Mcphs Cardiovascular Physical Exam

Front 1

What is the sequence of the cardiovascular exam?

Back 1

Heart Rate
BP
Neck-JVP/Carotid Pulses/Carotid Bruit
Precordium-Inspection/Palpatation/Auscultations
Upper Extremities
Lower Extremities
Pulses
Additional Assessments

Front 2

What are three important things to do in regards to Pulse, BP and BP in this exam?

Back 2

Take pulse even if already done for you.

Take BP if not done

Repeat BP if: Values given to you are high/low, Values given you are suspect,

Front 3

What do you look for in the cardiovascular exam when the patient is seated?

Back 3

Signs of distress

Neck veins

Central cyanosis

Front 4

What do you look for when the patient is supine at 30 degrees?

Back 4

Heaves
Lifts
Pulsations/Retractions
Visible PMI

Front 5

When palpating the patient in the cardiovascular exam, at the supine 30 degree angle, what do you do?

Back 5

Systemic approach to palpating the precordium 2nd RICS, 2nd LICS, 3rd LICS, 4th LICS, 5th LICS MCL PMI and the midepigastrum.

Front 6

When palpating the precordium what area of anatomy are being palpated in the right second interspace?

Back 6

Aortic Area

Front 7

When palpating the precordium what area of anatomy is being palpated in the left second interspace?

Back 7

Pulmonic Area

Front 8

When palpating the precordium what area of anatomy is being palpated in the left sternal border?

Back 8

Right ventricular area

Front 9

When palpating the precordium what area of anatomy is being palpated at the PMI/APEX?

Back 9

Left ventricular area

Front 10

What is a crude way of testing for cardiomegaly, it is rarely if ever used anymore?

Back 10

Percussion to determine size, determine position - displacement of PMI, echocardiogram is now employed.

Front 11

When inspecting the patients neck while they are supine in the 30 degree position what are you inspecting?

Back 11

Carotid artery upstrokes, angular venous pulsations

Front 12

What is a good measurement for JVP?

Back 12

Ideally 3cm

Front 13

This test is done by applying firm pressure, to the midepigastrum and right costochondral angle, observe the neck for elevation of column of blood in the internal jugular vein.

Back 13

Hepatojugular reflex

Front 14

What are you looking for in the upper extremities with the cardiovascular inspection?

Back 14

erythema, pallor, cyanosis, edema

Front 15

When palpating the upper extremities in the cardiovascular exam, what are you feeling for?

Back 15

Temperature, tenderness, edema, capillary refill, Allen test

Front 16

This is the test when you apply pressure to the nail bed until it turns white, blood returns to tissue and you measure how long that it takes.

Back 16

Capillary refill

Front 17

How long should it take for the fingertips to refill?

Back 17

around 2 seconds

Front 18

This is the test where you ask the patient to make a tight fist, compress BOTH radial and ulnar arteries, ask the patient to open the fist, release either the radial or ulnar artery, watch for color to return to the palm and measure the time.

Back 18

Allen test

Front 19

How long should it take for blood to return to the palm in the Allen test?

Back 19

3-5 seconds

Front 20

When inspecting the lower extremities in the cardiac exam, what do you look for?

Back 20

Rubor
Edema
Varicosities
Hair Loss
Ulcerations
Cyanosis

Front 21

When palpating the lower extremities in the cardiovascular exam, what are you feeling for?

Back 21

Temperature
Tenderness
Edema
Capillary Refill
Perform Homan's Test

Front 22

When you are checking for pitting edema what areas do you inspect?

Back 22

Foot, ankle and the tibial area up to the knee.

Front 23

There is no pitting with what?

Back 23

lymphadema

Front 24

This is a test used to check for DVT?

Back 24

Homan's sign

Front 25

When examining the pulses in the cardiovascular exam, what do you look for?

Back 25

Bilateral comparison
Rate and Rhythm
Amplitude
Variations

Front 26

What pulses are to be checked in the cardiovascular exam?

Back 26

Carotid
Brachial
Radial
Popliteal
Dorsalis Pedis
Posterior Tibialis

Front 27

What are the ATLS/BP equivalents?

Radial impalpable?

Back 27

<80mmHg

Front 28

What are the ATLS/BP equivalents?

Femoral impalpable?

Back 28

<70mmHg

Front 29

What are the ATLS/BP equivalents?

Carotid impalpable?

Back 29

<60mmHg

Front 30

What is the order of the femoral triangle from lateral to medial?

Back 30

Nerve
Artery
Vein
Lymphatics

Front 31

When auscultating in the cardiovascular exam What do you listen for in the supine at 30 degree position?

Back 31

Carotid Bruits

General Auscultation

Front 32

When auscultating in the cardiovascular exam what do you listen for in the left lateral decubitus position?

Back 32

Mitral stenosis, Gallops

Front 33

When auscultating in the cardiovascular exam what do you listen for in the sitting up and leaning forward position?

Back 33

Aortic murmurs

Front 34

What do you use the bell of the stethoscope to listen for?

Back 34

Low frequencies, Bruits, Bicuspid, and Mitral stenosis

Front 35

What do you use the diaphragm of the stethoscope to listen for?

Back 35

High frequencies, Aortic regurgitation and pulmonic stenosis.

Front 36

When auscultating the patient in the supine 30 degree position, what areas do you listen to?

Back 36

Use both diaphragm and Bell
Five traditional auscultation areas
-2nd RICS
-2nd LICs
-3rd LICS (Erb's point)
-4th LICS
-5th LICS MCL - Apex

Front 37

When auscultating the 2nd RICS what are you listening to?

Back 37

Aortic valve/aortic area

Front 38

When auscultating the 2nd LICS what are you listening to?

Back 38

Pulmonic valve

Front 39

When auscultating the 3rd LICS what are you listening to?

Back 39

Pulmonic area

Front 40

When auscultating the 4th LICS what are you listening to?

Back 40

Bicuspid

Front 41

When auscultating the 5th LICS what are you listening to?

Back 41

Bicuspid

Front 42

When auscultating the apex what are you listening to?

Back 42

Mitral valve

Front 43

In these two age groups apical pulse is easily palpated, third heart sound is usually heard, systolic flow murmers are innocent and noted at the 2nd and 4th interspaces.

Back 43

Infants and Young Children

Front 44

In this age group apical pulse is more difficult to palpate, splitting of the 2nd heart sound is less audible, S4 may be heard, and Aortic systolic murmur is noted in some patients and isn't always pathologic.

Back 44

Elderly

Front 45

This heart sound is heard in a 1/3 of people over 60 and in 1/2 of people by age 80.

Back 45

Aortic systolic murmur

Front 46

These ulcers are seen in patients with diabetes and the pain isn't always felt.

Back 46

Neuropathic ulcer of the foot.

Front 47

This is when you see elevation of the neck veins (and of the central venous pressure) during inspiration.

Back 47

Kussmaul's sign

Front 48

Kussmaul's sign can be a visible indication of what?

Back 48

A visible indication of pericardial effusion or tamponade or of other disorders that affect the filling of the right side of the heart

Front 49

What are five examples of the disorders Kussmaul's sign can represent?

Back 49

Cardiac tamponade (rare)
Constrictive pericarditis
Restrictive cardiomyopathy
Pericardial effusion
Right ventricular infarction

Front 50

This is discoloration or redness caused by inflammation. It is one of the four classic symptoms of inflammation.

Back 50

Rubor

Front 51

Apart from rubor, what are the other three classic symptoms of inflammation?

Back 51

Calor - heat
dolor - pain
tumor - swelling

Front 52

Edema has two categories, what are they?

Back 52

Pitting and non pitting

Front 53

Non pitting edema is seen with what?

Back 53

lymphadema

Front 54

Pitting edema can be measured on what kind of scale?

Back 54

1+ to 4+

Front 55

This is slight pitting, no visible distortion, disappears rapidly (2mm depression)

Back 55

1+ pitting edema

Front 56

This is a somewhat deeper pit, no readily detectable distortion, and it disappears in 10-15 seconds (4mm) depression.

Back 56

2+ pitting edema

Front 57

This pit is noticeably deep and may last more than a minute; the dependent extremity looks fuller and swollen (6 mm depression)

Back 57

3+ pitting edema

Front 58

The pit is very deep, lasts as long as 2-5 minutes, and the dependent extremity is grossly distorted (8 mm depression)

Back 58

4+ pitting edema

Front 59

These both measure lower extremity circumference in multiple locations bilaterally to compare size of both extremities.

Back 59

Pitting and non pitting edema

Front 60

A difference of more than _____ is abnormal when measuring the lower extremity circumference in pitting/non pitting edema?

Back 60

1-2 cm

Front 61

What four circumferences can you measure in regards to pitting and non pitting edema?

Back 61

The forefoot

The smallest possible circumference above the ankle

The largest circumference at the calf

The mid thigh a measured distance above the patella with the knee extended

Front 62

This is when you flex a patient's knee slightly with one hand, and with the other dorsiflex the foot. The complaint of calf pain with the procedure is a positive sign and often indicates venous thrombosis.

Back 62

Homan's sign

Front 63

These are due to either change in rate (faster (tachy) or slower (brady)) or a change in volume status (hyper or hypovolemia).

Back 63

Pulse abnormalities

Front 64

What are the five measurements for pulse?

Back 64

0: Absent
1+: Thread
2+: Normal
3+: Full
4+: Bounding

Front 65

This is a weak pulse alternating with a strong one.

Back 65

pulsus alternans

Front 66

This is an alternating weak and strong pulse resulting from bigeminy (altering sinus beat and premature ventricular contraction)

Back 66

Pulsus bigeminus

Front 67

Ordinarily there is a slight dip in systolic pressure with inspiration. If that dip is larger than 10mmHg then this occurs.

Back 67

Pulsus paradoxus

Front 68

What are the likely causes of pulsus paradoxus?

Back 68

Obstructive airway disease, cardiac tamponade, pericarditis

Front 69

This is when there is a slowly rising plateau pulse that occurs in severe aortic stenosis from the slow ejection of blood through a narrowed orifice.

Back 69

Pulsus tardus

Front 70

This is a small hard pulse that rises and falls slowly.

Back 70

Pulsus parvuse et tardus

Front 71

This is a pulse that is bounding and forceful as if it were the hitting of a water hammer that was causing the pulse.

Back 71

Water hammer pulse

Front 72

This is a fast upstroke and downstroke, typically encountered in aortic regurgitation, tyrotoxicosis, and essential hypertension.

Back 72

Bounding pulse

Front 73

What is normal BP

Back 73

<120, <80

Front 74

What is prehypertension?

Back 74

120-139, 80-89

Front 75

What is Stage 1 hypertension?

Back 75

140-159, 90-99

Front 76

What is Stage 2 hypertension?

Back 76

greater to or equal 160/100

Front 77

What term is now preferred over "congestive heart failure" and why?

Back 77

Heart failure is preferred because not all patients have volume overload on initial presentation.

Front 78

What are the four factors influencing arterial pressure?

Back 78

1. Left ventricular stroke volume.
2. Distensibility of the aorta and the large arteries.
3. Peripheral vascular resistance, particularly at the arteriolar level.
4. Volume of blood in the arterial system.

Front 79

What are common or concerning symptoms with the cardiovascular system?

Back 79

Chest pain
Palpitations
Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea
Swelling or edema

Front 80

Classic exertional pain, pressure, or discomfort in the chest, shoulder, back, neck or arm in angina pectoris is seen in 50% of patients with what?

Back 80

Acute myocardial infarction

Front 81

What are some atypical symptoms associated with myocardial infarction?

Back 81

cramping, grinding, pricking

Front 82

What are some rare symptoms associated with myocardial infarction?

Back 82

jaw and tooth pain.

Front 83

The annual incidence of this is 1 per 1000 in the population 30 years or older.

Back 83

exertional angina

Front 84

This is increasingly used to refer to any of the clnical syndromes caused by acute myocardial ischemia, icluding unstable angina, non-ST elevation myocardial infarction and ST elevated myocardial infarction.

Back 84

Acute coronary syndrome

Front 85

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

Back 85

Acute aortic dissection

Front 86

Symptoms or signs of irregular heart action warrant what?

Back 86

An EKG

Front 87

What heart rhythm can be reliably identified at the bedside and why?

Back 87

Atrial fibrillation, because it is irregularly irregular

Front 88

What are three cases in which you can have sudden dyspnea?

Back 88

pulmonary embolism, spontaneous pneumothorax, anxiety

Front 89

What are three things that you can see orthopnea with?

Back 89

Left ventricular heart failure, or mitral stenosis, also in obstructive lung disease

Front 90

this is dyspnea that occurs when the patient is lying down.

Back 90

Orthopnea

Front 91

This is when there are episodes of sudden dyspnea and orthopnea that awaken the patient from sleep.

Back 91

Paroxysmal nocturnal dyspnea

Front 92

Paroxysmal nocturnal dyspnea can occur with what things?

Back 92

Left ventricular heart failure, mitral stenosis, may be mimicked by nocturnal asthma attacks.

Front 93

This appears in the lowest body parts: the feet and lower legs when sitting, or the sacrum when bedridden.

Back 93

Dependent edema

Front 94

What are the causes of dependent edema?

Back 94

Cardiac (congestive heart failure) Nutritional (hypoalbuminemia), or positional

Front 95

This occurs in renal and liver disease: periorbital puffiness, tight rings in nephrotic syndrome, enlarged waistline from ascites and liver failure.

Back 95

Edema

Front 96

What are four important things in health promotion and counseling in regards to the cardiovascular system?

Back 96

1. Screening for HTN
2. Screening for Coronary heart disease and stroke.
3. Screening for dyslipidemias
4. Promoting lifestyle modification and risk factor reduction

Front 97

This type of patient may have to lie flat before you see the neck veins.

Back 97

Hypovolemic patient.

Front 98

When jugular venous pressure is increased, an elevation of ______ may be required to see the neck veins.

Back 98

elevation of 60 or even 90 degrees

Front 99

In all the different positions a patient is in, supine during the cardiac position, 30, 60, 90 degrees, the sternal angle usually remains about _ cm above the what?

Back 99

5 cm above the right atrium

Front 100

Increased JVP means what?

Back 100

Right sided congestive heart failure

Front 101

Increased JVP can less commonly mean what three things?

Back 101

constrictive pericarditis, tricuspid stenosis, or superior vena cava obstruction.

Front 102

Venous pressure may appear elevated on expiration only in what and why?

Back 102

In patients with obstructive lung disease, because the veins collapse on inspiration.

Front 103

If a patient with obstructive lung disease has elevated venous pressure on expiration and absent venous pressure on inhalation, does this mean they have congestive heart failure?

Back 103

No

Front 104

An elevated JVP is 98% specific for what two things and it means an increase risk of what?

Back 104

An elevated JVP is 98% specific for an increased left ventricular end diastolic pressure and low left ventricular ejection fraction, and it increases risk of death from heart failure.

Front 105

What is the usual cause of unilateral distention of the external jugular vein?

Back 105

Local kinking or obstruction

Front 106

Prominent a waves in increased resistance to right atrial contraction is seen in what?

Back 106

Tricuspid stenosis
first degree atrioventricular block
supraventricular tachycardia
junctional rhythms
pulmonary hypertension
pullmonic stenosis

Front 107

Absent a waves are seen in?

Back 107

atrial fibrillation

Front 108

Large v waves are seen in what?

Back 108

tricuspid regurgitation
constrictive pericarditis

Front 109

This may produce a unilateral pulsatile bulge?

Back 109

A tortuous and kinked carotid

Front 110

Causes of decreased pulsations include?

Back 110

Decreased stroke volume and local factors in the artery such as atherosclerotic narrowing or occlusion

Front 111

This may cause a reflex drop in pulse rate or blood pressure.

Back 111

Pressure on the carotid sinus

Front 112

Small, thready, or weak pulse may be seen in what two things?

Back 112

cardiogenic shock, bounding pulse in aortic insufficiency.

Front 113

Delayed carotid upstroke occurs in?

Back 113

aortic stenosis

Front 114

This can radiate to the neck and sound like a carotid bruit.

Back 114

aortic valve murmur

Front 115

The prevalence of asymptomatic carotid bruits increases with what?

Back 115

age

Front 116

If you find a low pitched extra sound such as an S3, opening snap, diastolic rumble of mitral stenosis it can be an accentuated finding where?

Back 116

Listening at the apex/PMI with the bell of the Stethoscope with patient in left lateral decubitus.

Front 117

when listening at the left sternal border, and at the apex with the diaphragm of the stethoscope what accentuated finding might be noted?

Back 117

Soft decrescendo diastolic murmur of aortic insufficiency.

Front 118

S1 is decreased in ?

Back 118

first degree heart block

Front 119

S2 is decreased in?

Back 119

Aortic stenosis

Front 120

Thrills may accompany loud, harsh, or rumbling murmurs as in?

Back 120

aortic stenosis, patent ductus arteriosus, ventricular septal defect, and less commonly mitral stenosis

Front 121

This is a rare occasion when the heart is situated on the right side?

Back 121

dextrocardia

Front 122

A congenital condition in which the major visceral organs are reversed or mirrored from their normal positions.

Back 122

situs inversus

Front 123

A right sided heart with a normally placed liver is usually associated with what?

Back 123

congenital heart disease.

Front 124

Pregnancy or a high left diaphragm may displace the ___________ upward and to the left.

Back 124

apical impulse

Front 125

Lateral displacement outside the midclavicular line increases the likelihood of what?

Back 125

cardiac enlargement, low left ventricular ejection fraction by 3-4 and 10, respectively

Front 126

In the left lateral decubitus position, a diffuse PMI with a diameter greater than 3 cm indicates?

Back 126

Left ventricular enlargement

Front 127

This may reflect hyperthyroidism, severe anemia, pressure overload of the left ventricle (as in aortic stenosis), or volume overload of the left ventricle (as in mitral regurgitation)

Back 127

Increased amplitude

Front 128

A sustained high amplitude impulse that is normally located suggests what?

Back 128

Left ventricular hypertrophy from pressure overload as in HTN

Front 129

A sustained low amplitude (hypokinetic) impulse may result from?

Back 129

dilated cardiomyopathy

Front 130

A brief middiastolic impulse indicates a what?

Back 130

S3

Front 131

An impulse just before the systolic apical beat itself indicates a what?

Back 131

S4

Front 132

A marked increase in amplitude with little or no change in duration occurs in ?

Back 132

chronic volume overload of the right ventricle as from an atrial septal defect.

Front 133

An impulse with increased amplitude and duration occurs with?

Back 133

Pressure overload of the right ventricle, as in pulmonic stenosis or pulmonary HTN

Front 134

In obstructive pulmonary disease, hyperinflated lung may prevent palpation of what?

Back 134

an enlarged right ventricle in the left parasternal area.

Front 135

A prominent pulsation at the 2nd left interspace - pulmonic area - often accompanies dilatation or increased flow in the what?

Back 135

pulmonary artery

Front 136

A palpable S2 suggests increased pressure in the ?

Back 136

Pulmonary artery (pulmonary HTN)

Front 137

A palpable S2 suggests systemic HTN, a pulsation at the aortic area - 2nd right interspace, suggests a what?

Back 137

dilated or aneurysmal aorta

Front 138

A markedly failing heart may have a ________ that is displaced far to the left.

Back 138

hypokinetic apical impulse

Front 139

A large ___________ may make the apical impulse undetectable.

Back 139

pericardial effusion

Front 140

When describing where murmurs and sounds are best heard it is correct to use what?

Back 140

Anatomical location rather than valve area

Front 141

The left lateral decubitus position accentuates or brings out what?

Back 141

left sided S3 and S4 mitral murmurs, especially mitral stenosis

Front 142

When the patient is sitting up and leaning forward it accentuates or brings out what?

Back 142

Aortic murmurs

Front 143

If you don't listen for a diastolic murmur of aortic regurgitation in this position you will likely miss it.

Back 143

Left lateral decubitus position.

Front 144

Injury to vascular endothelial cells can provoke what?

Back 144

thrombus formation, atheromas, and vascular lesions of HTN

Front 145

This begins in the intima as lipid filled foam cells, then fatty streaks.

Back 145

Atheroma

Front 146

These are thickened asymmetric plaques that narrow the lumen, reducing blood flow, and weaken the underlying media. They have a soft lipid core and a fibrous cap of smooth muscle cells and a collagen rich matrix.

Back 146

Complex atheroma

Front 147

plaque rupture may precede?

Back 147

thrombosis

Front 148

This can cause symptomatic limb ischemia with exertion; distinguish this fro spinal stenosis which produces leg pain with exertion that may be reduced by leaning forward (stretching the spinal cord in the narrowed vertebral canal) and less readily relieved by rest.

Back 148

Atherosclerosis

Front 149

This occurs over the anterior tibiae with decreased arterial perfusion. Dry or brown-black ulcers from gangrene may ensue.

Back 149

Hair loss

Front 150

Only about __% of patients have the classic triad of leg pain with exertion that stops with rest.

Back 150

10%

Front 151

Symptom location suggests the site of arterial ischemia:

1. Aortoiliac ?
2. Iliacpudendal ?
3. Common femoral or aortoiliac ?
4. Superficial femoral ?
5. Popliteal ?
6. Tibial or peroneal ?

Back 151

1. buttock, hip
2. Erectile dysfunction
3. Thigh
4. Upper calf
5. Lower calf
6. Foot

Front 152

Abdominal pain, "food fear" and weight loss suggest what?

Back 152

Intestinal ischemia of the celiac or superior or inferior mesenteric arteries.

Front 153

Prevalence of abdominal aortic aneurysms in first degree relatives is?

Back 153

15-28%

Front 154

Lymphadema of the arm and hand may follow?

Back 154

Axillary node dissection and radiation therapy

Front 155

Prominent veins in an edematous arm suggest?

Back 155

venous obstruction

Front 156

With this wrist pulses are typically normal, but spasm of more distal arteries causes episodes of sharply demarcated pallor of the fingers.

Back 156

Raynaud's disease

Front 157

Bounding carotid, radial and femoral pulses are seen in?

Back 157

aortic insufficiency, asymmetric diminished pulses in arterial occlusion from atherosclerosis or embolism

Front 158

An enlarged epitrochlear node may arise from?

Back 158

local or distal infection or may be associated with general lymphadenopathy

Front 159

This is enlargement of nodes with or without tenderness.

Back 159

Lynphadenopathy

Front 160

How do you distinguish between generalized and local lymphadenopathy?

Back 160

Find either a 1. Causitive lesion in the drainage area or 2. enlarged nodes in at least two other non contiguous lymph node regions.

Front 161

Chronic arterial occlusion usually from atherosclerosis causes?

Back 161

intermittent claudication

Front 162

An exaggerated widened femoral pulse suggests a ?

Back 162

Femoral aneurysm a pathologic dilation of this artery.

Front 163

An exaggerated widened popliteal pulse suggests an aneurysm of the ?

Back 163

Popliteal artery

Front 164

Popliteal and Femoral arteries occur in?

Back 164

men older than 50 years old and are usually caused by atherosclerosis

Front 165

Atherosclerosis most commonly obstructs arterial circulation in the thigh. The femoral pulse is then ? and the popliteal is?

Back 165

The femoral pulse is then normal, the popliteal is decreased or absent.

Front 166

This may be congenitally absent or may branch higher, so search for pulse more laterally.

Back 166

Dorsalis pedis artery

Front 167

Decreased or absent pedal pulses with normal femoral and popliteal pulses suggest occlusive disease in the ?

Back 167

Lower popliteal artery or its branches - often seen in diabetes mellitus

Front 168

A painful, pale swollen leg, together with tenderness in the groin over the femoral vein, suggests what?

Back 168

Deep iliofemoral thrombosis

Front 169

Local swelling, redness, warmth and a subcutaneous cord suggest?

Back 169

superficial thrombophlebitis

Front 170

Brownish discoloration or ulcers just above the malleolus sugest?

Back 170

chronic venous insufficiency

Front 171

Thickened brawny skin suggest?

Back 171

lymphedema and advanced venous insufficiency

Front 172

These are dilated and tortuous, their walls may feel somewhat thickened.

Back 172

Vericose veins

Front 173

Arterial occlusive disease is much less common in the ___ than in the ___.

Back 173

Much less common in the arms than in the legs.

Front 174

Absent or diminished pulses at the wrist are found in what?

Back 174

Acute embolic occlusion and in Buerger's disease, or thromboangiitis obliterans.

Front 175

What do you not do in the Allen test?

Back 175

Don't extend the hand fully, it can give you a falsely positive test.

Front 176

Persisting pallor in the Allen test indicates occlusion in ?

Back 176

either the radial or ulnar artery and its distal branches

Front 177

When veins are incompetent dependent rubor and the timing of color return and venous filling are not reliable tests for?

Back 177

arterial insufficiency

Front 178

Rapid filling of the superficial veins while the saphenous vein is occluded indicates incompetent valves in the?

Back 178

communicating veins

Front 179

Blood flows quickly in retrograde direction from the deep to the ?

Back 179

Saphenous system

Front 180

Sudden additional filling of superficial veins after rleas of compression indicates?

Back 180

Incompetent valves in the saphenous vein

Front 181

Heart Sound - Closure of the Mitral Valve

Back 181

S1

Front 182

Heart Sound - Closure of the Aortic Valve

Back 182

S2

Front 183

Normally S1 to S2 interval is ?

Back 183

shorter than S2 to S1 interval

Front 184

The left ventricular pressure curve is highest when?

Back 184

In Systole

Front 185

If you have a louder S1 it can mean what three things?
–

Back 185

Shortened PR interval
– Tachycardia
– Mitral Stenosis

Front 186

If you have a softer S1 it can mean what four things?

Back 186

– Prolonged PR interval
– Thick chest wall
– Pericardial disease
– Mitral disease

Front 187

Louder S2 can mean?

Back 187

– High closing pressures
– Pulmonary Hypertension
– Diseased Valves

Front 188

•Softer S2 can mean?

Back 188

– Decreased Blood Pressure
– Damaged Valves

Front 189

• Physiologic reasons for splitting of S2

Back 189

– Wider on inspiration
– Narrower on expiration

Front 190

• Paradoxical reasons for splitting of S2

Back 190

– Narrower on inspiration
– Wider on expiration

Front 191

Widened - Pathological splitting of S2 can be caused by?


–

Back 191

– VSD - Ventricular Septal Defect
– Mitral Regurgitation
– RBBB
– Pulmonic Stenosis

Front 192

• Narrowed (Paradoxical) - Pathological splitting of S2 can be caused by?

Back 192

LBBB
– Aortic Stenosis

Front 193

• Fixed - Pathological splitting of S2 can be caused by?

Back 193

– ASD - Atrial Septal Defect

Front 194

•This is characterized by Increased flow across Normal valve,
• Forward flow across a Stiff or
Thickened valve,
• Backward flow across an Incompetent
or Insufficient valve

Back 194

Murmurs

Front 195

What is used to describe murmurs?

Back 195

• Location
• Timing/Duration
• Intensity
– loudness/grade
• Effect of Respiration
• Relation to body position
• Radiation/Transmission
• Frequency
– pitch
• Quality
• Configuration

Front 196

How would you describe location of a murmur?

Back 196

• Location
– At Which ICS did you appreciate it ?

Front 197

What questions would you ask yourself to find out the timing/duration of a murmur?

Back 197

Timing/Duration*
– Where in the Cardiac Cycle Does it Occur?
– How much of the cycle does it encompass?

Front 198

What do you ask yourself so that you can grade the intensity of a murmur?

Back 198

– How loud is it?

Front 199

How many levels are there in grading murmurs and what are they?

Back 199

• I – barely audible
• II – clearly audible, but faint
• III – moderately loud
• IV – loud
• V – very loud
• VI – loudest possible

Front 200

The following terms describe the what of a murmur?
– High
– Medium
– Low

Back 200

Frequency (pitch)

Front 201

what are the five terms used to describe the quality of a murmur?

Back 201

• Quality:
– Musical
– Harsh
– Blowing
– Rumbling
– Mechanical

Front 202

What terms are used to describe the Configuration (shape) of a murmur?

Back 202

– Crescendo
– Decrescendo
– Crescendo-Decrescendo
– Plateau

Front 203

What do you have to take notice of with a murmur during exhalation and inhalation?

Back 203

If the murmur gets louder or quieter with one or the other.

Front 204

What three body positions must you relate the murmurs sounds to?

Back 204

Relation to body position:
– Supine
– Lateral Decubitus
– Sitting/Leaning Forward

Front 205

When measuring the Radiation/Transmission of a murmur what is a good question to ask yourself?

Back 205

Does it Transmit Sound or Radiate to another Anatomic Location?

Front 206

What murmurs can be heard in the Systolic?
–

Back 206

Aortic Stenosis
– Pulmonic Stenosis
– Mitral Regurgitation
– Tricuspid regurgitation
– ASD
– VSD
– Coarctation
– Innocent/Physiologic

Front 207

What murmurs can be heard in the diastolic?

Back 207

– Aortic Regurgitation
– Mitral Stenosis

Front 208

What murmurs can be heard as continuous?

Back 208

– PDA

Front 209

• Right 2nd ICS
• Midsystolic
• Patient Leaning Forward
• Loud
• Medium pitch
• Harsh
• Crescendo/Decrescendo
• Associated S4 Gallop
• Best appreciated with the patient sitting up and leaning
forward
• Radiates to the carotids, down left sternal border and to the
Apex

Back 209

Aortic Stenosis

Front 210

• 2nd LICS, 3rd LICS
• Midsystolic
• Soft to Loud
– If loud will have an associated Thrill
• Medium pitch
• Harsh
• Crescendo/Decrescendo
• Radiates towards L Shoulder and/or Neck

Back 210

Pulmonic Stenosis

Front 211

• Apex
• Pansystolic (Holosystolic)
• Soft to Loud
– If loud will have an associated Apical Thrill
• Medium to High pitch
• Harsh
• Plateau
• Midsystolic click, S3
• May Radiate to Left Axillae

Back 211

Mitral regurgitation

Front 212

• Lower Left Sternal Border
• Pansystolic (Holosystolic)
• Soft to Loud
• Blowing
• Plateau
• Intensity may increase with inspiration
• May have associated S3
• Increased JVP
• Radiation to Xyphoid

Back 212

Tricuspid regurgitation

Front 213

• 2nd LICS
• Systolic Ejection
• Loud
• High Pitch
• Harsh
• Crescendo/decrescendo
• Diastolic Rumble across the Tricuspid Valve
• Radiates along Lower Left Sternal Border
• Split and Fixed S2

Back 213

Atrial septal defect

Front 214

• Left Sternal Border
– 3RD, 4TH, 5TH LICS
• Holosystolic
• Very Loud with an associated Thrill
• High pitch
• Harsh
• Radiates Widely to right of Sternum across the precordium

Back 214

Ventral septal defect

Front 215

• Back/Left Axilla
• Midsystolic
• Faint to Loud (Grade II-IV)
• Blowing
• UE BP is usually Greater than LE BP
– By at least 20mmHg
• Femoral pulses Diminished or Absent

Back 215

Coarctation of the Aorta

Front 216

• Left Sternal Border
– 2nd,4th LICS
• Early Diastolic
• Soft to Moderately Loud (Grades I-III)
• High Pitched
• Blowing
• Decrescendo
• Patient Sitting, Leaning Forward Holding their Breath After
Exhalation
• Pistol Shot Femoral Pulses

Back 216

Aortic Regurgitation

Front 217

• Apex
• Mid to Late Diastolic
• Soft to Loud (Grades I-IV)
• Low pitched Rumble
• Blowing
• Decrescendo
• Opening Snap following S2
• Associated S3 Gallop
• Left Lateral Decubitus

Back 217

Mitral Stenosis

Front 218

• Upper Left Sternal Border
– 2nd LICS
• Continuous
• Loudest in Systole, Fades in Diastole
– Sometimes associated with a Thrill
• Medium Pitch
• Harsh, Machinery like
• Crescendo/Decrescendo
• Bounding, Full Pulses

Back 218

Patent Ductus Arteriosus

Front 219

The extra heart sounds, S3 and S4 are known as?

Back 219

Gallops

Front 220

Gallop:

– Ventricular
– Associated with increased volume
– Physiologic in children and young adults
– Common in Last Trimester of Pregnancy
– Pathologic in adults over 40 y/o

Back 220

S3 (Kentucky)

Front 221

Gallop:

– Apex
– Early Diastole
• Right after S2
– Dull
– Low pitched*
– Left lateral decubitus

Back 221

S3 (Kentucky)

Front 222

Gallop:

– Atrial
– Physiologic in:
• Young patients
• Athletes
• Some older adults

Back 222

S4 (Tennessee)

Front 223

Gallop:

– Apex
– Late in diastole, )
• Just before S1
– Dull
– Low Pitched*
– Left lateral decubitus

Back 223

S4 (Tennessee)

Front 224

Rubbing of the visceral and parietal pleura due to inflammation
– May occur late in atrial systole, during apex beat of
ventricular contraction, and during rapid ventricular
filling
– One, Two or Three sounds

Back 224

Pericardial friction rub

Front 225

Abnormal heart sound, Opening Snap is heard with what three things?

Back 225

– Diastole
– Mitral stenosis
• rheumatic heart disease

Front 226

Abnormal heart sound, Click is heard with what two things?

Back 226

– Systole
– Diseased Aortic or Pulmonic valves

Front 227

Abnormal heart sound heard with the following:
– mitral regurge
– snapping of chordae tendinae of mitral valve
– associated with sudden death
• Prosthetic valves
• Older pacemakers

Back 227

• Midsystolic click