1
Q
what is pulse pressure
A
systolic pressure - diastolic pressure
2
Q
what is Bisferiens pulse? What condition causes it?
A
- significant aortic valve regurgitation
- double pulse felt due to backflow of blood in early diastole
3
Q
what are the two pulses felt in Bisferiens pulse
A
- first carotid pulse is normal systole
- second pulse early diastolic due to the regurgitating blood
4
Q
What is pulsus alternans
A
physical finding with aterial pulse waveform showing alternating strong and weak beats
5
Q
pulsus alternans is almost always indicative of what condition? Describe the pathophysiology
A
- left ventricular systolic impairment
- ejection fraction will decrease -> reduction in stroke volume
- increase in end-diastolic volume
- next cycle: myocardial muscle will be stretched more than usual
- will cause an increase in myocardial contraction
- stronger systolic pulse
- will cause an increase in myocardial contraction
- ejection fraction will decrease -> reduction in stroke volume
6
Q
what is jugular venous distension
A
- elevated jugular venous pressure (> 7 mmHg)
- sign of fluid overload
7
Q
what is jugular venous pressure an indicator of
A
right atrial pressure; elevation suggests fluid overload
8
Q
how do you measure JVD (specialized exam)
A
- elevate head of bed to 30 deg
- find internal jugular venous pulsations
- locate highest point of pulsation
- measure from sternal angle
- sternal angle is considered to be 5 cm above right atrium)
9
Q
what JVD measurement indicates elevated right heart pressure
A
JVP higher than 4 cm above the sternal angle (9 cm above R. atrium) indicates elevated right heart pressure
10
Q
What is the hepatojugular reflux (specialized exam) testing for?
A
- a test for fluid overload (heart failure)
11
Q
how would you perform hepatojugular reflux (specialized exam)
A
- patient is supine; head at 30 deg angle
- apply firm and sustained pressure to the abd in the RUQ over the liver for greater than 10 seconds
- observe the neck for an increase in JVP, followed by a decrease as the hand is released
12
Q
what indicates a positive hepatojugular reflux (specialized exam)
A
- JVP will increase in all patients with this maneuver, but it is exaggerated in right heart failure
- > 3 cm increase is positive
13
Q
Where would you locate the apical impulse
A
5th intercostal space in Midclavicular line
14
Q
When you locate the PMI, you should note its size and appearance. What should the PMI not exceed?
A
should not exceed 2.5 cm in diameter, or the width of one intercostal space
15
Q
what is a thrill
A
a palpable murmur, usually due to vibrations that accompany loud murmurs
16
Q
what is a lift (or heave)
A
when the cardiac impulse feels more vigorous than normal, and ca be felt or seen through the chest wall
17
Q
what do lift or heaves usually indicate
A
right ventricle hypertrophy
- pulmonary HTN
- coronary heart disease
18
Q
bell mode allows you to hear what frequency sounds?
A
bell mode = low frequency
- light contact with chestpiece
19
Q
diaphragm mode allows you to hear what frequency sounds?
A
diaphragm mode = high frequency
- use firm pressure
20
Q
in what two positions do you want the patient to be in to auscultate soft mumurs at the base
A
- sitting up
- leaning forward
- ask patient to lean forward, exhale completely, and hold
* listen at base for possible aortic or pulmonic regurgitation
21
Q
in what two positions do you want the patient to be in to auscultate low pitched filling sounds
A
left lateral decubitus
- place bell of stethoscope on the apical impulse
22
Q
the first heart sound is best heard where?
A
at the apex
23
Q
what does the first heart sound (S1) correspond to?
A
systole
- aortic and pulmonic valves are forced open and blood in ejected into arteries
- closure of mitral and tricuspid valves produce S1 “lub” sound
24
Q
What does a louder S1 heart sound indicate
A
- diseased A-V valve or more forceful closure of A-V valve
- e.g. mitral stenosis, tachycardia, fever
25
What does a softer S1 heart sound idicate
* weak contraction of heart
OR
* reduced sound transmission from thick chest wall or emphysematous lung
26
Where is the second heart sound S2 best heard
at the base of the heart (1, 2)
27
what produces the second heart sound S2
Diastole
* closure of aortic and pulmonic valves produces the S2 sound -\> "Dub"
* during this time, the heart is relaxed, ventricles start to refill and mitral and tricuspid valves are open
28
There is a normal or physiologic splitting of S2 during what
inspiration
29
what is split during physiologic splitting of S2
* split to hear
* aortic valve closure
* pulmonic valve closure
30
Wide splitting is due to what? What conditions can cause this?
Delayed closure of pulmonic valve
* pulmonary stenosis
* RBBB
31
fixed splitting, or splitting of S2 that does not vary with inspiration indicates what
atrial septal defect or right ventricular failure
32
paradoxical splitting present during expiration and gone during inspiration; A2 follows P2 indicates what?
delay in contraction of left ventricle due to a left bundle branch block
33
what creates a third heart sound S3
* created in early diastole by early passive rapid filling of the ventricles with blood from the atria
* S3 is produced by rapid distension of the ventricular walls, causing vibration
34
describe third heart sound S3. Where is it best heard?
* **low pitched**
* heard best with **bell**, at **apex**
35
what combination of sounds produced what is known as ventricular gallop rhythm
S1+ S2+ S3
36
What patient populations can have a non-pathological S3 gallop
* children
* healthy young adults
* pregnant women
37
What patient populations can develop a pathological S3 gallop
* \> 40 y.o
38
pathological S3 gallop is due to what conditions
* heart failure
* anemia
* volume overload of ventricle
* decreased myocardial contractility
39
what creates the fourth heart sound S4
* sound created by second phase of ventricular filling as the atria contract and eject blood into the ventricles ("atrial kick"
* S4 may be produced as the rush of blood causes vibration of valves, papillary muscles and ventricular walls
40
what combination of heart sounds are referred to as atrial gallop rhythm
S1+ S2+ S4
41
Describe S4 sound? Where is it best heard?
* **low pitched**
* best heart with **bell**, at **apex**
42
S4 may be normal in what patient population?
trained athletes
\*\*but usually uncommon in healthy adults
43
what pathology causes an S4 heart sound
resistance of ventricular filling
* stiffness of heart muscle (reduced compliance)
44
what conditions can cause an S4 heart sound
* coronary artery disease
* cardiomyopathy
* atrial stenosis
45
what is an aortic or pulmonic ejection click?
* high pitched; opening sound of valve
* indicates
* valve disease
* dilated aorta
* pulmonary HTN
46
aortic or pulmonic ejection click are heard best using what aspect of the stethoscope?
diaphragm
47
what is mitral prolapse?
ballooning of mitral leaflets into the left atrium during systole
48
what audible sounds can be heard from mitral valve prolapse
* mid-late systolic clicks
* variable pitch
* mitral regurgitation may also occur, with late systolic murmur
49
In describing and documenting a murmur, you should be able to characterize what 4 properties of an "abnormal" heart sound
1. location
2. timing
3. grade or intensity
4. quality and shape
50
What is a grade 1/6 murmur
barely audible in a quiet room
51
what graded murmur is this: quiet but clearly audible
grade 2/6 murmur
52
what graded murmur is this: moderately loud
Grade 3/6
53
what graded murmur is this: loud, associated with thrill
Grade 4/6
54
what graded murmur is this: very loud, heard with stethoscope partially off chest; obvious thrill
grade 5/6
55
what graded murmur is this: very loud, heart with stethoscope entirely off the chest, obvious thrill
grade 6/6
56
describe shape of systolic ejection murmur
usually crescendo decrescendo
57
what causes systolic ejection murmur
usually due to blood flow across semilunar valves
58
shape of pansystolic (holosystolic) murmur
plateau
59
what causes pansystolic (holosystolic) murmur
* usually regurgitation across A-V valves
Or
* ventricular septal defect
60
a late systolic murmur is typical of what condition
mitral prolapse
61
systolic ejection murmur occurs during when blood flows from what pressure system to what pressure system?
**from high pressure to high pressure**
* from left ventricle through aortic valve into aorta
* from right ventricle through pulmonic valve into pulmonary artery
62
where would you best hear a systolic ejection murmur
listen at base
* right and left sternal borders
63
aortic and/or pulmonic stenosis can cause what type of murmur
systolic ejection murmur
64
innocent systolic murmur are usually associated with what valve
pulmonic
65
innocent systolic murmur usually have what characteristics
* grade 1-2; rarely \>3/6
* medium pitch
* may decrease or disappear with sitting
* results from turbulent blood flow without valvular narrowing or obstruction
66
innocent systolic murmur are commonly found in what patient populations
* children and young adults
* pregnancy
* anemia
* fever
* hyperthyroidism
67
mitral or tricuspid regurgitation commonly results in what type of murmur
Pansystolic or holosystolic
68
Pansystolic or holosystolic results when blood flows between what two pressure systems?
from **high pressure to low pressure** system
69
describe the physiology of a high to low pressure pansystolic murmur
* pressure in L and R ventricles is significantly higher than in the atria
* when ventricles contract, if tricuspid or mitral valves leak, the ventricular pressure remains well above the atrial pressure throughout systole and the blood flow from ventricle into atrium is not slowed, so the murmur does not increase and decrease in intensity, it remains the same
70
what is an atrial septal defect
* congenital anomaly
* left-to-right shunt of blood (LA -\>RA)
* RV enlargement and increase flow through pulmonic valve
71
atrial septal defect causes what type of murmur
systolic ejection murmur
* fixed splitting of S2
72
Where can you hear a ventricular septal defect?
* Harsh systolic murmur at LLSB
73
ventricular septal defect causes what type of murmur? Why?
* pansystolic murmur
* there is no resistance to flow in the RV therefore, blood is moving from a high pressure to a low pressure system
74
early diastolic mumurs usually have what shape
decrescendo
75
regurgitant flow across leaking semilunar valves (aortic or pulmonic) causes what type of murmur
early diastolic murmur
76
mitral/tricuspid stenosis (turbulent flow across atrioventricular valves) causes what type of murmur
mid diastolic murmurs
77
mitral stenosis causes what noises
* opening snap
* diastolic rumble
78
aortic stenosis and aortic insufficiency (regurgitation) causes what shape murmur
crescendo-decrescendo murmur
79
identify the two maneuvers to identify systolic murmurs
1. standing or strain phase of valsalva
2. squatting or release phase of valsalva
80
what does the standing or stain phase of valsalva cause
* decreased left ventricular volume from decreased venous return to heart
* decreases vascular tone
* decreased BP
* decreased pulmonary vascular resistance
81
what does the squatting or release phase of valsalva cause
* increased left ventricular volume from increased venous return to heart
* increased vascular tone
* increased BP
* increased peripheral vascular resistance
82
what is patent ductus arteriosis
failure of channel between aorta and pulmonary artery to close after birth
83
Name some causes of "To and Fro" systolic/diastolic murmurs
* severe aortic regurgitation
* aortic stenosis
84
what does this abbreviation stand for: MSC
midsystolic click
85
what does this abbreviation stand for: MRG
murmurs, rubs, gallops
Physical Diagnosis
flashcards
Decks in class (16)
# Cards
