clinical skills- cardiovascular pt 2 (exam)

head to SVC to R heart

what does the jugular v drain blood from?

R atrial pressure (jv)

what does the jugular v reflect?

R atrial pressure

what correlates with central venous pressure and RV end-diastolic pressure?

fluid overload states

what causes jugular vein distension?

distance from R atrium to venous pulsations

what is jugular vein pressure?

pressure changes in the cardiac cycle

what causes jugular venous pulsations?

R internal jugular v

where is jugular venous pressure (JVP) best assessed?

R external jugular v

what other vessel can be used to assess JVP besides R internal jugular v?

deep to SCM

where is the R internal jugular vein located?

fluid status

what does the level of pulsations measured in the neck correlate with?

laying at 30 degrees, head turned slightly to left, tangential lighting

how should you position a pt to assess JVP?

between SCM attachments

where should you look for pulsations of internal jugular v?

1. find point of highest pulsation and place index card on it

2. identify sternal angle and place ruler perpendicular to it

3. measure where the index card crosses over

4. add 5cm

describe how to measure JVP

it is the distance from sternal angle to center of the R atrium

why do you add 5cm when measuring JVP?

6-8cm

what is WNL when measuring JVP?

hypervolemia

if JVP is measured as >8cm, what is it called?

acute and chronic heart failure, tricuspid stenosis, pulmonary HTN, SVC obstruction, cardiac tamponade, constrictive pericarditis

what is hypervolemia seen with?

hypovolemia

if JVP is measured as <5cm, what is it called?

elevated JVP on expiration and vein collapse on inspiration

what can COPD cause in terms of JVP?

diaphragm

what part of stethoscope is bruit of carotids best heard with?

atherosclerotic stenosis

what is bruit most often caused by?

stroke

what can bruit lead to?

carotids

where might murmurs from the heart radiate to?

amplitude

what is strength of the beat in carotids?

speed of upstroke, summit, and downstroke

what is the contour of the pulse wave in carotids?

brisk

describe normal contour of pulse wave in carotids

varied peak, bisferiens/double systolic peak, bigeminal, rapid rise or collapse

what are abnormal contours of pulse wave in the carotids?

rhythm is regular but the force of the pulse alternates

describe pulsus alternans

severe left ventricular dysfunction

what does pulsus alternans indicate?

alternating loud and soft Korotkoff sounds or sounds double as the cuff pressure declines

what might be heard with pulsus alternans when taking BP?

increased pulse pressure with double pulse peak

what is biferiens pulse?

aortic diseases, particularly aortic regurgitation and hypertrophic obstructive cardiomyopathy

what is bisferiens pulse often seen in?

large drop in systolic blood pressure during inspiration with correlating decrease in pulse amplitude during inspiration

what is paradoxical pulse?

pericardial tamponade, COPD or asthma exacerbations and constrictive pericarditis

what is paradoxical pulse seen in?

abnormal heart rhythm with extra, premature contraction between each normal beat

what is bigeminal pulse?

normal, decreased

with a bigeminal pulse, the regular beats have ___ amplitude and the extra beats are typically ___ in amplitude

electrical abnormality/arrhythmia that affects ventricles

what is the cause of a bigeminal pulse?

water hammer pulse

what is a hyperkinetic/bounding pulse aka?

elevated pulse amplitude with rapid upstroke and descent

describe a hyperkinetic/bounding pulse

fever, anemia, systolic HTN, cirrhosis, aortic or mitral regurgitation, patent ductus arteriosus

what are the pathologic causes of a hyperkinetic/bounding pulse?

stress, exercise, pregnancy

what are the physiologic causes of hyperkinetic/bounding pulse?

point of maximal impulse

what does PMI stand for?

left border of heart/apex

what does PMI locate?

fourth or fifth ICS, midclavicular line

what is the location of apical impulse/PMI?

1-2.5cm

what is the diameter of apical impulse/PMI in supine pts?

body habitus and positioning

the apical impulse/PMI may not be palpable or visible due to...

pulsations

what are visible chest wall impulses?

heart enlargement

what causes lateral displacement of PMI?

hypertrophic cardiomyopathy

what causes double impulse in apical region?

RV hypertrophy or AAA

what causes epigastric and subxiphoid movement?

shortly after

when should the carotid pulse occur in relation to S1?

left lateral decubitus position

PMI is best noted with a pt in what position?

sustained impulse from enlarged ventricle

what are heaves?

palm or finger pads

what are heaves best felt with?

buzzing or vibration sensation due to turbulent blood flow

what are thrills?

ball of hand

what are thrills best felt with?

apex

where are S3 and S4 best felt at?

pregnancy, heart failure, cardiomyopathy, ischemic heart disease, thoracic deformities

displaced apical impulse may be seen in...

hypertrophic cardiomyopathy (d)

what might a double apical impulse be seen with?

high pitched sounds

what sounds is the diaphragm best for?

diaphragm

S1 and S2 can be best heard with what part of the stethoscope?

aortic and mitral regurgitation and pericardial friction rubs

what are examples of sounds that can be heard with the diaphragm?

throughout the pericardium

where should the diaphragm be used first?

light pitch sounds

what sounds is the bell best for?

bell

light pressure should be used when using what side of the stethoscope

S3, S4, and mitral stenosis

what are examples of sounds that can be heard with the bell?

apex then medially along the lower sternal border/tricuspid area

where is the bell typically used?

valvular heart disease

cardiac auscultation is a screening method for...

murmurs

valvular heart diseases causes changes to normal blood flow in the heart creating altered or additional sounds called...

stiffened valves

___ have altered sounds when closing and may cause opening sounds like snaps or clicks

hypertrophy, tetralogy of fallot, ventricular septal defects

murmurs can also be due to other structural heart diseases or defects like...

valvular

auscultation occurs over what type of areas?

systole

what is the interval between S1 and S2?

diastole

what is the interval between S2 and S1?

during inspiration

when can splitting of S2 be normal?

wide, fixed, and paradoxical

what are different abnormal splitting variants of S2?

low pitch, bell

S3 has what type of vibration? should you use diaphragm or bell?

low pitched, bell

S4 has what type of vibration? should you use diaphragm or bell?

early in diastole

when does S3 occur?

apex (3,4)

S3 and S4 are both heard best at the...

rapid filling of the ventricle

what is S3 due to?

heart failure

what is S3 normally a sign of?

athletes, young children, and pregnant pts

S3 may be normal in....

S3

does ventricular gallop refer to S3 or S4?

S4

does atrial gallop refer to S3 or S4?

atrial contraction to push blood into a stiff ventricle

what is S4 due to?

late diastole

when does S4 occur?

athletes

S4 may be normal in...

hypertrophic obstructive cardiomyopathy (HOCM) or fibrosis

what are some abnormal causes of S4?

abnormal heart sounds

what are murmurs?

narrowing of heart valve, regurgitant blood flow over a heart valve

what are causes of murmurs?

left sided

for murmurs, what side heart issues are most clinically relevant?

turbulent flow across thickened or narrowed semilunar valves or regurgitant flow over AV valves

what are systolic murmurs due to?

midsystolic

turbulent flow across thickened or narrowed semilunar valve causes systolic murmurs that are typically...

pansystolic

regurgitant flow over AV valves causes systolic murmurs that are typically...

turbulent flow across thickened or narrowed AV valves or regurgitant flow across semilunar valves

what are diastolic murmurs due to?

diastolic murmurs

mitral or tricuspid stenosis causes what type of murmur?

mid-diastolic or late diastolic/presystolic

diastolic murmurs due to turbulent flow across thickened or narrowed AV valves is usually....

diastolic murmur

aortic regurgitation can cause what type of heart murmur?

early diastolic

diastolic murmurs due to regurgitant flow across semilunar valves is usually...