Lecture 4 cv

Question 1

CARDIOVASCULAR PHYSICAL EXAMINATION

Answer 1

• INSPECTION
• PALPATION
• PERCUSSION
• AUSCULTATION

Question 2

INSPECTION

Answer 2

GENERAL INSPECTION

INSPECTION OF THE ANTERIOR THORAX.

Question 3

GENERAL INSPECTION

Answer 3

1. HEIGHT , WEIGHT => NUTRITIONAL STATUS
2. FACIES
3. CONSTITUTIONAL TYPE
4. PSYCHIC STATUS
5. SPEAKING
6. DECUBITUS
7. OTRHOSTATISM AND WALKING

Question 4

INSPECTION
EXAMINATION OF SKIN, MUCOSAE AND
SUBCUTANEOUS TISSUE.

Answer 4

• CYANOSIS
• PALOR
• TELEANGIECTASIS
• JAUNDICE
• NAILS
• ERITEMA
• FINGERS
• CARDIOVASCULAR

Question 5

INSPECTION
INSPECTION OF THE ANTERIOR THORACIC
REGION

Answer 5

- INSPECTION OF THE ANTERIOR VERVICAL
REGION.
- INSPECTION OF THE PRECORDIAL REGION
- INSPECTION OF THE RIGHT THORACIC REGION
AND OF THE INFERIOR STERNAL REGION.

Question 6

INSPECTION

PERIODS

Answer 6

• STATIC

- DYNAMIC

Question 7

INSPECTION OF THE ANTERIOR CERVICAL REGION

Answer 7

1. CAROTID PULSATION (ARTERIAL DANCE)

• JUGULAR PULSATION
• JUGULAR TURGOR

2. AORTIC PULSATION

Question 8

INSPECTION OF THE PRECORDIAL REGION

Answer 8

• VISIBLE APICAL IMPULSE
• LEFT VENTRICULAR ANURYSM
• AORTIC ANEURYSM

Question 9

INSPECTION OF THE RIGHT HEMITHORAX AND STERNAL REGION

Answer 9

• AORTIC ANEURYSM
• LIVER PULSATIONS
• RIGHT VENTRICULAR IMPULSE

Question 10

PALPATION

Answer 10

1. ANTERIOR CERVICAL REGION
2. STERNAL NOTCH
3. APICAL IMPULSE
4. MEZOCARDIAC REGION
5. AUSCULTATION AREAS
6. IRRADIATION AREAS
7. EPIGASTRIC REGION

Question 11

PALPATION

APICAL IMPULSE

Answer 11

• LOCATION
• SURFACE
• AMPLITUDE
• UNICITY
• RITHMICITY

Question 12

PALPATION

AREAS- FOCI

Answer 12

1. CARDIAC SOUNDS EQUIVALENTS
2. THRILLS –palpable vibrations from murmurs or
   bruits- grade 4/6 or louder.
3. PERICARDIAL RUB.

Question 13

PERCUSSION

2 MOMENTS

Answer 13

• SUPERFICIAL
• DEEP.
  LOCATION OF THE CARDIAC DULLNESS -> RELATIVE
  ABSOLUTE

Question 14

PERCUSSION

Answer 14

RV -> RIGHT EDGE OF THE STERNUM III – VI IC.
-> DOWNWARDS INCREASED DULLNESS
LV -> POSTERIOR PERCUSSION

AO -> RIGHT EDGE. SP II – III IC.

PA -> SP III IC. LEFT.

Question 15

CARDIAC AUSCULTATION

Answer 15

DIRECT CORRELATION BETWEEN
HEMODYNAMIC PHENOMENA – ACOUSTIC
PHENOMENA = ACURACY OF THE CONCLUSION

PRACTICABLE IN ANY CONDITIONS
C. A. => DIRECT (IMEDIATE)
INDIRECT (MEDIATE)

Question 16

BIAURICULAR STHETOSCOPE

Answer 16

• AURICULAR PIECE: COMFORTABLE
• TUBES: 25 – 30cm, lumen ≥ 3mm
• CHEST PIECE: FLAT RESPONSE CURVE FOR: 50 – 1200 Hz

 TECHNIQUE
-  QUIET ROOM
 WE LISTEN FOR
    1. LOW FREQUENCIES
    2. HIGH FREQUENCIES
-  COMFORTABLE POSITION
-  PACIENT IN DORSAL DECUBITUS
-  SPECIFIC MANOEUVRES
-  ORTHOSTATISM

Question 17

AUSCOULTAION FOCI(AREAS)

Answer 17

LOOK AT THE PRESENTATION

Question 18

– – TUM – TA – – TUM – TA – –

Answer 18

SOUND I

FREQUENCY — VARIABLE

RHYTHMICITY — VARIABLE

INTENSITY — INTENSE

PITCH — LOWER

DURATION — LONGER

DELIMITATION — LESS CLEAR

AUDIBILITY — MITRAL AREA

Question 19

SOUND II

Answer 19

FRECUENCY — VARIABLE

RHYTHMICITY — VARIABLE

INTENSITY — LESS INTENSE

PITCH — HIGHER

DURATION — SHORTER

LIMITS — CLEAR

AUDIBILITY — BASE OF THE HEART.

Question 20

HEART SOUNDS

Answer 20

TAKE A LOOK AT SLIDE 22

Question 21

CONCOMITANT

Answer 21

DIMINUATION

ENHANCEMENT

Question 22

SEPPARATE

Answer 22

DIMINUATION
ENHANCEMENT
VARIABLE
SPLITTING

Question 23

CHANGES IN HEART SOUNDS

DIMINUATION

Answer 23

EMPHYSEMA
OBESITY
EXTREME TACHY

Question 24

CHANGES IN HEART SOUNDS

ENHANCEMENT

Answer 24

• “FETAL RHYTHM”
• CARDIOGENIC SHOCK
• RHEUMATIC FEVER (initial)

Question 25

CHANGES IN HEART SOUNDS | _______ ----->

Answer 25

- CHILDREN - HYPERKINETIC status. - hypertension - ----> - RHEUMATIC FEVER(late)

Question 26

CHANGES IN SOUND I | SOUND I INTENSITY IS DETERMINED BY:

Answer 26

1. POSITION OF THE CUSPS. 2. VALVULAR INTRINSIC MOBILITY. 3. LV CONTRACTION VELOCITY 4. MITRAL VALVE COMPLETE CLOSURE. 5. OTHER BIOLOGICAL AND PHYSICAL CHARACTERISTICS OF THE VALVES.

Question 27

ENHANCEMENT OF SOUND I | EHANCEMENT

Answer 27

- NONCALCIFIED MITRAL STENOSIS. | - SCLEROUS VALVES.

Question 28

SOUND I DIMINUATION

Answer 28

TAKE A LOOK AT SLIDE 27 ,28

Question 29

Changes in sound I VARIABLE S I ------> SPLITTING OF S I

Answer 29

- ATRIAL FIBRILLATION - -----> - AV DISSOCIATION. 1 .MITRAL component 2. – TRICUSPID component PHYSIOLOGIC PATHOLOGIC − RBBB,LBBB − idioventricular rythm

Question 30

Intensity changes for Sound II

Answer 30

``` S II formed of - ­ II A - II P ENHANCEMENT - PHYSIOLOGIC – pulmonary area (↑ in inspiration) - PATHOLOGIC ``` AORTIC AREA (CLANGOR) - hypertension - AORTIC ATHEROMA PULMONARY AREA (pulmonary hypertension) - MITRAL STENOSIS - COR PULMONARE (±) - Primary pulmonary hypertension - Congenital heart disease - Interatrial septal defect.

Question 31

CHANGES IN INTENSITY-SOUND II | DIMINUATION

Answer 31

AORTIC area - hypotension - SHOCK - AORTIC REGURGITATION - AORTIC STENOSIS, CALCIFIED Pulmonary area - PULMONARY VALVULAR STENOSIS

Question 32

CHANGES IN INTENSITY-SOUND II | SPLITTING

Answer 32

SPLITTING > PHYSIOLOGICAL - ONLY in the pulmonary area in INSPIRATION. > PATHOLOGIC LARGE SPLITTING - RBBB. - PULMONARY VALVULAR STENOSIS - MITRAL REGURGITATION FIXED SPLITTING (NO change in inspiration) - ATRIAL SEPTAL DEFECT REVERSED SPLITTING - LBBB - AORTIC STENOSIS

Question 33

THREE STROKE CARDIAC RHYTHM

Answer 33

1. PHYSIOLOGIC - S III physiologic 2. PATHOLOGIC 3. SPLITTING of SI 4. SPLITTING of SII 5. CLICKS - PROTOSYSTOLIC -->AORTIC PULMONAR - MEZOTELESYSTOLIC - IZODIASTOLIC - MITRAL VALVE OPENING. 6. GALOPURI

Question 34

CLICKS | PPROTOSYSTOLIC CLICK

Answer 34

PPROTOSYSTOLIC CLICK - Short, snaped , ejectional click - Large psudosplitting of SI = SI + click AORTIC - it can be listened in the mitral area. - no obvious respiratory variation - Noncalcified AS – aortic sclerosis. - AR sometimes. ``` PULMONARY pulmonary area disappearance in inspiration. - LARGE PS - PAH - MS ```

Question 35

CLICKS | MESOTELESYSTOLIC CLICK

Answer 35

``` MESOTELESYSTOLIC CLICK - LARGE INTENSITY - SHORT - SNAPED in PRIMARY VALVULAR MITRAL PROLAPSE ``` - VIBRANT - SUPERFICIAL - Also called – triolet sound.

Question 36

CLICKS | ISODIASTOLIC CLICK

Answer 36

ISODIASTOLIC CLICK - LARGE INTENSITY - SHORT - HIGH PITCH - IT HAPPENS “UNDER THE EAR” - MAXIMAL INTENSITY –LOWER STERNUM in CONSTRICTIVE PERICARDITIS.

Question 37

CLICKS | MITRAL OPENING CLICK (TRICUSP)

Answer 37

MITRAL OPENING CLICK (TRICUSP) - LARGE INTENSITY - SHORT - IT IS PERCEIVED AT A DEFINITE DISTANCE FROM SII. - BETTER HEARD AT THE APEX AND LOWER STERNUM - CHARACTERISTIC FOR MS WITH NONCLCIFIED VALVES. - IN MS, MITRAL DISEASE , MR (RARE)

Question 38

GALLOPS

Answer 38

- PATHOLOGICAL SOUNDS - ONLY IN DIASTOLE - LOW PITCH - LOW INTENSITY - DULL ARMONICS.

Question 39

GALLOPS LEFT RIGHT

Answer 39

- PRESYSTOLIC - PROTODIASTOLIC - SUMMATION

Question 40

GALLOPS | PRESYSTOLIC = S IV PATHOLOGIC

Answer 40

PRESYSTOLIC = S IV PATHOLOGIC - CONNECTED TO THE ATRIAL SYSTOLE - SIGN OF DIASTOLIC LV DYSFUNCTION-elevated filling pressure. - CAUSES: 1. HYPERTENSION 2. LEFT VENTRICULAR HYPETROPHY 3. CAD 4. AMI 5. HYPERTROPHIC CARDIOMYOPATHY concentric 6. Severe Aortic Stenosis 7. Third degree AV block.

Question 41

GALLOPS | PROTODIASTOLIC = S III pathologic

Answer 41

``` PROTODIASTOLIC = S III pathologic > Ventricular gallop > SVERE LEFT VENTRICULAR DYSFUNCTION. > PROGNOSIS ( 4 – 5 YEARS) > CAUSES: - CAD - HYPERTENSION - DILATED CARDIOMYOPATHIES - EXCENTRIC HYPERTROPHIC - CARDIOMYOPATHY. ```

Question 42

GALLOPS | MESODIASTOLIC = SUMMATION

Answer 42

MESODIASTOLIC = SUMMATION - SUM OF THE S3 AND S4. - TACHYCARDIA - GRADE I AV BLOCK. RIGHT. - LOWER EXTREMITY OF THE STERNUM - ENHANCED IN POSTINSPIRATORY APNEEA.