CPD II: cardiovascular introduction

today we began talking about the diagnosis of cardiovascular diseases in all their manifestations. we started with a review of the cardiac anatomy and physiology, the cardiac cycle and sounds, and began talking about different aspects of the physical exam and history of the patient with heart disease. we then looked at several characteristic symptoms that might arise that are indicative of different heart diseases.

questions
heart sounds...
1. S1 is the sound of...
2. S2 is the sound of...
3. what is "S2 splitting"?
4. S2 splitting is considered normal in...
5. what do fixed and parodoxical splitting represent?
6. S3 is the sound of...
7. prominent S3 sound might indicate what?
8. S4 is the sound of...
9. S4 might indicate what?

physical examination...
10. what is orthostatic hypotension?
11. what are xanthomatas?
12. what are some cardiac related conditions that could result in altered facial appearance?
13. what is the malar flush and what might it result from?
14. if the carotid pulses are different bilaterally, what might this indicate?
15. what is the hepatojugular reflex?
16. increased jugular venous pressure can indicate...
17. common fundoscopic findings for cardiac disease?
18. how might the fingernails appear in a cardiac patient?
19. describe some common PE findings for the hands of a cardiac patient.

auscultation...
20. where is the aortic area located?
21. where is the pulmonic area?
22. where is Erb's point and what is its significance?
23. where is the tricuspid area?
24. where is the mitral area?
25. why might open heart surgery interfere with auscultation?
26. what is an ejection murmur?
27. what is a regurgitant murmur?
28. describe the sound of a diastolic murmur.
29. what are mid/late diastolic murmurs caused by?
30. what does a continuous murmur indicate?
31. what does a pericardial friction rub sound like?

answers
1. mitral and tricuspid valves closing at the beginning of systole.
2. pulmonary and aortic valves closing at the beginning of diastole.
3. when S2 has two different sounds instead of one, resulting from the aortic valve closing before the pulmonary.
4. during inspiration, common under 30yo.
5. fixed: R heart overload, RBBB, ASD, pulmonic stenosis. parodoxical: cardiac disease.
6. diastolic sound from rapid ventricular filling.
7. CHF, ASD, mitral or aortic insufficiency, VSD, PDA.
8. diastolic sound due to lower ventricular compliance.
9. aortic stenosis, HTN, CAD, cardiomyopathy, mitral regurg., MI.

10. a drop in systolic BP of more than 20mmHg upon moving from a lying to standing position.
11. lipid deposits in the skin associated with high cholesterol and diabetes.
12. cushing's, acromegaly, paget's, (as well as anxiety, pain)
13. flushing of the cheeks, might be related to valvular disease such as mitral stenosis (leads to pulmonary HTN, leads to dilation of blood vessels)
14. atherosclerosis, especially with bruits.
15. pressing on the lower abdomen to see how much the jugular venous pressure rises.
16. RCHF, constrictive pericarditis, SVC obstruction.
17. Roth's spots / flame hemorrhage.
18. might have splinter hemorrhages or clubbing.
19. cyanosis, arachnodactyly, osler nodes/janeway lesions.

20. 2nd intercostal space (IS), to the right of the sternum.
21. 2nd IS, to the left of the sternum.
22. 3rd IS to the left of the sternum; useful as a point to hear the "overall" heart cycle.
23. lower half of sternum, right parasternal area.
24. 5th IS, just medial to midclavicular line.
25. sometimes as a result of open heart surgery the pericardium sticks to the myocardium and inhibits sound conduction.
26. systolic murmur: blood flowing through a stenotic valve.
27. systolic murmur: blood flowing back into the chamber from which is being pumped out of.
28. higher pitched, decrescendo.
29. forward flow through AV valves.
30. an abnormal pathology, such as a congenital shunt.
31. high pitched, squeeking; best heard if patient leans forward.