increase calf size, red, warm, painful
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What are these?
Varicose veins
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What is this?
Venous Stasis & Ulceration
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What is this?
Upper extremity venous thrombosis
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What is special about superifical venous thrombosis?
Not dangerous so you do not need to admit patient
113
On routine physical examination, a 40-year-old teacher is found to have a single second heart sound. The most likely explanation for this finding is what?
A. Auscultation occurred during inspiration.
B. The patient has a right bundle branch block.
C. Auscultation occurred during expiration.
D. The patient has pulmonic stenosis.
E. The patient has a left bundle branch block
C. Auscultation occurred during expiration.
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A first-year medical student is examining a standardized patient with a structurally normal heart. The student is having difficulty auscultating the splitting of the second heart sound. At what area on the patient's chest would the student have the best opportunity of hearing this sound?
A. Left second and third interspace
B. Lower left sternal border
C. Apex
D. Right second interspace
E. Midsternum
A. Left second and third interspace
115
77-year-old man is experiencing progressive shortness of breath and dizziness. The patient undergoes cardiac catheterization, and the systolic blood pressure measured in the left ventricle is 180 mm Hg, while the systolic blood pressure measured in the aorta is 140 mm Hg. The patient is most likely experiencing symptoms related to what valvular condition?
A. Aortic stenosis
B. Pulmonic stenosis
C. Aortic insufficiency
D. Mitral stenosis
E. Mitral regurgitation
A. Aortic stenosis
116
A 45-year-old physician is placed on a β-blocker for hypertension. Prior to medication administration, the patient's heart rate is 75 beats per minute with a cardiac output of 5 liters per minute. Following initiation of the medication, the heart rate decreases to 60 beats per minute without a change in stroke volume. What would be the expected new cardiac output?
4 L per min
CO = HR x SV
117
An elderly patient with a history of smoking two packs of cigarettes a day for 50 years complains to her physician of progressive shortness of breath. On cardiac examination, the physician feels the most prominent palpable impulse to be in the xiphoid area. This is most likely a result of what condition?
A. Mitral regurgitation
B. Pulmonary hypertension
C. Aortic stenosis
D. Hypertrophic cardiomyopathy
E. Hypertension
B. Pulmonary hypertension
118
A 55-year-old actress sustains a heart attack and the follow-up electrocardiogram demonstrates a left bundle branch block. What would be the likely duration of the QRS complex?
100 milliseconds
75 milliseconds
95 milliseconds
125 milliseconds
90 milliseconds
125 ms
119
A newborn baby has an embryologic defect affecting the aortic valve. What other cardiac valve is most likely to be affected?
A. Pulmonic valve
B. Pyloric valve
C. Mitral valve
D. Eustachian valve
E. Tricuspid valve
A. Pulmonic valve
120
A 55-year-old truck driver with obstructive sleep apnea has diastolic heart failure. An echocardiogram demonstrates significant biatrial enlargement. What portion of his electrocardiogram would likely be abnormal?
QRS complex
S wave
R wave
P wave
T wave
P wave
* P wave is the result of atrial depolarization and would therefore have changes associated with atrial enlargement
121
A 70-year-old retired business executive presents to the Emergency Department with progressive shortness of breath and two-pillow orthopnea. On physical examination, the blood pressure is 145/90 mm Hg, there is jugular venous distension, lower extremity pitting edema to the knee, and a blowing holosystolic murmur heard best at the lower left sternal border. No other murmurs or thrills are auscultated on physical exam. Which of the following interventions is to most likely to improve the patient's symptoms?
A. Repair of a ventricular septal defect
B. Decrease in blood pressure
C. Replacement of the mitral valve
D. Replacement of the aortic valve
E. Removal of intravascular volume with diuresis
E. Removal of intravascular volume with diuresis
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A 20-year-old college student is experiencing dyspnea on exertion and palpitations. On cardiac auscultation, the second heart sound is split and fixed on both inspiration and expiration. What is the most likely cardiac condition associated with this finding?
A. Right bundle branch block
B. Tricuspid stenosis
C. Pulmonic stenosis
D. Left bundle branch block
E. Atrial septal defect
E. Atrial septal defect
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