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168 Cards in this Set

  • Front
  • Back
What are 3 components of the cardiovascular system?
1. heart
2. peripheral vascular system
3. lymphatic system
What is the precordium?
an area on the anterior chest that covers the heart and great vessels
Where is the precordium located?
in the middle 1/3 of the thoracic cage
Name 5 internal position/surface landmarks of the CVS.
1. precordium
2. mediastinum
3. 2nd-5th intercostal
4. base vs apex
5. apical impulse/PMI
Where is the heart located?
1. from the 2nd to the 5th intercostal space
2. from the RIGHT border of the sternum to the LEFT midclavicular line
Where is the base of the heart?
at the top
What is PMI?
point of maximal impulse
Where is the apex of the heart?
the point at the bottom
The heart is close enough to the chest wall that you can feel what kind of impulse?
the apical impulse aka PMI
Where can you ascultate the apical impulse/PMI?
the 5th intercostal space of the midclavicular line
Where does the right ventricle of the heart predominantly face?
anterior
Where does the left ventricle of the heart predominanty face?
posterior

**the heart is twisted enough in the body that we hear the left aortic valve
Name the 5 great vessels of the heart.
1. aorta
2. pulmonary artery
3. pumonary veins
4. inferior vena cava
5. superior vena cava
What is the function of the aorta?
Pushes oxygenated blood to the brain and body
What is the function of the pulmonary artery?
carries deoxygenated blood away from the heart to the lungs
What is the function of the pulmonary veins?
carries oxygenated blood from the lung back to the heart
What is the function of the inferior vena cava?
Brings blood/lymph from the lower body to the heart
What is the function of the superior vena cava?
Brings blood/lymph from the upper body to the heart
Where is the right external jugular vein located?
Over the muscles of the neck
Where is the carotid artery located?
near the trachea and sternocleidomastoid
The timing of carotid contraction coincides with what?
systole
What are 3 layers of the heart?
1. epicardium
2. myocardium
3. endocardium
What is the epicardium?
A protective, CT layer covered by epithelium (aka visceral pericardium)
What is the myocardium?
Thick cardiac muscle with many capillaries, associated lymphatic vessels, and innervation
What is the endocardium?
-lines the chambers of the heart
-Composed of endothelial CT, elastic and collagenous fibers
-contains cardiac purkinje fibers
Describe the pathway of blood pumping begininng at the RA (right atrium).
RA-->
RV-->
Pulmonary artery-->
Lungs (O2*)-->
pulmonary veins-->
LA-->
mitral valve-->
LV-->
aortic valve-->
aorta
Do the right and left sides of the heart pump simultaneously?
yes
Why is the left ventricle thicker?
it does more pumping
Name the 2 atrioventricular valves.
AV valves:

1. Tricuspid (right)
2. Mitral valve (left)
Describe the status of the AV valves during diastole.
AV valves OPEN

(during the filling phase)
Describe the status of the AV valves during systole.
AV valves CLOSED

(pumping phase)
How does the right heart pump blood to the lungs?
under low pressure
Name the 2 semilunar valves.
1. aortic valve
2. pulmonic valve
Describe the status of the semilunar valves during systole.
semilunar valves OPEN
Describe the status of the semilunar valves during diastole
semilunar valves CLOSED
What happens during systole?
-ventricles contract
-AV valves close
-pulmonic and aortic valves open
What is S1?
the sound heard by the closing of the AV valves during systole (specifically, the mitral valve)
Describe the blood flow from the RV during systole.
RV pumps blood into the pulmonary arteries
Describe the blood flow from the LV during systole
LV pumps blood into the aorta
What is diastole?
the relaxation of the ventricles
What is S2?
the closure of the semilunar valves, specifically the aortic valve
Describe the tricuspid and mitral (AV) valves during diastole.
open
Describe the blood flow from the right atrium during diastole.
blood flows into the right ventricle
Describe the blood flow from the left atrium during diastole.
blood flows into the left ventricle
What are the expected sounds during valve opening and closure?
opening valves should be silent

closing valves should be heard
What is S1?
"lub"

sound heard when the mitral and tricuspid valves close
Where do you hear S1 the best?
at the apex of the heart
What is S2?
"dub"

sound heard when aortic and pulmonic valves close
Where do you hear S2 the best?
loudest at the base because that's where the valves are located
What is the cardiac output?
the amount of blood an adult can pump/min

CO=SV x HR
What is the typical adult cardiac output?
CO= 4-6 L/min
Define the BP in mathematical terms.
BP= CO x SVR
What is SVR?
systemic vascular resistance
What is the stroke volume?
the volume of blood ejected during each contraction (systole)
What 2 factors affect the heart's ability to increase cardiac output?
1. preload
2. afterload
What is preload?
refers to the load that stretches the cardiac muscle before contraction
What might cause an increase in preload?
pregnancy, exercise
Briefly describe Starling's Law
greater preload (stretching)=greater contraction
What is afterload?
refers to the degree of vascular resistance to ventricular contraction
What is a pathological increase in preload?
volume overload
What is a pathological increase in afterload?
pressure overload
What pressure does the afterload relate to?
the pressure that the ventricles must isometrically generate against the aortic valve (ie, if diastolic pressure is 80 mm Hg, then afterload pressure is 80 mm Hg)
Why is it important for diastolic pressure to stay low?
hypertrophy might result from the increase of muscle contraction
In CHF patients, what should you do if too much blood collects on the right side of the heart?
give a diuretic
What subjective data do you want to collect during CV health history?
1. chest pain
2. dyspnea
3. orthopnea
4. cough
5. fatigue
6. cyanosis or pallor
7. edema
8. nocturia
9. past cardiac history
10. family cardiac history
11. cardiac risk factors
What is dyspnea?
shortness of breath
What is orthopnea?
shortness of breath while lying flat
What should you ask a patient with orthopnea?
How many pillows do you need at night?
What is a huge risk factor of a heart problem?
fatigue
Why does diuresis occur at night in the form of nocturia?
When you're lying flat, you don't need as much pressure to pump fluid through kidneys
What are 6 cardiac risk factors?
1. increased BP
2. increased cholesterol
3. diabetes (effects small vessels)
4. obesity
5. sedentary lifestyle
6. cigarette smoking
What 4 assessments should you make during the physical exam?
1. general appearance
2. BP
3. neck vessels
4. precordium (inspect, palpate, ascultate)
What is the SBP?
the pressure generated by the LV during systole (when the LV ejects blood into the aorta and the arterial tree)
What is DBP?
the pressure generated in the arteries by blood remaining in the arterial tree during diastole (when the ventricles are relaxed)
How often should you check the carotid arteries in an at-risk patient?
every time
Where should you palpate the carotid arteries?
the upper or lower 1/3 of the neck
What should you avoid when palpating the carotids? Why?
thyroid cartilage

this is the site where the corotid sinus is; rubbing it decreases HR
When would you massage the carotid sinus?
if a person has supraventricular tachycardia
When listening to the carotid arteries, what should you tell your patient to do?
hold his breath
What are 2 sounds you don't want to hear during carotid ascultation?
1. thrills
2. bruit
What is a bruit and how do you listen to it?
blowing, swishing sound of turbulent blood flow; the sound made when blood flows past an obstruction

use a bell to listen to it
Which 2 assessments of the carotid should you perform?
1. palpation
2. ascultation
What are 4 reasons why you want to inspect the neck?
1. inspect the jugular venous pulse
2. estimate the jugular venous pressure
3. hepatojugular reflex
4. inspect neck for distension of neck veins
What is jugular venous pressure (JVP)?
the amount of pressure in jugular veins
How is JVP commonly expressed?
the vertical height (cm) of the column of blood (the head) in relation to the sternal angle (angle of Louis)
What does the mean height of the column of blood in the JVP represent?
hydrostatic pressure in the right atrium (usually 6-10 cm H2O)
Where is the head of the jugular venous pulse commonly seen in a normal subject?
at the level of the clavicle when he/she is reclining at 45 degrees
What does pressure in the jugular veins reflect?
right atrial pressure (gives clinicians an important clinical indicator of cardiac function and right heart hemodynamics)
Which jugular vein do we try to use to measure JVP? Why?
JVP is best estimated from the internal jugular vein (usually on the RIGHT) side because it has a more direct anatomic channel into the right atrium

*internal jugular vein is deep to sternocleidomastoid, so difficult to find
*may use external if internal can't be found, but it's less reliable
What happens in right-sided heart failure? What are the signs?
the right side builds up with blood

signs:
1. edema in feet
2. distension in JVS
How far away is the right atrium from the angle of Louis?
5 cm
How do you measure the JVP?
1. place a ruler perpendicular to the Angle of Louis
2. Use a straight edge to measure the level of pulsations of the jugular vein
If the height of JVP is 8-10 cm, what does this indicate?
normal
If the height of JVP is above 10 cm, what does this indicate?
extra fluid (right-sided heart failure)
When might you need to switch a patient position to find the JVP?
if they have extra fluid or are dehydrated
What are 4 assessments that you must make of the precordium?
1. Palpate across the precordium
2. Percuss to outline the cardiac borders (not usually done because sternum/stomach get in the way)
3. Inspect the anterior chest
4. Palpate the apical impulse
Why should you inspect the precordium (anterior chest)?
to look for heaves (lifts);

you are looking for lifting of chest wall over 1 of the valves
When might you see extra lift in the anterior chest?
in the event of heart failure because the heart is overloaded
When you palpate the precordium, what should you feel for?
thrills (palpable feeling of turbulent blood flow that feels like a cat purr)
Where is the apical impulse located?
at the 5th intercostal space in the MCL

ie. PMI 5th ICS MCL
What if the apical impulse occured at the 6th ICS or beyond the MCL?
Heart might be enlarged.

Possibly due to
-ventricular hypertrophy
-too much preload
What pattern describes the heart ascultation routine?
Z-pattern
APT M describes the Z-pattern of ascultation. What do these letters mean?
A: aortic area
P: pulmonic area
T: tricuspid area
M: mitral area
Where is the aortic valve located?
the left side of the heart
Where do we best hear the aortic valve?
on the right side of the sternal border because the heart is twisted in the body
Which side is the pulmonic valve heard best?
on the left side of the sternal border in the second intercostal space
Where is the tricuspid area heard best?
on the left sternal border, 5th intercostal space
Where is the mitral area of the heart heard best?
left midclavicular line, 5th intercostal space
Where is Erb's point?
3rd intercostal space at left sternal border
What is the significance of Erb's point?
you can hear S1 and S2 equally
How should you approach heart ascultation?
1. listen to S1 and S2 separately
2. then listen for other sounds
What are 2 positions for ascultation?
1. sitting + lean forward
2. lying
What does the sitting + lean forward position optimize your ability to hear?
since it brings the base of the heart forward, it allows you to hear the aortic and pulmonic valves better
What does the lying position enable you to hear?
the whole heart (listen with diaphragm and bell)
What does the LEFT LATERAL DECUBITUS POSITION allow you to ascultate? Why?
allows you to listen to the mitral area by bringing the apex of the heart closer to the chest wall
If you press on the liver, and you notice excess fluid in the jugular that doesn't decrease, what does this indicate?
CHF
When ascultating for heart sounds, what should you listen for?
1. rate
2. rhythm
What is the adult pulse rate normally?
60-100 (should be fairly regular)
Name 2 extra heart sounds
1. S3
2. S4
Describe S3
early systolic clicks
Describe S4
midsystolic click & opening snap
Name 4 murmurs.
1. aortic pulmonic stenosis
2. aportic pulmonic regurgitation
3. mitral/tricuspid stenosis
4. mitral/tricuspid regurgitation
List 3 properties of S1
1. S1 is louder than S2 at the apex
2. S1 coincides with carotid artery pulse
3. S1 coincides with R wave on ECG
Describe a property of S2
S2 is heard louder at the base (closure of aortic/pulmonic valves)
What is the physiological split S2
"more to the right, less to the left"

when you inspire, more blood in the lungs picks up O2 (so there is slighly more blood in the right vs the left side of the heart) .:. the left ventricle finishes the contraction before the right side

-so you hear the aortic valve close before the pulmonic valve!!
What does the thirst heart sound indicate?
ventricular gallop
What does the fourth heart sound indicate?
atrial gallop
What does early systolic ejection click indicate?
1. aortic stenosis
2. pulmonic stenosis
What does midsystolic click incidate?
mitral regurgitation
What does an opening snap indicate?
mitral stenosis
Name 2 abnormal ventricular filling sounds.
S3 and S4
What causes S3?
left ventricular dilation from too much fluid
Describe S3.
-occurs in early diastole
-if the ventricle is noncompliant to filling, it makes a turbulent blood sound (sounds like distant thunder)
What body position allows you to best hear for S3?
lateral decubitus
What does S3 sound like?
Ken-tu-key
What disease is associated with S3?
left ventricular heart failure
Describe S4.
ventricle is noncompliant to blood flow during the atrial kick

hypertrophic ventricles are stiff, so they do not expand well .:. they do not receive extra blood that is contributed by the atrial kick
What does S4 sound like?
Ten-nes-see
Where is S4 best heard?
at the apex in the left lateral position

**heard with the bell
What pathology is associated with S4?
Left ventricular hypertrophy
What is a summation gallop?
S3 + S4 (kentucky/tennessee)
How can you determine if the S3 or S4 sounds are pathologic?
From the left-lateral position, have the patient sit up.

If the sound disappears-->benign
If the sound doesn't disappoear--> pathologic
When are S3 and S4 heart sounds normal/abnormal?
Normal: kids~30 y/o

Abnormal: over 30 y/o
Name 2 abnormal sounds that occur during systole.
1. systolic clicks
2. extra sounds (noisy when they shouldn't be)
In which valves can you hear an early systolic ejection click?
aortic and pulmonic valves
What is the cause of midsystolic click?
mitral regurgitation
Normally, opening of the AV valves (tricuspid and mitral) is __
silent
What occurs in stenosis?
the AV valves open with noise
How do stenosed AV valves sound?
sharp and high pitched
Where can you hear stenosed AV valves?
Place your diaphragm at the 3rd or 4th ICS at the sternal border
Give an example of an extra diastolic sound.
opening snap of the mitral valve
Name 8 features of murmurs.
1. timing (systolic vs. diastolic?)
2. location (apex, base, sternal border)
3. loudness/intensity (on scale of 1-6)
4. pitch (high-, medium-, low-)
5. pattern (plateau, crescendo, decrescendo, both)
6. quality (harsh, musical, soft, blowing, rumbling)
7. radiation (to neck?)
8. position of patient (standing, sitting, squatting)
If murmurs radiate to the neck, what might this indicate?
aortic stenosis
Why is the location of the murmur important?
It gives you an idea of the valve involved
How do you grade the loudness or intensity of a murmur?
roman numberals I-VI

I/VI: barely audible in exam room
II/VI: faint in ICU and office
III/VI: moderately loud
IV/VI: hear thrill
V/VI: thrill (louder)
VI/VI: very loud; the stethoscope can hover over the chest
Distinguish between a systolic murmur and a diastolic murmur.
1. systolic: occurs between lub-dub
2. diastolic: occurs between dub-lub
Which is more dangerous (fatal), a diastolic or systolic murmur?
diastolic murmur
Name and describe 4 possible valve structures.
1. normal valve
2. stenotic valve (plaque buildup causes stiffness; bloodflow sounds turbulent, leading to murmur sound)
3. Incompetent valve (blood flows in wrong direction)
4. Abnormal opening
Name 4 classes of murmurs
1. midsystolic ejection murmurs
2. diastolic rumbles of AV valves
3. pansystolic regurgitant murmurs
4. early diastolic murmurs
2 types of midsystolic ejection murmurs?
1. aortic stenosis
2. pulmonic stenosis
2 types of pansystolic regurgitant murmurs?
1. mitral regurgitation
2. tricuspid regurgitation
2 types of diastolic rumbles of AV valves?
1. mitral stenosis
2. tricuspid stenosis
2 types of early diastolic murmurs?
1. aortic regurgitation
2. pulmonic regurgitation
Describe aortic stenosis
-calcification of the aorta
-high diastalic pressure keeps the valve closed

**this is a midsystolic ejection murmur
What is the most common murmur?
mitral regurgitation

(systolic)
What causes mitral regurgitation?
prolapse of mitral valve (leaflets and blood flow back)
What might cause chest pain?
pericardial rub
describe pericardial rub.
-grating sound from not enough fluid
-hear in both systole and diastole