Cardiovascular and peripheral vascular system 🫀

how can you tell the difference between pulse coming from the carotid artery and the jugular vein?

you can see both

you should not have pulse in jugular

if you palpate its the artery

you cannot palpate the vein

if you SEE the pulsation then its the vein

this will only occur with increased pressure/congestion

SEE = JV pulse (congestion)

FEEL = carotid artery (normal)

who is S3 normal in?

children

when do you hear S4?

before S1

whats the difference between S3 and S4?

S3 is ventricular gallop

S4 is atrial gallop

what is CO formula?

stroke volume x heart rate

what is bloop pressure formula?

cardiac output x systemic vascular resistance

what are M1 T1 and A2 P2?

S1 and S2 just with the names of the valves

what are you hearing in S3?

mitral and tricuspid valves opening

what are you hearing with S4?

Ventricles dilate, an energy-requiring effort that draws

blood into the ventricles as the atria contract, thereby

moving blood from the atria to the ventricles

Atria contract as ventricles are almost filled

Causes complete emptying of atria

what is the electrical path of heart conduction?

Sinoatrial node (SA node)

AV node

Bundle of His

Purkinje fibers

what does EKG measure?

conduction!!!

hes not testing specifics of EKG

what are the three major system that can cause chest pain?

cardio, pulmonary, GI

whats orthopnea?

person needs to sit up to breathe

what is proximal nocturnal dyspnea?

waking up at the middle of the night running to the window for air bc you cant breathe

what is the musculoskeletal pain you can have in the chest?

rib pain - TC syndrome

what will be in hx of pt complaining of CP from each of these systems?

cardiac:

MSK:

GI:

cardiac: cardiac risk factors

MSK: hx of trauma ~ rib pain

GI: hx of indigestion

how will the onset of CP vary in each of the following?

cardiac:

MSK:

GI:

cardiac: specifically noted time of onset

MSK: vague

GI: vague

what will exacerbate CP in each of the following?

cardiac:

MSK:

GI:

cardiac: physical effort or emotional

MSK: physical effort

GI: food consumption or psychosocial stress

does CP cease in each of these? if so, how?

cardiac:

MSK:

GI:

cardiac: disappears if stimulating cause can be terminated

MSK: continues after cessation of effort

GI: may go on for several hours; unrelated to effort

how do each of the following CP's affect sleep?

cardiac:

MSK:

GI:

cardiac: may awaken pt from sleep

MSK: delays falling asleep

GI: may awaken from sleep, particularly during early morning

which factor of blood pressure do we worry the most about?

the diastolic BP

what is systolic blood pressure a measure of?

pressure generated by the LV during systole, when LV ejects blood into the aorta and arterial tree

what is diastolic BP a measure of?

pressure generated by blood remaining in the arterial tree during diastole when ventricles are relaxed

what is radial vs apical pulse?

apical = between 5th and 6th intercostal spaces on midclavicular line

what do we observe for:

what do we palpate for:

what do we auscultate for:

****

observe: *heaves or lifts*

palpate: *thrills*

auscultate: *murmurs*

what are heaves? what are lifts?

abnormal ventricular movements: ventricular hypertrophy

they're the same thing

what are thrills?

vibration from high pressure

what do you use to palpate for thrills?

the ball of the hand

where do you palpate for thrills?

aortic valve, pulmonic valve, erb's point, tricuspid (4 to 5th sternal border), mitral (midclavicular 4th to 5th)

what is JVP?

jugular venous pressure

how should table be positioned for JVP measurement?

raise the head of the bed or examining table to about 30º and turn the patients head slightly away from the side you are inspecting

where is the brachial pulse located?

medial

where will you hear the loudest sounds?

the mitral valve

what is PMI and where is it?

point of maximal impulse

mitral

what does a tapping PMI indicate?

normal

what does a sustained PMI indicate?

LV hypertrophy from hypertension or

aortic stenosis

what does diffuse PMI suggest?

a dilated ventricle from congestive heart

failure or cardiomyopathy

how do you position pt for palpation of apical impulse?

left lateral decubitus position

what is the diaphragm of the stethoscope for? what is the bell for?

diaphragm = *high pitched* sounds

bell = *low pitched* sounds

which sounds will you hear with the diaphragm?

S1, S2, and S4 and most murmurs

which sounds will you hear with the bell?

S3 and the rumble of mitral stenosis

how hard are the different grades of murmurs to hear?

1 only cardiologist will hear

2 prof will hear

4-6 students can hear

what are the extra heart sounds?

Gallops

Mitral snaps

Ejection clicks (mitral)

Friction rubs

what are the basic heart sounds?

S1 or S2 most distinct

Splitting

S3 and S4 difficult to hear

how do you describe timing and duration of a murmur?

timing: are they systolic or diastolic

duration: Early / mid / or late systolic

Early / mid / or late diastolic

what must you indicate about a murmur?

Timing (systole, diastole, or both)

Location (base, sternal, or apex)

Intensity (grade I-VI)

Quality (blowing, harsh, rumbling, or musical)

Shape (crescendo or decrescendo, holosystolic,

midsystole)

Radiation (yes or no)

Pitch (high, medium, or low)

which murmur is crescendo-decrescendo?

aortic stenosis

which murmur has a plateau?

mitral regurgitation

describe mitral regurgitation?

Harsh 2/6 medium-pitched holosystolic murmur best heard at

the apex

describe aortic regurgitation

Soft, blowing 3/6 decrescendo diastolic murmur best heard at the 2 ICS

what grade of mitral regurgitation will have an accompanying thrill?

grades 4-6

what can a systolic murmur between 1st and 2nd heart sounds be (what types of murmurs)?

mid-systolic (AS), pansystolic (MR)

what can a diastolic murmur between 2nd and 1st heart sounds be?

divided into three phases,

Early (AR), Mid-diastole (MS), presystole

what are continuous murmurs?

begins in systole and extends into all or part of a diastole (but is not necessarily uniform throughout)

what are examples of continuous murmurs?

congenital

patent ductus arterious, AV fistulas (HD), venous hums, and pericardial friction rubs

how do the crescendo and decrescendo of a continuous murmur look

how does a crescendo murmur look?

late disatolic (presystolic)

murmur of mitral stenosis

what is a decrescendo murmur example?

AR

which murmur is crescendo-decrescendo?

midsystolic murmur of aortic stenosis and

innocent flow murmur

which murmur is pansystolic?

MR

what is the cardiovascular effect of standing strain phase of valsalva?

*decreased LV volume* from decrease in venous return to the heart

*decreased vascular tone*; ↓ arterial BP and ↓ peripheral vascular resistance

what are the cardiovascular effects of squatting release of valsalva?

*increased LV volume* from decrease in venous return to the heart

*increased vascular tone*; ↑ arterial BP and ↑ peripheral vascular resistance

what sounds and murmurs is the valsalva maneuver used for?

MVP

Hypertrophic cardiomyopathy

AS

hw will standing strain phase of valsalva affect MVP?

↑prolapse of mitral valve

click moves earlier in systole and murmur lengthens

*↑ intensity of murmur*

what does squatting release of valsalva do to MVP?

↓ prolapse of mitral valve

delay of click and murmur shortens

*↓ intensity of murmur*

what effect does standing strain phase of valsalva have on hypertrophic cardiomyopathy?

↑ outflow obstruction

*↑ intensity of murmur*

what effect does squatting release phase of valsalva have on hypertrophic cardiomyopathy?

↓outflow obstruction

*↓intensity of murmur*

what effect does standing strain phase of valsalva have on aortic stenosis?

↓blood volume ejected into aorta

*↓ intensity of murmur*

what effect does squatting release of valsalva have on aortic stenosis?

↑blood volume ejected into aorta

*↑ intensity of murmur*

what is an isometric handgrip?

Increase the systolic murmur of mitral

regurgitation, pulmonary stenosis, and

VSD, as well as the diastolic murmur of

aortic regurgitation and mitral stenosis

what is transient arterial occlusion?

Transient compression of both arms by

bilateral blood pressure cuff inflation to 20

mm Hg greater than peak systolic blood

pressure

what will transient arterial occlusion augment?

augments the murmurs of mitral regurgitation, aortic regurgitation, and VSD

all diastolic murmurs are _________

pathologic

what is water hammer pulse?

bounding/forceful.

Rapidly increasing & subsequently collapsing.

seen in AR Also seen in PDA

what is corrigans pulse?

rapid upstroke & collapse

of the carotid artery pulse.

seen in AR Also seen in PDA

what is de Musset's sign?

rhythmic nodding or

bobbing of the head in synchrony with the

beating of the heart

seen in AR

what is Quincke's sign?

pulsation of the capillary bed

in the nail (rhythmic expansion of an artery that

may be felt with the finger)

seen in AR

what is traube's sign?

a "pistol shot", systolic sound

heard over the femoral artery when it is

compressed distally

seen in AR

what is Duroziez's sign?

audible systolic & diastolic

murmur heard over the femoral artery when

compressed

seen in AR

what are the two main signs and two pulses we see with AR?

water hammer pulse

corrigans pulse

de musset's sign

traube's signs

which vessels contain one way valves?

deep, superficial, and perforating vein

propel blood toward heart, preventing pooling, venous stasis, and backward flow

how can you asses if a patient with PAD has intermittent claudication?

ask pts, "have you ever had any pain or cramping in the legs when walking or with exercise?" "does the pain get better with rest?"

how can you asses if a pt with PAD has arterial spasm in their fingers and toes?

ask the, "do your fingertips or toes ever change color in cold weather, or when you handle cold objects?"

how do you asses venous peripheral vascular disease?

swelling of feet and legs, ask about ulcers on lower legs, often near ankles

what are the three continuous murmurs?

PDA

venous hump

pericarditis

what are the pulses from top to bottom?

temporal

carotid

brachial

radial

femoral

ant and post tibial

dorsalis pedis

who gets varicose veins?

pregnancy, standing for long periods of time, overweight

what are the two types of Raynaud's?

Raynauds phenomenon and disease

disease is a problem with the blood (has a cause) phenomenon is idiopathic (usually in the fingers)

what can you use to treat Raynaud's phenomenon?

low dose CCB

what are the 5 P's for artery problems?

1. pallor

2. pulslessness

3. paresthesia

4. pain

5. paralysis

what diseases may cause Raynaud's?

lupus, rheumatoid

any connective tissue disease

what triad will reveal to you that your pt most likely has PAD?

Triad of exercise-induced calf pain that causes patient

to stop exercise and experience relief of pain in 10

minutes is present in only 10% of affected patients

what is ABI used to asses?

BP in arms and ankle to asses PAD in the legs

who gets a higher ABI number and why?

diabetic pts because of calcification

ABI levels

normal: 1.0-1.4

borderline PAD: .91-.99

mild PAD: .7-.9

moderate: .4-.69

severe: less than .4

greater than 1.4 is calcification of arteries

what does a normal ABI indicate?

good blood flow to legs

what does borderline ABI indicate?

possible early signs of PAD

what does mild PAD on ABI indicate?

moderate narrowing of arteries in legs

what does moderate PAD result on ABI suggest?

significant narrowing and may cause sxs like claudication

what does serve PAD result on ABI suggest?

serve artery blockage and potential for tissue damage