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Clin med II exam II Cardio > Murmurs and Shock > Flashcards

Murmurs and Shock Flashcards

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1
Q

descrive the 4 heart valves

A

Aortic Valve (three leaflets) – between PV and aorta

Tricuspid Valve (three leaflets) – between RA and RV

  • Pulmonic Valve (three leaflets) – between RV and PA
  • Mitral Valve (two leaflets) – between LA and LV
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2
Q

explain the grades of murmurs

A
  • Grade 1 – very soft heard after careful auscultation
  • Grade 2 – readily heard soft murmur
  • Grade 3 – moderately loud, not associated w/ palpable thrill
  • Grade 4 – Loud, no or intermittent palpable thrill
  • Grade 5 – loud associated w/ palpable pericardial thrill. Murmur not audible when stethoscope is lifted from thoracic wall
  • Grade 6 – loud murmur associated w/ palpable pericardial thrill and heard when stethoscope is lifter from thoracic wall
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3
Q

define sclerosis, stenosis, regurg

A
  • Sclerosis – valve thickening and calcification without significant pressure gradient (<2 m/sec)
  • Stenosis – valve thickening and calcification with significant pressure gradient (>2 m/sec)
  • Regurgitation – inadequate closure of the valve leaflets, causing back flow of blood into the ventricle
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4
Q

thinking symptom wise where will right and left sided heart failures be noted

A
  • RIGHT side of Heart – back up into body
  • Lower extremity edema
  • Ascites
  • LEFT sided – pulmonary associated symptoms à backs up into lungs first
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5
Q

define preload vs after load

A

preload - volume in ventricles at end of diastole

after load - resistance left ventricle must overcome to circulate blood

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6
Q

what causes an increase in preload vs afterload

A

preload

hypervolemia

regurg of cardiac valves

HF

afterload

vasocontriction

HTN

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7
Q

describe effects of special tests on preload and afterload

valsalva

Squatting from standing

Standing from Squatting

Legs raise (passive)

Handgrip exercise

A

INCREASES preload -

quatting from standing

leg raise

DECREASE preload

Standing from Squatting

valsalva

INCREASED afterload - handgrip

DECREASE afterload - valsalva

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8
Q

most common valvular dz?

A

Aortic regurg

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9
Q

most common causes of AR and AS in:

developed countries

developing countries

A

DEVELOPED countries - Calcific disease

developing countries - rheumatic valve disease

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10
Q

valvular dz assoc w/ sx:

  • Exertional dyspnea
  • Exertional angina
  • HF symptoms – orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, lower extremity edema
  • Awareness of heart beats due to dilation**
A

AR

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11
Q

describe physical exam findings for AR vs AS

A

AR

Wide pulse pressure in BP (140/50)

  • Displacement of apical pulse laterally and inferiorly
  • Prominent pulsation/thrill over sternal notch – aortic dilation
  • Bounding pulse due to arterial pulse falling off rapidly

AS

  • Carotid pulse DEC in amplitude
  • Split S2 (pulmonic valve closing prior to aorta) or deceased S2
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12
Q

As has similar si/sx as AR but we more frequently see:

A

•Pre-syncope or syncope

AR: aware of heart beats due to dilation

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13
Q

describe patho of AR vs AS

A

AR

Increases volume overload in LV -> increase in LV capacity to ensure ventricular compliance -> ventricular wall thickness increases in proportion to increase in chamber radius -> eccentric hypertrophy

AS

Increase afterload in LV à LV needs to generate more force to overcome afterload à thickening of LV à less LV compliance and impedes filling à concentric LV hypertrophy

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14
Q

gold standard for dx of valvular dz?

A

Echo – TTE w/ Doppler

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15
Q

tx of AR/AS

A

Limited physical activity

Tx underlying CV dz

HTN tx challenging

HF management - Low dose diuretic w/ ACE

Palliative care

surgical options

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16
Q

surgical tx of AR and AS

A

SURGICAL

AVR or SAVR – open heart surgery

TAVR – done via femoral, axillary artery or directly via aorta –> Originally used for high-risk pts but not approved for all

F/u

•2-4 wks after discharge, then every 3-6 mo eventually transition to 6-12 mo

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17
Q

Asymptomatic pt monitoring: exam + echo in pts w/ AS

A
  • Mild AS w/o calcification 2-3 yrs
  • Mild AS w/ significant calcification – yearly
  • Moderate AS – yearly
  • Severe AS – every 6 mo
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18
Q

Exercise stress tests are used to dx AS/AR in what pt population

A

•pts w/ severe AS who live sedentary life

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19
Q

metabolic dz such as Paget’s, Fabry’s Lupus are assoc w/

A

AS

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20
Q

sx of MS

A
  • Exertional dyspnea/ exercise intolerance
  • Paroxysmal or persistent Afib
  • Chest pain – due to portal HTN
  • Fatigue
  • Ascites

•Lower extremity edema

  • Thromboembolism
  • Hemoptysis – INC pressure in pul. system
  • Hoarseness – increase in L atrial size that compresses recurrent laryngeal n.
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21
Q

sx of MR

A

Asymptomatic –

•sx don’t occur until late in dz –> develop due to LV enlargement, systolic dysfunction, pHTN or Afib

then develop same sx as MS

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22
Q

Most common cause of MR in developed and developing countries

A

developed –MVP and CAD

developing –rheumatic heart disease

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23
Q

MVP is associated w/ an ______ in sudden cardiac death

A

INCREASE in sudden cardiac death

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24
Q

most common cause of MR

A

MVP

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25
Ct disorders such as Marfans, OI and Ehlers Danlos are associated w/ what valvular dz?
MVP
26
describe primary vs secondary causes of mitral valves dz
Primary – due to valve dysfunction * Degenerative dz * Rheumatic heart dz * Endocarditis * Congenital Secondary is due to other factors * CAD * Dilated CM * HCM * RV pacing
27
HF symptoms more common in MR / MS / MVP
MS ## Footnote * Crackles in lungs * Peripheral edema * Ascites
28
Mitral facies are associated w?
MS Mitral facies – pinkish/purple patches on cheeks
29
tx of Mitral dz
Asymptomatic – routine monitoring by cardiologist Medical management of sx – mostly HF sx ACE, ARB, BB, aldosterone antag •Diuretics surgical procedures: FIRST line – Mitral Valve Balloon valvotomy * Asymptomatic to severe MS * Severe MS w/out MR Transcatheter mitral valve clip * MR only * Femoral vein access w/ transseptal puncture Surgical repair / replacement * Failed balloon valvotomy * Other surgical issues MR or MVP * MS w/ MR
30
describe the different procedures assoc w/ MS vs MR
FIRST line – Mitral Valve Balloon valvotomy --\> MS * Asymptomatic to severe MS * Severe MS w/out MR Transcatheter mitral valve clip --\> MR only
31
split S2 is associated w/
AS and PS
32
describe the displacement of apical pulse in MR vs AR
AR - laterally and inferiorly MR - Leftward displacement
33
Mitral valve dz Non-surgical candidate monitoring:
routine echo yearly ## Footnote * Mild – echo every 2-3 yrs * Moderate – echo every 1-2 yrs * Severe – echo every 6-12 mo
34
Non ejection click is assoc w/
MVP
35
diagnostic imaging of choice for mitral valve dz?
Echo – * usually TTE w/ doppler * but TEE is suboptimal
36
CXR of valvular dz show?
aortic - widened aortic notch mitral - Nonspecific LA and LV enlargement tricuspid - Cardiomegaly from RV enlargement & Pleural effusions pulmonary - Cardiomegaly w/ RV enlargement
37
si/sx of tricuspid dz
* Neck pulsations (JVD) * Palpations * Edema (peripheral) * Ascites * Abdominal pain/bloating * Sx related to cause NO LEFT SIDED sx such as pre-syncope or syncope
38
Opening snap can follow murmur in what valvular dz
TS
39
JVD- Kussmal’s sign is associated w/
TS and TR ## Footnote •Lack of or decrease or rise in JVP
40
sx associated w/ tricuspid dz
Edema - – ascites, peripheral and occasional anasarca Hepatomegaly JVD
41
RA and RV dilation (pHTN, chronic PE, severe COPD) are all causes of:
TR
42
tx option of choice for most pts w/ tricuspid dz
Surgical repair or replacement
43
tx of TS
percutaneous balloon valvotomy
44
medical management of tricuspid dz
Med management aimed at sx - Diuretics / aldosterone antag
45
sx of?? Asymptomatic * Exertional dyspnea * Fatigue * Syncope * Chest pain * Right HF sx (edema, abdominal bloating)
pulmonary valve dz
46
tx for PS and PR
Should undergo annual screening and monitoring Correct any underlying issues * Pulmonary artery vasodilators * HF medication Congenital PS – fixed in infancy w/ surgery or balloon valvotomy Symptomatic or severe PR --\> Surgical intervention tissue or mechanical valve
47
name the systolic murmurs
occur b/w S1 and S2 AS MR MVP TR PS
48
name diastolic murmurs
AR MS TS PR
49
what murmurs are heard best over apex
MS - held in expiration MR MVP
50
what murmur is heard best ar ERb's
AR
51
what murmurs INCREASE w/ squatting and leg raises
AR / AS MR / MS / MVP
52
AR vs MR special test differnetiation AS vs MS
AR - handgrips inc murmur MR - hangdrips no effect AS - handgrips decrease MS - inspiration decreases
53
hangrips have what effect on these 2 murmurs?
AR - increase AS - decrease
54
in a MS murmur (inspiration / expiration) increases murmur while (inspiration / expiration) decreases murmur
expiration increases inspiration decreases
55
inspiration increases and decreases what murmurs
increases TS and TR decreases - MS
56
HOCM vs AS
AS ## Footnote DECREASES * Valsalva * Standing HOCM will do opposite As radiates to carotid, HOCM does not
57
standing or valsalva decreases what murmurs
AR and AS MS and MR
58
what murmurs radiate to axilla
MR and MVP
59
murmur that is described as blowing sound
AR descrecendo early-diastolic
60
murmur described as harsh
AS crescendo-descresendo (soft-loud-soft)
61
murmur described as rumble (3)
MS - loud S1 followed by decresc-cresc, low pitched MR - medium to high pitch, rumble increases twoard end TS- opening snap may follow, decresc-cresc, low pitched, rumble increases twoard end
62
murmur described as non-ejection click
MVP - low pitched
63
murmur described as continuous blowing
AR - early diastolic TR - systolic
64
murmurs heard best on LSB
AR - 3rd and 4th ICS TS - 3rd to 5th ICS (bell)
65
murmur described as pulmonary ejection click
PS - systolic, Crescendo-decrescendo
66
murmurs described as Crescendo-deccrescendo Decrescendo-Crescendo
Crescendo-deccrescendo AS and PS Decrescendo-Crescendo MS and TS
67
what murmur can radiate to neck and carotids
AS
68
describe chemoreceptors and their role
* specialized areas in the medulla oblongata, aortic arch, and carotid arteries that are sensitive to concentrations of O2, CO2, and H+ ions (pH) in the blood * Decrease in arterial oxygen or pH and/or increase in carbon dioxide → smooth muscles to contract → vasoconstriction → increase in BP
69
describe baroreceptors and their role
* major stretch receptors located in the aorta and carotid * Respond to changed in smooth muscle fiber length by altering their rate of discharge * Increase in arterial BP → increase rate of baroreceptor firing → travel afferent nerves → medulla → slows the heart rate via vagus nerve → decreases myocardial contractility → increases arteriolar and venous dilation → reduces BP
70
# define orthostatic hypotension Tx?
changes in vital signs taken within 3 minutes of position change (supine to sit or sit to stand) * Decrease in SBP \>20 * Decrease in DBP \>10 * Increase in HR \>20 bpm _give fluids_ - if resolve ortho hypo! _tx undeerlying dz_ Increase salt in diet Increase fluid in diet Elevation of head in bed Medication changes
71
define hypotension
Sustained symptomatic systolic blood pressure (SBP) \<90 mmHg •or an acute drop in SBP of \>30 mmHg from baseline
72
name 4 types of shock
distributive cardiogenic hypovolemic obstructive
73
causes of distributive vs obstrucitve shock
distributive - septic shock SIRS * Neurogenic shock – TBI, spinal cord injury * Anaphylactic shock * Drug and toxin-induced shock – insect bite * Endocrine shock – Addisons, Myxedema obstructive Mechanical * Tension pnuemo * Pericardial tamponade * Constrictive pericarditis * Restrictive CM Pulmonary vascular * PE * Severe pHTN
74
si/sx of shock
look sick hypotension tachycardia Oliguria (\<30-50cc/hr) tachypnea - reduce acidosis Cool, clammy, cyanotic skin
75
Metabolic acidosis – “high ion gap metabolic acidosis automaticaaly think??
shock
76
Hyperlactatemia correlation w/ mortality w shock
* Normal lactate is 0.1-3mmol/L * \*\*higher the lactate higher the mortality
77
management of shock
recognize identify probable cause oxygen \>94% •Maintain IV access at ALL times give fluids maintian ABCs * Vasopressors – levophed, phenylephrine, vasopressin * Inotropic support – dobutamine, epinephrine * Mechanical support for cardiogenic shock * Intra-aortic balloon pump * Advanced cardiac mechanical support
78
appropriate fluid for type of shock
* LV ischemia or depressed EF: 500-1000cc * RV ischemia or sepsis: 2-5L à preload dependent, RA need fluid or it will collapse * Hemorrhagic shock: 3-5L
79
complications of shock
* Limb ischemia – can lead to dry gangrene which would require amputation * Acute respiratory distress syndrome (ARDS) * Death – high mortality associated with some causes of shock * Permanent organ damage or death
80
Distributive shock is due to
due to severe peripheral vasodilation
81
cardiogenic vs hypovolemic shock due to
card -due to intra-cardiac causes of cardiac pump failure that results in reduced cardiac output hypovol -due to reduced intravascular volume, which in turns, reduced CO
82
obstructive shock is due to
due to extra-cardiac causes of cardiac pump failure and is often associated with poor RV output

Clin med II exam II Cardio (3 decks)

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