PHA 603 Quiz 3 (Chapters 9 and 12)

What are the tunica media and tunica adventitia?

The media is composed of smooth muscle cells that dilate and constrict to accommodate blood pressure and flow. Its inner and outer boundaries consist of elastic fibers, or elastin, and are called internal and external elastic laminae, or membranes. The outer layer of the artery is the adventitia, the connective tissue containing nerve fibers and the vasa vasorum.

What is a paradoxical pulse?

Paradoxical pulse: this is a greater than normal drop in systolic blood pressure during inspiration.

How do you inspect a patient's cardiovascular system?

Pay special attention to the patient's color, respiratory rate, and level of anxiety, in addition to blood pressure and heart rate.

What is the metabolic syndrome?

The metabolic syndrome consists of a cluster of risk factors that increase risk of both CVD and diabetes. They include waist circumference, fasting plasma glucose, HDL cholesterol, triglycerides and blood pressure.

What is peripheral artery disease?

Peripheral artery disease is generally defined as atherosclerotic disease distal to the aortic bifurcation. Prevalence increases with age. Detection is doubly important because PAD is both a marker for cardiovascular morbidity and mortality, and a harbinger of functional decline. Thromboembolic disorders of the peripheral venous system in the lower extremities are also common. Almost one quarter of PE cases present with sudden death. Superficial venous thrombosis also poses risks—one third of those affected are diagnosed with DVT or PE.

What is vein mapping?

Mapping can demonstrate varicose veins and their origin. With the patient standing, place your palpating fingers gently on a vein and, with your other hand below it, compress the vein sharply. Feel for a pressure wave transmitted to the fingers of your upper hand. A palpable pressure wave indicates that the two parts of the vein are connected.

How do you screen for abdominal aortic aneurysm?

AAA is defined as an infrarenal aortic diameter greater than or equal to 3 cm. The dreaded consequence of AAA is rupture, which is often fatal. The strongest risk factors for AAA are older age, male sex, smoking, and family history. Because symptoms are uncommon and screening can reduce AAA-related mortality by about 50% over 13-15 years, the USPTF recommends a one-time ultrasound screening of men aged 65-75 years who have smoked more than 100 cigarettes in a lifetime.

What is the third heart sound?

After the mitral valve opens, there is a period of rapid ventricular filling as blood flows early in diastole from left atrium to left ventricle. In children and young adults, a third heart sound may arise from rapid deceleration of the column of blood against the ventricular wall. It is best heard at the cardiac apex.

What is the fourth heart sound?

Although not often heard in normal adults, a fourth heart sound marks atrial contraction.

How do artery anatomy and size vary?

Artery anatomy and size vary according to their distance from the heart. The aorta and its immediate branches are large highly elastic arteries. These arteries course into medium-sized muscular arteries. The elastic recoil and smooth muscle contraction and relaxation in the media of large and medium-sized arteries produce arterial pulsatile flow. Medium-sized arteries divide into small arteries and even smaller arterioles. Resistance to blood flow occurs primarily in the arterioles. Capillaries have an endothelial cell lining, but no media, facilitating rapid diffusion of oxygen and carbon dioxide.

What is the second heart sound?

As left ventricular pressure continues to rise, it quickly exceeds the pressure in the aorta and forces the aortic valve open. Normally, maximal left ventricular pressure corresponds to systolic blood pressure. As the left ventricle ejects most of its blood, ventricular pressure begins to fall. When left ventricular pressure drops below aortic pressure, the aortic valve closes. *Aortic valve closure produces the second heart sound.*

How do you position a patient to measure their JVP?

As you begin you assessment, consider the patient's volume status and whether you need to alter the elevation of the head of the bed or examining table. o The usual starting position for the head of the bed or examining table when assessing the JVP is 30 degrees. Turn the patient's head slightly to the left, then the right, and identify the external jugular vein on each side. Then focus on the internal jugular venous pulsations on the right, transmitted from deep in the neck to the overlying soft tissues. The JVP is the highest oscillation point, or meniscus, of the jugular venous pulsations that is usually evident in euvolemic patients. o If the patient is hypovolemic, you can anticipate the JVD will be low, causing you to lower the head of the bed. o If the patient is hypervolemic, the JVP will be high, causing you to raise the head of the bed.

Where can you hear the tricuspid and mitral valves?

At or near the lower left sternal border: tricuspid valve. At and around the cardiac apex: mitral valve.

Which valves are open during systole and diastole in the right ventricle?

At the same time, during systole the pulmonic valve opens and the tricuspid valve closes as blood is ejected from the RV into the pulmonary artery. During diastole, the pulmonic valve closes and the tricuspid valve opens as blood flows into the right atrium.

How do you screen for renal artery disease?

Atherosclerotic renal artery stenosis (RAS) is present in substantial proportions of patients with end-stage renal disease, congestive heart failure, co-occurring diabetes and hypertension, and other atherosclerotic diseases. Conditions suspicious for renal artery disease include: o Onset of hypertension at age 30 years or less o Onset of severe hypertension at age 55 years or less o Accelerated, resistant or malignant hypertension o New worsening of renal function or worsening function after use of an ACE inhibition o An unexplained small kidney or size discrepancy of >1.5 cm between the two kidneys o Sudden unexplained pulmonary edema, especially in the setting of worsening renal function

How do you auscultate the carotid arteries?

Auscultate both carotid arteries to listen for a bruit, a murmur-like sound arising from turbulent arterial blood flow. Ask the patient to stop breathing for ~15 seconds, then listen with the diaphragm of the stethoscope. Listen for bruits in older patients and patients with suspected cerebrovascular disease. In patients with carotid obstruction, kinking, or thrills, assess the pulse in the brachial artery.

Where are the lymph nodes of the arm?

Axillary lymph nodes drain most of the arm. Lymphatics from the ulnar surface of the forearm and hand, the little and ring fingers, and the adjacent surface of the middle finger, however, drain first into the epitrochlear nodes.

Where are the heart sounds best heard?

The first heart sound is usually louder than the second heart sound at the apex; the second heart sound is usually louder than the first heart sound at the base.

How do you examine the abdomen and pelvis for peripheral vascular disease?

Palpate and estimate the width of the abdominal aorta in the epigastric area by measuring the aortic width between two fingers. Assess for a pulsatile mass. Palpate the superficial inguinal lymph nodes, including both the horizontal and the vertical groups. Note their size, consistency, and discreteness, and note any tenderness.

What are heart murmurs?

Heart murmurs are distinct heart sounds distinguished by their pitch and their longer duration. They are attributed to turbulent blood flow and are usually diagnostic of valvular heart disease. At times, they may also represent innocent flow murmurs, especially in young adults. o A stenotic valve has an abnormally narrowed valvular orifice that obstructs blood flow. o A valve that allows blood to leak backward in a retrograde direction produces a regurgitant murmur.

How do you screen for global risk factors?

Begin routine screening at 20 years for individual risk factors or "global" risk of CVD and for any family history of premature heart disease (age <55 years in first-degree male relatives and age <65 in first-degree female relatives). Women and African-Americans are at increased risk for CVD.

How should complaints of chest pain be dealt with?

Chest pain is one of the most serious of all patient complaints. It is the most common symptom of coronary heart disease. CHD is the leading killer of both men and women. Both men and women with acute coronary syndrome usually present with the classic symptoms of exertional angina; however, women, particularly those over age 65, are more likely to report atypical symptoms that may go unrecognized, such as upper back, neck or jaw pain, shortness of breath, paroxysmal nocturnal dyspnea, nausea or vomiting, fatigue, making careful history taking especially important. Ask the patient to point to the pain and describe all seven features of the symptom.

What is the first heart sound?

During diastole, pressure in the blood-filled left atrium slightly exceeds that in the relaxed left ventricle, and blood flows from left atrium to left ventricle across the open mitral valve. Just before the onset of ventricular systole, atrial contraction produces a slight pressure rise in both chambers. During systole, the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial pressure, closing the mitral valve. *Closure of the mitral valve produces the first heart sound.*

Which valves are open during systole and diastole in the left ventricle?

During systole the aortic valve is open, allowing ejection of blood from the left ventricle into the aorta. The mitral valve is closed, preventing blood from regurgitating back into the left atrium. In contrast, during diastole the aortic valve is closed, preventing regurgitation of blood from the aorta back into the left ventricle. The mitral valve is open, allowing blood to flow from the left atrium into the relaxed left ventricle.

Why is jugular venous pressure important?

Estimating the jugular venous pressure (JVP) is one of the most important and frequently used skills of physical examination. The JVP closely parallels pressure in the right atrium, or central venous pressure, related primarily to volume in the venous system. The JVP is best assessed from pulsations in the right internal jugular vein, which is directly in line with the superior vena cava and right atrium. Note that the jugular veins and pulsations are difficult to see in children under 12 years of age, so inspection is not useful in this age group. The dominant movement of the JVP is inward, coinciding with the x descent. In contrast, the dominant movement of the carotid pulse, often confused with the JVP, is outward.

How should complaints of palpitations be dealt with?

Palpitations involve an unpleasant awareness of the heartbeat. Palpitations do not necessary mean heart disease. Teach selected patients how to take serial measurements of their pulse rates in case they have further episodes. For this group of symptoms, an ECG is indicated.

What is the Buerger test?

If pain or diminished pulses suggest arterial insufficiency, consider looking for postural color changes using the Buerger test. Raise both legs to about 90 degrees for up to 2 minutes until there is maximal pallor of the feet. Then ask the patient to sit up with legs dangling down. Compare both feet, noting the time required for: o Return of pinkness to the skin, normally about 10 seconds or less. o Filling of the veins of the feet and ankles, normally about 15 seconds.

Where can you hear the pulmonic valve?

Left 2nd and 3rd interspaces close to the sternum, but also at higher or lower levels: pulmonic valve.

What are the layers of arteries?

Arteries contain three concentric layers of tissue: the intima, the media, and the adventitia. The internal elastic membrane borders the intima and the media; the external elastic membrane separates the media from the adventitia.

How do you palpate heaves, lifts, thrills and impulses?

Begin with a general palpation of the chest wall. Using the following techniques, palpate in the 2nd right interspace, the 2nd left interspace, along the sternal border, and at the apex for heaves, lifts, thrills, impulses from the RV, and the four heart sounds. o To palpate heaves and lifts, use your palm and/or hold your finger pads flat or obliquely against the chest. Heaves and lifts are sustained impulses that rhythmically lift your fingers, usually produced by an enlarged right or left ventricle or atrium and occasionally by ventricular aneurysms. o For thrills, press the ball of your hand firmly on the chest to check for a buzzing or vibratory sensation caused by underlying turbulent flow. If present, auscultate the same area for murmurs. o Palpate impulses from the RV in the right ventricular area, normally at the left sternal border and in the subxiphoid area. o To palpate the first and second heart sounds, place your right hand on the chest wall. With your left index and middle fingers, palpate the carotid upstroke to identify the first and second heart sounds just before and just after the upstroke. With practice, you will succeed in palpating the first and second heart sounds.

Do blood pressures vary throughout the day?

Blood pressures fluctuate strikingly throughout any 24-hour period, varying with physical activity, emotional state, pain, noise, environmental temperature, use of coffee, tobacco, and other drugs, and even time of day.

What is cardiovascular disease?

CVD, which consists primarily of hypertension, CHD, heart failure, and stroke, is the leading cause of death in the US. Heart disease has a long asymptomatic latent period. Consequently, clinicians are encouraged to assess lifetime risk in asymptomatic patients, possibly beginning as early as age 20 years. Women have become increasingly aware that CVD is their leading cause of death. Nonetheless, the AHA cautioned that reversing a trend of the past 4 decades, CHD death rates in women 35-54 years of age now actually appear to be increasing, which the AHA attributed to the effects of obesity.

What is cardiac output?

Cardiac output, the volume of blood ejected from each ventricle during 1 minute, is the product of heart rate and stroke volume. Stroke volume depends in turn on preload, myocardial contractility, and afterload.

How do you inspect the chest wall for the apical impulse?

Careful inspection of the anterior chest may reveal the location of the apical impulse or PMI, or less commonly, the ventricular movements of a left-sided third or fourth heart sound. Shine a tangential light across the chest wall over the cardiac apex to make these movements more visible.

What are common or concerning symptoms regarding the peripheral vascular system?

Common or concerning symptoms: o Abdominal, flank or back pain. o Pain or weakness in the arms or legs. o Intermittent claudication. o Cold, numbness, pallor in the legs; hair loss. o Swelling in calves, legs or feet. o Color change in fingertips or toes in cold weather. o Swelling with redness or tenderness.

What are common or concerning symptoms regarding the cardiovascular system?

Common or concerning symptoms: o Chest pain o Palpitations o Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea o Swelling (edema) o Fainting (syncope) For chest symptoms, be systematic as you think through the range of possible cardiac, pulmonary and extra-thoracic etiologies. When assessing cardiac symptoms, it is important to quantify the patient's baseline level of activity.

How should complaints of fainting or syncope be dealt with?

Fainting or syncope is a transient loss of consciousness followed by recovery. The most common cause is neurocardiogenic.

How should you position a patient for cardiac examination?

For cardiac examination, stand at the patient's right side. The patient should be supine, with the upper body and head of the bed raised to about 30 degrees. To assess the PMI and extra heart sounds, ask the patient to turn to the left side, termed the left lateral decubitus position—this brings the ventricular apex closer to the chest wall. To bring the left ventricular outflow tract closer to the chest wall and improve detection of aortic regurgitation, have the patient sit up, lean forward, and exhale.

How can you enhance detection of mitral stenosis and aortic regurgitation?

For new patients and patients needing a complete cardiac examination, use two additional maneuvers to enhance detection of mitral stenosis and aortic regurgitation. o Mitral stenosis: ask the patient to roll into the left lateral decubitus position, which brings the left ventricle closer to the chest wall. Place the bell of your stethoscope lightly on the apical impulse. o Aortic regurgitation: ask the patient to sit up, lean forward, exhale completely, and briefly stop breathing after expiration. Pressing the diaphragm of your stethoscope on the chest, listen along the left sternal border and at the apex, pausing periodically so the patient may breathe.

Cont.

If swelling or edema is present, palpate for pitting edema. Press firmly but gently with your thumb for at least 2 seconds (1) over the dorsum of each foot, (2) behind each medial malleolus, and (3) over the shins. Look for pitting—a depression caused by pressure from your thumb. Normally there is none. • Palpate for any venous tenderness or cords. Palpate the inguinal area just medial to the femoral pulse for tenderness of the femoral vein. Next, with the patient's leg flexed at the knee and relaxed, palpate the calf. With your finger pads, gently compress the calf muscles against the tibia, and search for any tenderness or cords. • If you suspect arterial insufficiency in the arm or hand, try to palpate the ulnar pulse as well as the radial or brachial pulses.

How do you auscultate the heart?

In a quiet room, auscultate the heart with your stethoscope with the patient's head and upper chest elevated to 30 degrees. Start at either the base or apex, listening first with the diaphragm, then with the bell. o Starting at the apex and moving to the base: move the stethoscope from the PMI medially to the left sternal border, superiorly to the 2nd interspace, then across the sternum to the 2nd interspace at the right sternal border, stopping at the six listening spots. o To start at the base and move toward the apex: with your stethoscope in the right 2nd interspace close to the sternum, move along the left sternal border in each interspace from the 2nd through the 5th, and then toward the apex.

What is pulsus alternans?

In pulsus alternans, the rhythm of the pulse remains regular, but the force of the arterial pulse alternates because of alternating strong and weak ventricular contractions. Pulsus alternans almost always indicates severe left ventricular dysfunction.

How should you examine the arms and hands for peripheral vascular disease?

Inspect both arms from the fingertips to the shoulders. Note: o Size, symmetry and any swelling o The venous pattern o The color of the skin and nail beds and texture of the skin Palpate the radial pulse, if you suspect arterial insufficiency, palpate the brachial pulse. Palpate one or more epitrochlear nodes. o With the patient's elbow flexed to about 90 degrees and the forearm supported by your hand, reach around behind the arm and feel in the groove between the biceps and triceps muscles, about 3 cm above the medial epicondyle. If a node is present, note its size, consistency and tenderness. Epitrochlear nodes are difficult to identify in most healthy people.

What are key components of the peripheral arterial examination?

Key components of the peripheral arterial examination: o Measure the blood pressure in both arms o Palpate the carotid upstroke, auscultate for bruits o Auscultate for aortic, renal, and femoral bruits; palpate the aorta and assess its maximal diameter o Palpate the pulses of the brachial, radial, ulnar, femoral, popliteal, DP and PT arteries o Inspect the ankles and feet for color, temperature, and skin integrity

What are lymph nodes?

Networks of lymphatic capillaries, the lymphatic plexuses, originate in the extracellular spaces, where the capillaries collect tissue fluid, plasma proteins, cells, and cellular debris via their porous endothelium, which lacks even a basement membrane. The right lymphatic duct drains fluid from the right side of the head, neck, thorax, and right upper limb and empties into the junction of the right internal jugular and the right subclavian veins. The thoracic duct collects lymph fluid from the rest of the body and empties into the junction of the left internal jugular and the left subclavian veins. Lymph nodes vary in size according to their location. Cells within the lymph nodes engulf cellular debris and bacteria and produce antibodies. Most filtered fluid returns to circulation not as fluid resorbed at the venous end of the capillaries, but as lymph.

How do you examine the carotid pulse?

Next, examine the carotid pulse, including the carotid upstroke, its amplitude and contour, and the presence or absence of thrills or bruits. The carotid pulse provides valuable information about cardiac function, especially aortic valve stenosis and regurgitation. To assess amplitude and contour, the patient should be supine with the head of the bed elevated to about 30 degrees. First inspect the neck for carotid pulsations, often visible just medial to the SCM muscles. Then place your index and middle fingers or left thumbs on the right carotid artery in the lower third of the neck and palpate for pulsations. Press just inside the medial border of a relaxed SCM muscle, roughly at the level of the cricoid cartilage. Avoid pressing on the carotid sinus, which lies adjacent to the top of the thyroid cartilage. For the left carotid artery, use your right fingers or thumb. Never palpate both carotid arteries at the same time. This may decrease blood flow to the brain and induce syncope.

What is the cardiac conduction system?

Normally, each electrical impulse originates in the sinus node located in the right atrium near the junction of the vena cava. The sinus node acts as the cardiac pacemaker. This impulse travels through both atria to the AV node located low in the atrial septum. Here, the impulse is delayed before passing down the bundle of is and its branches to the ventricular myocardium. Muscular contraction follows: first the atria, then the ventricles.

Which lymph nodes are accessible to physical examination?

Only the superficial lymph nodes are accessible to physical examination. These include the cervical lymph nodes, the axillary lymph nodes, and nodes in the arms and legs.

What is the ankle-brachial index?

PAD can be diagnosed noninvasively using the ABI. The ABI is the ratio of blood pressure measurements in the foot and arm; values <0.9 are considered abnormal. For patients with PAD and intermittent claudication, supervised exercise programs are strongly recommended as the initial treatment.

What are the palpation areas of the chest wall?

Right 2nd interspace: aortic area Left 2nd interspace: pulmonic area Left sternal border: Right ventricular area Apex: left ventricular area

How do heart sounds compare on the right and left sides?

Right heart sounds occur at pressures that are usually lower than those on the left, and are usually less audible.

Where can you hear the aortic valve?

Right second interspace to the apex: aortic valve.

How do you screen for lower-extremity peripheral disease?

Risk factors for lower-extremity peripheral arterial disease include: o Age 65 or older o Age 50 years or older with a history of diabetes or smoking o Leg symptoms with exertion o Nonhealing wounds

Why are the jugular veins important?

The jugular veins provide an important index of right heart pressures and cardiac function. Jugular venous pressure (JVP) reflects right atrial pressure, which in turn equals central venous pressure and right ventricular end-diastolic pressure. The JVP is best estimated from the right internal jugular vein, which has the most direct channel into the right atrium.

How should you screen for cardiovascular risk factors?

Screening for cardiovascular risk factors: o Step 1: screen for global risk factors. o Step 2: calculate 10-year and lifetime CVD risk using an online calculator. o Step 3: track individual risk factors—hypertension, diabetes, dyslipidemias,

Where is the apical impulse found?

The left ventricle forms the left lateral margin of the heart. Its tapered inferior tip is often termed the cardiac apex. It is clinically important because it produces the apical impulse, identified during palpation of the precordium as the point of maximal impulse (PMI). This impulse locates the left border of the heart and is normally found in the 5th intercostal space at or just medial to the left midclavicular line.

How do you track individual risk factors?

Screening should be initiated at age 45 years and repeated at 3-year intervals. Screening should be initiated at any age for adults having a BMI greater than or equal to 25 and additional risk factors. The USPSTF has issued a grade A recommendation for routine lipid screening for all men of age >35 years and women >45 years who are at increased risk for CHD. Risk factors such as smoking, family history, and obesity contribute substantially to the population burden of CVD.

How should complaints of shortness of breath be dealt with?

Shortness of breath is a common patient concern that can represent dyspnea, orthopnea, or PND. o Dyspnea is an uncomfortable awareness of breathing that is inappropriate to a given level of exertion. This complaint is common in patients with cardiac or pulmonary problems. o Orthopnea is dyspnea that occurs when the patient is supine and improves when the patient sits up. o PND describes episodes of sudden dyspnea and orthopnea that awaken the patient from sleep, usually 1-2 hours after going to bed, prompting the patient to sit up, stand up, or go to a window for air.

What should you assess about the carotid pulse?

Slowly increase pressure until you feel a maximal pulsation; then slowly decrease pressure until you best sense the arterial and contour. Assess: o The amplitude of the pulse; correlates reasonably well with pulse pressure. o The contour of the pulse wave: the speed of the upstroke, the duration of its summit, and the speed of the downstroke. o Variations in amplitude. o The timing of the carotid upstroke in relation to the heart sounds.

How do you measure a patient's JVP?

Steps for measuring the JVP: o Raise the patient's head slightly on a pillow to relax the SCM muscles. o Raise the head of the bed or examining table to about 30 degrees. o Use tangential lighting and examine both sides of the neck. o If necessary, raise or lower the head of the bed until you can see the oscillation point or meniscus of the internal jugular venous pulsations in the lower half of the neck. o Focus on the right internal jugular vein. o Identify the highest point of pulsation in the right jugular vein. Measurer the vertical distance in centimeters above the sternal angle where the horizontal object crosses the ruler and add to this distance 5 cm, the distance from the sternal angle to the right atrium. Observe the amplitude and timing of the jugular venous pulsations. To time them, feel the left carotid artery with your right thumb or listen to the heart simultaneously.

What is the sequence of the cardiac examination?

Supine, with the head elevated 30 degrees: After examining JVP and the carotid pulse, inspect and palpate the precordium: the 2nd ight and left interspaces; the RV; and the LV, including the apical impulse (diameter, location, amplitude, duration). Left lateral decubitus: Palpate the apical impulse to assess its diameter. Listen at the apex with the *bell* of the stethoscope. Supine, with the head elevated 30 degrees: Listen at the 2nd right and left interspaces, down the left sternal border to the 4th and 5th interspaces, and across to the apex the six listening areas with the *diaphragm*, then the *bell.*. As indicated, listen at the lower right sternal border for right-sided murmurs and sounds, often accentuated with inspiration, with the diaphragm and bell. Sitting, leaning forward, after full exhalation: listen down the left sternal border and at the apex with the diaphragm.

What layer do all blood vessels contain?

Surrounding the lumen of all blood vessels is the *intima*, a single continuous lining of endothelial cells with remarkable metabolic properties. Intact endothelium synthesizes regulators of thrombosis such as prostacyclin, plasminogen activator, and heparin-like molecules. It produces prothrombotic molecules such as von Willebrand factor and plasminogen activator inhibitor. It modulates blood flow and vascular reactivity through synthesis of vasoconstrictors and vasodilators. The intimal endothelium also regulates immune and inflammatory reactions through elaboration of interleukins, adhesion molecules, and histocompatibility antigens.

How should complaints of swelling or edema be dealt with?

Swelling or edema refers to the accumulation of excessive fluid in the extravascular interstitial space. Focus on the location, timing, and setting of the swelling, and on associated symptoms. Consider asking patients who retain fluid to record daily morning weights because edema may not be obvious until several liters of extra fluid have accumulated.

What is the Allen test?

The Allen test compares patency of the ulnar and radial arteries. It also ensures patency of the ulnar artery before puncturing the radial artery for blood samples. The patient should rest with hands in lap, palms up. Ask the patient to make a tight fist with one hand; then compress both radial and ulnar arteries firmly between your thumbs and fingers. Next, ask the patient to open the hand into a relaxed, slightly flexed position. The palm is pale. Release your pressure over the ulnar artery. If the ulnar artery is patent. The palm flushes within about 3-5 seconds. Test patency of the radial artery by releasing the radial artery while still compressing the ulnar artery.

What is an EKG?

The ECG consists of six limb leads in the frontal plane and six chest or precordial leads in the transverse plane. o Electrical vectors approaching a lead cause a positive, or upward deflection. o Electrical vectors moving away from the lead cause a negative, or downward deflection. o When positive and negative vectors balance, they are isoelectric and appear as a straight line. o The P wave represents atrial depolarization. o The QRS complex represents ventricular depolarization. o The T wave represents ventricular repolarization.

How do you assess the apical impulse?

The apical impulse represents the brief early pulsation of the left ventricle as it moves anteriorly during contraction and contacts the chest wall. Once you have found the apical impulse, make finer assessments with your fingertips, and then with one finger. Now assess the *location, diameter, amplitude and duration* of the apical impulse. o Location: initially try to assess location with the patient supine. Locate two points: the *interspaces, usually the 5th or possibly the 4th*, which give the vertical location; and the distance in centimeters from the *midclavicular* line, which gives the horizontal location. o Diameter: palpate the diameter of the apical impulse. In the supine patient, it usually measures *less than 2.5 cm*. o Amplitude: estimate the amplitude of the impulse. Is the PMI brisk and tapping, diffuse or sustained? Normally, the amplitude of the PMI is small and feels *brisk and tapping.* o Duration: the most useful characteristic of the apical impulse for identifying hypertrophy of the left ventricle. To assess duration, auscultate the heart sounds as you palpate the apical impulse, or watch the movement of your stethoscope as you listen at the apex. Normally, it lasts through the first two thirds of systole, or often less, but does not continue to the second heart sound.

What are the deep and superficial leg veins?

The deep veins of the legs carry approximately 90% of the venous return from the lower extremities. They are well supported by surrounding tissues. In contrast, the superficial veins are subcutaneous, with relatively poor tissue support. They include the great saphenous vein, and the small saphenous vein. Bridging or perforating veins connect the superficial system with the deep system.

What is the pulse pressure?

The difference between systolic and diastolic pressure is known as the pulse pressure.

Where is the right ventricle on the surface anatomy?

The right ventricle occupies most of the anterior cardiac surface. The inferior border of the RV lies below the junction of the sternum and the xiphoid process. The RV narrows superiorly and joins the pulmonary artery at the level of the sternal angle.

Of the two second heart sounds, which is louder?

The second heart sound and its two components are caused primarily by closure of the aortic and pulmonic valves, respectively. Of the two components in the second heart sound, the closure of the aortic valve is normally louder, reflecting the high pressure in the aorta. It is heard throughout the precordium. In contrast, the closure of the pulmonic valve is relatively soft, reflecting the lower pressure in the pulmonary artery.

Where are the inguinal lymph nodes?

The superficial inguinal nodes include two groups. The horizontal group lies in a chain high in the anterior thigh below the inguinal ligament. It drains the superficial portions of the lower abdomen and buttock, the external genitalia (but not testes), the anal canal and perianal area, and the lower vagina. The vertical group clusters near the upper part of the saphenous vein and drains a corresponding region of the leg.

How do you estimate the level of the JVP?

To estimate the level of the JVP, learn to find the highest point of oscillation in the internal jugular vein. The JVP is usually measured in vertical distance above the sternal angle. JVP measures at >3 cm above the sternal angle, or >8 cm above the right atrium, is considered elevated or abnormal.

How do you calculate 10-year risk?

Use the CVD risk calculators to establish 10-year and lifetime risk for patients ages 40-79 years.

What is the Trendelenburg test?

Use the retrograde filling (Trendelenburg) test to assess the valves of the communicating veins and the saphenous system. With the patient supine, elevate one leg to about 90 degrees to empty it of venous blood. Occlude the great saphenous vein in the upper thigh by manual compression, using enough pressure to occlude this vein but not the deeper vessels. Ask the patient to stand. While you keep the vein occluded, watch for venous filling of the leg. Normally, the saphenous vein fills from below, taking about 35 seconds as blood flows through the capillary bed into the venous system. After the patient stands for about 20 seconds, release the compression and look for sudden additional venous filing. Normally, slow filling continues because competent valves in the saphenous vein block retrograde flow.

What are veins?

Veins are thin-walled and highly distensible, with a capacity for containing up to two thirds of circulating blood flow. The venous intima consist of nonthrombogenic endothelium. Protruding into the lumen are unidirectional valves that promote venous return to the heart. The media contains circumferential rings of elastic tissue and smooth muscle that change vein caliber in response to even minor changes in venous pressure. The smallest veins, or venules, drain capillary beds and form interconnecting venous plexuses. Because of their weaker wall structure, the legs veins are susceptible to irregular dilatation, compression, ulceration, and invasion by tumors, and warrant special attention.

What is the arterial pulse?

With each contraction, the left ventricle ejects a volume of blood into the aorta that then perfuses the arterial tree. As the ensuring pressure wave moves through the arterial system it generates the arterial pulse.

How should you pursue these symptoms?

o Ask about abdominal, flank or back pain, especially in older smokers. Is there unusual constipation or distention? Inquire about for urinary retention, difficulty voiding, or renal colic. o If there is persisting abdominal pain, ask about any related "food fear," weight loss, or dark stool. o Ask about any pain or cramping in the legs during exertion that is relieved by rest within 10 minutes, called intermittent claudication. o Ask about coldness, numbness or pallor in the legs or feet or loss of hair over the anterior tibial surfaces. • Because most patients with PAD report minimal symptoms, enquire about two common types of atypical leg pain from PAD that occur prior to critical limb ischemia: leg pain on exertion and rest (exertional pain that can begin at rest), and leg pain/carry on (exertional pain that does not stop the patient from walking).

What are the two types of hypertension?

o Primary (essential) hypertension is the most common cause of hypertension: risk factors include age, genetics, black race, obesity and weight gain, excessive salt intake, physical inactivity, and excessive alcohol use. o Secondary hypertension accounts for less than 5% of hypertension cases. Causes include sleep apnea, chronic kidney disease, renal artery stenosis, medications, thyroid disease, parathyroid disease, Cushing syndrome, hyperaldosteronism, pheochromocytoma, and coarctation of the aorta.

What are important topics for health promotion and counseling with regard to peripheral vascular disease?

o Screening for lower-extremity peripheral artery disease o The ankle-brachial index o Screening for renal artery disease o Screening for abdominal aortic aneurysm

What are tips for identifying heart murmurs?

o Timing: first decide if you are hearing a systolic murmur, falling between the first heart sound and the second heart sound, or a diastolic murmur, falling between the second heart sound and the first heart sound. Palpating the carotid pulse as you listen can help you with timing. Murmurs that coincide with the carotid upstroke are systolic. o Shape: the shape or configuration of a murmur is determined by its intensity over time. o Location of maximal intensity: this is determined by the site where the murmur originates. Find the location by exploring the area where you hear the murmur. Describe where you hear it best in terms of the intercostal space and its proximity to the sternum, the apex, or its measured distance from the midclavicular, midsternal, or one of the axillary lines. o Radiation or transmission from the point of maximal intensity: this reflects not only the site of origin but also the intensity of the murmur, the direction of blood flow, and bone conduction in the thorax. Explore the area around a murmur and determine where else you can hear it. o Intensity: this is usually graded on a six-point scale and expressed as a fraction. The numerator describes the intensity of the murmur wherever it is loudest; the denominator indicates the scale you are using. Intensity is influenced by the thickness of the chest wall and the presence of intervening tissue. o Pitch: this is categorized as high, medium or low. o Quality: this is described in terms such as blowing, harsh, rumbling, and musical.

Where are the palpable arteries in the body?

• In the arms, you can locate arterial pulses at the brachial artery, the radial artery, and the ulnar artery. • In the abdomen, you can locate the pulsations of the aorta in the epigastrium. Not palpable are the three deeper branches, the celiac trunk and the superior and inferior mesenteric arteries. • In the legs, pulses are palpable in the femoral artery, the popliteal artery, the dorsalis pedis artery, and the posterior tibial artery.

How do you inspect the legs for peripheral vascular disease?

• Inspect both legs from the groin and buttocks to the feet. Note: o Their size, symmetry, and any swelling or edema o The venous pattern and any venous enlargement o Any pigmentation, rashes, scars or ulcers o The color and texture of the skin, the color of the nail beds, and the distribution of hair on the lower legs, feet and toes. o Inspect the color of the skin. • Inspect the saphenous system for varicosities. If present, ask the patient to stand, which allows any varicosities to fill with blood and makes them visible. Palpate along any varicosities to check for thrombophlebitis. • Inspect and compare the thighs, calves, and ankles for symmetry. Note their relative size and the prominence of veins, tendons and bones. • If you detect unilateral swelling or edema, measure the calves 10 cm below the tibial tuberosity. Normally, the difference in calf circumference is less than 3 cm. • Palpate the femoral, popliteal, and pedal pulses to assess the arterial circulation. • Assess the temperature of the feet and legs with the backs of your fingers. Compare one side with the other.

What lifestyle modifications can be made to improve the risk of CVD?

• Lifestyle modifications to prevent or manage hypertension include optimal weight, no tobacco use, lowered sodium intake, regular aerobic exercise, moderate alcohol consumption, and diets rich in fruits, vegetables, whole grains, and low-fat dairy products. • A Mediterranean diet (fruits, vegetables, seafood, white meat, wine) has been shown to reduce major CV events among high-risk patients. • Healthy fats include monounsaturated fats, polyunsaturated fats, and omega-3 fatty acids. Unhealthy fats are saturated and trans fats.

When should you use the diaphragm and bell of your stethoscope?

• The diaphragm of the stethoscope is better for picking up the relatively high-pitched sounds of the first and second heart sounds, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs. Listen throughout the precordium with the diaphragm, pressing it firmly against the chest. • The bell of the stethoscope is more sensitive to the low-pitched sounds of the third and fourth heart sounds and the murmur of mitral stenosis. Apply the bell lightly, with just enough pressure to produce an air seal with its full rum. Use the bell at the apex, then move medially along the lower sternal border.

When do you use the Valsalva maneuver versus isometric handgrip?

• The following techniques help (1) to identify a prolapsed mitral valve and (2) to distinguish hypertrophic cardiomyopathy from aortic stenosis. o Instruct the patient to squat next to the examining table and hold on to it for balance. Listen to the heart with the patient in the squatting position and again in the standing position. • The Valsalva maneuver involves forcible exhalation against a closed glottis after full inspiration, causing increased intrathoracic pressure. The normal systolic blood pressure response follows four phases: (1) transient increase during onset of the "strain" phase when the patient bears down, due to increased intrathoracic pressure; (2) sharp decrease to below baseline as the "strain" phase is maintained, due to decreased venous return; (3) further acute drop of both blood pressure and left ventricular volume during the "release" phase, due to decreased intrathoracic pressure; (4) "overshoot" increased blood pressure, due to reflex sympathetic activation and increased stroke volume. o Can be used to identify hypertrophic cardiomyopathy: listen at the lower left sternal border. o Can be used to identify heart failure and pulmonary hypertension. • Isometric handgrip increases the systolic murmurs of mitral regurgitation, pulmonic stenosis, and ventricular septal defect, and also the diastolic murmurs or aortic regurgitation and mitral stenosis. • Transient compression of both arms by bilateral blood pressure cuff inflation to 20 mmHg greater than peak systolic blood pressure augments the murmurs of mitral regurgitation, aortic regurgitation and ventricular septal defect.