CPD Midterm Combined (JK+)

Radio-Femoral Delay o The normal transmission time of the pulse wave to the radial artery is ( ) and to the femoral artery is ( ). In disease conditions with obstruction to the flow of blood to the ( ), the ( ) pulse is delayed in arriving, e.g. ( ) syndrome, and ( ) of the aorta. Measure the blood pressure in the ( ) in the supine position. This reveals a ( ) blood pressure in the ( ) than in the ( ) (a reversal of normal).

-75 ms -70 ms (milliseconds) -lower extremities -femoral pulse -Leriche's syndrome (isolated aorto-iliac disease) - post subclavian coarctation -upper and lower extremities -lower blood pressure -thigh -arm

What is a large bounding pulse?

-Defined as 3+ (normal is 2+) -does not fade out -not easily obliterated (hyperdynamic circulation)

Maneuver done to obliterate the radial pulse. Why would this be done? What abnormalities may this indicate? What happens in normal versus disease states? When should you check for this during physical exam?

-Elevate the pressure in the blood pressure cuff sufficiently (beyond systole) to obliterate the radial pulse -To check for rigidity of arterial wall from atherosclerosis -normal: vessel walls no longer palpable when flow is eliminated -abnormal: radial artery is palpable and riged->positive Osler's sign -While your taking BP: palpate the radial artery region to fell for positive Osler's sign

A bruit heard in both systole and diastole (two phase bruit) heard over peripheral arteries such as the femoral artery. (A bruit is normally heard only in systole.) What causes this?

-Femoral bruit ("pistol shot") - Durozie's sign. -due to rapid "back and forth" flow of blood as seen in aortic insufficiency.

Pulse contour and amplitude pattern associated with premature ventricular contraction. How is this pattern described?

-Pulsus Bigeminal -2 beats in rapid succession: normal beat plus premature beat->the two beats vary in amplitude due to reduced stroke volume with the second beat.

Abnormal contour with amplitude with 2 beats in rapid succession: a normal beat plus premature beat. The two beats vary in amplitude due to the reduced stroke volume with the second beat What is this associated with?

-Pulsus Bigeminal -premature ventricular contraction

Pulse contour and amplitude pattern associated with pure aortic regurgitation or aortic stenosis plus aortic regurgitation. How is this pattern described?

-Pulsus Bisferiens (biphasic pulse) -2 main peaks: 2 strong systolic beats seperated by midsystolic dip

Abnormal contour with amplitude with 2 main peaks, 2 strong systolic beats separated by a mid systolic dip. What can cause this?

-Pulsus Bisferiens (biphasic pulse) -pure aortic regurgitation, aortic stenosis plus aortic regurgitation

Abnormal contour with amplitude with exaggeration of the normal fall in amplitude of the pulse during inspiration-> This decrease is best determined by changes in the systolic blood pressure. Under normal circumstances, there may be a fall of up to 10 mm Hg during inspiration. What may cause this?

-Pulsus Paradoxus (misnomer) -severe obstructive lung disease -pericardial tamponade -(less commonly) contrictive pericarditis

measures arteriolar constriction. What is the formula for this?

-SVR = Systemic Vascular Resistance -SVR - (MAP-CVP)/(CO x 79.9)

In assessing pulses in the lower extremities one must also make note of:

-Temperature of feet: cold may indicate arterial insufficiency -color of skin and reaction to elevation -hair distrubition -loss of hair over toes

Which pulse pattern is associated with backflow through aortic valve due to aortic regurgitation or patent ductus arteriosis. How is this pattern described?

-Water Hammer Pulse/Corrigan pulse, collapsing pulse -Greater amplitude, rapid rise upstroke, normal summit, sudden downstroke

Water Hammer Pulse/Corrigan pulse, collapsing pulse) Abnormal pulse with: o Greater amplitude o Rapid rise (upstroke) o Normal summit o Sudden descent What can cause this?(backflow through aortic valve) (aortic regurgitation and patent ductus arteriosus)

-Water Hammer Pulse/Corrigan pulse, collapsing pulse -backflow through aortic valve: aortic regurgitation and patent ductus arteriosis

constitute the character of the pulse. Where character of pulse often assessed?

-amplitude (volume) and contour (waveform: upstroke, plateau, and downstroke) -right carotid artery

Produces reduced a small amplitude (volume) pulse called ( ) and and a delayed upstroke called ( ); the plateau is low and delayed and the downstroke is slow.

-aortic stenosis -pulsus parvus: small amplitude -pulsus tardus: delayed upstroke

On contraction of the left ventricle of the heart, blood is ejected into the ( ) system. This creates a ( ) which is palpable and is perceived as the ( ).

-arterial system -pressure wave -arterial pulsation

Pulse deficit is created by a difference between the heart rate by ( ) at the ( ) and the ( ) rate determined by ( ). What is one example and cause of pulse deficit?

-auscultation -apex -peripheral pulse -palpation -rapid irregular rhythm d/t atrial fibrillation

In aortic stenosis, there is reduced ( ) and the outflow is at a ( ) rate. The pulse is of small ( ); the upstroke is ( ) resulting in a condition called ( ); the plateau is ( ) and ( ) and the down stroke is ( ).

-cardiac output -slower rate -amplitude (pulsus parvus); -upstroke delayed->pulsus tardus -plateau low and delayed -slow

In aortic regurgitation, backflow occurs during ( ). This augments the ( ) available during ( ). The pulse is ( ); the upstroke is ( ); the summit is ( ) and is moved closer to ( ) and the down stroke is ( ).

-diastole -volume of blood -systole -strong and bounding -brisk -brief -S1 -rapid

Water Hammer Pulse/Corrigan pulse, collapsing pulse: amplitude, upstroke, summit, downstroke. What can cause this?

-greater amplitude -rapid upstroke -normal summit -sudden downstroke -backflow through aortic valve: aortic regurgitation, patent ductus arteriosis

To palpate radial artery: Place the index and middle fingers, pulps in line with the course of the ( ), over the ( ) aspect of the wrist, with the fingers going from ( ) to ( ). The ( ) finger is at the wrist crease. The radial pulse is felt underneath one of the fingers. Vary the finger ( ) as required to feel a strong pulse. Count the pulse rate for ( ). If the distal pulse (radial) is not felt, palpate the next ( ) pulse. Compare the pulse ( ) on both sides (right and left) and ( ) (upper extremity) and ( ).

-radial artery -volar -medial to lateral -middle finger -pressure -1 minute - proximal pulse (brachial). -volume -proximally -distally (lower extremity)

The pulse, and hence the pulse contour, is influenced by the ( ) and ( ) of flow and ( ) to flow, during ( ) systole and diastole. Events occurring in systole influence the ( ) and ( ) of contour while the ( ) is influenced by events in diastole. The normal pulse contour has a ( ) which occurs close to S1; a ( ) occurring in mid systole and a ( ) that is less rapid than the ( ) and contains a ( ).

-rate and volume -resistance -left ventricular -upstroke and plateau -down stroke -smooth rapid upstroke -rounded brief plateau -down stroke that is less rapid than the upstroke

Basic aspects of pulsation that must be determined when taking vital signs

-rate, rhythm, amplitude, symmetry, contour, and rigidity of arterial wall

-The normal cardiac rhythm is called ( ) -Irregular rhythms: o ( ) - (repetitive pattern) caused by premature atrial or ventricular contraction o ( ) - caused by atrial dysrthytmia, such as AF. In atrial fibrillation, there is ( ) in rhythm and volume. An abnormal rhythm is best determined with an ( ).

-regular -Regular irregularity -Irregular irregularity -irregularity -EKG

The character of the pulse is often best assessed in this location. What is the definition of character of pulse?

-right carotid artery. -amplitude (volume) and contour (waveform: upstroke, plateau, and downstroke)

Indicative of atherosclerotic disease of the blood vessel. How can this be checked for in the radial artery? When should you check for this during physical exam?

-rigid arterial wall -Osler's maneuver->radial pulse still palpable and rigid even after arterial flow is obliterated using blood pressure cuff -While your taking BP: palpate the radial artery region to fell for positive Osler's sign

When the left ventricle ejects blood into the aorta, the maximal pressure in the aorta is termed the ( ) pressure. During ( ), the left ventricle relaxes and blood flows into the left ventricle through an open ( ). Blood also leaves the ( ). The lowest pressure in the aorta just before ventricular contraction is the ( ).

-systolic blood -diastole -mitral valve -aorta -diastolic blood pressure

The pulse should be symmetrical in ( ) on both sides (right & left) and between ( ) and ( ) body regions. Asymmetry (pulsus differens) is often due to ( ) differences and may indicate local ( ) or ( ) in the path of the vessel with the weaker pulse.

-volume -upper with lower -volume -stenosis or compression

WIIPEEP

-wash handes -introduce yourself -indentify the patient: ask for name; if in an institution, look at the identification band on the patient's wrist -permission to examine -explain nature and purpose of procedure -expose the area to be examined -position the patient

Pulse amplitude description and scale associated with obstruction or shock.

0: absent, not palpable

Scale of absent pulse that is not palpable. Which can cause this?- indicates obstruction or shock

0: obstruction or shock

1) Normal heart/pulse rate 2) Tachycardia 3) Bradycardia

1) 60-100 beats per minute(140 in babies) 2) >100 beats per minute 3) <60 beats per minute

Factors affecting Blood Pressure: 1) Force of ( ) action 2) Amount of resistance in the blood vessels 3) Amount of blood in the blood vessels 4) Other (non-cardiac):

1) heart's pumping action 2) resistance 3) blood 4) Pain, emotion Age, disease, obesity, Drugs/medication, Physical fitness, Trauma

Pulse amplitude description and scale associated with heart failure.

1: diminished, barely palpable, thready

Scale of diminished, barely palpable, thready pulse. What can cause this?

1: heart failure

Pulse amplitude description and scale associated with the normal (expected).

2

Scale of pulse with normal amplitude. What is amplitude?

2: volume and strength

Pulse amplitude description and scale associated with hyperdynamic circulation (hyperthyroidism).

3: full and increased

Scale of pulse with full and increased amplitude. What may cause this?

3: hyperdynamic circulation (hyperthyroidism)

Scale of bounding pulse amplitude. What causes this?

4: aortic regurgitation

Pulse amplitude description and scale associated with aortic regurgitation.

4: bounding

This is scaled 0 to 4

Amplitude (of pulse) - volume and strength

A rough representation of the stroke volume of the heart.

Amplitude (volume)

Often due to volume differences and may indicate local stenosis or compression in the path of the vessel with the weaker pulse.

Asymmetry (pulsus differens)

monitors Arterial BP

Baroreceptors

In the antecubital fossa it lies medial to the biceps tendon but at this location it may not be palpable.

Brachial artery pulse

Pulse felt approximately 2 fingers breath above the medial epicondyle in the groove between the biceps and brachialis muscles by displacing the biceps laterally.

Brachial artery pulse

Calculated MAP (mean arterial pressure)

CO x SVR OR Diastolic + 1/3 Pulse Pressure (Systolic - Diastolic)

It is manifested as alternating flushing and blanching of the nail bed due to pulsations in the subpapillary arteriolar and venous plexuses. What causes this?

Capillary pulsation in the nail bed - Quincke's sign-> It can be encountered in aortic insufficiency. It is manifested as alternating flushing and blanching of the nail bed due to pulsations in the subpapillary arteriolar and venous plexuses.

Influence Heart Rate and Myocardial contractility - Receptors - ()

Cardiac Center

This is best determined over the carotid or brachial artery.

Contour (shape or waveform)

Refers to the speed of the upstroke, the duration of the summit and the speed of the down stroke. Where is this best determined?

Contour (shape or waveform) : over the carotid or brachial artery

Formular for SV

EDV-ESV

An abnormal rhythm is best determined with this

EKG

Performed if the rate is rapid in order to determine the rhythm.

EKG

It is due to rapid "back and forth" flow of blood as seen in aortic insufficiency. A bruit is normally heard only in systole.

Femoral bruit ("pistol shot") - Durozie's sign: A bruit heard in both systole and diastole (two phase bruit) heard over peripheral arteries such as the femoral artery. (A bruit is normally heard only in systole.)

This change in systolic blood pressure is indicative of Pulsus Paradoxus. What might cause this? (severe obstructive lung disease, pericardial tamponade and less commonly in constrictive pericarditis)

If the systolic blood pressure declines greater than 12-15mm Hg -severe obstructive lung disease -pericardial tamponade -(less commonly) contrictive pericarditis

Caused by atrial dysrthytmia, such as AF

Irregular irregularity

Pulse pattern with: o Defined as 3+ (normal is 2+) o Does not fade out o Not easily obliterated (hyperdynamic circulation)

Large, Bounding pulse

Causes of Radio-Femoral pulse delay

Leriche's syndrome (isolated aorto-iliac disease) and or post-subclavian coarctation of aorta.

Difference between the heart rate by auscultation at the apex and the peripheral pulse rate by palpation (rapid irregular rhythm e.g. atrial fibrillation)

Pulse deficit

Pulse pattern created by rapid irregular rhythm e.g. atrial fibrillation.

Pulse deficit: difference between heart rate at apex measured via auscultation and peripheral pulse rate measured by palpation.

Alternating weak and strong beat with a normal rhythm (left ventricular failure)->Usually associated with a left sided S3

Pulsus alternans

Causes by Leriche's syndrome (isolated aorto-iliac disease) and or post-subclavian coarctation of aorta.

Radio-Femoral delay: obstruction to blood flow in the lower extremities: femoral pulse is delayed in arriving

Caused by (repetitive pattern) premature atrial or ventricular contraction.

Regular irregularity of pulse rhythm

Formula for CO

SV x HR (L/min)

Volume must be noted in both limbs to determine ( ).

Symmetry - as it relates to volume. T 2. Rigidity of the arterial wall.

Part of contours that represents the diastolic phase that occurs after closure of the aortic valve.

The down stroke (or reflective wave)

Influence SVR

Vasomotor Center

Quinke's sign

alternating flushing and blanching of the nail bed d/t pulsation in the subpapillary arteriolar and venous plexuses->felt as capillary pulsation in the nail bed which can be encountered in aortic insufficiency

What is Pulsus alternans and what causes it?

alternating weak and strong beats with normal rhythm->left ventricular failure

This vessel is a branch of the popliteal artery. At the ankle it lies midway between the medial and lateral malleoli. It continues distally as the dorsalis pedis.

anterior tibial artery

Produces a strong and bounding pulse with a brisk upstroke, brief summit (plateau) moved closer to S1, and a rapid downstroke.

aortic regurgitation

force exerted by the blood against the walls of the artery

blood pressure

used to determine the contour of the pulse

carotid and brachial pulses

May indicate arterial insufficiency in the lower extremities

cold temperature when assessing LE pulses

It is usually indicative of aortic regurgitation

de Mussett's sign: Head nodding coinciding with the carotid pulse

Head nodding coinciding with the carotid pulse. What does this indicate?

de Mussett's sign: It is usually indicative of aortic regurgitation

pulsus tardus

delayed upstroke occurring in aortic stenosis

Palpated on the dorsum of the distal foot just lateral to the tendon of the Extensor Hallucis Longus muscle and medial to the the extensor digitorum longus at the base of the second toe.

dorsalis pedis pulse

Located medial to the femoral nerve and lateral to the femoral vein.

femoral artery

This pulsation is felt in the femoral triangle, about 2-3cm inferior to the midpoint of the inguinal ligament (between the anterior superior iliac spine and pubic tubercle).

femoral artery

When does a drop in systolic blood pressure normally occur and what is a normal decline? What happens if it drops by more than than this? What may cause such a condition?

inspiration: drop in systolic BP up to 10 mm Hg -decline >12-15 mm Hg: Pulsus paradoxus: severe obstructive lung disease, pericardial tamponade, constrictive pericarditis

May be indicated by asymmetry (pulsus differens) of volume

local stasis or compression in the path of the vessel with the weaker pulse

visualizes lower and middle turbinates (conchae), inferior meatus and rarely the middle turbinates

nasal speculum

Has a smooth rapid upstroke which occurs close to S1; a rounded brief plateau occurring in mid systole and a down stroke that is less rapid than the upstroke and contains a dicrotic notch.

normal contour pulse

This vessel lies deep in the popliteal fossa, almost on the knee joint.

popliteal artery pulse

To palpate this pulse, the knee must be flexed and the finger tips must be inserted deeply into the popliteal fossa.

popliteal artery pulse

This vessel is a branch of the popliteal artery and its pulsation is felt posterior to the medial malleolus.

posterior tibial artery

Can be felt 1 to 2 fingers breath above the volar crease of the wrist near the radial styloid.

radial artery pulsations

used to evaluate the rate, rhythm and volume of the pulse

radial pulses (Rate, Rhythm and Volume of pulse)

The ( ) of all pulses in an individual are the same because these parameters are centrally generated by the heart.

rate and rhythm

use the radial artery and/or the apex beat of the heart to assess these qualities of pulsation

rate and rhythm

In normal sinus rhythm, the pulse produced has regular ( ).

rate and volume

Found to be irregular in atrial fibrillation

rhythm and volume (irregular irregularity)

pulsus parvus

small amplitude of pulse occuring in aortic stenosis

It is felt about 1 finger's breath above the crease of the wrist along the above course and lateral to the flexor Carpi Ulnaris.

ulnar artery pulsation

There are three elements in contour (wave form)- Amplitude and contour .

upstroke, plateau and down stroke.

These may result in reduced blood flow and weak or absent peripheral pulses.

vasoconstriction, low blood volume, or occlusion of arterial flow

Aspect of pulse which should be symmetrical in volume on both sides (right & left) and upper with lower.

volume