Chapter 14 Seidel Heart

When examing a neonate, a thrill is felt over the lower left sternal border. This finding is consistent with which anomaly? A. Atrial septic defect B. Ventricular septal defect C. Patent ductus arteriosus D. Tetralogy of Fallot

D. Tetralogy of Fallot

relative sizes of left and right ventricles are 2:1 as the adult ratio by what age?

1 year

Five areas of auscultation

Aortic valve: 2nd right intercostal space at right sternal border. Pulmonic valve: 2nd left intercostal space at left sternal border. Second pulmonic area: 3rd left intercostal space at left sternal border Tricuspid area: 4th left intercostal space along lower left sternal border. Mitrial (apical) area: at apex of heart in 5th left intercostal space at midclavicular line.

Common ECG changes in older adults:

1st degree AV block BBB ST-T wave abnormalities premature systole left anterior hemiblock left ventricular hypertrophy afib

The thick muscular middle layer of the heart that is responsible for contraction is the: A. atrial musculorum. B. myocardium. C. chordae tendineae. D. ventricular muscularis.

B. myocardium.

Ductus arteriosus closes in:

24-48 hours.

Maternal blood volume increases by:

40-50%. Begins in 1st trimester and peaks at week 30. Left ventricle increases in thickness and mass. Returns to pre-pregnancy volume in 3-4 weeks. CO increases 30-40%. Returns to normal 2 weeks after.

apicle pulse in adults is visible at:

5th left intercostal space

Mr. Herrara is a 42-year-old patient who presents for routine well visit. On examination during cardiac auscultation, you note a midsystolic murmur with a medium pitch; a coarse thrill is palpated as well. These findings are consistent with which condition? A. Aortic stenosis B. Aortic regurgitation C. Pulmonic stenosis D. Mitral stenosis

A. Aortic stenosis

Where are the semilunar valves located? A. At the exit of each ventricle where the great vessels originate B. Between the left ventricle and left atria C. At the bifurcation of the pulmonary ascending aorta D. At the entrance of the superior vena cava into the right atria

A. At the exit of each ventricle where the great vessels originate

Mr. Venturi is a 55-year-old marathon runner who presents to your office with a complaint of many days of fever, shortness of breath, and some chest discomfort. On examination, you note clinical signs of congestive heart failure. Which disease process should you consider? A. Bacterial endocarditis B. Infarction C. Myocarditis D. Cardiac tamponade

A. Bacterial endocarditis

Mr. Jones is a 72-year-old patient who presents with a complaint of fever and fatigue. On examination, you note tachycardia and pulsus alternans. Of which condition are these signs and symptoms most suggestive? A. Myocarditis B. Left ventricular hypertrophy C. Cardiac tamponade D. Cor pulmonale

A. Myocarditis

Mr. Torres is a 62-year-old patient who presents to your office with complaints of shortness of breath and dyspnea on exertion. On examination, you are unable to palpate the apical pulse. In addition, the heart sounds are very faint on auscultation. What condition should be considered? A. Pleural or pericardial fluid B. Congestive heart failure C. Mitral valve regurgitation D. Atrial septal defect

A. Pleural or pericardial fluid

Which of the following best describes initiation of ventricular contraction? A. Pressure in the ventricle forces atrioventricular valves to close. B. Ventricular contraction is initiated at the Purkinje point and proceeds in concentric circles around the ventricles. C. Pressure in the ventricles forces semilunar valves to close. D. Ventricular contraction is initiated within the myocardial septum and is transmitted vertically from the endocardium to the epicardium.

A. Pressure in the ventricle forces atrioventricular valves to close.

Mrs. Gorski is a 38-year-old patient who is 8 months pregnant and presents to your office for a routine visit. Which of the following cardiovascular findings would be considered normal for Mrs. Gorski? A. The position of the heart shifts up and to the left; the apex moves laterally. B. Percussion reveals a decrease in left ventricular size. C. Assessment of the lower legs reveals 3+ pitting edema. D. Blood pressure is 150/118.

A. The position of the heart shifts up and to the left; the apex moves laterally.

Mrs. Tanker is a 62-year-old patient who presents to your office with a complaint of chest pain. On cardiac auscultation, you note a split heart sound. What is the physiological basis of a split sound? A. The right side of the heart contracts later than the left side. B. The atria contract later than the ventricles. C. The ventricles contract later than the atria. D. The atria contract before the ventricles.

A. The right side of the heart contracts later than the left side.

What is the major function of the heart valves? A. Separate the right side of the heart from the left B. Permit the flow of blood in one direction C. Separate the upper chambers from the lower chambers D. Augment the flow of blood through the heart

B. Permit the flow of blood in one direction

Mr. Sherman is a 65-year-old patient who has long-standing hypertension. Which clinical finding would you expect? A. Decreased blood volume B. Thickened myocardium C. Increased stroke volume D. Decreased cardiac irritability

B. Thickened myocardium

Mrs. Yates is a 55-year-old patient who presents to your office with complaints of chest pain. To assess the timing of the cardiac cycle, you place one hand over the precordium and the other hand over the: A. jugular pulse. B. carotid pulse. C. brachial pulse. D. femoral pulse.

B. carotid pulse.

Heart size estimated by percussion should be confirmed by: A. auscultation of the heart sounds. B. location of the apical pulse or PMI. C. palpating the left sternal border. D. palpating the heart base.

B. location of the apical pulse or PMI.

Ductus arteriosus is a defining characteristic of the fetal circulation. What is its function? A. Facilitates blood flow through the kidneys B. Increases blood supply to the liver C. Allows blood to bypass the lungs D. Diverts large amounts of oxygenated blood to the brain

C. Allows blood to bypass the lungs

Mr. Kingman is a healthy 17-year-old who presents with acute, severe chest pain. He has no history of illness or injury. Which cause of chest pain is the most logical problem to consider? A. Myocardial infarction B. Pulmonary embolus C. Cocaine use D. Unstable angina

C. Cocaine use

Which is a pregnancy associated change that occurs within the cardiovascular system? A. Significant ECG changes related to stress testing B. Decrease in cardiac output C. Increase in blood volume D. Axis rotation resulting in dextrocardia

C. Increase in blood volume

Mrs. Bower is a 55-year-old patient who presents to your office with a complaint of fatigue. On palpating the precordium during her examination, a heave is identified with lateral displacement of the apical pulse. Which problem might this finding indicate? A. Mitral regurgitation B. Aortic stenosis C. Left ventricular enlargement D. Pericarditis

C. Left ventricular enlargement

The primary muscle mass of the heart is formed by which of the following? A. Right ventricle and right atria B. Left ventricle and left atria C. Right and left ventricles D. Right and left atria

C. Right and left ventricles

Where would you place your stethescope to auscultate the aortic valve area? A. Fourth left intercostal space along the lower left sternal border B. Second left intercostal space at the left sternal border C. Second right intercostal space at the right sternal border D. Third left intercostal space at the left sternal border

C. Second right intercostal space at the right sternal border

Mrs. Wolf is a 48-year-old patient who presents to your office with a complaint of chest pain. On examination, you note a murmur of medium pitch that fills systole. It is heard best at the apex and along the left sternal border. Which is a cause of these clinical findings? A. Aortic regurgitation B. Tricuspid stenosis C. Subaortic stenosis D. Mitral stenosis

C. Subaortic stenosis

Which events occur during the systolic phase of the cardiac cycle? A. The atria contract and the ventricles relax. B. The atria and the ventricles contract. C. The ventricles contract and the atria relax. D. The right side of the heart contracts and the left side relaxes.

C. The ventricles contract and the atria relax.

What happens to the electrical impulses as they pass through the AV node? A. They are converted to mechanical impulses. B. Their amplitude is augmented. C. They are slightly slowed down. D. They are selectively transmitted to the Purkinje node.

C. They are slightly slowed down.

Mrs. Baker brings her 5-year-old daughter in for a routine examination. On examination, you note a systolic ejection murmur that is loud, harsh, and high in pitch heard over the second intercostal space along the left sternal border. Which problem should you suspect? A. Mitral valve prolapse B. Mitral valve stenosis C. Coarctation of the aorta D. Atrial septal defect

D. Atrial septal defect

Mr. Green is a 56-year-old patient who presents to your office for follow-up. On examination, you note a readily visible and palpable apical pulse. Which factors can account for this finding? A. The individual is too thin. B. There is an intensity of the heartbeat that suggests an underlying problem. C. The individual may be in the wrong position. D. Both a and b.

D. Both a and b.

Where would you palpate a carotid pulse? A. Superior to the clavicle at the midclavicular line B. Superior and lateral to the cricoid cartilage C. Fingerbreadth above the suprasternal notch D. Inferior and medial to the angle of the jaw

D. Inferior and medial to the angle of the jaw

What is the fibrous sac that encases and protects the heart called? A. Mediastinum B. Precordium C. Endocardium D. Pericardium

D. Pericardium

Mrs. Tubbs is a 42-year-old patient who presents to your office for a routine follow-up. Which is the best technique for hearing low-pitched filling sounds of the heart? A. Place the patient in supine position and listen with the bell of the stethoscope. B. Place the patient in a sitting position and listen with the diaphragm of the stethoscope. C. Place the patient in a sitting position and listen with the bell of the stethoscope. D. Place the patient in a left lateral recumbent position and listen with the bell of the stethoscope.

D. Place the patient in a left lateral recumbent position and listen with the bell of the stethoscope.

Mr. Lukas is a 48-year-old patient with diabetes and hypertension. Which heart sound heard on auscultation suggests pathology and requires additional evaluation? A. Split S1 B. Split S2 C. S3 D. S4

D. S4

Atherosclerosis

Deposition of cholesterol, lipids, inflammatory process Leads to thickening and narrowing Subjective: May be asymptomatic Angina, SOB, palpitations Family history Objective: Dyslipidemia Dysrhythimias and signs of CHF

______ _____ accounts for most acquired murmurs.

Kawasaki disease.

Mitral Stenosis: heard with bell at apex, patient in left lateral decubitus position

Low frequency diastolic mumble, more intense in early and late diastole, does not radiate. often occurs with mitral regurgitation. caused by rheumatic fever or cardiac infection narrowed valve restricts forward flow

Senile cardiac amyloidosis: Amyloid, fibrillary protein produced by inflammation or neoplastic disease, deposition in heart

Patho: Heart contractility reduced Causes HF Subjective: Palpitations LE edema Fatigue Reduced activity tolerance Objective: Pleural effusion Arrythmia LE edema Dilated neck veins Hepatomegaly ECG- thickened LV

Mitral insufficiency, regurgitation: Abnormal leaking of blood through the mitral valve from left ventricle into left atrium

Patho: Symptoms of CHF SOB Pulmonary edema Orthopnea PND Objective: High pitched pansystolic murmur radiating to axilla May have third sound

S2-dub

Pressure in ventricles falls below the aorta and pulmonary artery closing valves. This is S2. indicates end of systole. best heard in aortic and pulmonic areas. higher pitch and shorter duration than s1.

Aortic Stenosis: heard over aortic area; ejection sound at 2nd right intercostal border

midsystolic ejection murmur, medium pitch, coarse, radiates along left sternal border. may be cause of sudden death caused by congenital bicuspid valve, rheumatic heart disease

Electrical cycle

SA node=> AV node=> Bundle of His=> Perkinje fibers

Order of carciac valves:

Try Pulling My Arm Tricusupid Pulmonic Mitral Aortic

Older adults

heart decreases in size unless there is a medical condition.

4th heart sound in pregnancy:

abnormal

Loud S4:

allows suggest pathology and needs evaluation.

tricuspid regurgitation: heard at left lower sternum,

holosystolic murmur over right ventricle, blowing, increased on inspiration. caused by congenital defets, bacterial endocarditis, pulmonary HTN.

heave or lift

apical pulse that is more vigorous than expected.

Heart position:

behind sternum and contiguous parts of 3rd-6th costal cartilages.

pulmonary ejection click:

best heard on expiration in 2nd left intercostal space

mitral regurgitation: heard best at apex, loudest there, transmitted into left axilla

holosystolic, high pitch, harsh blowing quality. valve incompetence caused by rheumatic fever, MI,

mitral valve prolapse: heard at apex and left lower sternal border; easily missed in supine position,

late systolic murmur preceded by midsystolic clicks

aortic ejection click:

less sharp, may be heard in 2nd right intercostal space.

Tricuspid stenosis: heard with bell over tricuspid area

diastolic rumble accentuated early and late in diastole, resembles mitral stenosis but louder on inspiration. caused by rheumatic heart disease, congenial,

aortic regurgitation: heard with diaphragm, sitting up and leaning forward; ejection click heard in 2nd intercostal space.

early diastolic, high pitch, blowing, caused by rheumatic heart disease, endocarditis, aortic disease, syphilis

innermost layer

endocardium

thin outermost muscle layer

epicardium

Infants blood flow:

flows from right atrium into left by foramen ovale. Right ventricle pumps through patent ductus arteriosus instead of into lungs.

Infants with right sided CHF:

have large, firm livers with inferior edge 5-6cm below right costal margin.

S4 in older adults:

more common; indicates decreased left ventricular compliance.

Subaortic stenosis: heard at apex and along left sternal border

murmur fills systole, medium pitch, coarse

still murmur:

occurs in active, healthy children between 3-7 years old. caused by vigorous expulsion of blood from left ventricle into aorta, increases with activity and diminishes when child is quiet.

splitting

occurs when mitral and tricuspid valve or pulmonic and aortic valves do not close simultaneously.

Ventricular septal defect: opening between right and left ventricles

patho: 30-50% close spontaneously during first 2 years subjective: recurrent respiratory infections if large, rapid breathing, poor growth, sx of CHF objective: arterial pulse small, jugular venous pulse unaffected holosystolic murmur, often loud, coarse, high pithced. best heard along left sternal border in 3rd to 5th intercostal. left peristernal lift smaller defect causes louder murmur

patent ductus arteriosus:

patho: blood flows through ductus during systole and diastole, increasing pressure in pulmonary circulation and workload of RV. subjective: small-asymptomatic. larger-dyspnea on exertion objective: dilated and pulsatile neck vessels widened pulse pressure harsh, loud continuous murmru at 1st to 3rd intercostal pace and lower sternal border. usually unaltered by postural change

Cardiac tamponade: excessive accumulation of effused fluids or blood between percardium and heart

patho: constrains cardiac relaxation, impairing blood return to right heart causes: pericarditis, malignancy, aortic dissection, trauma subjective: anxiety, restlessness CP, SOB discomfort relieved when sitting forward syncope, lightheaded pale, gray, blue skin palpitations rapid breathing swellling of abdomen or arms, neck veins objective: beck triad (JVD, hypotension, muffled heart sounds)

Right sided CHF: heart fails to propel blood forward with usual force, results in congestion in SYSTEMIC circulation.

patho: decreased CO causes decreased blood flow to tissues. many causes same as left sided. subjective: peripheral edema, at end of day and when sitting weight gain objective: pitting edema in LE JVD

myocarditis: focal or diffuse inflammation of myocardium

patho: direct cytotoxic effect of secondary immune response causes: viral-enterovirus, coxsackie, influenza, etc. Bacterial-TB, streptococci Spirochetal-syphilis, Lyme Fungal-candidiasis protozoal-chagas, toxoplasmosis Helminthic (trichinosis), Bites/stings, Amphetamines, systemic inflammatory disease, peripartum cardiomyopathy subjective: initial sx vague fatigue, dyspnea, fever, palpitations, history of flu like symptoms in last 1-2 weeks. objective: cardiac enlargment murmurs, gallop, tachycardia dysrhythmias pulsus alternans (alternation of strong and weak arterial pulse)

tetralogy of fallot: congenital; composed of four defects: ventricular septal defect, pulmonic stenosis, dextropositing of aorta, RV hypertrophy

patho: increased RV outflow obstruction leads to increased right-to-left shunt of blood through underdeveloped interventricular septum. Results in cyanosis during hypercontractile episodes, with agitation/crying subjective: dyspnea with feeding, poor growth, exercise intolerance tetralogy spell-paroxysmal dyspnea w/lLOC and central cyanosis objective: parasternal heave and precordial prominence, systolic ejection murmur over 3rd intercostal space, sometimes radiates to neck, single S2 older children have clubbing may develop HF

Atrial septal defect:

patho: large ASD >9mm, allows left to right shunting of blood may cuase overload of right atrium and ventricle results in enlargment of right side of heart and shunt reversal and heart failure subjective: often asymptomatic heart failure rare in children but often in adults objective: diamoned-shaped systolic ejection murmur often loud, high pitched and harsh over pulmonic area may have brief rumbling early diastolic murmur S2 widely split

Left sided CHF: heart fails to propel blood forward w/usual force, results in congestion in PULMONARY circulation

patho: many causes. LV hypertrophy cardiomyopathy damanged aortic/mitral valves ischemic cardiomyopathy nonischemic cardiomyopathy toxic exposure viruses DIastolic HF-advanced glycation cross-linking collagen and creating stiff ventricle unable to dilate actively. Diastolic HF-occurs in older adults with DM who tissue is exposed to glucose for long times. subjective: fatigue, breathing difficulty, SOB, orthopnea, exercise intolerance. objective: sudden w/acute pulmonary edema or gradual symptom onset crackles systolic CHF has narrow pulse pressure diastolic CHF has wide pulse pressure.

Myocardial Infarction: ischemic myocardial necrosis from abrupt decrease in coronary blood flow to segment of myocardium

patho: most common to left ventricle results from atherosclerosis of coronary blood vessel plaques rupture, thrombosis forms, sudden blood flow obstruction. subjective: deep substernal or visceral pain raidates to jaw, neck, left arm. may mild in older adults or with DM nausea fatigue SOB objective: dysrhythmias S4 usually present distant heart sounds soft, systolic blowing murmur thready pulse hypertension in early phase

angina: caused by myocardial ischemia

patho: occurs when myocardial demand exceeds supply subjective: substernal pain or intense pressure radiating to neck, jaws, arms, particularly left SOB, fatigue, diaphoresis, faintness, syncope objective: no exam findings suggest angina tachy, tachypnea, HTN, diaphoresis ischemia may lead to crackles d/t pulmonary edema or reduction in S1 or an S4. higher risk w/COPD, xanthelasma, HTN, PAD, murmurs

sick sinus syndrome: caused by malfunction of sinus node

patho: secondary to HTN, atherosclerosis, rheumatic heart subjective: fainting, dizzy speals, light headed, seizures, palpitations, angina objective: dysrhytmias signs of CHF.

Bacterial endocarditis: infection of endothelial layer of heart and valves

patho: suceptibele with congenital or acquired valve defects, hx of endocarditis, IV drug use subjective: fever, fatigue sudden onset CHF objective: murmur signs of neuro dysfunction Janeway lesion (small erythematous or hemorrhagic macules on palms and soles osler nodes (appear on tips of fingers or toes and caused by septic emboli)

cor pulmonale: enlargement of right ventricle secondary to chronic lung disease

patho: usually chronic, occasionally acute acute-right side of heart dilates and fails. cause-massive PE, ARDS chronic-gradual hypertrophy of RV progresses until HF cause-COPD and pulmonary arterial HTN. subjective: fatigue tachynpea exertional dyspnea cough,hemoptysis light-headed syncope objective: pulmonary disease sx: wheezes, crackles, increase chest diameter, labored respiratory effort right HF and hypertrophy sx: distended neck veins and prominent A or V waves Cyanosis left parasternal systolic heave loud S2 exaggerated in pulmonic region LE edema

Conduction disturbances: either proximal to bundle of His or throughout system

patho: variety of causes-ischemic, infiltrative, rarely neoplastic subjective: transient weakness syncope strokelike episodes palpitations objective: rapid or irregular heartbeat rhythm disturbance

Pericarditis: inflammation of pericardium

patho: viral infection cause (echovirus or coxsackie) seen in: cancer, HIV/AIDs, hypothyroid, renal failure, TB, rheumatic fever, kawasaki. Other causes: MI, heart surgery, meds (procainamide, hydralazine, phenytoin), radiation therapy to chest. may cause pericardial effusion subjective: sharp stabbing CP pain worse w/coughing, swallowing, deep breathing, lying flat. relieved by sitting up and forward pain in back, neck, shoulder SOB lying down dry cough anxiety or fatigue objective: scratchy, grating, triphasic frction rub easily heard left of sternum in 3rd and 4th intercostal space

acute rheumatic fever: systemic connective tissue disease after streptococcal pharyngitis or skin infection

patho: wide manifestations May result in serious cardiac valvular involvement of mitral or aortic valve, usually does not involve tricuspid or pulmonic. Valve becomes stenotic and regurgitant. Ages 5-15years usually. Prevention: adequate treatment for strep or skin infections Subjective: Fever Swollen joints Flat or raised painless rash with pink margins and pale center(erythema marginatum) Jerky movements Chest pain, palpitations Objective: Murmurs Cardiomegaly Friction rub Signs of CHF

Fibrous sac encasing the heart:

pericardium

PMI

point where apical pulse is most readily seen or felt. usually at left 5th intercostal space, midclavicular line in adults and 4th intercostal space medial to nipple in children.

ST segment and T wave

return of stimulated ventricular muscle to resting state (ventricle repolarization)

lift at left sternal border:

right ventricular hypertrophy

thrill

rushing vibration at the right or left second intercostal space. indicates turbulence or disruption of expected blood

pulmonic regurgitation:

secondary to pulmonary HTN or bacterial endocarditis

Mitral valve

separates left atrium from left ventricle

Tricuspid valve

separates right atrium from right ventricle

Pulmonic valve

separates right ventricle from pulmonary artery

aortic valve

separates the left ventricle and the aorta.

U wave

small deflection rare seen after T wave, thought to be repolarization of Purkinje fibers.

P wave

spread of stimulus through atria (atria depolarization)

QRS complex

spread of stimulus through ventricles (ventricle depolarization) < 0.10

Pulmonic stenosis: heard over pulmonic area radiating to left and into neck; thrill in second and third left intercostal spaces

systolic murmur, medium pitch, coarse, usually with thrill. almost always congenital

myocardium

thick musclular middle layer, responsible for pumping

QT interval

time elapsed from onset of ventricular depolarization until completion.

PR interval

time from initial stimulation of atria to ventricles, 0.12-0.20

During systole:

ventricles contract

During diastole:

ventricles dilate

S1-lub beginning of systole

ventricular contraction raises pressure in ventricle and forces mitral and tricuspid valve closed, preventing backflow. This is S1. Intraventricular pressure rises until it exceeds pressure in aorta and pulmonary artery. Then valves open and blood ejects into arteries. best heard toward apex. lower pitch and longer than s2.