Week 8 - Ch. 20 & 21 Flashcards

Question

Define a murmur ? what are some aspects of a murmur ?

Answer 1

Blood circulating through normal cardiac chambers andvalves usually makes no noise. some conditions create turbulence in blood flow and collision currents these result in a murmur, much like the sound of noisy water flow created by a pile of stones or a sharp turn in a stream A murmur is a gentle, blowing, swooshing sound that can be heard on the chest wall. The following conditions result in a murmur: 1. Increases in velocity of blood flow (flow murmur; e.g., in exercise, thyrotoxicosis) 2. Decreases in viscosity of blood (e.g., in anemia) 3. Structural defects in the valves (narrowed valve, incompetent valve) or unusual openings in the chambers (dilated chamber, septal defect

Answer 2

All heart sounds are described by four characteristics: 1. Frequency (pitch): heart sounds are described as high pitched or low pitched, although these terms are relative because all are low-frequency sounds, and you need a high-quality stethoscope to hear them 2. Intensity (loudness): loud or soft 3. Duration: very short for heart sounds; silent periods are longer 4. Timing: systole or diastole

Answer 3

The heart pumps automatically in response to electrically current conveyed by a conduction system There are specialized cells in the Sinoatrial Node (Is the pacemaker) near the superior venae Cava The current flows first across the Atria to the AV node low in the atrial septum - at the AV node the current is delayed a little so that the atria can contract before the ventricles are stimulated The impulse then travels down the Bundle of His (which is a collection of heart muslces cells specialized for eletrical conduction) - from the bundlle of his the current travels to the point of the apex of the fasicular branches (called the right and left branches) then through the ventricles

Answer 4

The electrical impulse that stimulates the heart - a small amout spreads to the bodies surface where it can be measured - It is measured on the ECG - the waves are lablled as PQRST P wave: depolarization of the atria P–R interval: the interval from the beginning of the P wave to the beginning of the QRS complex (the time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles) QRS complex: depolarization of the ventricles T wave: repolarization of the ventricles Electrical events slightly precede the mechanical events in the heart

Answer 5

The cardiac output is the amount of blood that is pumped out of the heart - normally this is 4 to 6L of blood per minute throughout the body *Cardiac Output* equals the volume of blood in each *systole* (*Stroke Volume*) times the number of *Beats per minute* (Rate:R) The heart can alter the cardiac output based on the bodies metabolic needs - preload and afterload affect the the hearts ability to increase cardiac output *Preload*: is the venous return that builds during diastole; it is the length in which the ventricular muscle is stretched at the end of diastole just before contratction - when the volume of blood returned to the ventricles increases (ex: exercise) the muscle bundles stretch beyond the normal resting state - the force of this switch is PRELOAD - the greater the stretch the greater the hearts contraction which results in an increase of blood ejected Afterload: is the opposing pressure that the ventricle must generate to open the aortic valve against the higher aortic pressure - It is the resistance against which the ventricle must pump its blood = Once the ventricle is filled with blood, the ventricular end-diastolic pressure is 5 to 10 mm Hg - whereas that in the aorta is 70 to 80 mm Hg - To overcome this difference, the ventricular muscle tenses (isovolumic contraction) - After the aortic valve opens, rapid ejection occurs.

Answer 6

The catotid artery is a central artery - it is close to the heart The carotid artery pulse timing occurs at the same time as the ventricular systole The carotid artery is located in the groove between the trachea and the sternomastoid muscle, medial to and alongside that muscle The dicrotic notch caused by the closure of the aortic valve is marked D in the figure

Answer 7

The jugular veins empty unixygenated blood directly into the superior vena cava the jugular vein gives information about the activity on the right side of the heart this is because there is no cardiac valve that exists to seperate the superior vena cava from the right atrium The jugular veins reflect the filling pressure and volume changes - when the right side of the heart fails to pump efficietly - the volume and pressure increase is exposed by the jugular veins

Answer 8

There are two jugular veins: (1) *Internal Jugular Vein* is larger and lies deep and medial to the sternomastoid muslce - it is usually not visible even though the diffuse pulsations may be seen at the sternal notch when the person is upine (2) *External Jugular Vein* is more superficial and it lies lateral to the sternomastoid muscle above the clavicle

Answer 9

The jugular vein pulse has five components - The five components of the jugular vein pulse occur because of events in the right side of the heart The A wave reflects atrial contraction because some blood flows backward to the vena cava during right atrial contraction The C wave, or ventricular contraction, is backflow from the bulging upward of the tricuspid valve when it closes at the beginning of ventricular systole (not from the neighbouring carotid artery pulsation) The X descent shows atrial relaxation when the right ventricle contracts during systole and pulls the bottom of the atria downward The V wave occurs with passive atrial filling because of the increasing volume in the right atria and increased pressure The Y descent reflects passive ventricular filling when the tricuspid valve opens and blood flows from the right atrium to the right ventricle

Answer 10

The fetal heart begins to beat at the end of 3 weeks of gestation - the lungs are non functional but the fetal circulation compensates for this - Oxygenation takes place at the placenta and the aterial blood is returned to the right side of the heart - there is no point in pumping all the freshly oxygentaed blood to through the lungs so the blood is routed in two ways (1) 2/3 of the blood is shunted through the opening in the atrial septum called the ***Foramen Ovale***, into the left side of the heart (2) the rest of the oxygenated blood is pumped by the right side of the heart out through the pulmonary artery but it is detoured through the ***Ductus Arteriosus*** to the aorta \*\* because both sides of the heart are pumping into systemic circulation - the right and the left ventricles are equal in weight and muscle thickness\*\*

Answer 11

During birth, the inflation and aeration of the lungs at birth produces circulatory changes the blood is oxyegnated via the lungs instead of the placenta the Foreman Ovale closes within the first hour after birth because of the new pressure in the right side of the heart which is lower than the left side of the heart The Ductus Arteriosus closes later usually within the 10 to 15 hours of birth The left ventricle has a greater workload of pumping into systemic circulation - when the baby reaches 1 year of age than the left ventricles mass increases to reach the adult proportion (the ratio of left to the right ventricle is 2:1) The heart position in an infant is more horizontal than in an adult - this means that the apex is higher in infants located at the 4th inercostal space - it reaches the adult position at 7 years of age

Answer 12

The blood volume increases by 30 to 40% during pregnancy This expansion is more rapid in the second trimester - this expansion increases the stoke volume and cardiac output and increases the pulse rate by 10 to 15bpm Pulse rate rises in the first trimester and peaks in the third trimester and returns to the baseline within the first 10 days postpartum Arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation - blood pressure drops to its lowest point during the second trimester and then rises

Answer 13

Lifestyle modifies the developement of the Cradiovascular system: smoking, diet, alcohol use, exercise patterns, and stress Lifestyle affects the aging process as well

Answer 14

With aging, Systolic blood pressure increases - caused by the thickening and stiffening of the large arteries which is caused by calcium and collagen deposits in vessel walls and loss of elastic fibres The stiffening (Arteriosclerosis) creates an increase in pulse wave velocity b/c the less complaint arteries cannot store the volume ejected * The overall size of the heart does not increase with age, but left ventricular wall thickness increases. This is an adaptive mechanism to accommodate the vascular stiffening mentioned earlier that creates an increased workload on the heart * Diastolic blood pressure may decrease after the sixth decade. Together with a rising systolic pressure, this increases the pulse pressure (the difference between the two) * No change in resting heart rate occurs with aging. * Cardiac output at rest is not changed with aging. There is decreased ability for the heart to augument cardiac output with exercise - this is shown by decreased maximum heart rate with exercise and decreased sympathetic response

Answer 15

Noncardiac factors also cause a decrease in maximum work performance with aging decrease in skeletal muscle performance increase in muscle fatigue increased sense of dyspnea Persistent exercise conditioning modifies many of the aging changes in CV function

Answer 16

The presence of supraventricular and ventricular arrythmias increase with age Ecotopic beats are common in older adults - these are usually asymptomatic in healthy older adults - these may comproise cardiac ouput and blood pressure when disease is present Tachydysrythmias may not be tolerated by older adults - the myocardium is thicker and less compliant and early diastolic filling is impaired at rest - Tachdyrythmias do not tolerate Tachycradia as well b/c of the shortened diastole

Answer 17

Changes in ECG include: * Prolonged P–R interval (first-degree AV block) and prolonged Q–T interval; the QRS interval is unchanged * Left axis deviation from mild age-related left ventricle (LV) hypertrophy and fibrosis in the left bundle branch * Increased incidence of bundle branch block

Answer 18

Cardiovascular disease is the second leading cause of death in canada for individuals over 65 years of age Hypertension and heart failure increase with age \*\*physical activity even at the moderate level shows a reduction in the risk of CVD and respiratory illness\*\*

Answer 19

Income, cultural food choices and employment security are influencing factors that inhibits ones ability to manage CVD Indigenous people in Canada have a higher incidence rate, greater than national averages for the development of CVD over the age of 20 years Death from CVD decreases on an annual basis but the incidence of CVD continues to increase men and women have equal rates of CVD in Canada Men are two times more likely to suffer from a heart attack early heart attack signs were missed in 78% of women, resulting in delay in treatment and greater injury to the myocardium associated with initial misdiagnosis heart disease was the second leading cause of death for Canadians, at 20% of all deaths, while cancer remains the leading cause of death, at 29% of all deaths The prevalence of heart disease and stroke is higher among adults of African descent than inany other ethnic group Concerns about food security continue to be in the forefront of arguments for action to diminish heart disease - “Food security is described as the condition in which all people, at all times, have access to nutritious, safe, personally acceptable, and culturally appropriate foods, produced in ways that are environmentally sound and socially just” A lack of food security as a result of economic or geographical barriers, as in most northern communities, is a significant determinant of health and an important heart health issue for many Income and employment, access to resources, and extended health care plans also influence the ability to support a heart-healthy lifestyle The major risk factors for heart disease and stroke are high blood pressure, smoking, high cholesterol levels, obesity, physical inactivity, and diabetes The use of hormone replacement therapy (HRT) increases the risk of heart disease for postmenopausal women

Answer 20

5.3 million Canadians (17.7%) aged 12 and older reported being diagnosed with hypertension no significantdifferences based on sexThe 2014 rate is lower than the self-reported value reported in the 2010 Canadian Community Health Survey (19.4%).12 This discrepancy could reflect the number of Canadians self-managing their hypertension without pharmaceutical intervention The Atlantic provinces continue to have the highest prevalence of hypertension in the nation; the western and the northern provinces (Yukon, British Columbia, and Northwest Territories) have the lowest rates

Answer 21

In 2016, 16.9% of Canadians aged 12 and older (roughly 5.2 million people) smoked either daily or occasionally

Answer 22

``` During childhood (ages 4 to 19), children and adolescents of African descent have higher levels of total cholesterol, low-density lipoprotein cholesterol (the “bad” cholesterol), and high-density lipoprotein cholesterol(the “good” cholesterol) than do children and adolescents of Euro-Canadian descent ``` These differences reverse during adulthood, so that individuals of African descent have lower serum cholesterol levels than do those of Euro-Canadian descent

Answer 23

Overweight is defined by a body mass index (BMI) of 25 to 29.9 kg/m2 and obesity by a BMI of 30 kg/ m2 or higher Currently, 59% of adult Canadians are either classified as overweight or obese, with the Atlantic provinces reporting the highest incidence the combined prevalence of overweight and obesity among those aged 2 to 17 years increased from 15 to 26% - Increases were highest among youth, aged 12 to 17 years, with overweight and obesity more than doubling for this age group, from 14 to 29% There is significant evidence that obesity is at least partly genetic Certain ethnic groups are more vulnerable to obesity and obesity-related disorders - strong environmental influences interacting with existing genes Children are particularly vulnerable to their environment because they have less ability to shape it - Children’s eating habits and physical activity patterns tend to be similar to those of their parents - which is one environmental reason why obesity and obesity-related disorders often run in families Exposure to gestational diabetes or maternal obesity, high birth weight, and intrauterine growth delay with rapid catch-up growth are all associated with obesity later on breastfeeding in infancy may reduce the risk for obesity, as may other health practices, such as getting enough sleep, and eating only in response to appetite cues

Answer 24

More than 9 million Canadians live with diabetes or are prediabetic - Canadian lifestyles are increasingly sedentary, and nearly 80% of all new Canadians belong to Hispanic, Asian, South Asian, and African populations, which are at increased risk of developing type 2 diabetes The personal cost of diabetes may include a reduced quality of life and an increased likelihood of complications, such as heart disease, stroke, kidney disease, blindness, need for amputation, and erectile dysfunction Medical costs for individuals with diabetes are two to three times higher than those for individuals without the disease

Answer 25

Canadian Diabetes Strategy (CDS): The strategy focuses on promoting health; preventing chronic disease by reducing risks for Canadians at risk; and supporting early detection and management of chronic diseases. Aboriginal Diabetes Initiative (ADI): The ADI focuses on increasing awareness of diabetes among Indigenous populations to reduce the prevalence and incidence of diabetes in these high-risk communities Canadian Chronic Disease Surveillance System (CCDSS): The CCDSS is a collaborative network of provincial and territorial surveillance systems, supported by the Public Health Agency of Canada. Starting with diabetes surveillance, the CCDSS is expanding to include other chronic disease conditions Healthy Weights: In 2010, federal, provincial, and territorial ministers of health endorsed Curbing Childhood Obesity: A Federal, Provincial, and Territorial Framework for Action to Promote Healthy Weights. Through the framework, the ministers agreed to make childhood obesity a collective priority In 2011, Canada endorsed a United Nations Declaration on preventing and controlling noncommunicable diseases - The Declaration acknowledges the four main noncommunicable diseases as (a) cancer, (b) diabetes, (c) chronic respiratory diseases, and (d) CVD

Answer 26

1. Chest pain: Any chest pain or tightness 2. Dyspnea: Any shortness of breath ? 3. Orthopnea: How many pillow do you use when sleeping or lying down ? assume more upright position to breathe - note the exact number of pillows used 4. Cough: do you have a cough ? 5. Fatigue: do you seem to tire easily ? are you able to keep up with your family and co workers ? - fatigue from decreased cardiac output is worse in the evening 6. Cyanosis or Pallor: ever notes your facial skin turn blue or ashen ? this occur with myocardial infraction or low cardiac output as a result of decreased tissue perfusion 7. Edema: Any swelling of your feet and lungs ? cardiac edema is worse in the evenings and better in the morning - it is also bilateral - unilateral swelling has a local vein cause 8. Nocturia: Do you awaken at night with an urgent need to urinate ? how long has this been occuring ? any recent change ? 9. Cardiac History: History of hypertesion ? 10. Family Cardiac History 11. Personal Habits: Nutrition, SMOKING, alcohol, exercise, medications, stress

Answer 27

women experience chest pain however they describe the pain differently which impacts the diagnosis and treatment Women tend to use descriptors such as “pressure” or “tightness,” with associated signs and symptoms such as nausea, unusual fatigue, or jaw pain—not always an elephant sitting on their chest or pain radiating down the left arm Heart disease is the most common cause of death in Canadian women - women are protected by estrogen which provides a protective effect on a women CV health During menopause, womens risk of heart disease and stroke increases b.c of the decreased production of estrogen - this decreased estrogen also causes a increase in fat above the waist which effects the way blood clots and affects the way that the body metabolizes sugar drop in estrogen causes an increase in cholesterol Inactive women are twice as likely to develop heart disease vs active women

Answer 28

1. Maternal Health: how was the mothers health during pregnancy ? rubella, fever, hypertension, other infections, medication taken ? 2. Feeding: have you noted any cyanosis while the baby is nursing or crying ? is the baby able to eat, nurse, or finish bottle without tiring ? 3. Growth: how is the babies growth ? same as siblings and peers? poor weight gain? 4. Activity: is the infant reaching milestones ?

Answer 29

1. Growth 2. Activity 3. Joing pain and fever: unexplained join pains or unexplained fever 4. Headaches & noseblleds: are they frequent ? 5. Respiratory disease: frequent respiratory infections ? how many per year? how are they treated ? 6. Family History

Answer 30

1. High blood pressure. Have you had any high blood pressure during this or earlier pregnancies? What was your usual blood pressure level before pregnancy? How has your blood pressure been monitored during the pregnancy? If high, what blood pressure treatment has been started? Any associated symptoms: weight gain; protein in urine; swelling in feet, legs, or face? 2. Faintness or dizziness. Have you had any faintness or dizziness with this pregnancy?

Answer 31

1. Disease 2. Medications 3. Environement: Nonadherence to a treatment regimen may be related to adverse effects or lack of finances

Answer 32

The Neck Vessels 1. Asculate the Carotid Artery: asculate carotid artery for individuals with sigs of CVD for the presence of BRUIT - bruit can indicate artherosclerotic narrowing - keep the neck in neutral position - Lightly apply the bell of the stethoscope over the carotid artery at three levels: (1) the angle of the jaw, (2) the midcervical area, and (3) the base of the neck - ask patient to breathe, exhale and hold still breifly w/o breathing 2. Palpate the Carotid Artery: do not put to much pressure as excessive vagal stimulation could slow down the heart rate especially in older adults - palpate one carotid artery at a time 3. Inspect the Jugular Venous Pulse: you can asses the central venous pressure (CVP) and you can judge the hearts efficency as a pump - the internal jugular vein is more reliable than the external jugular vein b/c it is attached more directly to the superior Vena cava - position the patiet supine (30- to 45 degree angle) - turn patients head away from where you are inspecting and shine a light onto the neck

Answer 33

1. Inspect the anterior chest: apical pulse pulsation can be seen on the fourth and fufth intercostal spaces or inside the midcavicular lne - A *heave* or *lift* is forceful thrusting that is caused by thrusting of the venrticle during systole which is a result of ventricular hypertrohpy as a result of increased owrkload 2. Palpate the Apical Pulse: ask paient to exhale and hold makes it easier to locate - you may need to rotate patient midway to the left to find it (this displaces apical pulse to the left) - the following charateristics should be found ( the location should occupy only one interspace either the 4th or 5th intercostal - size should be 1 to 2 cm - amplitude should be short, gentle tap - Duration should be first half of systole) 3. Palpate across the Precordium: gently palpate over apex 4. Ascultation: the valve areas (Second right interspace: aortic valve area, Second left interspace: pulmonic valve area, Fifth intercostal space at left lower sternal border: tricuspid valve area, Fifth interspace at around left midclavicular line: mitral valve area) - follow a Z \*\*apical pulse is not palpable in obese paients\*\* \*\* high cardiac output cuases the apical impulse to increase in amplitude and duration\*\*

Answer 34

1. Note rate and rythm: 60 to 100bpm is normal - rythm should be regular - Sinus Arrhythmia occurs normally in young adults and children (rythm increases at the peak of inspiration and slows with expiration) - if there is irregularity you need to check for a pulse deficit by palpating the apical pulse and the radial pulse simutaneously (A pulse deficit signals a weak contraction of the ventricles; it occurs with atrial fibrillation, premature beats, and heart failure) 2. Identify S1 & S2: This is important because S1 is the start of systole and thus serves as the reference point for the timing of all other cardiac sounds - you can identify S1 instantly because you hear a pair of sounds close together (lub-dup), and S1 is the first of the pair - The guideline works except in the cases of the tachydysrhythmias (rates \>100 beats/min) - Diastolic filling time is shortened, and the beats are too close together to distinguish. Other guidelines to distinguish S1 from S2 are as follows: • S1 is louder than S2 at the apex; S2 is louder than S1 at the base. • S1 coincides with the carotid artery pulse. Feel the carotid pulse gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1 (Fig. 20.20). • S1 coinciding with the R wave (the upstroke of the QRS complex) if the person is on an ECG monitor 3. Liste to S1 & S2 seperately

Answer 35

1. First heart sound (S1): caused by the closure of AV valves - S1 signals the beginning of systole - loudest at the apex but can be heard throughout pericardium - split S1 sound is normal but is rare - a spilt S1 indiates that you are hearing the mitral and tricuspid components seperately - the spilt is very rapid with the two components 0.03 sec apart 2. Second Heart Sound (S2): signals the closure for semilunar valves - s2 loudest at the base 1. Splitting of S2: A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people - Recall that closure of the aortic and pulmonic valves is nearly synchronous - inspiration separates the timing of closure of the two valves, and the aortic valve closes 0.06 seconds before the pulmonic valve - Instead of one “DUP,” you hear a split sound: “T-DUP” - During expiration, synchrony returns, and the aortic and pulmonic components fuse together - A split S2 is heard only in the pulmonic valve area (the second left interspace).

Answer 36

1. Timing: its important to define the murmur by its occurence in systole or diastole - try to define it further as early, middle, or late systole or diastole 2. Loudness: they are six grades for intensity ( Grade 1: barely audible, heard only in a quiet room and then with difficulty - Grade 2: clearly audible, but faint - Grade 3: moderately loud, easy to hear - Grade 4: loud, associated with a thrill palpable on the chest wall - Grade 5: very loud, heard with one corner of the stethoscope lifted off the chest wall; associated thrill- Grade 6: loudest, still heard with entire stethoscope lifted just off the chest wall; associated thrill 3. Pitch: high, medium, low - pitch depends on pressure and the rate of blood flow producing the murmur 4. Pattern: The intensity may follow a pattern during the cardiac phase, growing louder (crescendo), tapering off (decrescendo), or increasing to a peak and then decreasing (crescendo–decrescendo, or diamond-shaped). Because the whole murmur is just milliseconds long, it takes practice to diagnose any pattern 5. Quality: musical, blowing, harsh, rumbling 6. Location: location of the maximum intensity of the murmur by noting the valve area or intercostal spaces 7. Radiation: the murmur can be transmitted downstream in the direction of blood flow - may be heard other places other than pericardium

Answer 37

some murmurs disappear or appear with a change in position - some murmurs are common in healthy children or adolescens and are termed *functional or inncocent* * Innocent Murmurs:* have no valvular or other pathological cause * Funtional Murmurs:* are caused by increased blood flow in the heart (e.g., in anemia, fever, pregnancy, hyperthyroidism) The contractile force of the heart is greater in children; this increases blood flow velocity - Because of the increased velocity and a smaller chest measurement, a murmur is audible It is important to distinguish innocent murmurs from pathological ones - Diagnostic tests such as ECG and echocardiography will establish an accurate diagnosis When asculating the patient supine position - roll the patient twoards his/her left side - listen the apex - then ask patient to sit up lean foward slightly and exhale -

Answer 38

Fetal shunts normally close within 10 to 15 hours after birth but may take up to 48 hours - you should assess the CV system during the first 24 hours and again in 2 to 3 days. Note any extracardiac signs that may reflect heart status (particularly in the skin), liver size, and respiratory status The skin colour should be pink to pinkish brown, depending on the infant’s genetic heritage If cyanosis is present, determine its first appearance: at or shortly after birth versus after the neonatal period Normally, the liver is not enlarged, and the respirations are not laboured note the expected parameters of weight gain throughout infancy Palpate the apical impulse to determine the size and position of the heart - Because the infant’s heart has a more horizontal placement, expect to palpate - the apical impulse at the fourth intercostal space just lateral to the midclavicular line - It may or may not be visible The heart rate is best auscultated because radial pulses are hard to count accurately The heart rate may range from 100 to 180 per minute immediately after birth and then stabilize to an average of 120 to 140 per minute Infants normally have wide fluctuations with activity, from 170 per minute or more during cryin or other activity to 70 to 90 per minute during sleep Variations are greatest at birth and are even more so with premature babies Expect the heart rhythm to have sinus arrhythmia, the phasic speeding up or slowing down with the respiratory cycle Investigate any irregularity except sinus arrhythmia Expect heart sounds to be louder in infants than in adults because of the infant’s thinner chest wall S2 has a higher pitch and is sharper than S1 - Splitting of S2 just after the height of inspiration is common, not at birth, but beginning a few hours after birth Murmurs are relatively common in the first 2 to 3 days because of fetal shunt closure -These murmurs are usually grade 1 or 2, are systolic, accompany no other signs of cardiac disease, and disappear in 2 to 3 days absence of a murmur in the immediate neonatal period does not ensure that the heart is perfectc - a congenital defects can be present but not signalled by an early murmur

Answer 39

Note any extracardiac or cardiac signs that may indicate heart disease: poor weight gain, developmental delay, persistent tachycardia, tachypnea, DOE, cyanosis, and clubbing - Note that clubbing of fingers and toes usually does not appear until late in the first year, even with severe cyanotic defects The apical impulse is sometimes visible in children with thin chest walls - Note any obvious bulge or any heave; these are not normal Palpate the apical impulse: in the fourth intercostal space to the left of the midclavicular line until age 4 years - at the fourth interspace at the midclavicular line from ages 4 to 6 years; and in the fifth interspace to the right of the midclavicular line at age 7 years The average heart rate slows as the child grows older, although it still varies with rest and activity Physiological S3 is common in children - It occurs in early diastole, just after S2, and is a dull, soft sound that is best heard at the apex A *venous hum*—which represents turbulence of blood flow in the jugular venous system—is common in healthy children and has no pathological significance - It is a continuous, low-pitched, soft hum that is heard throughout the cycle, although it is loudest in diastole The venous hum is usually not affected by respiration, may sound louder when the child stands, and is easily obliterated by occluding the jugular veins in the neck with your fingers Results of some studies indicate that they have a 30% occurrence, and others indicate that nearly all children may demonstrate a murmur at some time Most innocent murmurs have these characteristics: soft, relatively short systolic ejection murmur; medium pitch; vibratory; and best heard at the left lower sternal or midsternal border, with no radiation to the apex, base, or back

Answer 40

The vital signs usually reveal that the resting pulse rate is increased by 10 to 15 beats per minute and that blood pressure is lower than the normal prepregnancy level The blood pressure decreases to its lowest point during the second trimester and then slowly rises during the third trimester-The blood pressure varies with position Usually lowest in left lateral recumbent position, a bit higher in the supine position, and highest in the sitting Inspection of the skin often reveals a mild hyperemia in light-skinned women because the increased cutaneous blood flow is an attempt to eliminate the excess heat generated by the increased metabolism Palpation of the apical impulse is higher and lateral than when the heart is in the normal position because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis Auscultation of the heart sounds reveals changes caused by the increased blood volume and workload: • Heart sounds: Exaggerated splitting of S1 and increased loudness of S1 A loud, easily heard S3 • Heart murmurs: A systolic murmur in 90%, which disappears soon after delivery Suspect pregnancy-induced hypertension with a sustained rise of 30 mm Hg systolic or 15 mm Hg diastolic under basal conditions A continuous murmur from breast vasculature is termed a mammary souffle - Mammary souffle occurs in 10% of women near term or when the mother is lactating; it is caused by increased blood flow through the internal mammary artery - The murmur is heard in the second, third, or fourth intercostal space; it is continuous, although it is accented in systole (\*\*You can obliterate it by pressure with the stethoscope or one finger lateral to the murmur - Murmurs of aortic valve disease cannot be obliterated \*\*) The ECG shows no changes except for a slight left axis deviation as a result of the change in the heart’s position.

Answer 41

gradual rise in systolic blood pressure is common in older patients - the diastolic blood pressure stays fairly constant - with a resulting widening of pulse pressure Some older adults experience orthostatic hypotension, a sudden drop in blood pressure when rising to sit or stand The chest often increases in anteroposterior diameter in older patients - This makes it more difficult to palpate the apical impulse and to hear the splitting of S2 The S4 often occurs in older people with no known cardiac disease - Systolic murmurs are common, occurring in more than 50% of older adults Occasional premature ectopic beats are common and do not necessarily indicate underlying heart disease \*\*When in doubt, obtain an ECG - consider that the ECG is a recording of only 1 isolated minute in time and may need to be supplemented by a test of 24-hour ambulatory heart monitoring\*\*

Answer 42

Decreased cardiac output occurs when the heart fails as a pump and the circulation becomes backed up and congested Signs and symptoms of heart failure come from two basic mechanisms: (a) the heart’s inability to pump enough blood to meet the metabolic demands of the body and (b) the kidney’s compensatory mechanisms of abnormal retention of sodium and water to compensate for the decreased cardiac output - This increases blood volume and venous return, which causes further congestion Onset of heart failure may be (a) acute, as after a myocardial infarction, when direct damage to the heart’s contracting ability has occurred, or (b) chronic, as with hypertension, when the ventricles must pump against chronically increased pressure

Answer 43

***Ejection Click***: occurs early in systole - results rom the opening of semilunar valves - normally the semilunar valves open silently however in the presence of stenosis their opening makes a sound - short , high pitched, with a click quality, heard better from stethoscope diagphragm - the aortic ejection click is heard at the second right interspace and apex - may be loudest at apex - intensity does not change with respiration - the pulmonic ejection is heard best at the left interspace and grows softer with inspiration ***Midsystolic (Mitral) Click***: the mitral valve leaflets not only close with contraction but balloon back up into the left atrium = During ballooning, the sudden tensing of the valve leaflets and the chordae tendineae creates the click - The sound occurs in mid- to late systole - short and high pitched, with a click quality - It is best heard with the diaphragm of the stethoscope at the apex, but it also may be heard at the left lower sternal border- The click usually is followed by a systolic murmur. The click and murmur move with postural change - when the patient assumes a squatting position, the click may sound sooner after S2, and the murmur may sound louder and delayed

Answer 44

Opening Snap: Normally the opening of the AV valves is silent - In the presence of stenosis, increasingly higher atrial pressure is needed to open the valve - The deformed valve opens with a noise: the opening snap - It is sharp and high pitched, with a snapping quality. It sounds after S2 and is best heard with the diaphragm of the stethoscope at the third or fourth left interspace at the sternal border - it is less well heard at the apex The OS usually is not an isolated sound - As a sign of mitral stenosis, the opening snap usually ushers in the low-pitched diastolic rumbling murmur of that condition

Answer 45

***Third Heart Sound***: The S3 is a ventricular filling sound - It occurs in early diastole during the rapid filling phase - Your hearing quickly accommodates to the S3, so it is best heard when you listen initially -dull, soft sound, and it is low pitched - at the apex - The S3 can be confused with a split S2. Use these guidelines to distinguish the S3: • Location: The S3 is heard at the apex or left lower sternal border; the split S2 is heard at the base • Respiratory variation: The S3 does not vary in timing with respirations; the split S2 does • Pitch: The S3 is lower pitched; the pitch of the split S2 stays the same The S3 may be normal (physiological) or abnormal (pathological) - The physiological S3 is heard frequently in children and young adults - it occasionally persists after age 40 years, especially in women -The normal S3 usually disappears when the patient sits up - In adults, the S3 is usually abnormal - The pathological S3 is also called a ventricular gallop or an S3 gallop, and it persists when the patient is sitting up - The S3 indicates decreased compliance of the ventricles, as in heart failure - The S3 may be the earliest sign of heart failure - The S3 may originate from either the left or the right ventricle - a left-sided S3 is heard at the apex in the left lateral position, and a right-sided S3 is heard at the left lower sternal border with the patient supine and is louder on inspiration Summation Sound (S3 + S4): quadruple rythm is heard - diastolic filling shortens and the s3 and s4 ove closer together - they sound sumperimposed - loud, prolonged, summated, and louder thn either S1 or S2

Answer 46

***Fourth Heart Sound***: S4 is a ventricular filling sound - ocurs when the atria contracts in late diastole - heard immediatly before S1 - soft, low pitch sound - heard best at apex with patient in left lateral position A *physiological S4* may occur in adults older than 40 to 50 yeards of age with no evidence of CVD especially after exercise A *pathological S4* is known as a atrial gallop or an S4 gallop - occurs with decreased compliance of the ventricle and with systolic overload including outflow obstruction to the ventricle and systemic hypertension - left sided S4 is heard best at apex in left lateral position A *right sided S4* is less common - heard at the left lower sternal border and may increase with inspiration - occurs with pulmonary stenosis or pulmonary hypertension

Answer 47

***Pericardial Friction Rub***: inflammation of the pericardium gives rise to a friction rub - sound is high pitched ad scratchy - heard when patient is sitting up and leaning forward with breath held at expiration - best heard at apex and left lower sternal border

Answer 48

***Base***: A *thrill* in the second and third right interspaces occur with severe aortic stenosis and systemic hypertension - A thrill in the 2nd and 3rd left interspaces occurs with pulmonic stenosus and pulmonic hypertension ***Left Sternal Border***: A *lift (heave)* occurs with right ventricular hypertrophy, as found in pulmonic valve disease, pulmonic hypertension, and chronic lung disease - you feel a diffuse lifting impulse during systole at the left lower sternal borde - may be associated with retraction at the apex because the left ventricle is rotated posteriorly by the enlarged right ventricle ***Apex***: Cardiac enlargement displaces the apical impulse laterally and over a wider area when left ventricular hypertrophy and dilatation are present -This is volume overload, which occurs in mitral regurgitation, aortic regurgitation, and left-to-right shunts - The apical impulse is increased in force and duration but is not necessarily displaced to the left when left ventricular hypertrophy occurs alone without dilatation -This is pressure overload, which occurs in aortic stenosis or systemic hypertension

Answer 49

***Patent Ductus Arteriosus (PDA)***: Persistence of the channel joining left pulmonary artery to aorta - This is normal in the fetus and usually closes spontaneously within hours of birth - S: Usually no symptoms in early childhood; growth and development are normal - O: Blood pressure has wide pulse pressure and bounding peripheral pulses from rapid runoff of blood into low-resistance pulmonary bed during diastole. Thrill often palpable at left upper sternal border. The continuous murmur heard in systole and diastole is called a machinery murmur ***Atrial Septal Defect (ASD)***: Abnormal opening in the atrial septum, resulting usually in left-to-right shunting of blood and causing a large increase in pulmonary blood flow - S: Defect is remarkably well tolerated. Symptoms in infants are rare; growth and development are normal. Affected children and young adults have mild fatigue and DOE - O: Sternal lift often present. S2 has fixed split, with P2 often louder than A2. Murmur is systolic ejection, medium pitch, best heard at base in second left interspace. Murmur caused not by shunting itself but by increased blood flow through pulmonic valve ***Ventricular Septal Defect (VSD)***: Abnormal opening in septum between the ventricles, usually in subaortic area. The size and exact position vary considerably - S: Small defects are asymptomatic. Infants with large defects have poor growth, slow weight gain; later look pale, thin, and delicate. Affected infants may have feeding problems; DOE; frequent respiratory infections; and, when the condition is severe, heart failure - O: Loud, harsh holosystolic murmur, best heard at left lower sternal border, may be accompanied by thrill. Large defects also produce soft diastolic murmur at apex (mitral flow murmur) as a result of increased blood flow through mitral valve

Answer 50

***Tetralogy of Fallout***: Four components: (a) right ventricular outflow stenosis, (b) VSD, (c) right ventricular hypertrophy, and (d) overriding aorta. The result is a large amount of venous blood shunted directly into aorta away from pulmonary system, so that blood is never oxygenated - S: Severe cyanosis, not in first months of life but developing as infant grows and RV outflow (i.e., pulmonic) stenosis gets worse. Cyanosis initially with crying and exertion, then at rest. Affected child uses squatting posture after starts walking. DOE common. Growth and development are slowed. - O: Thrill is palpable at left lower sternal border. S1 is normal; in S2, A2 is loud and P2 is diminished or absent. Murmur is systolic, loud, crescendo–decrescendo ***Coarctation of the Aorta***: Severe narrowing of descending aorta, usually at the junction of the ductus arteriosus and the aortic arch, just distal to the origin of the left subclavian artery. Results in increased workload on left ventricle. Associated with defects of aortic valve in most cases, as well as associated patent ductus arteriosus and associated VSD - S: In infants with associated lesions or symptoms, diagnosis occurs in first few months as symptoms of heart failure develop. For affected children and adolescents without symptoms, growth and development are normal. Diagnosis is usually incidental, as a result of blood pressure findings. Adolescents may complain of vague lower extremity cramping that is worse with exercise - O: Upper extremity hypertension, with readings 20 mm Hg higher than those of lower extremity, is a hallmark of coarctation. Another important sign is absence of or greatly diminished femoral pulses. A systolic murmur is heard best at the left sternal border, radiating to the back

Answer 51

**Midsystolic Ejection Murmurs:** ***Aortic Stenosis***: Calcification of aortic valve cusps restricts forward flow of blood during systole; hypertrophy of LV develops - S: Fatigue, DOE, palpitation, dizziness, fainting, and anginal pain are present - O: Pallor, slow diminished radial pulse, low blood pressure, and auscultatory gap are common. Apical impulse is sustained and displaced to left. Thrill occurs in systole over second and third right interspaces and right side of neck. S1 is normal; ejection click is often present, paradoxical split S2 is often present, and S4 is present with hypertrophy of LV. Murmur is loud, harsh, midsystolic, crescendo–decrescendo, and loudest at second right interspace; it radiates widely to side of neck, down left sternal border, or to apex ***Pulmonic stenosis***: Calcification of pulmonic valve restricts forward flow of blood - O: Thrill occurs in systole at second and third left interspace, ejection click is often present after S1, S2 is diminished and usually with wide split, and S4 is common with hypertrophy of RV. Murmur is systolic, medium pitch, coarse, crescendo– decrescendo (diamond shape), and best heard at second left interspace, and it radiates to left and neck.

Answer 52

**Pansystolic Regurgitant Murmurs:** ***Mitral Regurgitation*:** Stream of blood regurgitates back into LA during systole through incompetent mitral valve. In diastole, blood passes back into LV again along with new flow; results in dilatation and hypertrophy of LV - S: Fatigue, palpitation, orthopnea, and PND are common - O: Thrill occurs in systole at apex. Lift occurs at apex. Apical impulse is displaced down and to left. S1 is diminished, S2 is accentuated, S3 at apex is often present. Murmur is pansystolic, often loud, blowing, and best heard at apex, and it radiates well to left axilla ***Tricuspid Regurgitation***: Backflow of blood through incompetent tricuspid valve into RA - O: Neck veins are engorged and pulsating; liver is enlarged. Lift occurs at sternum if RV is hypertrophied; a thrill is often present at left lower sternal border - Murmur is soft, blowing, pansystolic, and best heard at left lower sternal border, and it increases with inspiration

Answer 53

**Diastolic Rumbles of AV valves:** ***Mitral Stenosis***: Calcified mitral valve does not open properly, impedes forward flow of blood into LV during diastole - Results in enlargement of LA and increasing pressure in LA - S: Fatigue, palpitations, DOE, orthopnea are common; PND or pulmonary edema occasionally occur. - O: Arterial pulse is diminished and often irregular. Lift occurs at apex; diastolic thrill is common at apex. S1 isaccentuated; opening snap after S2 is heard over wide area of precordium, followed by murmur. Murmur is a low-pitched diastolic rumble, best heard at apex with patient in left lateral position; it does not radiate ***Tricuspid Stenosis***: Calcification of tricuspid valve impedes forward flow into RV during diastole - O: Arterial pulse is diminished; jugular venous pulse is prominent - Murmur is a diastolic rumble; it is best heard at left lower sternal border and is louder in inspiration

Answer 54

**Early Diastolic Murmurs:** ***Aoritc Regurgitation***: Stream of blood regurgitates back through incompetent aortic valve into LV during diastole. Dilatation and hypertrophy of LV are caused by increased stroke volume of LV. Large stroke volume is ejected rapidly into poorly filled aorta - then rapid runoff occurs in diastole as part of blood is pushed back into LV - S: Affected patients have only minor symptoms for many years and then rapid deterioration: DOE, PND, angina, dizziness - O: Bounding “water-hammer” pulse is present in carotid,brachial, and femoral . Blood pressure has wide pulse pressure. Pulsations are palpable in cervical and suprasternal areas; apical impulse is displaced to left and down and feels brief. Murmur starts almost simultaneously with S2: It is soft, high-pitched, blowing diastolic, and decrescendo, best heard at third left interspace at base; as patient sits up and leans forward, murmur radiates down ***Pulmonic Regurgitation***: Blood flows backward through incompetent pulmonic valve, from pulmonary artery to RV - Murmur has same timing and characteristics as that of aortic regurgitation, and the two are hard to distinguish on physical examination

Answer 55

The heart pumps freshly oxygentad blood throuh the arteries to all body tissues - the artery walls are strong, tough, and tense to withstand pressure - arteries contain elastic fibers which allows their walls to stretch with systole and recoil with diastole Arteries also contain muscle fibres (Vascular smooth muscle) which controls the amount of blood delievered to tissues - the vascular smooth muscle contracts and ilates which changes the diameter of arteries to control the rate of blood flow Each heartbeat creates pressure waves - which makes the arteries expand and then recoil - its the recoil that causes the blood to propel like a wave - all arteroes have this pressure wave or ***Pulse*** throughout the length and you can only feel the pulse when the artery lies close to the skin or over the bone

Answer 56

***Temporal Artery***: palpated in front of the ear ***Carotid Artery***: palpated in the groove between the sternomastoid muscle and the trachea ***Arteries in the arm***: (1) ***Brachial Artery:*** runs in the biceps - triceps furrow of the upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendon - (2) ***Ulnar & Radial Arteries*** is what the brachial artery bifurcates into - they form distally and form two arches which supply he hand these two arches are called the superficial ad deep palmar arches *The Radial Pulse can be palpated medial to the radius at the wrist; The Ulnar Artery is located in the same relation to the ulna but it is deeper and difficult to feel*

Answer 57

The major arterty is the ***Femoral Artery*** it passes under inguinal ligament - travels fown the thigh - travels down the lower thigh it courses posteriorly and it turns into ***Popliteal Artery***- below the knee this artery divides into the ***Anterior Tibial Artery*** which travels down the front of the leg and on the dorsum of the foot where it becomes the Dorsalis Pedis In the back of the leg, the ***Posterior Tibial Artery*** travels down behind the medial malleolus and forms the ***plantar arteries*** in the foot

Answer 58

supply oxygen and essential nutrients to the tissues ***Ischemia*** is a deficient supply of oxygenated arteria blood to a tissue caused by an obstruction of the blood vessel - a complete blockage causes death to the distal tissue - a partial blockage causes the supply to be insufficient and this blockage may be apparent during exercise (when oxygen needs increase) ***Peripheral Artery Disease (PAD)*** affects noncoronary arteries and usually refers to arteries supplying the limbs - It usually is caused by atherosclerosis, and less commonly by embolism, hypercoagulable states, or arterial dissection

Answer 59

Veins run parallel to arteries The body has more veins and they closer to the skin surface

Answer 60

***Jugular Veins*** ***Veins in the Arm***: each arm has two sets of veins which are superficial and deep - superficial veins are in the subcutaneous tissue and are responsible for most of the venous return ***Veins in the Leg***: There are three types of veins in the legs 1) ***Deep Veins***: run alongside the deep arteries and conduct most of the venous return from the legs - these are the ***fermoral and popliteal veins*** \*\*as long as veins remain intact, the superficial veins can be excised w/o harming circulation\*\* 2) ***Superficial Veins***: are the ***great and smal Saphenous veins*** - the ***great saphenous veins*** inside the leg starts at the medial side of the dorsum of the foot - you can see it ascend in front of the medial malleolus then it crosses the tibia obliquely and ascends along medial side of thigh - the ***small saphenous vein*** in the outer portion of the leg which starts at the lateral side of the dorsum of the foot and asceds behind the lateral malleolus and up in the back of the leg where it joins the popliteal vein * \*\* blood flows from the superficial veins into the deep leg veins\*\** 3) ***Perforators**:* are connecting veins that join the two sets - they also have one way valves that route blood from the superficial veins into the deep veins and prevet reflux into the superficial veins

Answer 61

Veins drai deoxygenated blood ad its waste products from the tissues and return it to the heart - veins are a low pressure system b/c of this they need a mechanism to keep blood moving - this movement is accompolished by (a) the contracting skeletal muscles that milk the blood proximally, back toward the heart (b) the pressure gradient caused by breathing, in which inspiration maes the thoracic pressure decrease and the abdominal pressure increase (c) the intraluminal valves which ensure unidorectional flow - each valve is a paired semilunar pocket that open towards the heart and closes tightly when filled to prevet backflow of blood

Answer 62

***Calf Pump or Peripheral Heart:*** during walking the calves alternately contract (systole) and relax (diastole) - in the contraction phase the gastrocnemius and soleus muscles squeeze the veins and direct the blood flow proximally - b/c of the valves venous blood flows occur one way toward the heart Venous structure differs from Aterial structure - vein walls are thinner than arteries - veins have a larger diameter than arteries - veins are more distensible than arteries - veins can expand and hold more blood when blood volume increases compared to arteries (this is a compensantory mechanism to reduce stress on the heart b/c of this ability to stretch the veins are called ***Capacitance vessels***)

Answer 63

Efficient venous return is dependent on contracting skeletal muscles, comptent valves, and patent lumen - problems with any three of these elements leads to venous stasis The risk for venous disease is increased by prolonged standing,sitting, or bed rest because of the absence of the milking action that walking accomplishes Hypercoagulable states and vein wall trauma are other factors that increase risk for venous disease dilated and tortuous (Varicose) veins have incompetent valves - wherein the lumen is wide so the valve cusps cannot approximate - this condition increase venous pressure which further dilates the vein

Answer 64

The lymphatics form a seperate vessel system which retrieves excess fluid from the tissue spaces and returns it to the bloodstream during the circulation of blood more fluid exits the capillaries than the veins can absorb, without lymphatic drainage the fluid would build up in the interstitial spaces and poduces edema

Answer 65

1. Right Lymphatic Duct: empties into the right subclavian vein - it drains the right side of the heaad and neck, right arm right side of thorax, right lung and pleura, right side of the heart , right upper section of liver 2. Thoracic Duct: drains the rest of the body and empties into the left subclavian vein

Answer 66

(a) to conserve fluid and plasma proteins that leak out of capillaries (b) to form a major part of the immune system that defends the body against disease (c) to abosrb lipids from the intestinal tract the lymphatic system detects and elimnates foreign pathogens - both those that come from environmental and arising from the inside - this is accomplished by phagocytosis of substances by neutrophils and by monocytes or macrophages as as by the poduction of specific antibodies or specific immune response by lymphocytes

Answer 67

The lymphatic vessels have a unique structure - Lymphatic capillaries start as microscopic open-ended tubes -The capillaries converge to form small vessels. The small vessels, like veins, drain into larger ones - The vessels have valves, and so flow is in one direction from the tissue spaces into the bloodstream -The flow of lymph is slower than that of the blood - Lymph flow is propelled by contracting skeletal muscles, by pressure chanfes secondary to breathing, and by contractio of the vessel walls themselves

Answer 68

Lymph nodes are small oval clumps of lymphatic tissue located at intervals along the vessels - most nodes are arranged in groups both deep and superficial - nodes filter the fluid before it returns to the bloodstream - pathogens are exposed to lymphocytes in the lymph nodes - lymphocytes have an antigen specific response to eliminate pathogens \*\*when inflammation occurs nodes in the area become swollen and tender\*\*

Answer 69

***Cervical nodes:*** drain the head and neck ***Axillary nodes:*** drain the breast and upper arm ***The epitrochlear node:*** is in the antecubital fossa and drains the hand and lower arm ***The inguinal nodes:*** in the groin drain most of the lymph of the lower extremity, the external genitalia, and the anterior abdominal wall

Answer 70

***Spleen***: located in left upper quadrant of the abdomen - it has four functions (a) destroy old rbc's (b) produce antibodies (c) store rbc's (d) filter micro-organisms from the blood ***Tonsils***: (palatine, pharyngeal, and lingual) are located at the entrance to the respiratory and gastro-intestinal tracts and respond to local inflammation ***Thymus Gland***: is flat, pink-grey, and located in the superior mediastinum behind the sternum and in front of the aorta - It is relatively large in the fetus and young child and atrophies after puberty - It is important in developing the T lymphocytes of the immune system in children, but it serves no function in adults - The T and B lymphocytes originate in the bone marrow and mature in the lymphoid tissue.

Answer 71

The lymphatic system has the same function in children as in adults Lymphoid tissue is well developed at birth and grows rapidly until age 10 or 11 year - By age 6 years, the lymphoid tissue reaches adult size; it surpasses adult size by puberty, and then it slowly atrophies - It is possible that the excessive antigen stimulation in children causes the early rapid growth Lymph nodes are relatively large in children, and the superficial ones are often palpable even in healthy children Enlargement of the tonsils is a familiar sign in respiratory infections The excessive lymphoid response also may account for the common childhood symptom of abdominal pain with seemingly unrelated problems such as upper respiratory infections *\*\*Possibly, the inflammation of mesenteric lymph nodes produces the abdominal pain\*\**

Answer 72

Hormonal changes cause vasodilatation and the resulting drop in blood pressure in the first and second trimesters The growing uterus obstructs drainage of the iliac veins and the inferior vena cava - This condition lowers blood flow and increases venous pressure - These developments, in turn, cause dependent edema, varicosities in the legs and vulva, and hemorrhoids

Answer 73

Peripheral blood vessels grow more rigid with age, whichresults in arteriosclerosis - This condition produces the rise in systolic blood pressure PAD is a common, serious disease that is underdiagnosed, misdiagnosed, and undertreated PAD is a condition characterized by atherosclerotic occlusive disease of the lower extremities and is a major risk factor for lower extremity amputation. many people remain at risk for preventable heart attacks and strokes Aging produces a progressive enlargement of the intramuscular calf veins - Prolonged bed rest, prolonged immobilization, and heart failure increase the risk for deep vein thrombosis (DVT) and subsequent pulmonary embolism - These conditions are common in aging and also with malignancy and myocardial infarction (MI) Low-dose anticoagulant medication reduces the risk for venous thromboembolism Loss of lymphatic tissue leads to fewer numbers of lymph nodes in older people and to a decrease in the size of remaining nodes

Answer 74

1. leg pain or cramps: any leg pain (cramps) ? Where ? type of pain ? is it aggravated by walking or activity ? 2. Skin changes on arms or legs: Any skin changes in arms or legs ? what colour ? ( ***Varicose veins*** are swollen, twisted, and sometimes painful veins that have filled with an abnormal collection of blood. occur with chronic arterial and chronic venous disease) 3. Swelling in arms or legs: Do you have swellig in one or both legs ? (***Edema*** is bilateral when caused by a systemic problem such as heart failure or unilateral when it is the result of a local obstruction or inflammation) 4. Lymph node enlargement: any swollen glands ? where in body ? how log have you had them ? (Lymph nodes enlarge with infection, malignancies, and immunological diseases) 5. Medication: What medication are you taking ?

Answer 75

Lift both the patient’s hands in your hands. Inspect, then turn the patient’s hands over, noting colour of skin and nail beds; temperature, texture, and turgor of skin; and the presence of any lesions, edema, or clubbing With the patient’s hands near the level of his, her, or their heart, check capillary refill. This is an index of peripheral perfusion and cardiac output. Note conditions that can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia. Refill time of more than 1 or 2 seconds signifies vasoconstriction or decreased cardiac output (hypovolemia, heart failure, shock) The two arms should be symmetrical in size - Edema of upper extremities occurs when lymphatic drainage is obstructed, which may occur after breast surgery Palpate radial pulses bilaterally, noting rate, rhythm, elasticity of vessel wall, and equal force Grade the force (amplitude) on a four-point scale: 3+: increased, full, bounding 2+: normal 1+: weak 0: absent Check the epitrochlear lymph node in the depression above and behind the medial condyle of the humerus - Do this by “shaking hands” with the patient and reaching your other hand under the patient’s elbow to the groove between the biceps and triceps muscles, above the medial epicondyle

Answer 76

Uncover the patient’s legs while keeping the genitalia draped - Inspect both legs together, noting skin colour, hair distribution, venous pattern, size (swelling or atrophy), and any skin lesions or ulcers Both legs should be symmetrical in size without any swelling or atrophy If the lower legs look asymmetrical or if DVT is suspected, measure the calf circumference with a nonstretchable tape measure Measure at the widest point, taking care to measure the other leg in exactly the same place: the same number of centimetres down from the patella or other landmark. If lymphedema is suspected, measure also at the ankle, distal calf, knee, and thigh. Record your findings in centimetres Palpate the inguinal lymph nodes - It is not unusual to find palpable nodes that are small (1 cm or less), movable, and nontender Palpate the peripheral arteries in both legs: femoral, popliteal, dorsalis pedis, and posterior tibial Locate the femoral arteries just below the inguinal ligament, halfway between the pubis and anterior superior iliac spines To help expose the femoral area, particularly in obese patients, ask the patient to bend the knees to the side in a froglike position. Press firmly and then slowly release, noting the pulse tap under your - fingertips auscultate the site for a bruit The ***popliteal pulse*** is a more diffuse pulse and can be difficult to localize If you have difficulty with this manoeuvre, turn the patient prone and lift up the lower leg - Let the leg relax against your arm, and press in deeply with your two thumbs - Often a normal popliteal pulse is impossible to palpate For the ***posterior tibial pulse***, curve your fingers around the medial malleolus The ***dorsalis pedis pulse*** requires a very light touch. Normally the pulse is just lateral to and parallel with the extensor tendon of the big toe ***If pitting edema is present, grade it on the following scale:*** 1+: Mild pitting, slight indentation, no perceptible swelling of the leg 2+: Moderate pitting, indentation subsides rapidly 3+: Deep pitting, indentation remains for a short time, swelling of leg 4+: Very deep pitting, indentation lasts a long time, gross swelling and distortion of leg

Answer 77

Colour change: if you suspect an aterial deficit - raise the legs approximately 30cm off the table- light skinned people with be paler - then have the patient sit up with legs over the side table note the time it takes the time for the colour it should take 10 seconds or less - normal time is 15 seconds for superficial veins Test test the lower legs for sensation and strength The dopplet ultrasonic Stethoscope: is to detect a weak peripheral pulse to monitor bp in infants or children - it magnifies pulsatile sounds from the heart and blood vessels - position the patient supine - make sure legs are externally roated so the medial ankles are accesible

Answer 78

Pulse force should be normal and symmetrical - Pulse force also should be the same in the upper and lower extremities Lymph nodes are often palpable in healthy infants and children - They are small, firm (shotty), mobile, and nontender Vaccinations also can produce local lymphadenopathy Note characteristics of any palpable nodes and whether they are local or generalized

Answer 79

Expect diffuse bilateral pitting edema in the lower extremities, especially at the end of the day and into the third trimester Varicose veins in the legs also are common in the third trimester

Answer 80

The dorsalis pedis and posterior tibial pulses may become more difficult to find Trophic changes associated with arterial insufficiency (thin, shiny skin, thick-ridged nails, loss of hair on lower legs) also occur normally with aging

Answer 81

1. checking your feet everyday: cut, swelling, bruising, discoloartion, check nails 2. Keep blood flowing to the legs 3. Wearing shoes that fit and are comfortable 4. Keeping skin soft and smooth 5.

Answer 82

1. ***Weak "Thready" pulse 1+***: hard to palpate - hard to fid - may fade in and out - easily oblierated by pressure - it is associated with decreased cardiac output; peripherial aterial disease; arotic valve stenosis 2. ***Full, Bounding pulse 3+***: Easily palpable, pounds under examiner’s fingertips - Hyperkinetic states (exercise, anxiety, fever), anemia, hyperthyroidism 3. ***Water - Hammer (Corrigan's) Pulse 3+***: Greater than normal force, then sudden collapse - Aortic valve regurgitation; patent ductus arteriosus 4. ***Pulsus Bigeminus***: Coupled rhythm, wherein every other beat comes early or normal beat is followed by premature beat; force of premature beat is decreased because of shortened cardiac filling time - Conduction disturbance (e.g., premature ventricular contraction, premature atrial contraction) 5. ***Pulsus Alternans***: Regular rhythm, but force varying with alternating beats of large and small amplitude - When heart rate is normal: pulsus alternans occurs with severe left ventricular failure, which in turn is caused by ischemic heart disease, valvular heart disease, chronic hypertension, or cardiomyopathy 6. ***Pulsus Paradoxus***: Amplitude of beats: weaker with inspiration, stronger with expiration; rhythm best determined during blood pressure measurement; pressure decreases (\>10 mm Hg) during inspiration and increases with expiration - A common finding in cardiac tamponade (pericardial effusion in which high pressure compresses the heart and blocks cardiac output); also in severe bronchospasm of acute asthma 7. ***Pulsus Bisferiens***: Two strong systolic peaks, with a dip in between, in each pulse; best assessed at the carotid artery - Aortic valve stenosis plus regurgitation

Answer 83

This condition is characterized by episodes of abrupt progressive tricolour change of the fingers in response to cold, vibration, or stress: (a) white (pallor) from arteriospasm and resulting deficit in supply (b) blue (cyanosis) from slight relaxation of the spasm that allows a slow trickle of blood through the capillaries and increased oxygen extraction of hemoglobin (c) red (rubor) in heel of hand because of return of blood into the dilated capillary bed or reactive hyperemia Cold, numbness, or pain may accompany the pallor or cyanosis stage; then burning, throbbing pain, and swelling occur with rubor Lasts minutes to hours; occurs bilaterally - Several medications predispose episodes, and smoking can increase the symptoms

Answer 84

Lymphedema is high-protein swelling of the limb, most commonly caused by breast cancer treatment Surgical removal of lymph nodes with breast surgery or damage to lymph nodes and vessels with radiation therapy for breast cancer can impede drainage of lymph Protein-rich lymph builds up in the interstitial spaces, which further raises local colloid oncotic pressure and promotes more fluid leakage Stagnation of lymphatic fluid can lead to infection, delayed wound healing, chronic inflammation, and fibrosis of surrounding tissue Lymphedema after breast cancer is common but usually mild - Obesity increases risk Early symptoms include self-reported sensations of “tired,” thick, heavy arm; tightness of jewellery; swelling; and tingling sensation Objective data include a unilateral swelling and nonpitting brawny edema, with induration of overlying skin

Answer 85

Arterial ulcers result from the buildup of fatty plaques on intima (atherosclerosis) plus hardening and calcification of the arterial wall (arteriosclerosis) S: Deep muscle pain in calf or foot, claudication (pain with walking), pain at rest (indicative of worsening of condition) O: Coolness, pallor, elevational pallor, and dependent rubor; diminished pulses; systolic bruits; trophic skin; signs of malnutrition (thin, shiny skin, thick-ridged nails, absence of hair, atrophy of muscles); xanthoma formation; distal gangrene Ulcers occur at toes, metatarsal heads, heels, and lateral ankle and are characterized by pale ischemic base,well-defined edges, and no bleeding

Answer 86

Venous ulcers occur after acute DVT or with chronic incompetent valves in deep veins S: Aching pain in calf or lower leg, worse at end of the day, worse with prolonged standing or sitting O: Firm, brawny edema; coarse, thickened skin; normal pulses; brown pigment discoloration; petechiae; dermatitis Venous stasis causes increased venous pressure, which then causes RBCs to leak out of veins and into the skin The RBCs break down and leave hemosiderin (iron deposits) behind, which are the brown pigment deposits Ulcers occur at medial malleolus and are characterized by bleeding and uneven edges.

Answer 87

Diabetes hastens changes described with ischemic ulcer, with generalized dysfunction in all arterial areas: peripheral, coronary, cerebral, retinal, and renal Peripheral involvement is associated with diabetic neuropathy and local infection Without careful vigilance of pressure points on the feet, an ulcer may go unnoticed Pain and other sensation are decreased, and surrounding skin is callused

Answer 88

It is a Chronic Venous Disease Incompetent valves allow reflux of blood, which causes veins to become dilated and tortuous Unremitting hydrostatic pressure causes distal valves to be incompetent and causes worsening of the varicosity After age 45 years, occurrence is three times more common in women than in men S: Aching, heaviness in calf, easy fatigability, night leg or foot cramps O: Dilated, tortuous veins

Answer 89

It is a Acute Venous Disease A deep vein is occluded by a thrombus, which causes inflammation, blockage of venous return, cyanosis, and edema Virchow’s triad consists of the classical three factors that promote thrombogenesis: (a) stasis, (b) hypercoagulability, and (c) endothelial dysfunction. Cause may be prolonged bed rest; history of varicose veins; trauma; infection; cancer; and, in younger women, the use of oral estrogenic contraceptives Note that upper extremity deep venous thrombophlebitis is increasingly common because of the frequent use of invasive lines such as central venous catheters S: Sudden onset of intense, sharp, deep muscle pain; may increase with sharp dorsiflexion of foot O: Increased warmth; swelling (to compare swelling, observe the usual shoe size); redness; possibly mild dependent cyanosis; tenderness to palpation

Answer 90

Occlusions in the arteries are caused by atherosclerosis, which is the chronic gradual buildup of (in order) fatty streaks, fibroid plaque, calcification of the vessel wall, and thrombus formation Occlusions reduce blood flow, which reduces the availability of vital oxygen and nutrients Risk factors for atherosclerosis include obesity, cigarette smoking, hypertension, diabetes mellitus, elevated serum cholesterol level, sedentary lifestyle, and family history of dyslipidemia

Answer 91

An aneurysm is a sac formed by dilation in the artery wall Atherosclerosis weakens the middle layer (media) of the vessel wall. This stretches the inner and outer layers (intima and adventitia), and the effect of blood pressure creates the balloonlike enlargement The most common site is the aorta, and the most common cause is atherosclerosis The incidence increases rapidly in men older than age 55 years and in women older than age 70 years; the overall occurrence is four to five times more frequent among men

Week 8 - Ch. 20 & 21 Flashcards

(121 cards)