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128 Cards in this Set
- Front
- Back
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Palpitations
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-Uncomfortable sensation of heart beats assoc. w/ various arrhythmias
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What is dependent edema and what is the system differential?
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-Accumulation of excessive fluid in the interstitial tissue
-Cardiac, Kidney or Liver problems |
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What are the causes of nocturia?
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-Diabetes Insipidus
-Solute diuresis (DM) -Excessive Fluid Intake -Fluid retention states -Decreased concentrating ability of kidney's |
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What are the peripheral signs of the CVS exam?
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-Signs of dyspnea (posture, cyanosis, clubbing)
-Signs of elevated lipids (corneal arcus, xanthoma) -Splinter hemorrhage of nails -Lichtsteins sign -KWB -Peripheral edema |
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What are some causes of tachycardia?
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-Increased blood requirements by tissues
-Exercise, fever, throtoxicosis, anemia -Decrease SV -CHF, severe anemia, pericardial effusion -Meds that increase sympathetic N.S. -stimulates |
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What are some causes of bradycardia?
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-Decreases blood requirements by tissues
-hypothermia, myxedema -Increase SV -Well conditioned athlete -Heart blocks of altered conduction -Parasympathetic stimulation -CNS depressants, increase in ICP |
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Describe both types of irregular heart rhythm patterns
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-Irreg. regular - predictable pattern such as every 3rd or 4th beat
ex: Heart block -Irreg. Irregular = no pattern ex: Atrial or Ventricular fibrillation |
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What areas are best to evaluate contour of the pulse?
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-Apex
-Carotid -Brachial |
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Describe a normal pulse wave (contour)
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-Smooth in rounded ascending limb
-Peak -Descending limb |
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Describe the 0-4 scale of pulse amplitude
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0 = Absent
1 = Diminished 2 = Normal 3 = Full (Increased) 4 = Bounding |
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A pulse weaker or delayed in the legs indicates...?
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-Occlusive Aortic Ds
-Coarctation of the Aorta |
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What is pulse deficit and what causes it?
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-Diff. b/w distal pulse & the apical impulse
-Causes: Vascular Occlusion TOS Aneurysms Atrial Fib Pulses Alternans |
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What is Pulsus Alternans and what is it usually assoc. w?
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-Pulse that switches from high to low
-Left Ventricular failure -CHF |
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Why might you obtain BP in 3 diff positions?
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-Hx of: HTN, Stroke, and Fainting/dizziness
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What is the normal range for B/L difference in BP?
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5-10 mm/Hg
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B/L BP diff of > 10-15mm/Hg suggests?
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-Arterial Compression
-Obstruction on side of lower BP |
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What might cause Orthostatic HypOtension?
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-Diuretics
-Dehydration -Blood Loss -Prolonged bed rest -Peripheral Vascular ds. |
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What are the parameters for orthostatic hypotension?
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-Upon standing, fall of > 20mm/Hg in systolic BP -OR- > 10mm/Hg in diastolic pressure
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What side/chamber of the hrt is represented by JVP?
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-R atrial pressure
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What measurements for JVP indicate elevated R atrial pressure?
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- > 3-4cm above sternal angle
- > 8-9cm above R atrium |
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Absent "a" wave of JVP indicates?
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-Atrial Fib
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An increased "V" wave of JVP indicates?
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-Tricuspid valve regurgitation
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A more prominent "a" wave of JVP indicates?
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-Tricuspid Stenosis
-R Ventricular failure -Pulmonic Valve stenosis -Pulmonary HTN |
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An altered "y" descent of JVP indicates?
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-Tricuspid Valve stenosis
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Why do we perform hepatojugular reflux?
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-To test for venous congestion & R sided heart status
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Describe normal and abnormal hepatojugular reflux responses
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Normal = distension <1cm returns to normal in 2-3 cycles
Abnormal = >1cm & remains elevated |
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What are the components of precordial inspection?
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-Shape of Chest wall
-Apical impulse -Pulsations -Masses, lesions -Vascular distention |
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Where do you check the apical impulse?
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-5th ICS, L MCL
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Abnormal Pulsations
Sternoclavicular |
Aortic Arch Aneurysm
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Abnrml Pulsations
Sternal Notch |
Carotid Artery transmission
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Abnrml Pulsations
R Sternal border |
-Ascending Aortic Aneurysm
-R ventricular enlargement |
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Abnrmal Pulsations
Epigastric |
-Abdominal Aortic Aneurysm
-R ventricular enlargement |
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Describe the normal apical impulse
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Diameter = 2-3cm (1-1.5 ICS)
AMP = small, gentle tap Duration = <2/3 of systole |
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Where do you assess the tricuspid valve?
(L lower sternal border) |
L 4-5th ICS parasternally
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Abnrml L lower sternal border findings may indicate?
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R ventricular enlargement
anxiety hyperthyroidism severe anemia pulmonic stenosis pulmonary HTN |
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Where do we assess the pulmonic valve?
(L upper sternal border) |
L 2nd ICS parasternally
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Abnrml pulmonic valve findings indicate?
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Pulmonary HTN
-Pulm. valve stenosis -Conditions of increase CO |
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Where do we assess the aortic valve?
(R upper sternal border) |
R 2nd ICS parasternally
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Abnrml aortic valve findings indicate?
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Systemic HTN
-Aortic valve stenosis -Dilation/aneurysm of aortic arch |
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Where do we auscultate heart sounds?
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2nd ICS (ps) to apex (5th ICS L MCL)
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What are the 4 standard patient evaluation positions for auscultation?
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Supine
Upright L lateral decubitus Upright, leaning forward |
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Internal Jugular vs. Carotid pulse
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Jugular
-Rarely palpable -Soft, biphasic, undulating 2 elevations -Pulsations eliminated by light press -Height of pulsation changes w/ position (drops as pt. goes more upright) -Height of pulsations usually fails w/ inspiration Carotid -Palpable -Vigorous thrust w/ a single outward component -Pulsations not eliminated -Height of pulsations unchanged by position -Height of pulse not affected by inspiration |
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What conditions may be accompanied by thrills?
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Aortic stenosis
Patent ductus arteriosus Ventricular septal defect Mitral stenosis |
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When does S3 occur?
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During rapid ventricular filling of early diastole
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Risk factors for HTN...
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-Physical inactivity
-Microalbuminuria -GFR < 60ml/min -Fam. Hx of CVD (premature) -Increase in Na+ -Decrease in K+ -Increase Alcohol |
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What is the only irregular heart action that can be dx w/o an ECG?
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Atrial fibrillation
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What produces the 2nd hrt sound (S2)?
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Aortic valve closure
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What produces the 1st hrt sound (S1)?
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Closure of the mitral valve
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How do we perform ABI?
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-Avg 2 measurements of arm systolic press. (highest of either arm)
-Avg 2 meas. of ankle systolic (ht. of dorsal ped. or post. tib.) R ABI = Highest R ankle avg/highest arm (either) L ABI = Highest L ankle avg/highest arm (either) |
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Interpretation of ankle-brachial index
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> .90 (.9-1.3) = normal
< .89 to > .60 = mild PAD < .59 to > .40 = moderate PAD < .39 to severe PAD |
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Lymphedema
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-Soft in the early stages, becoming indurated & hard & nonpitting
-Very thick skin -Ulceration rare, no pigmentation -Found in feet/toes B/L -Causes : -Obstruction (tumor) -Fibrosis -Inflammation |
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What factors are assoc. w/ palpitations?
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-Exercise
-Chest pain -Headaches -Sweating -Dizziness -Heat/Cold intolerance -Alcohol/Caffeine usage -Medications -Dehydration |
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What are the 2 causes of Fowlers position?
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-Pulmonary Embolus
-Pericarditis |
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Chronic venous insufficiency edema
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-Soft, pitting on pressure, sometimes B/L
-Skin thickening near ankle -Ulceration & brown pigmentation -Causes: -Chronic obstruction -Incompetent values |
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Pitting Edema
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Soft, B/L w/ pitting on pressure
No skin problems Caused by: -Prolonged standing/sitting (dependent) -CHF -Nephrotic syndrome -Cirrhosis -Drug use |
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Characteristics of chronic venous insufficiency
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Pain: often
Mech: venous HTN Pulses: normal Color: normal to cyanotic, assoc w/ petechia Temp: normal Edema: present, often marked Skin changes: brown pigment, stasis dermatitis, thickening of skin & scarring Ulceration: sides of ankle, especially medial Gangrene: does not develop |
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Characteristics of chronic arterial insufficiency
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Pain: intermitten, progressing to @ rest
Mech: tissue ischemia Pulses: decrease or absent Color: pale on elevation, dusky red on dependency Temp: cool Edema: absent or mild Skin: thin, shiny, atrophic, loss of hair, nails thickened/ridged Ulceration: toes or points of trauma Gangrene: may develop |
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PMI located in the xyphoid/epigastric area instead of the apex indicates?
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R Ventricular hypertrophy
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A PMI > 2.5cm diameter, or displaced lateral to the mid-clavicular line indicates?
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L ventricular hypertrophy
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When is it pathologic to hear an S3 and what causes it?
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-Ppl over age 40
-Decreased contractility -CHF -Valve regurg. -A "gallop" is cadence of 3 heart sounds heart rapidly |
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When is an S3 normal?
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Children
Adults up to age 35-40 3rd trimester of pregnancy |
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What causes an increase or decrease in intensity of P2?
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Increase: Pulmonary HTN, Dilated pulmonary artery, and Atrial septal defect
Decrease: Increase A-P diameter of chest pulmonic stenosis |
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What causes an increase or decrease in intensity of A2?
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Increase: Systemic HTN and Dilated aortic root
Decrease: Calcific aortic stenosis |
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Describe paradoxical spitting of S2 and what causes it?
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Splitting on experation that disappears on inspiration
Left bundle branch block |
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Describe fixed splitting of S2 and what causes it?
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-Wide splitting w/ no variations
-Atrial septal defect -R ventricular failure |
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Describe wide splitting of S2 and what causes it
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-An increase in the usual splitting that persists throughout the respiratory cycle (may vary in intensity)
-Delatyed closure of pulmonic valve -pulmonic stenosis -R bundle branch block -Early aortic valve closure -Mitral regurgitation |
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What are the 3 types of splitting (pathological) of S2?
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-Wide splitting
-FIxed splitting -Paradoxical or reversed |
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Describe both normal and abnormal spitting of S1
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Normal: Along lower L sternal border where tricuspid component is audible
-Also heard @ apex but may be an S4 and not a split Abnormal: R bundle branch block, and premature ventricular contractions |
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What causes a varying S1 intensity?
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-Complete heart block
-Any irregular rhythm |
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What causes the diminishing of S1?
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-Primary heart block
-Calcified mitral valve -Mitral regurgitation -Reduced ventricular contractility -CHF -Coronary heart ds. |
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What causes an accentuation of S1?
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-Tachycardia
-Short P-R interval -High CO -exercise -anemia -hyperthyroidism -Mitral stenosis |
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Describe the normal variations of S1
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-S1 is SOFTER than S2 @ BASE
-S1 is LOUDER than S2 @ APEX |
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Describe the splitting of heart sounds w/ respiratory changes
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-W/ inspirtation: the closure of the pulmonic valve is delayed causing a splitting of S2
-W/ expiration: there is no split of S2 -S1 is not split by respiration |
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What is spitting of the heart sound?
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When events happening on one side of the heart occur earlier or later than on the other side of the heart so the sound has 2 discernable components
Ex: during S2 both the aortic valve & pulmonic valve close. If 1 closes before the other than the sound will be "split" |
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When does S4 occur?
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During atrial contraction
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Describe paradoxical pulse and its causes
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-Decrease in amplitude on inspiration
-w/ BP cuff decrease > 10mm/Hg on insp. -Pericardial tamponade -Constrictive pericarditis -Obstructive lung ds |
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Describe bigeminal pulse and its causes
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-Mimics pulsus alternans
-A normal beat alternating w/ premature contraction -premature amplitude is diminished |
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Describe Pulsus Alternans and its causes
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-Regular rhythm but alternating in amplitude
-LVF -Usually accompanied by L sided S3 |
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Describe bisferiens pulse and its causes
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-Increased arterial pulse w/ a double systolic peak
-Aortic regurg. -Aortic stenosis w/ regurg. -Hypertrophic cardiomyopathy |
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Describe large bounding pulses and their causes
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-Increase pressure, rapid rise, brief peak
-Increase SV or Decrease periph. resistance -Fever -Anemia -Hyperthyroid -Aortic regurg. -Patent ductus -Bradycardia -Complete block -Decrease compliance of aortic walls |
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Describe small, weak arterial pulses and their causes
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-Diminished pressure, slaved uptroke, prolonged peak
-Decrease SV -CHF -Hypovolemia -Aortic stenosis -Increase peripheral resistance -exposure to cold -severe CHF |
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What are some causes of pathologic S4?
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-Decrease myocardial compliance on L
-Hypertensive hrt ds on L -CAD on L -Aortic stenosis on L -Cardiomyopathy on L -Pulm. HTN on R -Pulmonic stenosis on R |
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When is S4 normal?
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Trained athletes
older age groups |
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Heart sounds w/ systolic & diastolic components?
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Venous Hum
Pericardial Friction rub Patent Ductus Arteriosus |
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Venous hum
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Continuous murmur, louder in diastole
Loc: above med. 1/3 of clavicle |
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Pericardial friction rub
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3 short components
3rd interspace to L of sternum |
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Patent ductus arteriosus
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-Continuous murmur w/ silent interval
-Loudest in late sysole -Obscures S2 -Loc: 2nd L interspace |
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What are the risks for vascular insufficiency?
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-Recent trauma/surgery
-Hyperlipidemia -Hypertension -Hx of cancer -smoker -diabetes -hx of fam. hx of thrombosis |
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What are the risks of deep vein thrombosis?
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-advanced age
-injury, fracture, infections -R sided HF or CHF -varicose veins -Fam hx of clots -prolonged bed rest -postpartum/difficult pregnancy -hx cancer -post op -obesity -hormone supplement |
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What features are noted during PVS inspection?
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-size, symmetry, swelling
-venous pattern -color of skin -nail beds, thickness, color, clubbing -hair pattern (loss) -lesions |
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What features are noted during palpation for PVS?
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-temp changes
-skin texture -turgor -moisture -mobility -lesions |
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What are the 5 P's of acute arterial occlusion?
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Pain
Pallor Paresthesia Paralysis Pulselessness |
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Color return times for postrual color change...
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-normal = immediate
-10-15 sec = older adults 15-25 sec = moderate occlusive ds > 40 sec = severe ischemia |
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What are the normal color return times for capillary refill?
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Fingers = < 2 sec
Toes = 3-5 sec |
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What arteries are auscultated for the PVE?
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-carotid
-temporal -abdominal aorta -renal |
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What are the components of the venous exam?
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-inspection
-palpation -manual compression test -trendelenberg test -assessment for edema |
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What are the signs of venous insufficiency?
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-Varicose veins
-thrombosis -hyperpigmentation -ulcer -pitting edema |
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What are the signs of deep vein thrombosis?
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LE shows:
-marked swelling -venous distention -erythema -pain -increase warmth -increase tenderness -resistance to ankle dorsiflexion |
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Describe Homan's sign
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-squeeze affected calf w/ slow dorsiflexion
-produces calf pain in pts w/ femoral vein thrombosis |
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What is the significance of virchow's nodes?
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tumors from many organs may metastasize to the supraclavicular space
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Define generalized lymphadenopathy?
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Presence of palpable lymph nodes in 3 or more lymph node chains
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What conditions can cause generalized lymphadenopathy?
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-lymphoma
-leukemia -collagen vascular disorders -systemic infections |
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What causes localized lymphadenopathy?
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localized infection of neoplasm
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What are the characteristics of pathological murmurs?
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Any diastolic murmur
Systolic murmurs -intensity greater than or equal to 3/6 -assoc. w/ palpable thrill -increased duration (holo or pansystolic) -Radiation of sounds |
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Aortic regurgitation murmur
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-Diastolic
-2nd & 4th interspaces -Assoc w/ ejection sound |
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Mitral stenosis murmur
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-Diastolic
-LOC: limited to apex -followed by opening snap |
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What are the types of diastolic murmurs?
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-Aortic regurgitation (early decrescendo diastolic murmurs)
-Mitral stenosis (rumbling diastolic murmurs) |
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Hypertrophic cardiomyopathy murmur
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-Midsystolic
-LOC: 3rd & 4th Left interspaces -No thrill |
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Aortic stenosis murmur
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-Midsystolic
-LOC: Right 2nd interspace -Assoc w/ thrill |
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Pulmonic stenosis murmur
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-Midsystolic
-LOC: 2nd & 3rd Left inerspaces -Thrill -Crescendo-decrescendo |
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Which 2 pathologic midsystolic murmurs are diamond shaped?
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Aortic stenosis
Pulmonic stenosis |
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What are the types of midsystolic murmurs?
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-Innocent murmurs
-Physiologic murmurs -Pathologic murmurs -aortic stenosis -Hypertrophic Cardiomyopathy -Pulmonic stenosis |
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Ventricular Septal Defect Murmur
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-Pansystolic
-LOC: 3rd, 4th, and 5th Left interspaces -Assoc w/ thrill -May obscure S2 -Blood flows from Left ventricle to Right |
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Tricuspid Regurgitation murmur
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-Pansystolic
-Lower Left sternal border -Intensity may slightly Increase w/ inspiration |
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Mitral regurgitation murmur
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Pansystolic
LOC: Apex Assoc w/ apical thrill Does NOT become louder w/ inspiration |
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Which murmurs can be both systolic & diastolic?
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-Pericardial friction rub
-SEVERE mitral valve prolapse -Venous Hum -Patent ductus arteriosus -Coarctation of the aorta -tetralogy of Fallot -Transposition of great vessels -Atrial septal defect |
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What causes an opening snap?
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Opening of a stenotic mitral or tricuspid valve
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What causes an ejection click?
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Opening of a stenotic aortic or pulmonic valve
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Ejection clicks will be heard during?
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Systole
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Opening snaps, & S3 + S4 heart sounds will be heard during?
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Diastole
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What might cause an aortic ejection sound?
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Dilated aorta
Aortic valve ds |
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What might cause a pulmonic ejection sound?
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-Pulmonary artery dilation
-Pulmonary HTN -Pulmonic stenosis |
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What is the most common cause of systolic click?
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Mitral valve prolapse
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How does a systolic (mitral) click differ from an ejection click?
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Systolic (mitral) click is often followed by a late systolic murmur (caused by mitral regurgitation)
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What causes an opening snap?
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Opening of a stenotic mitral valve
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Describe the 6 grades of murmur?
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1) very faint, not immediately heard, not heard in all positions
2) Quiet, heard immediately 3) moderately loud 4) Loud, w/ palpable thrill 5) Very loud, w/ thrill, may be heard w/ steth. partly off chest 6) Very loud, w/ thrill, may be heard w/ steth Entirely off chest |
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Define pansystolic murmur
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AKA = holosystolic
-Pathologic, caused by blood flowing through a valve that should be closed -Lasts from S1 to S2 |
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What are the types of pansystolic murmurs
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-Mitral regurgitation
-Tricuspid regurgitation -Ventricular septal defect |
