Bates Chapter 16 Cardiovascular

Displacement of the PMI lateral to the midclavicular line or >10cm lateral to the midsternal line occurs in?

Left ventricular hypertrophy (LVH). et in ventricular dilation from MI or heart failure

The bell is more sensitive to ?

-low pitched sounds of S3 and S4 -murmur of mitral stenosis

Normal left ventricular PMI classical descriptors?

Location: 4th or 5th Left intercostal space, midclavicular line Diameter: Discrete, or <=2cm Amplitude: Brisk and tapping Duration: <=2/3 of systole

Systolic Grade 3/6

Louder in volume than S1 and S2, moderately loud

Systolic Grade 4/6

Louder in volume than S1 and S2, with palpable thrill

Systolic Grade 5/6

Louder in volume than S1 and S2, with thrill; may be heard when stethoscope is partly off chest

Systolic Grade 6/6

Louder in volume than S1 and S2, with thrill; may be heard with stethoscope entirely off the chest

Pansystolic (holosystolic) murmurs are?

Pathologic, arising from blood flow from a chamber w/ high pressure to one of lower pressure, through a valve or other structure that should be closed. Begins immediately w/ S1 et continues up to S2 -Mitral regurgitation -Tricuspid Regurgitation -Ventricular Septal Defect

An S3 or ventricular gallop, may be pathologic or physiologic, In adults over 40, an S3 is usually?

Pathologic, arising from high left ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the rapid end of the filling phase of diastole.

In older adults an S3 "S3 gallop" usually indicates?

Pathology

Ejection Fraction (EF)?

Percentage of ventricular volume ejected during each heartbeat and is normally 60%

What is paradoxical pulse found in?

Pericardial tamponade (life threatening), Acute asthma, Obstructive pulmonary disease (COPD), Constrictive pericarditis, Acute pulmonary embolism

Liver failure or ascites may present with these symptoms?

Periorbital puffiness et tight rings of nephrotic syndrome et an enlarged waistline

A middiastolic murmur and PreSystolic murmur would reflect?

Turbulent flow across the Atrioventricular valves (mitral et tricuspid valves

Chest wall location: Right 2nd Intercostal space or cardiac apex, what is the typical origin of sound?

Typical origin of sound et murmur: Aortic Valve

Chest wall location: At or around the cardiac apex, where is the typical origin of sound?

Typical origin of sound et murmur: Mitral Valve

Chest wall location: Left 2nd et 3rd intercostal spaces close to the sternum, but also higher or lower levels, what is the typical origin of sound?

Typical origin of sound et murmur: Pulmonic Valve

Chest wall location: At or near the lower left sternal border, where is the typical origin of sound?

Typical origin of sound et murmur: Tricuspid valve

Listen for a right sided S3?

Typically heard along the lower left sternal border or below the xiphoid with the pt supine supine and is heard louder on inspiration

Although JVP accurately predicts elevations in fluid volume in heart failure, its prognostic value for heart failure outcomes and mortality is?

Unclear

a large pericardial effusion may make the apical impulse?

Undetectable

A tortuous et kinked carotid artery may produce a?

Unilateral pulsatile bulge

Both men et women with acute coronary syndrome usually present with classic symptoms of exertional angina, However women typically over 65 are more likely to present with atypical s/s that may go unrecognized such as?

Upper back, neck, or jaw pain, SOB, Paroxysmal Nocturnal dyspnea, N/V, Fatigue

When should you begin routine screening for individual risk factors et for any family history of premature heart disease (age <55 in 1st degree male relatives et <65 in 1st female relatives?

at 20 yrs old

absent a waves signal what?

atrial fibrillation

Diastolic Grade 1/4

barely audible

When A2 or P2 is absent as in aortic or pulmonic valve disease, the S2 sound typically splits into two components, however in this it is?

Persistently single

Systolic murmurs point to valvular disease but can also be?

Physiologic arising from normal heart valves

When obtaining a BP if the arm is at higher levels, the BP will be?

Lower

In conditions where you anticipate the JVP will be low, what may need done to see the point of oscillation best?

Lower the bed, even 0 degrees

Where does dependent edema occur?

Lowest body parts (feet, lower legs when sitting or sacrum when bedridden)

The pressure when sounds are heard throughout the cycle is the ?

Lowest systolic pressure.

Palpation of the chest is less useful in?

Pts with a thickened chest wall (obesity) or increased AP diameter (obstructive lung disease)

In pts with severe heart failure, during the valsalva maneuver, BP will?

Remain elevated et korotkoff sounds are heard during the phase 2 strain phase, but NOT during phase 4 release, termed "the square wave" response. Highly correlated with volume overload, elevated LV End diastolic pressure, in some studies outperforming BRAIN NATRIURETIC PEPTIDE

Pulsus Paradoxus varies with?

Respiration

BMI goal for CVD risk factors?

<= 25 kg/m2 waist circumference <=40" men <=35" women

A difference between these levels constitutes a paradoxical pulse?

>= 10mm Hg to 12 mm Hg

What is dextrocardia with situs inversus?

A rare congenital transposition of the heart, heart is situated in the right chest cavity and generates a right sided apical impulse. Use percussion to help locate the heart border, the liver, et stomach.

A simplified way to remember the three peaks is:

A: Atrial contraction C:Carotid transmission (although this may represent closure of the tricuspid valve V: Venous filling

Atrial or Nodal Premature Contractions (Supraventricular)?

Aberrant P wave Normal QRS T Rhythm--A beat of atrial or nodal origin comes earlier than the next expected normal beat. A pause follows, then rhythm resumes Heart Sounds-- S1 may differ in intensity from the S1 of normal beats, and S2 may be decreased

Anterior chest pain, often tearing or ripping et radiating into the back or neck, occurs in?

Acute Aortic Dissection

Diastolic Murmurs?

Always pathologic -2 basic types in adults -Early decrescendo signify regurgitant flow through an incompetent semilunar valve, usually the aortic -Rumbling in mid to late diastole point point to stenosis of an AV Valve usually the mitral -less common More difficult to hear and require more meticulous examination -Aortic Regurgitaion -Mitral Stenosis

Listen for left sided S3 in what position?

At the Apex in the left lateral decubitus position

bruits are typically caused by?

Atherosclerotic luminal stenosis

In what cardiac defect is S4 not heard?

Atrial Fib bc there are no atrial contractions

Although not often heard in normal adults, a fourth heart sounds S4, marks?

Atrial contraction. It immediately precedes S1 of the next beat et can also reflect a pathologic ventricular stiffness, as seen in HTN, or Myocardial Infarction

The mitral and tricuspid valves are called?

Atrioventricular valves

How can murmurs of mitral regurgitation et ventricular septal defect be differentiated from other systolic murmurs?

Augmentation of their intensity with handgrip et during transient arterial occlusion

The presence of a thrill changes the grading of murmur, if you notice a an underlying turbulent flow what next step should you do?

Auscultate the same area for murmurs, once a murmur is detected it is easier to palpate a thrill in the position that accentuates the murmur

In children et young adults a third heart sound, S,3,?

May arise from rapid deceleration of the column of blood against the ventricular wall

What presentation would be seen with a markedly dilated failing heart?

May have a hypokinetic apical impulse displaced far to the left

the higher the grade of stenosis, what happens to the frequmcy of the sound?

May have lower frequency or even absent sounds, More amenable to detection with the bell

Bigeminal Pulse is?

May mimic Pulsus Alternans, is caused by a normal beat alternating with a premature contraction. The stroke volume of the premature beat is diminished in relation to that of normal beats, and the pulse varies in amplitude accordingly

Roughly half of women with chest pain and normal angiograms have?

Microvascular coronary dysfunction

Causes of chest pain in the absence of obstructive coronary artery disease on angiogram include?

Microvascular coronary dysfunction et Abnormal cardiac nocioception (requires special testing)

What are the most common murmurs?

Midsystolic ejection

Irregularly Irregular AFIB and Atrial Flutter with Vary AV block

No P waves and fibrillation waves Rhythm-- The ventricular rhythm is totally irregular, although short runs of the irregular ventricular rhythm may seem regular Heart Sounds-- S1 varies is intensity

SPORADIC Ventricular Premature Contractions (Ventricular bigeminy or trigeminy)?

No P waves, Aberrant QRS and T waves Rhythm-- A beat of ventricular origin comes earlier than the next expected normal beat. A pause follows, and the rhythym resumes Heart Sounds-- S1 may differ in intensity from the S1 of the normal beats, and S2 may be decreased. Both sounds are likely to be split.

Paroxysmal Nocturnal Dyspnea may be mimicked by?

Nocturnal Asthma attacks

What helps to distinguish the midsystoloc from pansystolic murmur?

The gap b/t the murmur et the S2

Promoting Lifestyle changes and risk factor modifications means?

Health maintenance et screening for counseling regarding optimal weight, nutrition, diet, physical activity, tobacco cessation

The more concerning cause of syncope involve?

The heart not providing adequate blood flow to the brain, as occurs in end stage heart failure et arrythmias

In pts with obstructive pulmonary disease, d/t hyperinflation of the lungs, this can prevent palpation of the hypertrophied RV, Where should you palpate the RV in this case?

High in the epigastrium-epigastric or subxiphoid

To distinguish the hypertrophic cardiomyopathy murmur, ask the supine pt to?

Bear down like straining during a bowel movement, alternatively place one hand on the pts mid abdomen and ask pt to push against it, place stethoscope on the chest et listen at lower left sternal border. the systolic murmur will increase

Pulsus Alternans and Bigeminal pulse vary by?

Beat to beat

Anxious et Hyperthyroid pts may report?

Palpitations

Most serious dysrhythmias, such as ventricular tachycardia, often do not produce?

Palpitations

Diabetes?

Check Hemaglobin A1C or fasting every 3 yrs (if norm) beginning at age 45, more freq at any age with risk factors. Goal is to prevent DM with HbA1c 5.7%-6.4%

Causes of decreased pulsations include?

Decreased stroke volume from shock or MI et local atherosclerotic narrowing or occlusion

The carotid upstroke in aortic stenosis is?

Delayed

The split of S2 should disappear during exhalation, if not have pt sit up. If there is persistent splitting, it results from?

Delayed closure of the pulmonic valve or Early closure of the aortic valve

A pulsation in the Aortic outflow tract area suggests?

Dilated or aneurysmal aorta

Most feared complication of carotid artery palpation is?

Dislodgment of atherosclerotic plaque, which could result in stroke

sudden dyspnea occurs in?

pulmonary embolus, spontaneous pneumothorax, anxiety

Diastolic Grade 3/4

Easily heard

Heart failure has two common manifestations, and the classification if determined by?

Ejection fraction: Heart failure with preserved EF, et Heart failure with REDUCED EF are two distinct clinical entities with different treatment algorithms

JVP measured at >3cm above sternal angle or more than 8 cm in total distance above the right atrium is considered?

Elevated above normal

In pts w/ obstructive lung disease, the JVP can appear?

Elevated on expiration, but veins collapse on Inspiration (finding does not indicate heart failure

What lung disease can diminish the intensity of murmurs?

Emphysematous

Subxiphoid area corresponds to?

Epigastic

Systolic Grade 2/6

Equal in volume to S1 and S2, quiet, but heard immediately

If the PMI is forceful and terminates quickly (does not extend through systole) it would be considered? And occur in what states?

Hyperkinetic; Severe anemia, hyperthyroidism, volume overload of left ventricle from aortic regurgitation

Three additional types of ventricular impulses are?

Hyperkinetic; Sustained; Diffuse

Causes of left sided S4 include?

Hypertensive heart disease, aortic stenosis, ischemic et hypertrophic cardiomyopathy

Disorders that resemble Syncope?

Hypocapnia due to hyperventilation Hypoglycemia Fainting from Conversion Disorder (Termed Functional Neurologic Symptom Disorder

For pts who retain fluid bc fluid may not be obvious until several liters of extra fluid have accumulated, what should they do?

record daily morning weights

What is Pulsus Paradoxus?

Greater than normal drop in systolic pressure during inspiration

Shape of crescendo murmur?

Grows louder: note presystolic murmur of mitral stenosis in normal sinus rhythm

Shape of decrescendo murmur?

Grows softer; Note the early diastolic murmur of aortic regurgitation

Increased v waves occur in?

-tricuspid regurgitation -atrial septal defects -constrictive pericarditis

What does pressure on the carotid sinus cause?

reflex bradycardia or drop in blood pressure

In supine pts, the PMI is approximately?

1 to 2.5 cm (not always palpable even in healthy pts with a normal heart

Where are thrills in aortic stenosis transmitted to?

the carotid arteries from the suprasternal notch or second right intercostal space

Hypocapnia due to hyperventilation Presentation?

--Constriction of cerebral blood vessels from hypocapnia induced by hyperventilation --Anxiety, panic disorder precipitate --Anxiety predisposes --Dyspnea, palpitations, chest discomfort, numbness,tingling in hands et around mouth lasting several mins, consciousness often maintained --May occur in any position -Recovery is slow improvement as hyperventilation ceases

PDA Presentation?

--Continuous murmur in both systole et diastole, often w/ silent interval late in diastole. Loudest in late systole, Obscures S2, and fades in diastole -Heard in Left IC space et radiates toward the left clavicle --Intensity usually loud sometimes assoc with a thrill -Quality is harsh, machinery like and pitch is medium

Physiologic Midsystolic murmur presentation?

--Left 2nd to 4th IC B/T L sternal border et Apex -Minimal radiation Graded 1-, or 3 Soft to medium pitch -usually disappears on sitting -Turbulence d/t temporary increase in blood flow in predisposing conditions such as anemia, pregnancy, fever, HYPERTHYROIDISM

MI presentation?

--Sudden arrhythmia or decreased cardiac output --Variable, often exertion precipitates --Coronary artery disease; Coronary ischemia or vasospasm predisposes --Ischemic chest pain; may be silent prodromal manifestations --May occur in any position --Recovery variable; related to dx time et treatment

Massive PE Presentation?

--Sudden hypoxia or decreased cardiac output --Variable, includ prolonged bed rest, major surgery, clotting disorders, pregnancy precipitate --DVT, Bed rest, Hypercoag states (lupus, cancer) Protein S or C deficiency antithrombin III deficiency, estrogen therapy predispose --Tachypnea, chest or pleuritic pain, dyspnea, anxiety, cough prodromal manifestations --May occur in any position et recovery r/t to time to dx and tx

Aortic stenosis et Hypertrophic Cardiomyopathy presentation?

--Vascular resistance falls with exercise, but cardiac output does not rise due to outflow obstruction --Exercise precipitates --Cardiac disorders predispose --Chest pain or onset sudden --Occurs with or w/o exercise --Usually prompt return to normal

orthostatic hypotension presentation?

Hypovolemia, Standing up or after hemorrhage or dehydration; Aging;antihtn vasodilator drugs;Prolonged bed rest central disorders; Parkinsons; Multiple sytsem atrophy; Dementia w/ Lewy bodies; Peripheral Neuropathy; Diabetes; Amyloidosis Prompt return when lying down, Improves with volume repletion

What is an elevated JVP highly correlated with?

-Acute et Chronic heart failure Also seen in Tricuspid stenosis, Chronic Pulmonary HTN, Superior Vena cava obstruction, Cardiac Tamponade, Constrictive Pericarditis

Pathologic Midsystolic Aortic Stenosis Murmur Associated findings?

-As this worsens, murmur peaks later in systole and A2 decreases w/ intensity -A2 may be delayed w/ a slow rise, small amplitude, et decreased volume -The hypertrophied left ventricle may produce a sustained apical impulse et an S4 d/t decreased compliance. -After age 40 yrs, there may be dilated aorta et murmur of aortic regurgitation. -Subendocardial ischemia d/t poor coronary perfusion distal to the valve causes angina et syncope

Pathologic Midsystolic Hypertrophic Cardiomyopathy murmur Associated Findings?

-Carotid upstroke rises quickly unlike aortic stenosis -The apical impulse is sustained. -S2 may be single -An S4 usually present at Apex (unlike mitral regurgitation) -Usually benign but progresses in 25% to syncope, ischemia, AfIB, dilated cardiomyopathy et heart failure, et stroke w/ increased risk of sudden death

Venous hum presentation?

-Continuos w/o silent interval; Loudest during Diastole -Location above medial 3rd clavicles, esp on right, often when the head is turned opposite direction -best heard in sitting position; disappears supine -Radiates to left 1st et 2nd Intercostal spaces -Intensity is soft to mod, obliterated by pressure on the internal jugular vein -Quality is humming or roaring ey pitch is low heard better w/ bell

Arrhythmia presentation?

-Decreased cardiac output from cardiac ischemia, ventricular arrhythmias, prolonged QT syndrome; persistent bradycardia, infrafascicular block causing cerebral hypoperfusion; often sudden onset, sudden offset --Sudden change from brady to tachy --Ischemic or valvular heart disease; conduction abnormalities, pericardial disease, cardiomyopathy; aging decreases tolerance of abnormal rhythms --Palpitations usually lasting <5s; often none -May occur in any position --Prompt recovery to norm when arrhythmia resolves; Most common cause of cardiac syncope; cardiogenic syncope has a 6-mo mortality >10%

Pericardial Friction Rub Presentation?

-Inflammation of visceral et parietal pericardium from pericarditis produces a coarse grating sound with 1, 2 or 3 components (ventricular systole;ventricular filling and atrial contraction during diastole). Rubs are heard w/ et w/o pericardial effusions --Usually best heard in left 3rd IC space next to sternum w/ pt sitting et leaning forward w/ breath held after forced expiration. May come et go spontaneously et require auscultation in several positions -Causes include myocardial infarction, uremia, connective tissue disease -Minimal radiation, Superficial sound of varying intensity that seems close to the stethoscope --Quality is scratchy, scraping, grating et Pitch is high et heard better with diaphragm

Midsystolic murmurs can be?

-Innocent -Physiologic -Pathologic (Aortic Stenosis; Hypertrophic Cardiomyopathy; Pulmonic Stenosis

Pathologic Midsystolic Pulmonic Stenosis Murmur Associated Findings?

-JVP usually norm but may have a prominent wave -R Ventricular impulse often sustained -An early pulmonic ejection sound is present in mild to mod stenosis -In severe stenosis S2 is widely split et P2 softens -May hear a right-sided S4 over the left sternal border

Pathologic Midsystolic Pulmonic Stenosis Murmur presentation?

-Left 2nd et 3rd IC Spaces -Radiation-if loud toward the left shoulder et neck -Intensity soft to loud, if loud assoc w/ thrill -Pitch Medium, crescendo-decrescendo -Quality-Often harsh

Innocent Midsystolic Murmur presentation?

-Left 2nd to 4th IC B/T L sternal border et Apex -Minimal radiation Graded 1-, or 3 Soft to medium pitch -usually disappears on sitting -Assoc findings-norm splitting, no ejection sounds, no diastolic murmur, no palpable evid of ventricular enlargement, occas both innocent and pathologic are present -Mechanism-Turbulent flow prob generated by ventricular ejection of blood into the aorta from left et occas the right ventricle. -Very common in children, young adults, possibly older adults. -There is no underlying coronary vascular disease

Pathologic Midsystolic Hypertrophic Cardiomyopathy murmur presentation?

-Left 3rd et 4th IC Space -Radiation down the left sternal border to apex, possibly base but NOT THE NECK -Intensity variable, Medium pitch, Harsh Quality -Intensity decreases w/ squatting et valsalva release phase (increases venous return), increases w/ standing et Valsalva strain phase (Decreases left ventricular volume)

How to distinguish Carotid Pulsations?

-Palpable -More vigorous thrust w/ single outward component -Pulsations not eliminated by pressure on veins at sternal end of clavicle -Height of pulsations unchanged by position Height of pulsations not affected by inspiration

Pathologic Midsystolic Pulmonic Stenosis Murmur Mechanism?

-Primarily congenital disorder with valvular, supravalvular, or subvalvular stenosis -stenosis impairs flow across the valve increasing R Ventricular afterload. In atrial septal defect increased flow across the pulmonic valve may mimic pulmonic stenosis

How to distinguish Internal jugular pulsations?

-Rarely palpable -Soft biphasic, undulating quality, usually w/ 2 elevations et characteristics inward deflection (x descent) -Pulsations eliminated by light pressure on the vein just above the sternal end of the clavicle -Height of pulsations changes w/ position, normally dropping as pt becomes more upright -Height of pulsations usually falls w/ inspiration

Pathologic Midsystolic Aortic Stenosis Murmur presentation?

-S2 may be decreased -Heard at right 2nd et 3rd IC spaces -Often radiates to carotids down the Left sternal border even to Apex. If severe may radiate to 2nd et 3rd IC Spaces -Intensity Sometimes soft but often loud w/ thrill -Medium harsh crescendo-decrescendo may be higher at apex -Heard best w/ pt sitting et leaning forward

Pathologic Midsystolic Aortic Stenosis Murmur Mechanism?

-Significant stenosis causes turbulent flow across the valve et increases left ventricular afterload -The most common cause is valve calcification in older adults at times progressing from nonobstructing sclerosis (present in 25%) to stenosis -2nd most common cause is a congenital bicuspid aortic valve often not recognized until adulthood

What type of displacement is seen from ventricular dilatation in heart failure, cardiopulmonary, ischemic heart disease, thoracic deformities, et mediastinal shift?

Lateral displacement toward the axillary line

Pathologic Midsystolic Hypertrophic Cardiomyopathy murmur Mechanism?

-Unexplained diffuse or focal ventricular hypertrophy w. myocyte disarray et fibrosis assoc w/ unusually rapid ejection of blood from left ventricle during Systole -Outflow tract obstruction of flow may coexist -Associated distortion of the mitral valve may cause mitral regurgitation

Fainting from Conversion Disorder (Termed Functional Neurologic Symptom Disorder) presentation?

-Unknown mechanism --Skin color, V/S may be norm, sometimes with bizarre purposeful movements; usually occurs when other ppl present --Stress or trauma, psychological or physical, sometimes no precipitant identified --HX of multiple somatic symptoms, Often dissociative symptoms such as depersonalization, dissociative amnesia, or maladaptive personality traits, assoc w/ child abuse or neglect --Variable prodromal manifestations --A slump to the floor often from standing position, w/o injury --TX-variable; may be prolonged often w/ fluctuating responsiveness et inconsistent neuro findings

Micturition Syncope presentation?

-Vasovagal response; Sudden hypotension proposed -Emptying bladder after getting out of bed precipitates -Nocturia, usually in elderly adult men predisposing factor -Often no prodromal manifestations -Commonly just after or during voiding after standing up -Prompt return to normal

Where is the best location to palpate Point of maximal impulse (PMI)?

Left border of the heart on 5th intercostal space, midclavicular line

What may a diffuse PMI, usually >3cm indicate?

Left ventricular enlargement

Causes of small weak pulses include?

1. Decreased stroke volume, as in heart failure, hypovolemia, and severe aortic stenosis and 2. Increased peripheral resistance, as in exposure to cold and severe heart failure

squatting and standing up vascular et volume changes occur in opposite directions. These maneuvers help you to identify et distinguish?

1. IdentifyProlapsed mitral valve 2. Distinguish Hypertrophic cardiomyopathy from aortic stenosis

causes of large bounding pulse include?

1. Increased stroke volume, decreased peripheral resistance, or both as in, fever, anemia, Hyperthyroidism, Aortic Regurgitation, arteriovenous fistulas, and Patent Ductus arteriosus 2. Increased stroke volume bc of slow heart rates as in bradycardia et complete heart block 3. Decreased compliance (increased stiffness) of aortic walls as in aging atherosclerosis

A midsystolic ejection murmur may be?

1. Innocent-w/o any detectable physiologic or structural abnormality 2. Physiologic-from physiologic changes in body metabolism 3. Pathologic-arising from structural abnormalities in the heart or great vessels --Tend to peak near midsystole et usually stop before the S2. The crescendo-decrescendo or "diamond shape" may not always be audible -usually disappears on sitting

Carotid artery stenosis causes?

10% of ischemic strokes and doubles the risk of Coronary Heart Disease

Some authors report that at 30-45 degrees, the estimated JVP may be?

3cm lower than catheter measurements for the right mid atrium

What does atrial contraction produce?

An a wave in the jugular veins, just before S1, and systole caused by retrograde blood flow into the neck veins followed x descent of continued atrial relaxation

An S3 corresponds to?

An abrupt deceleration of inflow across the mitral valve

The murmur of hypertrophic obstructive cardiomyopathy is distinguished by all other murmurs by?

An increase in intensity during squatting to standing action AND by a decrease in intensity during standing to squatting action

In a thin individual you may detect a brief systolic tap especially when stroke volume is increased by conditions such as?

Anxiety

A medium pitched, grade 2/4, blowing decrescendo diastolic murmur, best heard in the fourth left intercostal space with radiation to the Apex may indicate?

Aortic Regurgitation

Right 2nd interspace corresponds to?

Aortic area

Relatively high pitched sounds of S1 et S2 are murmurs of?

Aortic et mitral regurgitation, et pericardial friction rubs

Leaning forward position if there a thrill and murmur noted to detecting?

Aortic regurgitation

murmurs detected during pregnancy should be promptly evaluated for possible risk to the mother et fetus especially those with?

Aortic stenosis et pulmonary HTN

Left ventricular area corresponds to?

Apex

How does the pulse present in aortic regurgitation?

Bounding pulse

In some pts, the precordial impulse may not be palpable at the apex of the heart. For ex in pts with?

COPD

Pathologic increases in preload and afterload, called volume overload et pressure overload, produce changes in ventricular function that may result in?

Clinical heart failure, when the heart becomes ineffective as a pump

What do bruits not correlate with?

Clinically significant underlying disease

During diastole, the aortic valve is?

Closed, preventing regurgitation of blood to flow from the aorta back into the left ventricle

The production of S1 is?

Closure of the mitral valve and tricuspid valve in the right side of the heart

Congenital PDA et AV fistulas (common in dialysis pts) produce what type of murmurs?

Continuous, nonvalvular in origin

A shape of the murmur is described as ?

Crescendo, Decresendo, or Holosytolic

Causes of decreased Right ventricular preload include?

Exhalation; dehydration; et pooling of blood in the capillary bed or the venous system

Syncope is ?

Fainting, blacking out, or transient loss of consciousness followed by recovery.

Shape - crescendo-decrescendo murmur?

First rises in intensity et then falls; Listen for the midsystolic murmur of aortic stenosis et innocent flow murmurs

When obtaining a BP if the arm is at lower levels, the BP will be?

Higher

The pressure when Kortokoff sounds are first heard is the?

Highest systolic pressure during the respiratory cycle

The height of the venous pressure as measured from the sternal angle is similar in 30,60,90 degree position, but your ability to measure the height of the column of venous blood, or JVP, differs according to?

How you position the pt

Left sided murmurs generally what with respiration?

Increase with Expiration

Right sided murmurs generally what with respiration?

Increase with inspiration

In the pulmonary artery area, a prominent pulsation here often accompanies dilatation or?

Increased flow in the pulmonary artery.

An S4 corresponds to?

Increased left ventricular end diastolic stiffness which decreases compliance

Abnormally prominent cannon a waves occur in?

Increased resistance to right atrial contraction, as in tricuspid stenosis -Severe 1st, 2nd, 3rd AV block -Supraventricular tachycardia -Junctional tachycardia -Pulmonary HTN -Pulmonic stenosis

To perform the valsalva maneuver for Heart failure et pulm htn you would?

Inflate Bp cuff to 15 mmHg above the systolic BP, ask pt to perform valsalva for 10 seconds then resume norm rr, Keep BP inflated during the maneuver et for 30 secs after. Listen for korotkoff sounds over brachial artery throughout. In a healthy pt, phase 2 the strain phase is silent; korotkoff sounds are heard after straining is released during phase 4

Orthopnea et Paroxysmal Nocturnal Dyspnea occur in?

Left ventricular heart failure et mitral stenosis et Obstructive lung disease

A PMI >2.5 cm is evidence of?

Left ventricular hypertrophy (LVH), often seen in hypertension or dilated cardiomyopathy

Hypoglycemia?

Insufficient glucose to maintain cerebral metabolism; epinephrine release contributes to symptoms, true syncope is uncommon --fasting, insulin, or metabolic disorders can preciptitate --Sweaty, tremors, palpitations, hunger, headache, confusion, abnormal behavior, coma --may occur in any position et treatment is variable based on severity et treatment

How do you Grade a murmur?

Intensity of murmur of 1-6 (systolic) et 1-4 (diastolic), pitch should be noted as high, medium, or low; and quality (blowing, harsh, rumbling, or musical)

The dominant movement of JVP is (?), coinciding with (?) descent?

Inward; X

What type of pulse is often identified at the bedside with A-Fib?

Irregularly Irregular

A palpable S2 in the pulmonary artery area points to?

Known as pulmonary artery tap; points to increased pulmonary artery pressure from pulmonary HTN

Point of maximal impulse (PMI)

the point where the apex of the heart touches the anterior chest wall and heart movements are most easily observed and palpated

If there is a sustained left parasternal movement later in systole, what would it be seen in?

Mitral regurgitation

Late systolic murmur usually (not always) preceded by a mid-systolic click?

Mitral valve prolapse or mitral regurgitation

Rapid weight gain is?

More than 1 to 2 lb per day et will occur prior to visible edema

Primary HTN risk factors?

Most common cause: Age, genetics, black race, obesity, weight gain, excessive salt intake, physical inactivity, excessive alcohol use

Bruit?

Murmur like sound arising from turbulent arterial blood flow

Radiates to the neck in the direction of arterial flow, especially on the right side would indicate what type of murmur?

Murmur of aortic stenosis

Radiates to the axilla, supporting transmission by bone conduction would indicate what type of murmur?

Murmur of mitral regurgitation

Cough Syncope Presentation?

Neurally mediated, possibly from reflex vasodepressor-bradycardia response; Cerebral hypoperfusion; Increased CSF pressure also proposed Severe paroxysm of coughing precipitates COPD; Asthma; Pulmonary HTN; Typically occurs in overweight middle aged pts often none except cough; blurred vision, lighthead may occur as prodromal May occur in any position et prompt return to normal w/i few seconds

Cardiac output

the volume of blood ejected from each ventricle in 1 minute, is the product of heart rate et stroke volume

The right ventricular impulse?

Normally not palpable beyond infancy and characteristics are indeterminate

Secondary HTN risk factors

OSA, chronic kidney disease, renal artery stenosis, meds, thyroid disease, parathyroid disease, Cushing syndrome, hyperaldosteronism, pheochromacytoma, coarctation of the aorta

If there are signs of irregular heart action, what should your next step be?

Obtain an ECG

The dominant movement of Carotid pulse is (?)?

Outward

In the healthy heart, the left ventricular impulse is usually the?

PMI, generated by the movement of the ventricular apex against the chest wall during contraction

Rapid irregular beating of sudden onset et offset may signify?

Possible Paroxysmal Supraventricular Tachycardia

Rapidly regular rate <120beats/min, esp if gradually starting et stopping may signify?

Possible Sinus Tachycardia

Clues in the history such transient skips et flops may signify?

Possible premature contractions

Unique stroke risk factors for women include?

Pregnancy, hormone therapy, early menopause, preeclampsia

How do you palpate thrills and what are they?

Press the ball of your hand (padded area if your palm near wrist) firmly on chest for a buzzing or vibratory sensation caused by underlying turbulent flow.

Causes of hyperkinetic left ventricular impulse?

Pressure overload from aortic stenosis, hypertension 1. Anxiety 2. Hyperthyroidism 3. Severe anemia

During palpation, A sustained left parasternal movement beginning at S1 points to?

Pressure overload from pulmonary hypertension et pulmonic stenosis or the chronic ventricular volume overload of an atrial septal defect.

If there is a loud P2 (closure of the pulmonary valve), if indicates?

Pulmonary HTN

You listen to s3 and S4 in same positions for L et R, et both are louder on inspiration, but causes include?

Pulmonary hypertension and Pulmonary stenosis

Left 2nd interspace corresponds to?

Pulmonic area

Bisferiens pulse is?

Pulse is an increased arterial pulse with a double systolic peak, detected during moderate compression of an artery.

Pulsus Alternans is?

Pulse is completely regular but has alternating strong et weak beats

What are Large bounding pulses?

Pulse pressure in increased, and the pulse feels strong and bounding

What are Small weak pulses?

Pulse pressure is diminished, pulse feels weak and small. The upstroke may feel slowed, the peak prolonged.

Alternately loud et soft kortokoff sounds or sudden doubling of the apparent heart rate as the cuff pressure declines signals what?

Pulsus Alternans

Causes of bisferiens pulse include?

Pure aortic regurgitation, combined aortic stenosis and regurgitation, et hypertrophic cardiomyopathy.

JVP (jugular venous pressure)?

Reflects right atrial pressure, which in turn equals central venous pressure et right ventricular end diastolic pressure.

Early diastolic murmurs typically reflect what type of blood flow?

Regurgitant across incompetent semilunar valves

The diaphragm is better for picking up which heart sounds?

Relatively high pitched sounds of S1 et S2,

Sporadic sinus arrhythmia?

Rhythm--The heart varies cyclically, usually speeding up with inspiration and slowing down with expiration. Heart Sounds--Normal, although S1 may vary with the heart rate.

In full situs inversus, the heart, tri-lobed lung, stomach and spleen are seen on the ______ (r/l) and the liver and gallbladder are on the ___(r/)

Right et Left

The JVP is best estimated from the?

Right internal jugular vein (which has the most direct channel into the right atrium)

Edema causes are frequently Cardiac such as?

Right or Left ventricular dysfunction Pulmonary HTN Pulmonary (obstructive lung disease) Hypoalbunemia (can be this d/t nutritional) Positional

JVP increases with?

Right or left heart failure, pulmonary hypertension, tricuspid stenosis AV Dissociation Increase vascular tone pericardial compression or tamponade

In dextrocardia, the PMI is located on the left or right side?

Right side

Left sternal border corresponds to?

Right ventricular area

Palpate impulses from the Right ventricle in the what area?

Right ventricular area, normally at lower left sternal border and in the subxiphoid area

In a first degree heart block what will you hear on auscultation?

S1 heart sound is diminished

In aortic stenosis what will you hear on auscultation?

S2 heart sound is diminished

A brief early to middiastolic impulse represents a palpable?

S3

What is a summation gallop?

S3 and S4 together

Auscultating in the left lateral decubitus position is important otherwise you may miss these important findings?

S3, S4, et mitral murmurs, especially mitral stenosis

An outward movement just before S1 signifies a palpable?

S4

Shape of Plateau murmur?

Same intensity throughout: note the pansystolic murmur of mitral regurgitation

The aortic and pulmonic valves are called?

Semilunar Valves

Midsystolic murmurs typically arise from blood across what two valves?

Semilunar valves (aortic and pulmonic)

Anasarca is?

Severe generalized edema extending to the sacrum et abdomen

What does pulsus alternans indicate?

Severe left ventricular failure

What can pregnancy or a high left diaphragm do to the apical impulse?

Shift upward and up to the left

How does the carotid pulse present in cardiogenic shock?

Small, thready (barely detectable), or weak

The JVP is 5 cm above sternal angle with head of bed elevated to 50 dg. Carotid upstrokes are brisk, a bruit is heard over the left carotid artery. The PMI is diffuse, 3cm in diameter, palpated at the anterior axillary line in 5th et 6th intercostal spaces. S1 et S2 soft, S3 present at apex. High pitched harsh 2/6 holosystolic murmur best heard at apex, radiating to axilla?

Suggest heart failure w/ volume overload with possible left carotid occlusion et mitral regurgitation

Palpating the carotid pulse as you listen can help assist with timing of murmurs, if the murmur coincides with carotid upstroke, the murmur would be considered systolic or diastolic?

Systolic

The most common extra systole sound is?

Systolic click of mitral valve prolapse

In most adults the diastolic sounds of S3 and S4 are pathologic and are correlated with?

Systolic et diastolic heart failure, respectively

Obesity, very muscular chest wall or increased AP diameter of chest may obscure the detection of?

The apical impulse

Afterload refers to?

The degree of vascular resistance to ventricular contraction. Sources of resistance to contraction include the tone in the walls of the aorta, the large arteries, et peripheral vascular tree (primarily small arteries et arterioles), et volume of blood already in aorta

As right atrial pressure begins to rise with inflow from the vena cava during the right ventricular systole, there is a second elevation, what is it?

The v wave, followed by the y descent as blood passively empties from the right atrium into the RV during early et middiastole

Bruits may be caused by?

Tortuous carotid artery; external carotid arterial disease; aortic stenosis; Hypervascularity of hyperthyroidism; et external compression from thoracic outlet syndrome

Transient arterial occlusion?

Transient external compression of both arms by bilateral cuff inflation to 20 mmHg greater than peak systolic pressure augments the murmurs of Mitral Regurgitation, Aortic Regurgitation and VSD (due to increase in afterload on LV)

What does detection of pulsus alternans and Pulsus paradoxus require?

Use of a BP cuff

How do you palpate heaves and what are they?

Use palm et/or hold your finger pads flat or obliquely against the chest; Sustained impulses that rhythmically lift your fingers, Usually produced by an enlarged right or left ventricle (note where felt) and occasionally by ventricular aneurysms

The split of S2 is normally heard late in inspiration, an expiratory splitting suggests?

Valvular abnormality

If the murmur is diastolic (b/t S2 et S1), it usually represents what type of heart disease?

Valvular heart disease

When a person squats?

Vascular et volume changes occur in the opposite direction

when a person stands?

Venous return to the heart decreases as does peripheral vascular resistance. Arterial blood pressure, stroke volume, et the volume of blood in the LV all decline

Diffuse ventricular Impulse is?

Ventricular dilation from chronic volume overload, or increased preload

The JVP is usually measured in?

Vertical distance above the sternal angle (also called angle of Louis), Bony ridge located around T4 adjacent to the 2nd rib where the manubrium joins the body of sternum

In COPD, the most prominent palpable impulse or PMI may be in the?

Xiphoid or epigastric area due to right ventricular hypertrophy

hyperkinetic ventricular impulse is?

transiently increased Stroke Volume; does not necessarily mean heart disease; --Examples of Causes: Anxiety; Hyperthyroid; severe anemia--Duration is <2/3 systole--the Amplitude is a more forceful tapping

In pts with dyslipidemias, when should you obtain baseline lipids?

age 21. Measure fasting in average risks every 5 yrs beginning from age 40 to 75

an elevated JVP is 98% specific for what?

an increased left ventricular end diastolic pressure and low ventricular ejection fraction,

The second heart sound (S2) indicates?

closure of the aortic (A2) and pulmonary (P2) valves

Causes of pathologic S3 include?

decreased myocardial contractility, heart failure, ventricular volume overload from aortic or mitral regurgitation, -et right to left shunts

In contrast, a pleural rub is heard only ?

during inspiration

Diastolic Grade 2/4

faint but immediately audible

the valsalva maneuver can also help identify?

heart failure et pulmonary hypertension

The murmur of hypertrophic cardiomyopathy is the only systolic murmur that?

increases during the "strain phase" of the Valsalva maneuver due to increased outflow tract obstruction

Cardiovascular disease for women is?

leading cause of death

JVP falls with?

loss of blood or decreased venous vascular tone

An identical degree of turbulence would cause a _____ murmur in a thin person than in a very muscular or obese person.

louder

Systolic murmurs are typically?

midsystolic or pansystolic

In a trained athlete, an S4 heart sound is?

occasionally normal.

During systole, the aortic valve is?

opened, allowing ejection of blood from the Left Ventricle into the aorta. The mitral valve is closed.

The opening of the mitral valve may be audible as?

pathologic opening snap (OS) if valve leaflet motion is restricted as in mitral stenosis

How can you place the pt to accentuate the finding of pulsus alternans?

place pt in the upright position

Multiple averaged BP measurements improve precision when using an automated home et ambulatory BP readings due to?

poor reliability of clinic BP measurements and are better correlated with cardiovascular outcomes

Vasovagal syncope presentation?

reflex withdrawal of sympathetic tone et increased vagal tone causing a drop in BP or Heart rate Fear/pain/prolonged standing/hot humid environment precipitate Fatigue/hunger/preload reduction from dehydration,diuretics, vasodilator predispose Usually >10 sec;palpitations;Nausea;Blurred vision;warm;pale;diaphoresis;lightheaded prodromal manifestations Usually occurs when standing/Prompt return of consciousness after lying down Most common type of Syncope Baroreflexes normal

Pansystolic murmurs often occur with?

regurgitant (backward) flow across the AV valves

Aortic valve closure, as well as the closure of pulmonic valves produces which heart sound?

second heart sound-S2

The second heart sound normally splits on inspiration and is?

single during expiration, and A2 (closure of the aortic valve) is louder than P2 (closure of the pulmonary valve), even in the pulmonary area

Auscultating the pt with him/her leaning forward is important to identify which findings?

soft diastolic decrescendo murmur of aortic regurgitation

Systolic Grade 1/6

softer in volume than S1 and S2, very faint

Afib in women increases?

stroke risk fivefold; often asymptomatic et undetected

Normally, maximal left ventricular pressure corresponds to systolic or diastolic pressure?

systolic blood pressure

In some pathologic conditions an early _______________ accompanies opening of the aortic valve

systolic ejection sound

In most exams, the apical impulse is?

the PMI

Systole is the period of?

ventricular contraction, when the left ventricle ejects blood into the aorta

A Sustained ventricular Impulse is?

ventricular hypertrophy from chronic pressure load (increased afterload)

An S4 is more commonly due to?

ventricular hypertrophy or fibrosis causing stiffness et increased resistance (or decreased compliance) during ventricular filling following atrial contraction

Diastole is the period of?

ventricular relaxation

Diastolic Grade 4/4

very loud