advanced physical assessment - Cardiovascular assessment
S1 is usually louder than S2 at
the apex;
optimal triglycerides
<150 mg/dL
optimal HDL?
> 45 mg/dl
are diastolic murmurs ever innocent?
no
where is Aortic Regurgitation best heard?
Best heard in the 2nd-4th ICS at the left sternal edge
what is the c in the JVP waveform?
C is for carotid transmission, closure of tricuspid valve. ventricular contraction (tricuspid bulges). YOU WON'T SEE THIS
When observing the amplitude and timing of the JVP by listening to the apex or palpating the carotid pulse, where will you see the waves?
The a wave just precedes S1 and the carotid pulse, the x descent can be seen as a systolic collapse, the v wave almost coincides with S2, and the y descent follows early in diastole
-Pressure generated by blood remaining in arterial tree during diastole, when the ventricles are relaxed
DBP
A _______ carotid pulse suggests aortic stenosis,
Delayed
describe a Crescendo murmur
Grows louder. ex: mitral stenosis
what is the most common kind of heart murmur?
Midsystolic (ejection) murmurs
where does pulmonic ejection sound radiate?
along the sternum - vertical
Describe a grade 3 murmur
Moderately loud
the Ankle-Brachial Index tests for what?
PAD
a waves would be elevated in what?
Pulmonary Hypertension
In a normal beating heart, what two sounds does it make?
S1 and S2
fourth intercostal space at the left sternal border
tricuspid area
__________ area: 2nd ICS, RSB
•Aortic
a diffuse PMI suggests:
-suggests a dilated ventricle from congestive heart failure or cardiomyopathy
where is Erb's point?
3rd ICS L sternal border
Where is Erb's point?
3rd ICS, LSB
Thrills are associated with murmurs of grades _______
4 through 6
Where is the mitral area?
5th ICS, left midclavicular line AKA apex/PMI
optimal total cholesterol?
75-169 mg/dL for those age 20 and younger 100-199 mg/dL for those over age 21
describe a Decrescendo murmur
: Grows softer. ex: aortic regurgitation
when would you hear a Middiastolic murmur?
: Starts a short time after S2. It may fade away, as illustrated, or merge into a late diastolic murmur. reflect turbulent flow across the AV valves.
when do you hear a Pansystolic (holosystolic) murmur
: Starts with S1 and stops at S2, without a gap between murmur and heart sounds. Pansystolic murmurs often occur with regurgitant (backward) flow across the AV valves
What LDL level is considered optimal
<70 mg: with CVD and high risk <100 mg: high risk with comorbidities/risk factors < 130: all others not at high risk
What would the PMI's characteristics be in HF or dilated CM?
A diffuse sustained low-amplitude (hypokinetic) impulse is seen in heart failure and dilated cardiomyopathy
when would a hyperkinetic PMI be abnormal?
A hyperkinetic high-amplitude impulse may occur in hyperthyroidism, severe anemia, pressure overload of the left ventricle from hypertension or aortic stenosis, or volume overload of the left ventricle from aortic regurgitation.
What is the "a" wave in JVP waveform?
A is for atrial contraction. The a wave is generated by atrial contraction, which actively fills the right ventricle in end-diastole. tricuspid valve is open Occurs during diastole, just prior to S1 a rise in right atrial pressure during atrial contraction. ABSENT IN AFIB
At higher arm levels, the blood pressure recordings will be __A_____; at lower levels, the blood pressure recordings will be ____B_____
A lower B higher
How would you differentiate LVH from volume overload when assessing the PMI?
A sustained high-amplitude impulse significantly increases the likelihood of LVH from the pressure overload seen in hypertension. if such an impulse is displaced laterally, consider volume overload.
what is the order of JVP waveform?
A wave C wave X decent V wave Y decent
when there is an s2 split, compare the intensity of the two components, A2 and P2. which is usually louder?
A2 is usually louder A loud P2 points to pulmonary hypertension
JVP that is over ___A___ cm above the sternal angle, or over __B___ cm above the right atrium, is considered elevated or abnormal.
A: >3 cm B: >8 cm
Right-sided heart murmurs generally increase with _____A_______ left-sided murmurs generally increase with ___B______
A: inspiration b: expiration
an elevated JVP is highly correlated with:
CHF - an increased left ventricular end diastolic pressure and low left ventricular EF It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis
what are some causes of edema
Causes are frequently cardiac (right or left ventricular dysfunction; pulmonary hypertension) or pulmonary (obstructive lung disease), but can also be nutritional (hypoalbuminemia), and/or positional. Dependent edema appears in the lowest body parts: the feet and lower legs when sitting, or the sacrum when bedridden. Anasarca is severe generalized edema extending to the sacrum and abdomen
in murmurs, how do you describe the location of maximal intensity?
Describe where you hear it best in terms of the intercostal space and its proximity to the sternum, the apex, or its measured distance from the midclavicu- lar, midsternal, or one of the axillary lines. For example, a murmur best heard in the 2nd right interspace often originates at or near the aortic valve.
Diastolic murmurs usually represent ________ Systolic murmurs usually represent ________
Diastolic murmurs usually represent valvular heart disease. Systolic murmurs point to valvular disease but can be physiologic flow murmurs arising from normal heart valves.
What is the most useful characteristic of the PMI for identifying LVH?
Duration
how do you check for Paradoxical Pulse
During BP, note the first Korotkoff sound. then continue to decrease to hear when the sound NO LONGER disappears with inspiration (becomes regular and doesn't skip a sound). 3-4 normal. over 10 = very positive
where is an aortic stenosis murmur best heard and where does it radiate?
Right 2nd and 3rd interspaces radiates Often to the carotids, down the left sternal border, even to the apex. If severe, may radiate to left 2nd and 3rd interspaces
describe Standing and Squatting in regards to the Special Technique/Maneuver to Identify Murmurs and Heart Failure
When a person is standing up, venous return to the heart decreases, as does peripheral vascular resistance. Arterial blood pressure, stroke volume, and the volume of blood in the left ventricle all decline. With squatting, vascular and volume changes occur in the opposite direction.
what are the peaks of the JVP wave form and what do the stand for?
a for atrial contraction c for carotid transmission v for venous filling
most common extra sound is:
a midsystolic click, often a mitral valve prolapse; known as a "gallop"
what is a bruit?
a murmur-like sound arising from turbulent arterial blood flow.
To assess the PMI and extra heart sounds such as S3 or S4, how should you assess the patient (position)?
ask the patient to turn to the left side, termed the left lateral decubitus position—this brings the ventricular apex closer to the chest wall. To bring the left ventricular outflow tract closer to the chest wall and improve detection of aortic regurgitation, have the patient sit up, lean forward, and exhale.
what kind of carotid pulse would you see in cardiogenic shock?
carotid pulse is small, thready, or weak
what causes regurgitation
causes a characteristic murmur when a valve fails to fully close, as in aortic regurgitation. Such a valve allows blood to leak backward in a retrograde direction and produces a regurgitant murmur.
Do the heart valves open or close during systole?
closing
how do you determine the timing of a murmur?
First decide if you are hearing a systolic murmur, falling between S1 and S2, or a diastolic murmur, falling between S2 and S1. Palpating the carotid pulse as you listen can help you with timing. Murmurs that coincide with the carotid upstroke are systolic.
describe a Crescendo-decrescendo murmur
First rises in intensity, then falls example: midsystolic murmur of aortic stenosis and innocent flow murmurs
How do you confirm Pulsus alternans during an assessment?
It is usually best felt by applying light pressure on the radial or femoral arteries. Use a blood pressure cuff to confirm your finding. After raising the cuff pressure, lower it slowly to just below the systolic level. The initial Korotkoff sounds are the strong beats. As you lower the cuff, you will hear the softer sounds of the alternating weak beats, which will eventually disappear, causing the remaining Korotkoff sounds to double
__________ accurately predicts elevations in fluid volume in heart failure
JVP
S3 is best heard where?
LV origin: best heard at the apex in supine or left lateral position RV origin: best heard at left lower sternal border or at the xiphoid
S4 is best heard
LV origin: best heard at the apex in supine or left lateral position. RV origin: left lower sternal border
what is a cannon a wave and when does it occur?
Large positive venous pulse during "a" wave. It occurs when an atrium contracts against a closed tricuspid valve during AV dissociation. Examples include: Premature atrial/junctional/ventricular beats Complete atrio-ventricular (AV) block Ventricular tachycardia
Patent Ductus Arteriosus is a _____________murmur
continuous
Congenital patent ductus arteriosus and AV fistulas, common in dialysis patients, produce what kind of murmurs?
continuous murmurs that are nonvalvular in origin.
when the pitch is high, what part of the stethoscope should you use?
diaphragm
systole or diastole? -Blood flows from the left atrium → left ventricle (mitral valve is open)
diastole
systole or diastole? -Blood flows from the right atrium → right ventricle (tricuspid valve is open)
diastole
systole or diastole? •The ventricles relax
diastole
a snap is a __________ sound
diastolic
In patients with obstructive lung disease, how does the JVP appear?
elevated on expiration, but the veins collapse on inspiration. This finding does not indicate heart failure.
Janeway lesions - diagnosis?
endocarditis
Splinter hemorrhages in fingernails may suggest what?
endocarditis
What is PND?
episodes of sudden dyspnea and orthopnea awakens the patient from sleep prompts patient to sit or stand up and get air There may be associated wheezing and coughing. The episode usually subsides but may recur at about the same time on subsequent nights
what is Friedrich's sign?
exaggerated "x" wave or diastolic collapse of the neck veins from constrictive pericarditis
what is the most common symptom of cardiac disease?
fatigue.
a Paradoxical Pulse is found most commonly in?
found most commonly in acute asthma and obstructive pulmonary disease It also occurs in pericardial tamponade and at times in constrictive pericarditis and acute pulmonary embolism
when is a Friction rub heard, and where is it best heard?
from inflammation of precordium best heard at apex and lower left sternal border with patient sitting and leaning forward; high-pitched and scratchy - like sandpaper; heard with pericarditis or after MI
How is the intensity of a heart murmur graded? How many grades?
graded on a 6 point scale, by intensity of sound.
what grades require the added presence of a palpable thrill?
grades 4 through 6
if a PMI is not detected during an exam, what should you do?
have the patient turn to the left in the left lateral decubitus position If you STILL cannot find the apical impulse, ask the patient to exhale fully and stop breathing for a few seconds.
when is s3 and s4 normal?
in athletes
Midsystolic murmurs include:
include the murmurs of aortic stenosis, pulmonic stenosis, hypertrophic obstructive cardiomyopathy and atrial septal defects Midsystolic murmurs typically arise from blood flow across the semilunar (aortic and pulmonic) valves
Splitting of S2 that does not disappear with expiration is
is abnormal and suggests a valvular abnormality
what is a normal finding when assessing the diameter of the PMI?
it usually measures less than 2.5 cm, about the size of a quarter, and occupies only one interspace. It may feel larger in the left lateral decubitus position.
Orthopnea and PND occur in
left ventricular heart failure and mitral steno- sis and also in obstructive lung disease
Are murmurs longer or shorter than heart sounds?
longer
what are you grading when grading a murmur?
loudness
s3 is a _____ frequency sound
low
s4 is a _____ frequency sound
low
Where is the tricuspid area?
lower left sternal border (4th/5th ICS)
Systolic clicks are usually caused by
mitral valve prolapse
you feel a sustained pulse at the Left Sternal Border in the 3rd, 4th, and 5th Interspaces. what could this indicate?
movement beginning at S1 points to pressure overload (pulmonary hypertension, pulmonic stenosis, or the chronic ventricular volume overload of an atrial septal defect). A sustained movement later in systole can be seen in mitral regurgitation
what is Kussmaul's sign?
neck veins rise in inspiration rather than fall—often a sign of pericardial tamponade or right heart failure (acute right ventricular myocardial infarction)
what is the most common cause of syncope?
neurocardiogenic (also called vasovagal syncope)
s4 in a pt > 30 years signifies
noncompliant or stiff ventricle •Hypotrophy of ventricle CHF, CAD
s3 and s4 in children and young adults is ___________
normal
•Pulmonary Flow Murmur -
older children, LUSB, louder in supine position is just like it sounds. In a pulmonary flow murmur, all you are hearing is normal blood flow across a normal pulmonary valve. Blood is a liquid, and it flows through the heart fairly rapidly in some cases. Sometimes this normal flowcan produce extra sounds or noises
Do the heart valves open or close during diastole?
opening
Patent Ductus Arteriosus
passageway between the aorta and the pulmonary artery remains open after birth ("a hole in the heart")
what •May enhance murmur of tricuspid regurgitation?
passive leg raise
a prominent PMI could indicate what?
pathologic conditions such as right ventricular hypertrophy, a dilated pulmonary artery, or an aortic aneurysm may produce a pulsation that is more prominent than the apex beat.
describe the isometric hand grip maneuver
performed by clenching one's fist forcefully for a sustained time until fatigued. Variations include squeezing an item such as a rolled up washcloth.
Sudden dyspnea occurs in
pulmonary embolus, spontaneous pneumothorax, and anxiety
alternating loud and soft Korotkoff sounds or a sudden doubling of the apparent heart rate as the cuff pressure declines signals what?
pulsus alternans Placing the patient in the upright position may accentuate this finding
When describing a heart murmur, what does radiation reflect?
reflects the intensity of the murmur and the direction of blood flow
Early diastolic murmurs typically reflect:
regurgitant flow across incompetent semilunar valves.
when a person squats, what phase of the Valsalva is this similar to?
release phase of Valsalva = squatting
what sound is the Tricuspid & Mitral valves?
s1
what sound is the closure Aortic & Pulmonic valves?
s2
Pulsus alternans almost always indicates __________________
severe left ventricular dysfunction.
what is a cardiovascular diagram?
shows a waveform of the heartbeat sound
how do you test for Paradoxical Pulse during an assessment?
use a blood pressure cuff to check for a paradoxical pulse. As the patient breathes quietly, lower the cuff pressure to the systolic level. Note the pressure level at which the first sounds can be heard. Then drop the pressure very slowly until sounds can be heard throughout the respiratory cycle. Again note the pressure level. The difference between these two levels is normally no greater than 3 or 4 mm Hg.
What is the v wave in JVP?
v is for venous filling..... The v wave reflects the passive increase in pressure and volume of the right atrium as it fills in late systole and early diastole. atrial venous filling (occurs at same of time of ventricular contraction) the atrium is tense, tricuspid closed. The tricuspid valve is closed, the chamber begins to fill, and right atrial pressure begins to rise again, creating the second elevation, the v wave.
Describe a grade 6 murmur
very loud, with thrill. May be heard with stethoscope entirely off the chest
s3 in a pt > 30 years signifies
volume overload to ventricle/chf
f the patient is ____________________ anticipate that the JVP will be high, causing you to raise the head of the bed.
volume-overloaded, or hypervolemic,
What happens during S1, and is it systolic or diastolic?
when the valves between the atria and ventricles close systolic
What happens during S2, and is it systolic or diastolic?
when the valves between the ventricles and the major arteries close. diastolic
when do abnormally prominent a waves occur?
when there is an increased resistance to right atrial contraction, as in tricuspid stenosis; also in severe 1st-, 2nd-, and 3rd-degree AV block, supraventricular tachycardia, junctional tachycardia, pulmonary hypertension, and pulmonic stenosis
if a patient is hypovolemic or septic, how would you position the patient to assess the JVP?
you can anticipate that the JVP will be low, causing you to lower the head of the bed, sometimes even to 0°, to see the point of oscillation best.
The amplitude of pulses is recorded how?
-4+ bounding -3+ increased -2+ normal -1+ weak -0+ absent
where are the Tricupsid heart sounds heard?
-4th ICS to the left of the sternum
where are the mitral heart sounds heard?
-5 th ICS in midclavicular line
A _______ carotid pulse suggests aortic insufficiency
-Bounding -
Physiologic Peripheral Pulmonic Stenosis Murmur
- newborns a narrowing within one or more branches of the pulmonary arteries that manifests on physical exam as a systolic ejection murmur in infants. This murmur is often an incidental finding in neonates.
what are Thrills?
- these are the vibrations of loud cardiac murmurs. They feel like the throat of a purring cat. Thrills occur with turbulent blood flow.
when a patient does the valsalva maneuver, what happens to the blood pressure in a normal patient?
(1) transient increase during onset of the "strain" phase when the patient bears down, due to increased intrathoracic pressure; (2) sharp decrease to below baseline as the "strain" phase is maintained, due to decreased venous return; (3) further acute drop of both blood pressure and left ventricular volume during the "release" phase, due to decreased intrathoracic pressure; and (4) "overshoot" increased blood pressure, due to reflex sympathetic activation and increased stroke volume
what is a functional murmur?
(innocent murmur, physiologic murmur) is a heart murmur that is primarily due to physiologic conditions outside the heart, as opposed to structural defects in the heart itself
describe the grades of intensity of a murmur
-Grade 1 = very faint -Grade 2 = quiet but heard immediately -Grade 3 = moderately loud -Grade 4 = loud -Grade 5 = heard with stethoscope partly off the chest -Grade 6 = no stethoscope needed *Note: Thrills are assoc. with murmurs of grades 4 - 6
what are carotid bruits caused by?
Although usually caused by atherosclerotic luminal stenosis, bruits are also caused by a tortuous carotid artery, external carotid arterial disease, aortic stenosis, the hypervascularity of hyperthyroidism, and external compression from thoracic outlet syndrome.
1. In which of the following clients will the nurse expect the apical impulse to be displaced laterally? a. A COPD client with barrel chest b. A client with hypotension c. A client with hypothyroidism d. A client with endocarditis
Ans: (A) In patients with chronic obstructive pulmonary disease, the most prominent palpable impulse or PMI may be in the xiphoid or epigastric area as a result of right ventricular hypertrophy.
1. Which of the following is accurate with ventricular pressures? a. Systole is the period of ventricular contraction b. In systole, the aortic valve is closed c. In diastole, the mitral valve is closed d. Systole is the period of atrial contraction
Ans: (A) Systole is the period of ventricular contraction while diastole is the period of ventricular relaxation. During systole the aortic valve is open, allowing pumping of blood from the left ventricle into the aorta. The mitral valve is closed, thereby preventing backflow of blood to the left atrium. In contrast, during diastole the aortic valve is closed, preventing regurgitation of blood from the aorta back into the left ventricle. The mitral valve is open, allowing blood to flow from the left atrium into the relaxed left ventricle.
1. A nurse is assessing a mother breastfeeding her newborn. Which of the following observation of the newborn would prompt the nurse to refer them to a physician? a. Presence of white spots on the tip of the baby's nose b. The areas around the mouth of the baby turns bluish while feeding c. The arms and legs looks bluish d. The baby has a good suck
Ans: (B) Circumoral cyanosis while feeding in the newborn, especially if accompanied by diaphoresis signifies poor perfusion caused by a possible cardiac problem.
1. The nurse is reviewing the conduction system of the heart because she is to be assigned to the care of a patient with atrioventricular block. The nurse knows that the part of the heart anatomy that acts as the heart's pacemaker is the a. Atrioventricular node b. Sinoatrial node c. Bundle of His d. Bundle of His branches
Ans: (B) Each electrical impulse in the heart is initiated in the sinus node, a group of specialized cardiac cells found in the right atrium near the junction of the vena cava. It acts as the cardiac pacemaker and automatically discharges an impulse about 60 to 100 times a minute.
1. The new nurse wants to understand how the heart works as a pump. In her review, which of the following describes the load that stretches the cardiac muscle before contraction? a. Stroke volume b. Preload c. Afterload d. Myocardial contractility
Ans: (B) Preload refers to the amount of blood that stretches the cardiac muscle before contraction, or the volume of blood in the right ventricle at the end of diastole. Stroke volume refers to the volume of blood ejected with each heartbeat. Afterload is the degree of vascular resistance to ventricular contraction. Myocardial contractility is the ability of the cardiac muscle to contract.
1. Which of the following components of a normal ECG is correct? a. QRS complex corresponds to ventricular repolarization b. P wave corresponds to atrial depolarization c. T wave coincides with ventricular depolarization d. R wave is the downward deflection from ventricular depolarization
Ans: (B) The P wave of an ECG component corresponds to the atrial depolarization. The QRS complex represents ventricular depolarization. The Q wave is a downward deflection from septal depolarization and followed by the R wave which is an upward deflection from ventricular depolarization. The S wave is a downward deflection following an R wave. The T wave coincides with ventricular repolarization.
1. The nurse notes that there are 7 QRS complexes in a 6-second ECG strip. What is the nurse's interpretation of this? a. It is a sign of an atrioventricular block b. The client has normal heart rate c. It is a sign of tachycardia d. The client has hypertension
Ans: (B) The QRS complex corresponds to ventricular depolarization or contraction and is therefore also indicative of ventricular rate if counted in an ECG strip. If there are 10 6-seconds in a minute, we multiply 7 QRS's to 10 to get a ventricular (heart) rate of 70, which is within normal range.
1. A nurse is assessing a pregnant client and wants to hear a possible S3. Which of the following auscultatory technique will help the nurse attain her objective? a. Places the diaphragm of the stethoscope over the apex of the heart and applies very slight pressure b. Places the bell of the stethoscope over the apex of the heart and applies very light pressure c. Positions the client on his left side and places the diaphragm over the 3rd ICS right sternal border d. Positions the client on his right and places the diaphragm over the 3rd ICS left sternal border
Ans: (B) The bell of the stethoscope is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Apply the bell on the apex with very light pressure to produce an air seal with its full rim. Use the bell at the apex to auscultate, and then move medially along the left lower sternal border.
1. Which assessment finding will alert the nurse for a possibility of abdominal aortic aneurysm? a. Pain in the costovertebral angle b. Pulsatile mass in the abdomen c. Unequal pulse between apical and radial pulses d. Board-like abdomen
Ans: (B) Abdominal aortic aneurysm is the abnormal dilatation and weakening of the abdominal aorta. A pulsating abdominal mass is a common finding.
1. A client has been admitted due to trauma sustained from a vehicular accident. The client has lost a significant amount of blood but is still conscious and coherent. What changes in the heart is true? a. Higher blood pressure b. Low jugular vein pressure c. Bounding carotid pulse d. High right ventricular pressure
Ans: (B) The jugular vein pressure (JVP) provides valuable information about the patient's volume status and cardiac function. In patients who are hypovolemic, the JVP may be low, necessitating lowering the head of the bed, sometimes even to 0°.
1. The nurse is reviewing the expected physiologic changes in aging. Which of the following findings does the nurse consider as pathologic in an 80-year old client? a. Increased residual volume b. Decreased sphincter control of the bladder c. Significant increase in diastolic pressure d. Decreased response to touch, heat and pain
Ans: (C) A modest increase in systolic blood pressure and not the diastolic pressure is expected in the elderly due to increased vascular resistance and decreased vessel elasticity. The significant change in diastolic pressure needs to be evaluated.
1. Which assessment finding in the elderly population is caused by increased peripheral vascular resistance and decreased vessel elasticity? a. Dementia b. Irregular heart rhythm c. Hypertension d. Tachycardia
Ans: (C) Blood pressure increases as a result of thickening and decreased elasticity of blood vessels. Because of this, there is impedance and resistance in distributing blood to different parts of the body causing hypertension.
1. The nurse is taking blood pressure measurements in a 5 month old infant using a pediatric cuff. Upon assessment, she noticed that blood pressure on her thigh is lower than that of her arms. She also appears flushed on her face and pale on her lower extremities. Which of the following should the nurse suspect? a. Patent ductus arteriosus b. Trigeminal neuralgia c. Coarctation of the aorta d. Heart failure
Ans: (C) In children, as well as in adults, systolic blood pressure readings from the thigh are approximately 10 mm Hg higher than those from the upper arm. If they are equal or lower, coarctation of the aorta is suspected.
1. A client with difficulty breathing also states that sometimes at night, he wakes up gasping for air. The nurse is sure to document this night time episode as a. Orthopnea b. Tachypnea c. Paroxysmal nocturnal dyspnea d. Cheyne-Stokes respiration
Ans: (C) Paroxysmal nocturnal dyspnea describes episodes of sudden dyspnea that awaken the patient from sleep, around an hour or two after reclining on the bed. The patient wakes up, suddenly sits, stands or goes to a window for air. There may be associated wheezing and coughing.
1. Which of the following is an abnormal finding when auscultating the chest for heart sounds? a. S1 heard at the 4th-5th ICS in a 36-year old male b. S2 heard at the 2nd to 3rd ICS in a 40 year old woman c. S4 heard at the apex in an 81-year old male d. S3 heard at the apex in a teenager
Ans: (C) S4 is an abnormal heart sound. It is indicative of decreased ventricular compliance.
1. The nurse is performing a complete physical examination on a hypertensive client. In auscultating the chest, which of the following nursing technique needs further evaluation? a. Auscultates for the pulmonic sounds at the 2nd and 3rd intercostal space at the sternal boarder b. Auscultates for the mitral sounds at the point of maximal impulse c. Auscultates for the aortic sounds at the 5th intercostal space midclavicular line d. Auscultates for the tricuspid sounds at the left lower sternal border
Ans: (C) Sounds and murmurs arising from the mitral valve are best heard at or near the cardiac apex. Tricuspid sounds are heard best at or near the lower left sternal border. Murmurs arising from the pulmonic valve are usually heard best in the 2nd and 3rd ICS at the sternal border. Murmurs originating in the aortic valve may be heard anywhere from the right 2nd intercostal space to the apex.
1. It is defined as an abnormal backflow of blood from the left ventricle (LV) to the left atrium (LA). a. Tricuspid Regurgitation b. Ventricular Septal Defect c. Mitral Regurgitation d. Aortic insufficiency
Ans: (C) When the mitral valve fails to close fully in systole, blood regurgitates from left ventricle to left atrium, causing a murmur. This leakage creates volume overload on the left ventricle, with subsequent dilatation.
1. The nurse is assessing the ECG strip of a client and notes that there are 11 QRS complexes in a 6-second strip. What is the client's heart rate? a. 70 b. 80 c. 90 d. 110
Ans: (D) A regular heart rate is calculated by multiplying the number of QRS complexes in a 6-second strip to 10. You multiply it by 10 because there are 10 6-seconds in a minute. 11 QRS's x 10 = 110
1. Which of the following findings indicates right ventricular failure in a 66-year old client? a. Pinkish sputum with very fine bubbles b. Cough c. Orthopnea d. Elevated jugular vein pressure
Ans: (D) Jugular venous distention is observed in right ventricular failure as volume overload happens. This overload is reflected upwards into the jugular veins.
1. On a very rare occasion, the nurse was surprised to note the client's point of maximal impulse is at the 5th ICS on the midclavicular line of the right side instead of the left. The nurse knows to document this condition as a. Right sided hypertrophy b. Cardiomyopathy c. Situs inversus d. Dextrocardia
Ans: (D) On rare occasions, a patient has dextrocardia—a heart situated on the right side. The apical impulse will then be found on the right side of the chest. In situs inversus, the liver, the stomach and the heart are on the opposite side. A right-sided heart with the liver and stomach in their right anatomical location is usually associated with congenital heart disease.
1. The nurse is assessing the cardiovascular system of several patients. Who of the patients will the nurse have the most challenging attempt to palpate for the apical impulse? a. A pre-school child b. A frail 22-year old male c. A 56-year old with aortic insufficiency d. A patient with an increased anteroposterior chest diameter
Ans: (D) The apical impulse is easily palpated in children and adults with a thin frame. Challenges palpating the apical impulse include increased anteroposterior chest diameter, obesity or a thick chest.
1. Which of the following statements of a client can signal the nurse that the client has a risk for developing coronary artery disease? a. "My mother died of cancer" b. "I jog around 2 blocks every other day." c. "I have difficulty breathing when the pollen count is high." d. "I just like fast food so much."
Ans: (D) Unhealthy eating habits, consuming foods that are high in saturated fats and simple sugars, are risk factors for developing coronary artery disease.
1. A nurse from the afternoon shift reviews the client's chart as endorsed by the nurse from an earlier shift. The chart read " Grade 6 murmur." The nurse knows that the meaning of grade 6 murmur is a. Moderately loud b. Loud, with palpable thrill c. Very loud, with thrill. May be heard when the stethoscope is partly off the chest d. Very loud, with thrill. May be heard with stethoscope entirely off the chest
Ans: (D) Using the 6-point scale of a murmur, a grade 6 is a very loud murmur with a thrill that may be audible even when the stethoscope is entirely off the chest.
2. What is responsible for the inspiratory splitting of S2? A) Closure of aortic, then pulmonic valves B) Closure of mitral, then tricuspid valves C) Closure of aortic, then tricuspid valves D) Closure of mitral, then pulmonic valves
Ans: A Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: During inspiration, the closure of the aortic valve and the closure of the pulmonic valve separate slightly, and this may be heard as two audible components, instead of a single sound. Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, you may not hear it away from the left second intercostal space. Because it is a low-pitched sound, you may not hear it unless you use the bell of your stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting.
3. A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur? A) Mitral B) Tricuspid C) Aortic D) Pulmonic
Ans: A Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: Mitral valve sounds are usually heard best at and around the cardiac apex.
17. Which is true of splitting of the second heart sound? A) It is best heard over the pulmonic area with the bell of the stethoscope. B) It normally increases with exhalation. C) It is best heard over the apex. D) It does not vary with respiration.
Ans: A Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: S2 splitting is best heard over the pulmonic area because this is the only place where both of its components can be heard well. The closure of the pulmonic valve is normally not loud because the right heart is a low-pressure system. The bell is best used because it is a low-pitched sound. S2 splitting normally increases with inhalation.
14. Where is the point of maximal impulse (PMI) normally located? A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum B) In the left 5th intercostal space, 10 to 12 cm lateral to the sternum C) In the left 5th intercostal space, in the anterior axillary line D) In the left 5th intercostal space, in the midaxillary line
Ans: A Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral to the sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its size should not be greater than the size of a US quarter, or about an inch. Left ventricular enlargement should be suspected if it is larger. The PMI is often the best place to listen for mitral valve murmurs as well as S3 and S4. The PMI is often difficult to feel in normal patients.
30. You are examining a patient with emphysema in exacerbation and are having difficulty hearing his heart sounds. What should you do to obtain a good examination? A) Listen in the epigastrium. B) Listen to the patient in the left lateral decubitus position. C) Ask the patient to hold his breath for 30 seconds. D) Listen posteriorly.
Ans: A Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: It is often difficult to hear the heart well in a patient with emphysema. The shape of the chest as well as the interfering lung noise make examination challenging. By listening in the epigastrium, these barriers can be overcome. It is impractical to ask a patient who is short of breath to hold his breath for a prolonged period. Listening posteriorly would make the heart sounds even softer. It is always a good idea to listen to a patient in the left lateral decubitus position, but in this case it would not make auscultation easier.
8. You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid pulse? A) Palpable B) Soft, rapid, undulating quality C) Pulsation eliminated by light pressure on the vessel D) Level of pulsation changes with changes in position
Ans: A Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.
28. How should you determine whether a murmur is systolic or diastolic? A) Palpate the carotid pulse. B) Palpate the radial pulse. C) Judge the relative length of systole and diastole by auscultation. D) Correlate the murmur with a bedside heart monitor.
Ans: A Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Timing of a murmur is crucial for identification. The carotid pulse should be used because there is a delay in the radial pulse relative to cardiac events, which can lead to error. Some clinicians can estimate timing by the relative length of systole and diastole, but this method is not reliable at faster heart rates. A bedside monitor is not always available, nor are all designed to correlate in time with the actual pulse.
13. A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a cardiac examination and find that his pulse rate is less than 60. Which of the following conditions could be responsible for this heart rate? A) Second-degree A-V block B) Atrial flutter C) Sinus arrhythmia D) Atrial fibrillation
Ans: A Chapter: 09 Page and Header: 375, Table 9-1 Feedback: A second-degree A-V block can result in a pulse rate less than 60. Atrial flutter and atrial fibrillation do not cause bradycardia unless there is a significant accompanying block. Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart rate.
22. During cardiac examination you notice a new parasternal systolic murmur of 2/6 intensity. On palpation, the PMI is slightly higher than usual. What do you suspect? A) Mammary souffle B) Mitral stenosis C) Mitral regurgitation D) Aortic insufficiency
Ans: A Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: Although a mammary souffle may be diastolic, the murmurs of mitral stenosis and aortic insufficiency cannot be heard in systole. Mitral regurgitation is a possibility, but the upward shift in PMI and lack of other symptoms make this less likely. Any new diastolic murmur should be investigated further.
A woman in her third trimester complains of shortness of breath on occasion, without other symptoms. She has a normal examination. The most likely cause of this symptom is: A) Hormonal B) Asthma C) Pulmonary embolus D) Infection
Ans: A Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: While these other etiologies must be considered in any dyspneic pregnant woman, the lack of other symptoms and findings makes it more likely that this is a hormonal effect of progesterone. Expect a normal respiratory rate and respiratory alkalosis.
Which of the following is true of assessment of the vascular system in the elderly? A) Fewer than one third of patients with peripheral vascular disease have symptoms of claudication. B) An aortic width of 2.5 cm is abnormal. C) Bruits are commonly benign findings. D) Orthostatic blood pressure and pulse are not useful in this population.
Ans: A Chapter: 20 Page and Header: 921, Techniques of Examination Feedback: It is the minority of patients with peripheral vascular disease who experience claudication; therefore, ankle-brachial ratios should be performed more frequently. The aorta should be 3 cm or less. Bruits usually indicate pathology, and even when there is not a significant blockage, the risk of vascular disease throughout the body is increased. Orthostatic vital signs are very useful in this population. Remember to observe the pulse as well, as failure of the heart to increase its rate is a common cause of orthostatic hypotension. This can occur as a result of autonomic neuropathy or medications such as beta-blockers, among other causes.
18. Which of the following is true of jugular venous pressure (JVP) measurement? A) It is measured with the patient at a 45-degree angle. B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP. C) A JVP below 9 cm is abnormal. D) It is measured above the sternal notch.
Ans: B Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: Measurement of the JVP is important to assess a patient's fluid status. Although it may be measured at 45°, it is important to adjust the level of the patient's torso so that the blood column is visible. This may be with the patient completely supine or sitting completely upright, depending on the patient. Any measurement greater than 4 cm above the sternal angle is abnormal. This would correspond to a JVP of 9 cm because we add a constant of 5 cm, which is an estimate of the height of the sternal notch above the right atrium.
19. Which of the following regarding jugular venous pulsations is a systolic phenomenon? A) The "y" descent B) The "x" descent C) The upstroke of the "a" wave D) The downstroke of the "v" wave
Ans: B Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: The most prominent upstrokes of jugular venous pulsations are diastolic phenomena. These can be timed using the carotid pulse. The only event listed above which is a systolic phenomenon is the "x" descent.
4. A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? A) Abdominal pain B) Orthopnea C) Hematochezia D) Tenesmus
Ans: B Chapter: 09 Page and Header: 337, The Health History Feedback: Orthopnea, which is dyspnea that occurs when the patient is lying down and improves when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.
23. Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52. What heart rate should she achieve? A) 80 B) 100 C) 120 D) 140
Ans: B Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Maximum heart rate is calculated by subtracting the patient's age from 220. For Mrs. Adams, 60% of this number is about 100. She must also be instructed in how to measure her own pulse or have a device to do so. Most people are able to carry on a conversation at this level of exertion.
7. You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is well-controlled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. Which of the following conditions is considered to be a coronary heart disease risk equivalent? A) Hypertension B) Peripheral arterial disease C) Systemic lupus erythematosus D) Chronic obstructive pulmonary disease (COPD)
Ans: B Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Peripheral arterial disease is considered to be a coronary heart disease risk equivalent, as are abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.
5. You are screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this? A) Normal B) Prehypertension C) Stage 1 hypertension D) Stage 2 hypertension
Ans: B Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Prehypertension is considered to be a systolic blood pressure from 120 to 139 and a diastolic BP from 80 to 89. Previously, this was considered normal. JNC 7 recommends taking action at this point to prevent worsening hypertension. Research shows that this population is likely to progress to more serious stages of hypertension.
24. In measuring the jugular venous pressure (JVP), which of the following is important? A) Keep the patient's torso at a 45-degree angle. B) Measure the highest visible pressure, usually at end expiration. C) Add the vertical height over the sternal notch to a 5-cm constant. D) Realize that a total value of over 12 cm is abnormal.
Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: In measuring JVP, the angle of the patient's torso must be varied until the highest oscillation point, or meniscus is visible. This varies. The landmark used is actually the sternal angle, not the sternal notch. We assign a constant height of 5 cm above the right atrium to this landmark. A value of over 8 cm total (more than 3 cm vertical distance above the sternal angle, plus the 5 cm constant) is considered abnormal.
12. You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur? A) Upright B) Upright, but leaning forward C) Supine D) Left lateral decubitus
Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). You can further your ability to hear this soft murmur by having the patient hold his breath in exhalation.
10. You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse? A) Hypothyroidism B) Aortic stenosis, with pressure overload of the left ventricle C) Mitral stenosis, with volume overload of the left atrium D) Cardiomyopathy
Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the apical impulse or not be palpable at all.
31. You are listening carefully for S2 splitting. Which of the following will help? A) Using the diaphragm with light pressure over the 2nd right intercostal space B) Using the bell with light pressure over the 2nd left intercostal space C) Using the diaphragm with firm pressure over the apex D) Using the bell with firm pressure over the lower left sternal border
Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: S2 splitting is composed of an aortic and pulmonic component. Because the pulmonic component is softer, it can usually be heard only over the 2nd left intercostal space. It is a low-pitched sound and thus should be sought using the bell with light pressure. Conversely, the diaphragm is best used with firm pressure.
33. Which valve lesion typically produces a murmur of equal intensity throughout systole? A) Aortic stenosis B) Mitral insufficiency C) Pulmonic stenosis D) Aortic insufficiency
Ans: B Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: This description fits a holosystolic murmur. Because aortic and pulmonic stenosis murmurs vary with the flow of blood during systole, they typically produce a crescendo-decrescendo murmur. The murmur of aortic insufficiency represents backleak across the valve in diastole. It is a decrescendo pattern murmur, which gets softer as the pressure gradient decreases.
An infant presents with a heart rate of 180, a respiratory rate of 68, and an enlarged liver. What diagnosis does this suggest? A) Pneumonia B) Heart failure C) Sepsis D) Necrotizing enterocolitis
Ans: B Chapter: 18 Page and Header: 776, Assessing the Infant Feedback: Heart failure presents differently in infants than in adults. This triad should suggest this diagnosis. Pneumonia, necrotizing enterocolitis, and sepsis should not necessarily cause hepatomegaly. Observe closely for central cyanosis of the lips and tongue. Peripheral cyanosis alone does not mean much in infants. Perform a careful cardiac examination in as quiet a setting as possible, perhaps while the infant is in the mother's arms, to look for evidence of valvular disease.
15. Which of the following events occurs at the start of diastole? A) Closure of the tricuspid valve B) Opening of the pulmonic valve C) Closure of the aortic valve D) Production of the first heart sound (S1)
Ans: C Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: At the beginning of diastole, the valves which allow blood to exit the heart close. It is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the mitral valve is thought to produce the first heart sound (S1).
You have been unable to hear normal S2 splitting in children up to this point. What technique will maximize your chances of hearing this phenomenon? A) Listen with the diaphragm over the left lower sternal border. B) Listen with the bell over the 2nd left intercostal space. C) Listen with the bell over the apex. D) Listen with the diaphragm in the axilla.
Ans: B Chapter: 18 Page and Header: 778, Assessing the Infant Feedback: S2 is made of aortic and pulmonic components. Of these, the pulmonic component is much softer and heard best over the pulmonic area. Even in the proper location, the pulmonic component may be difficult to hear with the diaphragm because it is a soft, low-pitched sound. For this reason, the bell should be used to listen for S2 splitting over the pulmonic area during inspiration, when splitting should be maximized. Breathing also changes heart rate more rapidly in children. One may think an arrhythmia is present until she notices that this rate change is related to the respiratory cycle.
Mr. Chin is an 82-year-old man who comes to your office for a routine check. On examination, you notice a somewhat high-pitched murmur in the second right intercostal space during systole. It does not radiate and the rest of his examination is normal for his age. Which is true of the most likely cause of this murmur? A) It often decreases carotid upstroke. B) It carries with it increased risk for cardiovascular disease. C) It is usually accompanied by an S3 gallop. D) It is found in 10% of otherwise normal elderly patients.
Ans: B Chapter: 20 Page and Header: 898, Anatomy and Physiology Feedback: This murmur most likely represents aortic sclerosis, a common murmur affecting about one third of those near 60 years of age. It is caused by calcification of the valve and is associated with cardiovascular risk. Aortic sclerosis does not usually cause obstruction to normal flow, so carotid upstroke should be normal, and it is not associated with an S3 gallop.
A 78-year-old retired seamstress comes to the office for a routine check-up. You obtain an ECG (electrocardiogram) because of her history of hypertension. You diagnose a previous myocardial infarction and ask her if she had any symptoms related to this. Which of the following symptoms would be more common in this patient's age group for an acute myocardial infarction? A) Chest pain B) Syncope C) Pain radiating into the left arm D) Pain radiating into the jaw
Ans: B Chapter: 20 Page and Header: 903, The Health History Feedback: This is an atypical symptom and more likely to be seen in this patient's age group.
Mr. White's son brings him in today because he notes that Mr. White has not been himself lately. He seems forgetful and has not taken care of himself as he normally does. He has reported falling twice at home to his son and has telephoned late at night because of insomnia. His blood pressure and diabetes have been difficult to control and his warfarin dosing has become more difficult. Which of the following should you suspect? A) Alzheimer's dementia B) Alcohol use C) Urinary tract infection D) Stroke
Ans: B Chapter: 20 Page and Header: 908, The Health History Feedback: All of these answers are common diseases of the elderly and many have atypical presentations in this age group. The fact that his hypertension has become more difficult to control and his warfarin dosing is challenging to manage should lead you to consider that there is alcohol use. Further questioning, quantifying his use of alcohol, and application of the CAGE questionnaire may be useful.
16. Which is true of a third heart sound (S3)? A) It marks atrial contraction. B) It reflects normal compliance of the left ventricle. C) It is caused by rapid deceleration of blood against the ventricular wall. D) It is not heard in atrial fibrillation.
Ans: C Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.
1. You are performing a thorough cardiac examination. Which of the following chambers of the heart can you assess by palpation? A) Left atrium B) Right atrium C) Right ventricle D) Sinus node
Ans: C Chapter: 09 Page and Header: 323, Anatomy and Physiology Feedback: The right ventricle occupies most of the anterior cardiac surface and is easily accessible to palpation. The other structures are less likely to have findings on palpation and the sinus node is an intracardiac structure. You may be able to diagnose abnormal rhythms caused by the sinus node indirectly by palpation, but this is less obvious.
21. In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines? A) Every 6 months B) Every year C) Every 2 years D) Every 5 years
Ans: C Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse.
6. You are participating in a health fair and performing cholesterol screens. One person has a cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease? A) Ethnicity B) Alcohol intake C) Gender D) Asthma
Ans: C Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Gender is used in the calculation of the 10-year risk for developing coronary heart disease, because men have a higher risk than women.
22. Which of the following is a clinical identifier of metabolic syndrome? A) Waist circumference of 38 inches for a male B) Waist circumference of 34 inches for a female C) BP of 134/88 for a male D) BP of 128/84 for a female
Ans: C Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: The physical examination criteria for identifying metabolic syndrome include a waist of 40 inches or greater for a male, a waist of 35 inches or greater for a female, and a blood pressure of 130/85 or greater. Other criteria include triglycerides greater than or equal to 150 mg/dL, fasting glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less than 50 for women.
9. A 68-year-old mechanic presents to the emergency room for shortness of breath. You are concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated. Which one of the following conditions is a potential cause of elevated JVP? A) Left-sided heart failure B) Mitral stenosis C) Constrictive pericarditis D) Aortic aneurysm
Ans: C Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: One cause of increased jugular venous pressure is constrictive pericarditis. Others include right-sided heart failure, tricuspid stenosis, and superior vena cava syndrome. You may wish to read about these conditions.
11. You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position? A) Aortic B) Pulmonic C) Mitral D) Tricuspid
Ans: C Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If you do not listen to the heart in this position with both the diaphragm and bell in a quiet room, it is possible to miss significant murmurs such as mitral stenosis.
34. You notice a patient has a strong pulse and then a weak pulse. This pattern continues. Which of the following is likely? A) Emphysema B) Asthma exacerbation C) Severe left heart failure D) Cardiac tamponade
Ans: C Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: This finding is consistent with pulsus alternans, which is associated with severe left heart failure. Occasionally, a monitor will read only half of the beats because half are too weak to detect. There may also be electrical alternans on EKG. This can be detected by using a blood pressure cuff and lowering the pressure slowly. At one point the rate of Korotkoff sounds will double, because the weaker beats can then "make it through." The other findings are associated with paradoxical pulse.
35. Suzanne is a 20-year-old college student who complains of chest pain. This is intermittent and is located to the left of her sternum. There are no associated symptoms. On examination, you hear a short, high-pitched sound in systole, followed by a murmur which increases in intensity until S2. This is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. Which of the following is the most likely diagnosis? A) Mitral stenosis B) Mitral insufficiency C) Mitral valve prolapse D) Mitral valve papillary muscle ischemia
Ans: C Chapter: 09 Page and Header: 382, Table 9-8 Feedback: The description above is classic for mitral valve prolapse. The extra sound is a midsystolic click, which is typically a short, high-pitched sound. Mitral stenosis is a soft, low-pitched rumbling murmur which is difficult to hear unless the bell is used in the left lateral decubitus position. Mitral insufficiency is a holosystolic murmur heard best over the apex, and papillary muscle ischemia often creates a mitral insufficiency with its accompanying murmur.
A mother is upset because she was told by another provider that her child has a worrisome murmur. You listen near the clavicle and notice both a systolic and diastolic sound. You remember that diastolic murmurs are usually indicative of bad pathology. What would you do next? A) Cardiology referral B) Echocardiogram C) Supine examination D) Reassure the mother
Ans: C Chapter: 18 Page and Header: 781, Assessing the Infant Feedback: The next step would be to examine the patient in the supine position. If this is a venous hum, this murmur will resolve almost completely in the supine position. This is a very common phenomenon in school-aged children, particularly over the clavicle, but can also occur outside this range. Reassurance cannot be given without further examination, especially with a diastolic murmur. Cardiology referral and echocardiography are unnecessary if examination in the supine position reveals no murmur.
You are examining a 5-year-old before he begins school. You notice a systolic, grade II/VI vibratory murmur over the LLSB and apex with normal S2 splitting. He has normal pulses as well. Which of the following is most likely? A) Tricuspid stenosis B) Mitral stenosis C) Still's murmur D) Venous hum
Ans: C Chapter: 18 Page and Header: 822, Assessing Young and School-Aged Children Feedback: This description is consistent with Still's murmur, a very common and benign murmur of childhood. Tricuspid and mitral stenosis would be diastolic murmurs and the venous hum is usually not heard in this area. Further evaluation is usually not necessary.
A 35-year-old bus driver comes to your office for a prenatal visit. She is approximately 28 weeks pregnant and has had no complications. She is complaining only of heartburn and has had no fatigue, headaches, leg swelling, contractions, leakage of fluid, or bleeding. On examination her blood pressure is 142/92 and her urine shows no glucose, protein, or leukocytes. Her weight gain is appropriate, with no large recent increases. Fetal tones are 140 and her uterus measures 32 cm from the pubic bone. Looking back through her chart, you see her prenatal blood pressure was 120/70 and her blood pressures during the first 20 weeks were usually 120 to 130/70 to 80. What type of blood pressure is this? A) Normotensive for pregnancy B) Chronic hypertension C) Gestational hypertension D) Preeclampsia
Ans: C Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: Gestational hypertension occurs in women who are normotensive before pregnancy and develop systolic pressures over 140 and diastolic pressures over 90 after week 20 of pregnancy. There will be no protein in the urine and no symptoms of preeclampsia such as rapid weight gain, leg edema, or headaches. These patients must be cautioned about symptoms of preeclampsia and receive aggressive follow-up.
A woman in her 24th week of pregnancy notices she feels faint when lying down for a period. What would you suspect as a cause for this? A) Adrenal insufficiency B) Orthostatic hypotension C) Supine hypotensive syndrome D) Hypoglycemia
Ans: C Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: It is unusual to become lightheaded in the supine position. The gravid uterus can cause decreased blood return through the inferior vena cava. Orthostatic hypotension as seen in adrenal insufficiency and with moderate dehydration will cause these symptoms in the upright position. Hypoglycemia should not be positional.
Blood pressure abnormalities found more commonly in Western elderly include which of the following? A) Isolated elevation of the diastolic BP B) Narrow pulse pressure C) Elevation of the systolic BP D) Elevation of the BP with standing
Ans: C Chapter: 20 Page and Header: 895, Anatomy and Physiology Feedback: Isolated systolic hypertension is common in the elderly because of stiffening of the large arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP changes are often seen with postural changes and can account for falls as well.
Mrs. Stanton is a 79-year-old widow who presents to your office for a routine BP visit. You note a new pulsatile mass in the right neck at the carotid artery. Which of the following is the most likely cause for this? A) Anxiety B) Carotid artery aneurysm C) Kinking of the artery D) Tortuous aorta
Ans: C Chapter: 20 Page and Header: 897, Anatomy and Physiology Feedback: While a carotid artery aneurysm is a possibility, it is more likely due to kinking of the carotid artery in this patient with HTN. A tortuous aorta will sometimes cause elevation of the left jugular vein by impairing drainage within the thorax.
20. How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure? A) 25% B) 50% C) 75% D) 100%
Ans: D Chapter: 09 Page and Header: 339, Health Promotion and Counseling Feedback: Each increase of BP by 20 systolic and 10 diastolic doubles the risk of cardiovascular disease. Being "low risk" by JNC 7 criteria confers a 72%-85% reduction in CVD mortality and 40%-58% reduction in overall mortality.
26. To hear a soft murmur or bruit, which of the following may be necessary? A) Asking the patient to hold her breath B) Asking the patient in the next bed to turn down the TV C) Checking your stethoscope for air leaks D) All of the above
Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: All examiners should carefully search for soft murmurs and bruits. These can have great clinical significance. A quiet patient and room, as well as an intact stethoscope, will greatly increase your ability to hear soft sounds.
25. You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you search out? A) Mitral valve prolapse B) Pulmonic stenosis C) Tricuspid insufficiency D) Aortic insufficiency
Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Bounding carotid pulses would be found in aortic insufficiency. This should be sought by listening over the third left intercostal space, with the patient leaning forward in held exhalation. This is a very soft diastolic murmur usually. A bounding pulse may also be seen in any condition which increases cardiac output, including stimulant use, anxiety, hyperthyroidism, fever, etc.
27. Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell? A) Mitral stenosis murmur B) Opening snap of the mitral valve C) S3 and S4 gallops D) All of the above
Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: Placing the patient in the left lateral decubitus position and auscultating with the bell will enable you to hear these sounds, which would otherwise be missed.
32. Which of the following is true of a grade 4-intensity murmur? A) It is moderately loud. B) It can be heard with the stethoscope off the chest. C) It can be heard with the stethoscope partially off the chest. D) It is associated with a "thrill."
Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: The grade 4 murmur is differentiated from those below it by the presence of a palpable thrill. A murmur cannot be graded as a 4 unless this is present. The thrill is a "buzzing" feeling over the area where the murmur is loudest. For practice, you may often feel a thrill over a dialysis fistula.
29. Which of the following correlates with a sustained, high-amplitude PMI? A) Hyperthyroidism B) Anemia C) Fever D) Hypertension
Ans: D Chapter: 09 Page and Header: 348, Techniques of Examination Feedback: While hyperthyroidism, anemia, and fever can cause a high-amplitude PMI, pressure work by the heart, as seen in hypertension, causes the PMI to be sustained.
Lucille is in her 24th week. You notice a new onset of high blood pressure readings. Today's value is 168/96. Her urine is normal. What do you suspect? A) Preeclampsia B) Chronic hypertension C) Supine hypotensive syndrome D) Gestational hypertension
Ans: D Chapter: 19 Page and Header: 881, Techniques of Examination Feedback: Because Lucille's BP is greater than 140/90 with onset after the 20th week and no proteinuria, this is gestational hypertension. Chronic hypertension, while the same BP cutoff is used, is present before the 20th week. If this patient had accompanying proteinuria, preeclampsia could be considered. Supine hypotensive syndrome does not cause hypertension.
An 85-year-old retired teacher comes to your office for evaluation of weakness. You obtain a complete history, perform a thorough physical examination, and order laboratory tests. You diagnose her with hyperthyroidism. Based on her age, which of the atypical symptoms of hyperthyroidism is more likely to be seen? A) Fatigue B) Weight loss C) Tachycardia D) Anorexia
Ans: D Chapter: 20 Page and Header: 903, The Health History Feedback: This is an atypical symptom of hyperthyroidism that is more likely to be seen in the older patient.
Claire's daughter brings her in today after Claire fell at her home. Which assessments are indicated at this time? A) Orthostatic vital signs B) Review of her medications C) Assessment of gait and balance D) All of the above
Ans: D Chapter: 20 Page and Header: 913, Techniques of Examination Feedback: Falls are common in the elderly and can often result in serious injuries. When assessing the cause of falls, gait and balance should be checked first. Medication, particularly use of more than three, is associated with falls. Vision problems, lower-limb joint problems, and cardiovascular problems such as arrhythmias may be reasonable to search for. Orthostatic vital sign changes should be sought.
how do you use a bell on a stethoscope?
Apply the bell lightly, with just enough pressure to produce an air seal with its full rim Firm pressure on the bell can stretch the underlying skin and make it function more like the diaphragm.
How would you assess for Mitral stenosis when listening to the heart sounds?
Ask the patient to roll into the left lateral decubitus position, which brings the left ventricle closer to the chest wall. Place the bell of your stethoscope lightly on the apical impulse This position accentuates a left-sided S3 and S4 and mitral murmurs, espe- cially mitral stenosis.
How would you assess for Aortic regurgitation when listening to the heart sounds?
Ask the patient to sit up, lean forward, exhale completely, and briefly stop breathing after expiration. Pressing the diaphragm of your stethoscope on the chest, listen along the left sternal border and at the apex, pausing periodically so the patient may breathe You may easily miss the soft diastolic decrescendo murmur of aortic regurgitation unless you listen at this position
how do you detect a carotid bruit?
Ask the patient to stop breathing for ∼15 seconds, then listen with the diaphragm of the stethoscope higher-grade stenoses may have lower frequency or even absent sounds, more amenable to detection with the bell. Place the diaphragm near the upper end of the thyroid cartilage below the angle of the jaw, which overlies the bifurca- tion of the common carotid artery into the external and internal carotid arteries. A bruit in this location is less likely to be confused with a transmitted murmur from the heart or subclavian or vertebral artery bruits
what is the y decent in jvp?
Atrial emptying, tricuspid open ventricular filling (tricuspid opens) When the tricuspid valve opens early in diastole, blood in the right atrium flows passively into the RV, and right atrial pressure falls again, creating the second trough, or y descent. The y descent represents the abrupt termination of the downstroke of the v wave during early diastole after the tricuspid valve opens and the right ventricle begins to fill passively.
when do you hear a midsystolic murmur, or SEM?
Begins after S1 and stops before S2. Brief gaps are audible between the murmur and the heart sounds. Listen carefully for the gap just before S2, which is more readily detected and, if pres- ent, usually confirms the murmur as midsys- tolic, not pansystolic.
when would you hear a Continuous murmur?
Begins in systole and extends into all or part of diastole is not necessarily uniform throughout
Xanthomas are associated with ______________.
HLD
describe a plateau murmur
Has the same intensity throughout. ex: pansystolic murmur of mitral regurgitation
what position is aortic stenosis best heard?
Heard best with the patient sitting and leaning forward
you are trying to distinguish hypertrophic cardiomyopathy from aortic stenosis during a cardiac examination. you have the patient do the valsalva maneuver. When the patient strains, the murmur intensifies, and when the patient releases, the murmur decreases in intensity. What would diagnosis would you suspect? where would you listen for this?
Hypertrophic Cardiomyopathy listen at the lower left sternal border
TRANSIENT ARTERIAL OCCLUSION: Place blood pressure cuff on both arms and occlude blood-flow for 20 seconds. what murmurs are increased?
INCREASED INTENSITY: Mitral Regurgitation,
when should you test for Paradoxical Pulse during an assessment?
If the pulse varies in amplitude with respiration or you suspect cardiac tamponade (because of jugular venous distention, dyspnea, tachycardia, muffled heart tones, and hypotension)
when assessing the PMI of a patient in the left lateral decubitus position, what would signal LV enlargement?
In the left lateral decubitus position, a diffuse PMI with a diameter >3 cm sig- nals left ventricular enlargement
describe how you would evaluate for HF and pulmonary HTN with the valsalva maneuver
Inflate the blood pressure cuff to 15 mm Hg greater than the systolic blood pressure and ask the patient to perform the Valsalva maneuver for 10 seconds, then resume normal respiration. Keep the cuff pressure locked at 15 mm Hg above the baseline systolic pressure during the entire maneuver and for 30 seconds afterward. Listen for Korotkoff sounds over the brachial artery. Typically, only phases 2 and 4 are significant, since phases 1 and 3 are too short for clinical detection. In healthy patients, phase 2, the "strain" phase, is silent; Korotkoff sounds are heard after straining is released during phase 4. In patients with severe heart failure, blood pressure remains elevated and there are Korotkoff sounds during the phase 2 strain phase, but not during phase 4 release, termed "the square wave" response. This response is highly correlated with volume overload and elevated left ventricular end-diastolic pressure and pulmonary capillary wedge pressure
what type of murmurs would be increased by the isometric hand grip maneuver?
Isometric handgrip increases the systolic murmurs of mitral regurgitation, pulmonic stenosis, and ventricular septal defect, and also the diastolic murmurs of aortic regurgitation and mitral stenosis
if the PMI is displaced laterally, what could this indicate?
Lateral displacement toward the axillary line from ventricular dilatation is seen in heart failure, cardiomyopathy, and isch- emic heart disease; and also in thoracic deformities and mediastinal shift.
where is a pulmonic stenosis murmur best heard and where does it radiate?
Left 2nd and 3rd interspaces if it is loud, may radiate toward the left shoulder and neck
where is a Hypertrophic CM murmur best heard?
Left 3rd and 4th interspaces Radiation: Down the left sternal border to the apex, possibly to the base, but not to the neck Does NOT radiate into neck
where is a Ventricular Septal murmur best heard and where does it radiate?
Left 3rd, 4th, and 5th interspaces Radiation. Often wide, depending on the size of the defect.
what is the murmur grading system called?
Levine grading system
Describe a grade 4 murmur
Loud, with palpable thrill
where is aortic stenosis murmur best heard and where does it radiate to?
Loudest in aortic area; radiates along the carotid arteries bIntensity varies directly with CO
where is a Tricuspid regurgitation murmur best heard and where does it radiate?
Lower left sternal border. radiation: to the right of the sternum, to the xiphoid area, and at times to the left midclavicular line, but not into the axilla.
how are murmurs differentiated from s1, s2, and extra sounds like clicks or snaps?
Murmurs are differentiated from S1, S2, and extra sounds by their longer duration.
What do murmurs sound like?
Murmurs heard as blowing, swishing sound that occurs with turbulent blood flow
how is the S1 sound generated?
Nearly simultaneous closing of the mitral valve and tricuspid valve normally generates a single S1 sound.
hepatojugular reflux: the examiner applies firm but persistent pressure over the liver for 10 seconds while observing the mean jugular venous pressure. what would be a normal finding?
Normally there is either no rise or only a transient (i.e., 2 to 3 sec) rise in mean jugular venous pressure. A sustained increase in the mean venous pressure until abdominal compression is released is abnormal and indicates impaired right heart function.
a patient is experiencing the following. what do you suspect? •Deep constant or pleuritic pain •Pericardial friction, may be related to resp. •Increases with cough •Sharp, stabbing •Fever or recent infection •Shallow breathing, sitting up, leaning forward relieves
Pericarditis
what are the pitches of murmurs?
Pitch - low, medium, high - determined by the rate of blood flow
what is s2 splitting?
Recall that the second heart sound (S2) is generated by two heart valves: the aortic valve and pulmonic valve. Nearly simultaneous closing of these valves normally generates a single S2 sound. S2 splitting is heard when aortic and pulmonic valves close at slightly different times.
what does pregnancy do to the PMI?
Pregnancy or a high left diaphragm may shift the apical impulse upward and to the left
pressure on the carotid sinus may cause what?
Pressure on the carotid sinus may cause reflex bradycardia or drop in blood pressure.
_________ refers to the pathological state of cardiac muscle in which it has to contract while experiencing an excessive afterload.
Pressure overload
what are the different qualities of murmurs?
Quality - musical, blowing, harsh, rumbling
Describe a grade 2 murmur
Quiet, but heard immediately after placing the stethoscope on the chest
what is s1 splitting?
Recall that the first heart sound (S1) is generated by two heart valves: the mitral valve and tricuspid valve. Nearly simultaneous closing of these valves normally generates a single S1 sound. Splitting of the S1 sound is heard when mitral and tricuspid valves close at slightly different times
How do you tell the difference between the right internal JVP and the carotid pulse on examination?
Rt internal JVP is inward, twice per heartbeat and not palpable. Pulsations eliminated by light pressure on the vein(s) just above the sternal end of the clavicle. Ht of pulse changes with position, normally dropping as the patient becomes more upright. Height of pulsations usually falls with inspiration carotid pulse pulses outward, palpable, once per heart beat, ht of pulse is not changed by position or inspiration.
in a 1st degree heart block, what sound would be diminished?
S1 is diminished in first- degree heart block;
Where is s1 loudest?
S1 is usually louder than S2 at the apex;
In aortic stenosis, what sound would be diminished?
S2 is diminished in aortic stenosis.
where is s2 loudest?
S2 is usually louder than S1 at the base
-Pressure generated by left ventricle (LV) during systole, when the LV ejects blood into the aorta and the arterial tree. Pressure waves in the arteries create pulses
SBP
when would a hyperkinetic PMI be normal?
Some young adults have an increased amplitude, or hyperkinetic impulse, especially when excited or after exercise; the duration, however, is normal.
when would you hear an Early diastolic murmur?
Starts immediately after S2, without a discernible gap, then usually fades into silence before the next S1
when would you hear a Late diastolic (presystolic) murmur?
Starts late in diastole and typically continues up to S1. reflect turbulent flow across the AV valves.
there is petechia inside the mouth and on the neck. what do you suspect?
Subacute bacterial endocarditis
what extra sounds would you hear in diastole?
Such as S3, S4, or an opening snap
what extra sounds would you hear in systole?
Such as ejection sounds or systolic clicks
systole or diastole? •The ventricles contract
Systole
what is the timing of most systolic murmurs?
Systolic murmurs are typically midsystolic or pansystolic
what areas of the chest is the Pulmonic Area?
The Left 2nd ICS
what areas of the chest is the right ventricular area?
The Left Sternal Border in the 3rd, 4th, and 5th Interspaces
where is the right ventricular area?
The Left Sternal Border in the 3rd, 4th, and 5th Interspaces.
what areas of the chest is the Aortic Area?
The Right 2nd ICS
what is the diaphragm of the stethoscope better used for when assessing heart sounds?
The diaphragm is better for picking up the relatively high- pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs.
what is the shape of a murmur determined by?
The shape or configuration of a murmur is determined by its intensity over time. Crescendo murmurs Decrescendo murmurs Crescendo-decrescendo murmur
a pulsation at the Right 2nd Interspace would indicate what?
This interspace overlies the aortic outflow tract A pulsation here suggests a dilated or aneurysmal aorta. A palpable S2 can accompany systemic hypertension
what would a prominent pulsation of the Left 2nd Interspace indicate?
This interspace overlies the pulmonary artery. A prominent pulsation here often accompanies dilatation or increased flow in the pulmonary artery. A palpable S2 points to increased pulmonary artery pressure from pulmonary hypertension
what is Paradoxical Pulse
This is a greater than normal drop in systolic blood pressure during inspiration
what are the categories of pitch when describing a murmur?
This is categorized as high, medium, or low.
if you heard a late systolic murmur, what would you suspect?
This is the murmur of mitral valve prolapse and is often, but not always, preceded by a systolic click. the murmur of mitral regurgitation may also be late systolic.
how is intensity of a murmur measured?
This is usually graded on a six-point scale and expressed as a fraction. The numerator describes the intensity of the murmur wherever it is loud- est; the denominator indicates the scale you are using.
how do you assess the PMI duration?
To assess duration, auscultate the heart sounds as you palpate the apical impulse, or watch the movement of your stethoscope as you listen at the apex. Estimate the proportion of systole occupied by the apical impulse. Normally, it lasts through the first two thirds of systole, or often less, but does not continue to the second heart sound
what maneuvers help distinguish (1) mitral valve prolapse and (2) distinguish hypertrophic cardiomyopathy from aortic stenosis?
Transient Arterial Occlusion. Valsalva Maneuver Standing and Squatting Isometric Handgrip
describe the maneuver: Transient Arterial Occlusion
Transient compression of both arms by bilateral blood pressure cuff inflation to 20 mm Hg greater than peak systolic blood pressure augments the murmurs of mitral regurgitation, aortic regurgitation, and ventricular septal defect
What is an echocardiogram?
US of heart. uses sound waves to create a moving picture of the heart
where is a mitral stenosis murmur best heard?
Usually limited to the apex
when do you hear a Late systolic murmur?
Usually starts in mid or late systole and persists up to S2.
Describe a grade 1 murmur
Very faint, heard only after listener has "tuned in"; may not be heard in all positions
Describe a grade 5 murmur
Very loud, with thrill. May be heard when the stethoscope is partly off the chest
_______________refers to the state of one of the chambers of the heart in which too large a volume of blood exists within it for it to function efficiently. Ventricular volume overload is approximately equivalent to an excessively high preload.
Volume overload
where does aortic ejection sound radiate?
across the chest from left chest (2nd ics) to right neck.
what is a stenotic valve
an abnormally narrowed valvular orifice that obstructs blood flow, as in aortic stenosis, and causes a characteristic murmur.
if the patient is volume-overloaded, or hypervolemic, how would you position the patient to assess the JVP?
anticipate that the JVP will be high, causing you to raise the head of the bed
Thrills in _________ are transmitted to the carotid arteries from the suprasternal notch or 2nd right ICS
aortic stenosis
you are trying to distinguish hypertrophic cardiomyopathy from aortic stenosis during a cardiac examination. you have the patient do the valsalva maneuver. When the patient strains, the murmur decreases in intensity, and when the patient releases, the murmur increases in intensity. What would diagnosis would you suspect?
aortic stenosis.
where is s1 loudest?
apex
where is a Mitral regurgitation murmur best heard?
apex may radiate To the left axilla, less often to the left sternal border
___________: 5th ICS L MCL (PMI)
apex/mitral area
mitral area is also the _________
apex/pmi
What are Janeway lesions?
are geographic, purple-red, painless macules found on the ventral and plantar surfaces of the hands and feet
When would A waves be absent?
atrial fibrillation
What is the x descent in JVP?
atrial relaxation starts with atrial relaxation, then filling, tricuspid valve closed. It continues as the RV, contracting during systole, pulls the floor of the atrium downward, and ends just before S2 The x descent reflects movement of the lower portion of the right atrium toward the right ventricle during the final phases of ventricular systole.
Where is S2 loudest?
base
when the pitch is low, what part of the stethoscope should you use?
bell
you can hear systole when?
between S1 and S2
You can hear diastole when?
between S2 and S1
what kid of carotid pulse would you see in aortic regurgitation?
bounding
how is the normal amplitude of a PMI described?
small, brisk, tapping
what position change decreases the intensity of MVP and Hypertrophic obstructive cardiomyopathy
squatting
what position increases the intensity/loudness of murmurs of MR and AR
squatting
In preforming maneuvers Aortic Stenosis, what would you expect when the patient squats, stands, or does the valsalva maneuver?
standing/release of valsalva: ↑ blood volume ejected into aorta, ↑ intensity of murmur squatting/strain of valsalva: ↓ blood volume ejected into aorta, ↓ intensity of murmur
In preforming maneuvers hypertrophic CM, what would you expect when the patient squats, stands, or does the valsalva maneuver?
standing/release of valsalva: ↓ outflow obstruction, ↓ intensity of murmur squatting/strain of valsalva: ↑ outflow obstruction, ↑ intensity of murmur
when a person stands, what phase of the Valsalva is this similar to?
stran phase of Valsalva = standing
a sustained PMI suggests:
suggests LV hypertrophy from hypertension or aortic stenosis
systole or diastole? -The left ventricle pumps blood into the aorta(aortic valve is open)
systole
systole or diastole? -The right ventricle pumps blood into the pulmonary arteries (pulmonic valve is open)
systole
what part of s1 and s2 are systole and diastole?
systole is between s1 and s2. diastole is between s2 and s1
a click is a __________ systolic
systolic
Midsystolic murmurs — also known as _______________
systolic ejection murmurs (SEM)
S2 is usually louder than S1 at
the base.
what is the bell of the stethoscope better used for when assessing heart sounds?
the bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis
where do you find the sternal angle (also called the angle of Louis),
the bony ridge adjacent to the second rib where the manubrium joins the body of the sternum.
what is pulsus alternans
the rhythm of the pulse remains regular, but the force of the arterial pulse alternates because of alternating strong and weak ventricular contractions.
how is the S2 sound generated?
the second heart sound (S2) is generated by two heart valves: the aortic valve and pulmonic valve. Nearly simultaneous closing of these valves normally generates a single S2 sound.
to the naked eye, what are the most visible events in the JVP waveform?
the two descents, x and y, are the most visible events in the cycle Of the two, the sudden collapse of the x descent late in systole is more prominent, occurring just before S2. The y descent follows S2 early in diastole
what are lifts or heaves?
these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs.
what components do you need to describe a heart murmur?
timing, shape, location, radiation, intensity
Going from top left, bottom left, top right, bottom right, name the valves
top left - tricuspid valve bottom left - pulmonary valve Top right - mitral valve bottom right - aortic valve
Increased v waves occur in?
tricuspid regurgitation, atrial septal defects, and constrictive pericarditis
how do you grade edema?
•+1 = 2mm •+2 = 4mm •+3 = 6 mm +4 = 8 mm
cardiac output x systemic vascular resistance =
•Blood pressure =
stroke volume x heart rate =
•Cardiac output =
Venous Hum
•Continuous at clavicles, disappears with supination, compression of jugular vein or turning head, early school years benign phenomenon
____________ area: 2nd ICS, LSB
•Pulmonic
what sound is the closure of atrial ventricular AV valves?
•S1
Still's Vibratory Murmur
•Systolic, LLSB & apex, intensifies during supination, early school age common type of benign or "innocent" functional heart murmur that is not associated with any sort of cardiac disorder or any other medical condition.
what questions do you ask to identify heart murmurs?
● Time the murmur—is it in systole or diastole? What is its duration? ● Locate where on the precordium the murmur is loudest—at the base, along the sternal border, at the apex? Does it radiate? ● Conduct any necessary maneuvers, such as having the patient lean forward and exhale or turn to the left lateral decubitus position. ● Determine the shape of the murmur—for example, is it crescendo or decrescendo, is it holosystolic? ● Grade the intensity of the murmur from 1 to 6, and determine its pitch and quality. ● Identify associated features such as the quality of S1 and S2, the presence of extra sounds such as S3, S4, or an OS, or the presence of additional murmurs.
