H&P: Cardio

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ACC
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112401
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H&P: Cardio
Updated:
2011-10-26 18:17:11
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cardiac exam
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review for cardiac portion of H&P exam
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  1. Aortic Area
    • Right 2nd Interspace
    • This interspace ocerlies the aortic outflow tract.
  2. Pulmonic Area
    • Left 2nd Interspace
    • This interspace overlives the pulmonary artery.
  3. A brief middiastolic impulse indicates which heart sound?
    • S3
    • Bates p.359
  4. An impulse just before the systolic apical beat itself indicates which heart sound?
    • S4
    • Bates p.359
  5. A systolic hear murmur will fall between the heart sounds in which order?
    • S1, systolic murmur, S2
    • bates p. 365
  6. A diastolic murmur will fall between the heart sounds in which order?
    • S2, diastolic murmur, S1
    • bates p. 365
  7. Heart murmurs that coincide with the carotid upstroke are systolic or diastolic?
    • systolic
    • bates p. 365
  8. Which murmur begins after S1 and stops before S2? Brief gaps are audible between the murmur and the hear sounds.
    • Midsystolic Murmur
    • Bates p. 366
  9. Which murmur starts with S1 and stops at S2, without a gap between murmur and heart sound?
    • Pansystolic (holosystolic) murmur
    • bates p. 366
  10. Which murmur usually starts in mid -or late systole and persists up to S2?
    • Late Systolic Murmur
    • bates p.366
  11. Name three types of systolic murmurs
    • Midsystolic
    • Pansystolic
    • Late Systolic
    • bates p.365
  12. Name three types of diastolic murmurs
    • Early Diastolic
    • Middiastolic
    • Late Diastolic
    • bates p.366
  13. Which murmur starts immediately after S2, without a discernible gap, and then usually fades into silence before the next S1?
    Early Diastolic Murmur
  14. Which murmur starts a short time after S2. It may fade away or merge into a late diastolic murmur?
    • Middiastolic Murmur
    • bates p.366
  15. Which murmur starts late in diastole and typically continues up to S1?
    • Late Diastolic (Presystolic) murmur
    • bates p. 367
  16. Which murmur starts in systole and continues without pause through S2, into but not necessarily throughout diastole?
    • Continuous Murmur
    • (the murmur of a patent ductus arteriosus)
    • Bates p. 367
  17. A murmur that grows louder is called
    a crescendo murmur
  18. A murmur that grows softer
    Descrescendo murmur
  19. A murmur that first rises in intensity, then falls
    crescendo-decrescendo murmur
  20. A murmur that has the same intensity throughout
    Plateau Murmur
  21. The ____of a murmur is usually graded on a 6-point scale and expressed as a fraction.
    • Intensity
    • The numerator describest the intensity of the murmur
    • The denominator indicates the scale you are using
    • Grade 1 - very faint
    • Grade 2 - quiet, but heard immediately after placing stethoscope on chest
    • Grade 3 - Moderately loud
    • Grade 4 - Loud, with palpable thrill
    • Grade 5 - Very loud, with thrill
    • Grade 6 - Very loud, with thrill. May be heard without stethoscope
    • bates p. 368
  22. Murmurs that are short, early, midsystolic murmurs that decrease in intensity with maneuvers that reduce left ventricular volume, such as standing, sitting up, and straining during the Vlasalva maneuver are considered...
    Functional Murmurs
  23. What is the cardiovascular effect of the standing maneuver (strain phase of the valsalva maneuver)?
    • Decreased Left Ventricular volume from decreased venous return to the heart.
    • Decreased vascular tone leads to decreased arterial blood pressure
    • bates p. 369
  24. What is the cardiovascular effect of the squatting maneuver (release phase of valsalva maneuver)?
    • Increased left ventricular volume from increased venous return to the heart
    • Increased vascular tone:
    • increased arterial blood pressure; increased peripheral vascular resistance
    • bates p. 369
  25. In hypertrophic cardiomyopathy, when the patient returns to standing during the squatting maneuver, there will be (increased/decreased) outflow obstruction and (increased/decreased) intensity of murmur.
    • while returning to standing position:
    • increased outflow obstruction
    • increased intensity of murmur
  26. In hypertrophic cardiomyopathy, when the patient squats down there will be an (increase/decrease) in outflow obstruction and an (increase/decrease) intensity of murmur.
    • while squatting:
    • decreased outflow obstruction
    • decreased intensity of murmur
  27. In mitral valve prolapse, when returning to standing position during the squatting maneuver, there will be an (increase/decrease) prolapse of mitral valve causing the murmur to _____.
    • while returning to standing position:
    • increase prolapse of mitral valve
    • 'Click' moves earlier in systole and murmur lengthens
  28. In mitral valve prolapse, when squatting, there will be a (increase/decrease) in prolapse of mitral valve causing the murmur to ______.
    • while squatting:
    • decrease in prolapse of mitral valve
    • delay of 'Click' and murmur shortens
  29. Explain the Valsalva Maneuver
    When a person strains down against a closed glottis, venous return to the right heart is decreased, and after a few seconds, left ventricular volume and arterial blood pressure both fall. Rlease of the effort has the opposite effect. These changes help to distinguish MVP and HCM from AS. bates p. 370
  30. In _______, the rhythm of the pulse remains regular but the force of the arterial pulse alternates because of alternating strong and weak ventricular contractions.
    • Pulsus Alternans: almost always indicates severe left-sided heart failure and is usually best felt by applying light pressure on the radial or femoral arteries.
    • bates. 370
  31. Greater than normal drop in systolic pressure during inspiration is called.
    • Paradoxical Pulse: as the patient breathes, quietly if possible, lower the cuff pressure slowly to the systolic level.
    • Note the pressure level at whcich the first sounds can be heard.
    • Then drop the pressure very slowly until sounds can be heard throughout the resp. cycle. Again note the pressure levle. The difference between these two pressures is normally no greater than 3 or 4 mmHg.
  32. In aortic stenosis, when the patient returns to standing during the squat maneuver, expect a (increase/decrease) in blood volume ejected into the aorta causing a (increase/decrease) in murmur intensity.
    • decrease
    • decrease
  33. In aortic stenosis, when the patient squats, expect a (increase/decrease) in blood volume ejected into the aorta causing a (increase/decrease) in murmur intensity.
    • increase
    • increase
  34. When examining JVP elevate the head of the bed to ___.
    • 30 degrees
    • For hypovolemic patients -> lower the head of bed
    • For hypervolemic patients -> raise the head of bed
  35. JVP measurement should accurately reflect ____pressure.
    Right Atrial Pressure
  36. Once your JVP measurement is obtained, add __cm to the number to reflect the distance from the right atrium. The normal value should be less than or equal to __?
    • add 5cm
    • normal = less than or equal to 9cm
  37. Conditions elevating right atrial pressure:
    • Heart Failure
    • Tricuspid Valve Dz
    • Pulmonic stenosis
    • Pericardial Dz
  38. Conditions decreasing the right atrial pressure
    Dehydration
  39. The jugular venous "a" wave corresponds to ___ contraction.
    Atrial
  40. Reasons for increased "a" waves
    • Increased resistance to right atrial emptying:
    • Decreased right ventricular compliance
    • R. Vent. Hypertrophy
    • Pulm. valve stenosis
    • COPD with assocaited Pulm HTN
    • Restrictive cardiomyopathy
    • Tricuspid Stenosis
  41. Reasons for absent "a" waves
    • atrial fibrillation
    • junctional/ventricular rhythms
  42. Reasons for intermittent prominent "a" waves (cannon "a" waves)
    • Atrial-ventricular dissociation (i.e. complete heart block)
    • V. Tach
  43. The jugular venous "x' descent corresponds to ____.
    atrial relaxation
  44. Reasons for prominent "x" descent
    • constrictive pericarditis
    • restrictive cardiomyopathy
    • pericardial tamponade
  45. Reasons for decreased or absent "x" descent
    • severe tricuspid regurg
    • A. Fib
  46. Jugular venous "c" wave represents ____.
    • The bulging of the tricuspid valve during systolic contraction
    • May or may not be present in every patient
  47. Jugular venous "v" wave reflects ____.
    • increased atrial pressure as venous return increases after systole
    • It becomes prominent in severe tricuspid regurg
  48. Jugular venous "y" descent represents ____.
    reduced pressure observed with tricuspid valve opening and atrial emptying during diastole
  49. Reasons for prominent "y" descent
    • constrictive pericarditis
    • restrictive cardiomyopathy
    • RV infarctions
    • ASD
    • Tricuspid regurg
  50. Reasons for slow "y" descent
    tricuspid stenosis
  51. Reasons for absent "y" descent
    pericardial tamponade
  52. Explain Kussmaul's sign
    • The observation of a JVP that rises with inspiration.
    • Kussmaul's sign suggests impaired filling of the right ventricle due fluid in the pericardial space or a poorly compliant myocardium or pericardium
  53. Explain hepato-jugular reflex
    • JVp is observed while pressure is firmly applied to the right upper quad, primarily used in patients with subacute right-sided HF and or passive hepatic congestion
    • The increased pressure augments venous return to the right atrium
  54. Normal carotid upstroke follows (which heart sound) and precedes (which heart sound).
    follows S1 and precedes S2
  55. When listening for a bruit, remember to have the patient...
    hold their breath
  56. If you are evaluating the cardiac cycle and discover that the carotid has bruits or thrills, utilize the _____artery to time the cardiac cycle.
    Brachial
  57. Where will you find the Apical Pulse (PMI)
    5th IC space, 1cm medial to the MCL
  58. Describe a normal apical impulse (PMI)
    • less than 2.5cm
    • one interspace
    • brisk and tapping
  59. S1 will be loudest at the (apex/base)
    apex
  60. S2 will be loudest at the (apex/base)
    base
  61. Remember to work from the patient's (left/right)side
    right
  62. Which part of the stethoscope is more sensitive to higher pitched sounds and elminates lower pitched sounds?
    Diaphragm
  63. Which part of the stethoscope is more sensitive to lower pitched sounds?
    • Bell
    • (Don't press)
    • (can use this side to listen to all sounds)
  64. Make sure to use the Bell when listening to which two cardiac areas?
    Mitral and Tricuspid
  65. When auscultating the 5 cardiac areas, should you ever remove your stethoscope from the patient's skin?
    Its a better idea to slide or inch the stethoscope from area to area listening for a change in tone
  66. What am I listening for?
    My stethoscope is in the 3rd IC space @ the left sternal border and my patient is sitting up and leaning forward. I ask my patient to exhale fully.
    diastolic murmur
  67. What am I listening for?
    My stethoscope is in the 2nd IC space @ the left sternal border. My patient is sitting upright and I ask them to inhale and exhale deeply but quietly.
    • Splitting of S2
    • (physiologuc, widened, fixed, paradoxical)
  68. What am I listening for?
    I am using the bell of my stethoscope to listen at the tricuspid and mitral (apex) areas. My patient is in the left lateral decubitus position.
    • Gallops (S3 and S4)
    • Mitral and Tricuspid stenosis
  69. The Allen test is used to determine patency of ____ artery. Perform this test before collecting blood from the ____ artery. Why would you collect blood from this artery?
    • Ulnar artery.
    • Radial artery.
    • To test arterial blood gasses
  70. By the _______ test you can assess the valvular compentcy in both the communicating veins and the saphenous system.
    • Trendelenburg test
    • bates p. 491

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