Heart And Blood Vessels

HEART I.

ANATOMY

AND

PHYSIOLOGY

- heart lies in the mediastinum, to the left of the midline, just above the diaphragm, cradled between the medial and lower borders of the lungs - positioned behind the sternum and contiguous parts of the 3rd to 6th costal cartilages precordium – area of the chest overlying the heart base – broader upper portion of heart apex – narrower lower tip of heart Chambers: right and left atria – top right and left ventricles – bottom Valves:

atrioventricular valves = tricuspid and mitral valves (S1

sounds) - situated between atria and ventricles - tricuspid separates right atrium from right ventricle - mitral separates left atrium from left ventricle semilunar valves – pulmonic and aortic valves (S2 sounds) - pulmonic separates right ventricle from pulmonary arteries - aortic lies between left ventricle and aorta A.

DEVELOPMENTAL VARIATIONS 1. Infants and Children – heart becomes very much like the adult heart early in fetal life - fetal circulation, including umbilical vessels, compensates for nonfunctional fetal lungs (right ventricle pumps through patent ductus arteriosus rather than lungs) - right and left ventricles pump blood into systemic circulation - at birth, changes include closure of ductus arteriosus (usually within 24 to 48 hrs) and functional closure of interatrial foramen ovale as pressure rises in left atrium - by 1 yr of age, relative sizes of left and right ventricles approximate the adult ratio of 2:1 - heart lies more horizontally in the chests of infants and young children - apex rides higher, sometimes well into 4th intercostal space - by 7 yrs of age, adult heart position is reached 2. Pregnant Women – maternal blood volume increases 40% over prepregnancy volume - rise is mainly due to increase in plasma volume, which begins in st 1 trimester and reaches maximum after 30th week

- plasma volume increases 50% with single pregnancy - plasma volume increases as much as 70% with twin pregnancy - left ventricle increases in both wall thickness and mass - blood volume returns to prepregnancy levels within 3 – 4 weeks after delivery - cardiac output increases 40 – 50% over that of nonpregnant state and reaches its highest level by about 25 – 32 weeks of gestation and maintained until term - cardiac output returns to prepregnancy levels about 2 wks after delivery - as uterus enlarges and diaphragm moves upward, position of heart is shifted toward a horizontal position 3. Older Adults – heart size may decrease unless there is enlargement associated with hypertension or heart disease - left ventricle wall thickens and valves tend to fibrose and calcify - heart rate slows, stroke volume decreases, and cardiac output declines by 30 – 40% - endocardium thickens - myocardium becomes less elastic and more rigid so that recovery of myocardial contractility is delayed - tachycardia is poorly tolerated - after any type of stress, return to expected heart rate takes longer - aged heart continues to function reasonably well at rest - common ECG changes include 1st degree a.v. block, bundle branch blocks, ST-T wave abnormalities, premature systole (atrial and ventricular), left anterior hemi-block, left ventricular hypertrophy, and atrial fibrillation B.

REVIEW OF RELATED HISTORY 1. History of Present Illness – if patient doesn’t have problems, it’s not necessary to ask ALL a. Chest Pain (angina) – onset and duration - characteristics: aching, sharp, crushing, pressure, tingling - location: radiation down arms, to neck, jaws, teeth - severity: interference with activity, need to stop everything until subsides - associated symptoms: anxiety, dyspnea, dizziness, nausea, vomiting - other medications: prescription, nonprescription, herbal b. Fatigue - unusual or persistent, inability to keep up, early bedtime

- associated symptoms: dyspnea on exertion, chest pain, palpitations, anorexia c.

- medications: prescription, nonprescription, herbal Cough – onset and duration - characteristics: dry, wet, nighttime, aggravated by lying

down d.

Difficulty Breathing – dyspnea, orthopnea - aggravated by exertion, worsening, remaining stable

2. Past Medical History – cardiac surgery or hospitalization for cardiac evaluation or disorder - rhythm disorder - acute rheumatic fever, unexplained fever, swollen joints - chronic illness: hypertension, bleeding disorder, diabetes, thyroid dysfunction, coronary artery disease, congenital heart defect - blood pressure may be elevated when not on medications (investigate past for possible issues) 3. Family History – diabetes, heart disease, hypertension, congenital heart defects (once it occurs in a family the likelihood of it recurring increases 3 – 5 times), sudden death 4. Personal and Social History – demands of employment, tobacco use, nutritional status, personality, relaxation, use of alcohol, use of illegal drugs - note anything not relating to historical issues, including herbal C.

DEVELOPMENTAL VARIATIONS 1. Infants – tiring easily during feeding - breathing changes: more heavily or rapidly than expected during feeding or defecation - cyanosis: perioral during eating, more widespread and persistent, related to crying - weight gain as expected - knee-chest position or other position favored for rest - mother’s health during pregnancy (rubella, unexplained fever, drug use) 2.

Children – tiring during play - naps: longer than usual or usual length - positions: squatting instead of sitting when at play or watching

t.v. - headaches, nosebleeds, unexplained joint pain, unexplained fever - expected height and weight gain - expected physical and cognitive development

3.

Pregnant Women – history of cardiac disease or surgery - dizziness or faintness on standing - indications of heart disease (dyspnea, progressive orthopnea,

chest pain) 4. Older Adults – confusion, dizziness, blackouts, palpitations, coughs and wheezes, SOB, chest pains or tightness, incontinence, constipation, impotence - fatigue, leg edema - diagnosed heart disease: drug reactions, interference with ADL, ability to cope with condition, orthostatic hypotension

II.

EXAMINATION

AND

FINDINGS

A.

INSPECTION - in most adults, apical impulse should be visible at about midclavicular line in 5th left intercostal space - may be visible in 4th left intercostal space - should not be seen in more than one space if heart is healthy - readily visible and palpable impulse when patient is supine suggests intensity that may be result of a problem B.

PALPATION - 1 pulse = 2 heartbeats - make sure hands are warm and with patient supine, use proximal halves of the four fingers - touch gently and let cardiac movements rise to your hand, because sensation will decrease as you increase pressure - feel for apical impulse and identify its location by intercostal space and distance from midsternal line - usually palpable within a small radius – no more than 1 cm - impulse is usually gentle and brief - if it is more vigorous than expected characterize it as a heave or lift point of maximal impulse (PMI) – point at which apical impulse is most readily seen or felt - feel for a thrill (fine, palpable, rushing vibration, a palpable murmur) often, but not always, over the base of the heart in the area of right or left 2nd intercostal space - locate each sensation in terms of intercostal space and relationship to midsternal, midclavicular, and axillary lines - while palpating precordium, use other hand to palpate carotid artery in order to describe carotid pulse in relation to cardiac cycle - carotid pulse and S1 are practically synchronous

- carotid pulse is located just medial to and below the angle of the jaw C.

PERCUSSION - percussion is of limited value in defining the borders of the heart or determining size - left ventricular size is better judged by location of apical impulse - chest x-ray is far more useful in defining heart borders D.

AUSCULTATION - should be performed in each of the five cardiac areas, using first the diaphragm and then the bell of the stethoscope Five Traditionally Designated Areas: Aortic Valve Area – 2nd right intercostal space at right sternal border Pulmonic Valve Area – 2nd left intercostal space at left sternal border Erb’s Point (2nd Pulmonic Area) – 3rd left intercostal space at left sternal border Tricuspid Area – 4th intercostal space along lower left sternal border Mitral (Apical) Area – at apex of heart in 5th left intercostal space at midclavicular line Procedure: - instruct patient when to breathe comfortably and when to hold breath in expiration and inspiration - assess rate and rhythm, noting auscultatory area - patient sitting up and leaning slightly forward, in expiration, listen in all five areas - best position to hear relatively high-pitched murmurs (with diaphragm) - holding breath in expiration, listen for S1 while palpating carotid pulse - concentrate on systole, listening for any extra sounds or murmurs - concentrate on diastole, listening for any extra sounds or murmurs - inhaling deeply, listen closely for S2 - patient supine, listen in all five areas - patient left lateral recumbent, listen in all five areas - best position to hear low-pitched filling sounds in diastole (with bell) - patient right lateral recumbent – best position for evaluating right rotated heart – listen in all five areas - inch, don’t jump, your way from area to area 1. Basic Heart Sounds – characterized by pitch, intensity, duration, and timing in cardiac cycle - S1 and S2 are most distinct heart sounds

- should be characterized separately, because variations can offer important clues to cardiac function - S1 and S2 result from closure of AV valves indicating beginning of systole - S1 best heard toward the apex where it is usually louder - at base, S1 is louder on the left than on the right but softer than S2 in both - S1 is lower in pitch and a bit longer than S2 - S2 results from closure of semilunar valves indicating end of systole - best heard in aortic and pulmonic areas - higher pitch and shorter duration than S1 2. Extra Heart Sounds – inflammation of pericardial sac causes roughening of surfaces, producing a rubbing sound audible through the stethoscope - usually heard widely, but is more distinct toward the apex - grating sound that may be intense enough to obscure the heart sounds - always be aware, based on history and inspection of chest, of a patient’s having had a cardiac surgical procedure - listen for distinct click early in diastole, loudest at the apex 3. diastole

Heart Murmurs – relatively extra sounds heard during systole or

- characteristics depend on adequacy of valve function, size of opening, rate of blood flow, vigor of myocardium, and thickness and consistency of overlying tissues - sounds have been described in many ways (harsh, blowing, whooshing) are caused by back flow of blood through valves that do not fit together snugly - solid evidence from additional testing is often mandatory before a murmur is dismissed as functional - many murmurs (especially in children, adolescents, and young athletes) have no apparent cause - usually Grade I or II, midsystolic, without anatomic landmarks or medium pitch, blowing, brief - often located in 2nd left intercostal space near left sternal border - determine steadiness of heart rhythm, which should be regular - if irregular, determine whether there is a consistent pattern - patternless, unpredictable, irregular rate may indicate heart disease or impairment

Intensity Scale: Grade I = barely audible in quiet room Grade II = quiet but clearly audible Grade III = moderately loud (louder than S1 – S2) Grade IV = loud, associated with thrill Grade V = very loud, thrill easily palpable Grade VI = very loud, audible with stethoscope not in contact with chest, thrill palpable and visible E.

DEVELOPMENTAL VARIATIONS 1. Infants – examine heart within first 24 hrs of life and again about 2 – 3 days of age - complete evaluation includes exam of skin, lungs, and liver - inspect color of skin and mucous membranes - should be reassuringly pink - purplish plethora, ashy white and central cyanosis suggests disorders - note distribution and intensity of discoloration - apical impulse is usually seen and felt at 4th – 5th left intercostal space just medial to midclavicular line - the smaller the baby or thinner the chest, the more obvious it will be - note any enlargement of heart, especially important to note position of heart if baby is having trouble breathing - right ventricle is relatively more vigorous than left in a well, fullterm newborn - S2 is somewhat higher in pitch and more discrete than S1 - S2 is usually heard without a split at birth - murmurs are relatively common until about 48 hrs of age - usually Grade I or II intensity, systolic, and unaccompanied by other signs and symptoms - usually disappear within 2 – 3 days - if you can’t tell a murmur from respiration, pinch the nares briefly, listen while baby is feeding, or time the sound with the carotid pulsation - if murmur persists beyond 2nd or 3rd day of life, is intense, fills systole, occupies diastole to any extent, or radiates widely, it must be investigated - infant heart rates are more variable than those of older children - variation is greatest at birth or shortly after and is even more marked in premature infants - rates close to 200 beats/min. are not uncommon - decrease in rate is relatively rapid, and at a few hours of age, rate may be much

closer to 120 2. Children – precordium tends to bulge over an enlarged heart if enlargement is of long standing - sinus arrhythmia is a physiologic event where heart rate varies in a cyclic pattern, usually faster on inspiration and slower on expiration - heart rates are more variable than those of adults, reacting with wider swings to stress of any sort - when examining a child with known heart disease, take careful note of weight gain (or loss), developmental delay, cyanosis, and clubbing of fingers and toes 3. Pregnant Women – heart rate gradually increases throughout pregnancy until it is 10 – 30% higher at term - no significant ECG changes - heart position shifts during pregnancy and depend on size and position of uterus - apical impulse is upward and more lateral by 1 – 1.5 cm - some changes in auscultated heart sounds - 4th heart sound is abnormal - presence of cyanosis, clubbing, persistent neck vein distention, or development of diastolic murmur suggests abnormality 4. Older Adults – some may not be able to lie flat for an extended time, or may not be able to control their breathing pattern at your request - heart rate may be slower because of increased vagal tone, or more rapid, with a wide range that may vary from low 40s to more than 100 beats/min - elderly who exercise regularly may reverse or deter some of the age-associated changes

III.

COMMON ABNORMALITIES

A. HEART MURMURS – most common source of significant murmurs is anatomic disorder of the heart valves B. RIGHT VENTRICULAR HYPERTROPHY – right ventricle works harder and enlarges with defects of pulmonary vascular bed, pulmonary hypertension, and left-to-right shunts - can cause a lift along left sternal border in 3rd and 4th intercostal spaces accompanied by occasional systolic retraction at the apex

C. CONGESTIVE HEART FAILURE – syndrome in which the heart fails to propel blood forward with its usual force, resulting in congestion in pulmonary or systemic circulation - decreased cardiac output causes decreased blood flow to tissues - may be predominantly left- or right-sided - can develop gradually or suddenly with acute pulmonary edema - prevalence increases with age, particularly after 50 years, more rapidly among women than men D. CARDIAC TAMPONADE – excessive accumulation of effused fluids or blood between pericardium and heart - fluid seriously constrains cardiac relaxation, impairing access of blood to the right heart and ultimately causing signs and symptoms of systemic venous congestion (edema, ascites, and dyspnea) - with scarring forming a shell around the heart that limits cardiac filling, heart sounds are muffled, blood pressure drops, pulse becomes weakened and rapid, and paradoxic pulse becomes exaggerated E. MYOCARDIAL INFARCTION – ischemic myocardial necrosis is caused by abrupt decrease in coronary blood flow to a segment of the myocardium - commonly affects left ventricle, but damage may extend to right or atria - symptoms include deep substernal or visceral pain that often radiates to jaw, neck and left arm, although discomfort may be mild, especially in older adults and those with diabetes - heart sounds are typically distant, with soft, systolic, blowing apical murmur - pulse may be thready and blood pressure varies F.

INFANTS AND CHILDREN 1. Tetralogy of Fallot – made up of 4 cardiac defects: ventricular septal defect, pulmonic stenosis, dextroposition of aorta, and right ventricular hypertrophy - infants often have paroxysmal dyspnea with loss of consciousness and central cyanosis - older children develop clubbing of fingers and toes - parasternal heave and precordial prominence - systolic ejection murmur is heard over 3rd intercostal space, sometimes radiating to left side of neck - surgical correction may allow tolerance of ordinary day-to-day living 2.

Ventricular Septal Defect – opening between left and right ventricles - arterial pulse is small and jugular venous pulse is unaffected

- regurgitation occurs through septal defect resulting in the murmur to be holosystolic - often loud, coarse, high-pitched, and best heard along left sternal border in 3 – 5 rd

th

intercostal spaces - distinct lift is often discernible along left sternal border and apical area - smaller defect causes louder murmur and more easily felt thrill than a large one - does not radiate to neck 3. Patent Ductus Arteriosus – patent in fetal circulation, fails to close after birth - blood flows through ductus during systole and diastole, increasing the pressure in pulmonary circulation and consequently the workload of the right ventricle - small shunt can be asymptomatic; larger one causes dyspnea on exertion - neck vessels are dilated and pulsate, and pulse pressure is wide - harsh, loud, continuous murmur is often heard at 1st – 3rd intercostal spaces and lower sternal border (machinelike quality) - usually, but not always, unaltered by postural change 4. Atrial Septal Defect – congenital defect in septum dividing left and right atria causing systolic ejection murmur that is diamond shaped, often loud, high in pitch, and harsh - best heard over pulmonic area and not over the lesion, and may be accompanied by brief, rumbling, early diastolic murmur - does not usually radiate beyond precordium - systolic thrill may be felt over the area of the murmur, along with palpable parasternal thrust G.

OLDER ADULTS 1. Angina – pain - indicates substernal pain or intense pressure radiating at times to the neck, jaws, arms (particularly the left) - often accompanied by SOB, fatigue, diaphoresis, faintness, and syncope - can occur in much younger men and women

BLOOD VESSELS I.

DEVELOPMENTAL VARIATIONS

A.

INFANTS AND CHILDREN - at birth, cutting of the umbilical cord mandates breathing - onset of respiration expands the lungs and carries air to alveoli - pulmonary vascular resistance drops and systemic vascular resistance increases - blood flows more freely to lungs and less freely systemically B.

PREGNANT WOMEN - systemically, vascular resistance decreases and peripheral vasodilation occurs, resulting in palmar erythema and spider telangiectases - systolic blood pressure decreases slightly - greater decrease in diastolic pressure - lower levels occur in 2nd trimester - hypotension is more often noted in supine position during 3rd trimester - secondary to venous occlusion - blood in lower extremities tends to stagnate in later pregnancy C.

OLDER ADULTS - calcification and other changes noted histologically (first proximally then throughout walls of arteries) cause dilation and twisting of aorta, aortic branches, and carotid arteries - superficial vessels of forehead, neck, and extremities become twisted and more prominent - arterial walls lose elasticity and vasomotor tone

II.

REVIEW

OF

RELATED HISTORY

A.

HISTORY OF PRESENT ILLNESS 1. Leg Pain or Cramps – onset and duration - characteristics: burning in toes, pain when pointing toes, charley horses - skin changes: cold, pallor, hair loss, sores, redness or warmth over veins - increased tendency to bruise easily or bleed excessively 2. Dizziness, Severe Headaches 3. Swollen Ankles – onset and duration - related circumstances (recent, long airplane travel; travel to high elevations) - associated symptoms: onset of nocturia, increased frequency of urination, increased SOB B.

PAST MEDICAL HISTORY - cardiac surgery or hospitalization for cardiac evaluation or disorder, congenital heart defect

- acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism - chronic illness: hypertension, bleeding disorder, diabetes, thyroid dysfunction, coronary artery disease, atrial fibrillation C.

FAMILY HISTORY - diabetes, heart disease, hypertension, family members with risk factors

D.

PERSONAL AND SOCIAL HISTORY - physical demands of employment, tobacco use, nutritional status, personality, relaxation, use of alcohol, use of illegal drugs, use of nonprescription drugs (including herbal) E.

DEVELOPMENTAL VARIATIONS 1. Infants and Children – hemophilia, renal disease, coarctation (narrowing or constricting) of aorta, leg pains during exercise 2. Pregnant Women – blood pressure: elevation during pregnancy, associated symptoms (headaches, visual changes, nausea, rapid onset of edema) - legs: edema, varicosities, pain or discomfort 3. Older Adults – leg edema: pattern, frequency, time of day most pronounced - interference with ADL - ability of patient and family to cope with condition - claudication (halt or lameness in walk – limp) - medications utilized to try to relieve

III. A.

EXAMINATION

AND

FINDINGS

PERIPHERAL ARTERIES 1. Palpation – best palpated over arteries that are close to the surface and that lie over bones - veins include: • carotid – in the neck, just medial to and below angle of jaw - most easily accessible - closest to cardiac source and most useful in evaluating heart activity • brachial – just medial to biceps tendon • radial – medial and ventral side of wrist (gentle pressure) • femoral – suprapubic / groin area • popliteal – popliteal fossa (press firmly), patient should be prone with knee flexed • dorsalis pedis – medial side of dorsum of foot with foot slightly dorsiflexed (pulse may

be hard to feel and may not be palpable in some well persons) • posterior tibial – behind and slightly inferior to medial malleolus of ankle (pulse may be hard to feel and may not be palpable in some well persons) - arteries include: • temporal • carotid (have patient hold their breath when auscultating) • aortic (midline and to the left just below end of ribcage) • 2 – renal (listen to both sides) • 2 – iliac (right below the belly button) - palpate at least one pulse point in each extremity, usually at the most distal point - palpate firmly but not so hard as to occlude the artery - if having difficulty finding pulse, try varying pressure, feeling carefully throughout area - pulse is most readily felt over bony prominence - palpate arterial pulses (most often radial) to assess heart rate and rhythm, pulse contour (waveform), amplitude (force), symmetry, and sometimes, obstructions to blood flow Amplitude Scale: 4 3 2 1 0

= = = = =

bounding full, increased expected diminished, barely palpable absent, not palpable

- determine steadiness of heart rhythm (should be regular) - if irregular, determine whether there is a consistent pattern - patternless, unpredictable, irregular rate may indicate heart disease 2. Auscultation – auscultated over an artery for a bruit (murmur or unexpected sound) if you are following the radiation of murmurs first noted during cardiac exam - sounds are usually low pitched and relatively hard to hear - place bell directly over artery - sites to auscultated for bruit are over temporal, carotid, subclavian, abdominal aorta, renal, iliac, and femoral arteries - when listening over carotid vessels, ask patient to hold a breath - assessment for arterial occlusion and insufficiency is first signaled by pain - pain is characterized as dull ache with accompanying muscle fatigue and, often, crampiness

- site of pain is distal to occlusion - pain, pallor, and pulselessness characterize occlusion - paresthesias and paralysis occur with acute occlusion of major artery B. HOMANS SIGN – flex patient’s knee slightly with one hand and, with the other, dorsiflex foot - complaint of calf pain with this procedure is a positive sign and often indicates venous thrombosis C. EDEMA – inspect extremities for edema manifested as a change in the usual contour of the leg - press index finger over bony prominence of tibia or medial malleolus for several seconds - depression that does not rapidly refill and resume original contour indicates orthostatic (pitting) edema - not usually accompanied by thickening or pigmentation of overlying skin Grading Scale:

1+ = slight pitting, no visible distortion, disappears

rapidly 2+ = somewhat deeper pit than in 1+, but no readily detectable distortion and disappears in 10 – 15 seconds 3+ = pit is noticeably deep and may last more than a minute - dependent extremity looks fuller and swollen 4+ = pit is very deep, lasts as long as 2 – 5 min., dependent extremity is grossly distorted D. VARICOSE VEINS – dilated and swollen, with diminished rate of blood flow and increased intravenous pressure E.

DEVELOPMENTAL VARIATIONS 1. Infants – brachial, radial, and femoral pulses of newborns are easily palpable - sustained increase in blood pressure is almost always significant - capillary refill times in infants and children younger than 2 yrs. old are very rapid, less than 1 second - prolonged capillary refill time, longer than 2 seconds, indicates dehydration or hypovolemic shock 2. Children – venous hum, common in children, has no pathologic significance - to detect, have child sit with head turned to left and tilted slightly upward (right if listening on left)

- auscultated over right supraclavicular space at medial end of clavicle and along anterior border of sternocleidomastoid muscle - when present, hum is continuous low-pitched sound that is louder during diastole - can be confused with patent ductus arteriosus, aortic regurgitation, and murmur of valvular aortic stenosis - blood pressure is easy to measure in children past the age of 2 or 3 yrs - if ability to hear is compromised by child’s crying or deeply placed brachial artery, palpate radial artery if digital sphygmomanometer is not available - do not make diagnosis of hypertension on basis of one reading - blood pressure varies with sex and height at any age - unlikely for child to have unexplained hypertension - most hypertension is caused by kidney disease, renal arterial disease, coarctation (twisting) of the aorta - venous thrombosis is less common in children 3. Pregnant Women – blood pressure readings gradually fall until they reach a nadir (lowest point) at 16– 20 weeks of gestation, then gradually rise to prepregnant levels at term - sustained systolic pressure of 140 mmHg or greater or diastolic pressure of 90 mmHg or more should alert you to probability of pregnancy-induced hypertension 4. to find

Older Adults – dorsalis pedis and posterior tibial pulses may be difficult - superficial vessels are more apt to appear twisted and distended - due to loss of elasticity in the aging process, systolic pressure

may increase - hypertension is a pressure greater than 140/90

IV.

COMMON ABNORMALITIES

A. ARTERIAL ANEURYSM – localized dilation of an artery caused by a weakness in arterial wall - noticed as pulsatile swelling along course of artery - occur most commonly in aorta, although renal, femoral, and popliteal are also common sites - thrill or bruit may be evident over aneurysm B. VENOUS THROMBOSIS – can occur suddenly or gradually and with varying severity of symptoms - can be result of trauma or prolonged immobilization

- clinical findings include redness, thickening and tenderness along involved segment - pulmonary embolism, sometimes fatal, may occur without warning - deep vein thrombosis signs and symptoms include tenderness along iliac vessels and femoral canal, in the popliteal space, and over the deep calf veins; slight swelling may be distinguished only by measuring and comparing upper and lower legs bilaterally; minimal ankle edema; lowgrade fever; and tachycardia - Homans sign can be helpful but is not absolutely reliable - Doppler flow studies are diagnostic C. ATRIAL FIBRILLATION – in the QRS interval, a wave is absent and pulse if typically irregular - only two venous pulsations for each arterial pulsation, and time between intervals is variable D. CARDIAC TAMPONADE – jugular venous pressure is particularly helpful for evaluating pericardial disease - Y-descent is abolished and jugular venous pressure is markedly elevated - JVP fails to fall with inspiration as it usually does and may actually increase - other findings include tachycardia and pulsus paradoxus (decrease in systolic pressure greater than 15 mmHg with inspiration) E. VENOUS ULCERS – generally found on medial or lateral aspects of lower limbs, most often in elderly - common associated findings are induration, edema, and hyperpigmentation - heart failure, hypoalbuminemia, nutritional deficiency may be factors adding to the result of aging veins - peripheral neuropathy, diabetes, and arterial disease may be causal