Heart: Blue text and Boxes, Red Text, Some Black (Nate's)
(Ausculatory Sounds) The systolic click of mitral valve _____ is the most common extra sound.
prolapse
(ID murmurs) Murmurs detected during pregnancy should be promptly evaluated for possible risk to the mother and fetus, especially those of: (1) aortic _____ (2) or pulmonary _____
-stenosis -hypertension
(Heart Murmurs) A ________ valve has an abnormally narrowed valvular orifice that obstructs blood flow, as in aortic ________, and causes a characteristic murmur.
-stenotic -stenosis
(Apical impulse or PMI; Cardiac examination) THE APEX BEAT IS PALPABLE IN: - 25% to 40% of adults in the ________ position. - and in 50% to 73% of adults in the ________ position, especially those who are ________. NOTE: Obesity, a very muscular chest wall, or an increased AP diameter of the chest may obscure detection.
-supine -Left lateral decubitis -thin
(Variation in heart sound - S1) S1 is ACCENTUATED in: (1) _____ - rhythms with a short PR interval, and high CO states - e.g., exercise, anemia, hyperthyroidism (2) _____. -still open wide at the onset of ventricular systole and then closes quickly.
-tachycardia -mitral stenosis.
(PALPATION; Cardiac examination) Palpation is less useful in patients with a ________ chest wall or ________ AP diameter.
-thickened -increased
Heart murmurs are attributed to ________ blood flow and are usually diagnostic of ________.
-turbulent -valvular heart disease
(PALPATION of heart sounds; Cardiac examination) :*To palpate S1 and S2::* - Palpate the carotid ________ to identify S1 and S2 just before and just after the ________. :*For S3 and S4:* - apply lighter pressure at the cardiac ________ to detect the presence of any extra movements.
-upstroke -upstroke -apex
(Apical Pulse Location) Pregnancy or a high left diaphragm may shift the apical impulse _____ and to the _____.
-upward -left
(ID murmurs) Diastolic murmurs usually represent _____ heart disease. Systolic murmurs point to valvular disease but can be physiologic flow murmurs arising from _____ heart valves.
-valvular -normal
(The JVP and Volume Status) As you begin your assessment, consider the patient's ________ status and whether you need to alter the ________ of the head of the bed or examining table.
-volume -elevation
During history taking you asked the patient 3 questions: 1) "Are the *rings* tight on your fingers? 2) Are your *eyelids puffy* or swollen in the *morning*? 3) Have you had to *let out your belt*?" *WHY ASK SUCH QUESTIONS!?*
1.) Periorbital puffiness = nephrotic syndrome 2.) Tight rings on fingers = nephrotic syndrome 3.) Enlarged waistline = ascites and liver failure.
(Jugular Venous Pressure) Some authors report that at 30° to 45°, the estimated JVP may be ________ cm lower than catheter measurements from the right midatrium.
3 cm Note: In the 3 positions in the picture the sternal angle is around 5 cm above right midatrium.
After palpation, what is the normal diameter of apical impulse?
:- in supine, less than 2.5 cm (quarter size; occupy 1 interspace)
(Jugular venous pulse & Pulsations) In Jugular pulsation curve, what causes the: - a wave - x - descent - v wave - y - descent
A wave = atrial contraction X-descent = atrial relaxation + RV pulls floor of atrium downward V wave = venous filling of right atrium Y - descent = blood passively empties in RV
(Variation in S2 heart sound) PHYSIOLOGIC SPLITTING: Listen in the 2nd or 3rd left interspace. - The _____ component of S2 is usually too faint to be heard at the apex or aortic area, where S2 is a single sound derived only from _____ valve closure. Normal splitting is accentuated by _____, which increases the interval between A2 and P2, and disappears on _____. In some patients, especially _____ ones, S2 may not become single on expiration until the patient _____ up.
-pulmonic -aortic -inspiration -expiration -younger -sits
(Jugular venous pulse & Pulsations) Jugular venous pressure ( JVP) reflects ________ atrial pressure, which in turn equals ________ pressure and ________ ventricular end-diastolic pressure (LVEDP) The JVP is best estimated from the right ________ jugular vein, which has the most direct channel into the ________ atrium.
-right -central venous -right -internal -right
(The Splitting of Heart Sounds) During inspiration, the ________ heart filling time is increased, which increases right ventricular ________ and the duration of right ventricular ________ compared with the neighboring left ventricle. This delays the closure of the ________, splitting S2 into its two audible components
-right -stroke volume -ejection -pulmonic valve (P2)
(Swelling; Assessing cardiac symptoms) ________ edema appears in the lowest body parts: - the feet and lower legs when sitting. - or the sacrum when bedridden.
Dependent
(The Splitting of Heart Sounds) The early mitral sound can be heard throughout the precordium and is loudest at the ________.
cardiac apex
Extra heart sounds in diastole: Pathologic S3: - Normal in adults over 40? - When do you hear it? - Causes? - Listen for left-sided S3 where? - Listen to right sided S3 where? - When is right sided S3 louder? - Cadence sounds like Kentucky/ Tennessee?
Kentucky
(Shortness of breath; Assessing cardiac symptoms) Sudden dyspnea occurs in: (1) pulmonary ________ (2) ________ pneumothorax (3) anxiety
embolus spontaneous
(The Splitting of Heart Sounds) During ________, these two components (A2 and P2) fuse into a single sound, S2
expiration
(Events in the Cardiac Cycle) You hear a S3 heart sound in a child or young adult, what causes this?
from rapid deceleration of the column of blood against the ventricular wall.
(Apical impulse or PMI; Cardiac examination) In ________, the heart, trilobed lung, stomach, and spleen are on the RIGHT, and the liver and gallbladder are on the LEFT.
full situs inversus
(PALPATION; Cardiac examination) The presence of a thrill changes the ________ of the murmur.
grading
(The JVP and Volume Status) Altering head of the bed depending on the patient: If patient is ________ or septic, you can anticipate that the JVP will be LOW, causing you to LOW the head of the bed, sometimes even to 0° before you see neck veins. ■ Likewise, if the patient is ________, anticipate that the JVP will be HIGH, causing you to RAISE the head of the bed to 60° or even 90° to locate the oscillation point.
hypovolemic hypervolemic
(Valsava) The murmur of hypertrophic cardiomyopathy is the only systolic murmur that _____ during the "strain phase" of the Valsalva maneuver due to increased outflow tract obstruction.
increases
(Events in the Cardiac Cycle) You hear a S3 heart sound in an older adult, what causes this?
indicates a pathologic change in ventricular compliance
(Shape of murmur) Crescendo murmur grows _____.
louder i.e presystolic murmur of mitral stenosis in normal sinus rhythm
(The Splitting of Heart Sounds) The softer later tricuspid component of S1 is heard best at the ________.
lower left sternal border
(The Splitting of Heart Sounds) Using surface anatomy where should you listen for the splitting of S1 on the patient?
lower left sternal border
The two kinds of extra heart sounds in systole can be heard in which sub stages?
mid and late Note: Ejection sound and clicks
What is the most common kind of heart murmur?
midsystolic ejection murmur
(Heart Murmurs) Heart murmurs can occur when a valve that fails to fully close, as in aortic regurgitation, allows blood to leak backward in a retrograde direction and produces a ________ murmur.
regurgitant
Characteristics of pansystolic murmur: Pansystolic murmurs often occur with _____ flow across the AV valves
regurgitant
(Right ventricular area) A sustained movement later in systole can be seen in mitral _____.
regurgitation
(Shape of murmur) Crescendo-Decrescendo murmur First _____ in intensity, then _____.
rises then falls Note: Listen for the midsystolic murmur of aortic stenosis and innocent flow murmurs
Characteristics of midsystolic murmur: Midsystolic murmurs typically arise from blood flow across the _____ (aortic and pulmonic) valves.
semilunar
(Ausculatory Sounds) When either A2 or P2 is absent, as in aortic or pulmonic valve disease, - S2 is persistently _____.
single
(Thee JVP!) Increased ________ waveforms of JVP pulse curve occur in: - tricuspid regurgitation - atrial septal defects - constrictive pericarditis.
v waves
(Ausculatory Sounds) Expiratory splitting suggests a _____ abnormality.
valvular
Heart murmurs may also represent "innocent" flow murmurs, especially in ________ adults.
young
(Apical Pulse Location) Lateral displacement toward the axillary line from ventricular dilatation is seen in: (1) heart failure (2) cardiomyopathy (3) ischemic heart disease (4) thoracic _____ (5) mediastinal _____
(1) heart failure (2) cardiomyopathy (3) ischemic heart disease (4) thoracic deformities (5) mediastinal shift
(Cardiac examination) During the PALPATION process: What characteristics are you paying attention to?
(1) heaves (2) lifts (3) thrills (4) impulses from the RV (5) the four heart sounds.
(Apical Pulse Amplitude) A hyperkinetic high-amplitude impulse may occur in: (1) _____thyroidism, (2) severe anemia (3) Press. overload of LV from HTN or aortic _____ (4) Vol. overload of LV from aortic _____.
(1) hyperthyroidism, (2) severe anemia (3) Press. overload of LV from HTN or aortic stenosis (4) Vol. overload of LV from aortic regurgitation.
(Thee JVP!) ABNORMALLY PROMINENT A WAVES OCCUR IN: (1) increased resistance to RA contraction, as in ________ stenosis (2) severe 1st-, 2nd-, and 3rd-degree ________ block (3) supraventricular ________ (4) junctional tachycardia (5) pulmonary ________ (6) pulmonic stenosis.
(1) increased resistance to RA contraction, as in TRICUSPID stenosis (2) severe 1st-, 2nd-, and 3rd-degree AV block (3) supraventricular TACHYCARDIA (4) junctional tachycardia (5) pulmonary HTN (6) pulmonic stenosis.
(Swelling; Assessing cardiac symptoms) Consider asking patients who retain fluid to record daily ________ weights because edema may not be obvious until several liters of extra fluid have accumulated.
*MORNING* Side Note: - Interstitial tissue can absorb up to 5 L of fluid, accommodating up to a 10% weight gain, before pitting edema appears.
(Jugular Venous Pressure) JVP measured at >________ cm above the sternal angle, or >________ cm above the right atrium, is considered ELEVATED ABOVE NORMAL.
-3 -8
(The Splitting of Heart Sounds) Of the two components of the S2: ________ is normally louder, reflecting the high pressure in the aorta. It is heard throughout the ________. In contrast, ________ is relatively soft, reflecting the lower pressure in the pulmonary artery.
-A2 -precordium -P2
After palpation, what is the normal Duration of apical impulse?
- Apical impulse should last through first 2/3 of systole or less Note: - Can ID LV hypertrophy - auscultate heart sounds as you palpate apical impulse - have pt breahe out and exhale and pause.
(Heart Murmurs) What are characteristics of murmurs that you should take note of to accurately ID them?
- Best heard where on chest wall - their timing in systole or diastole - their descriptive qualities (1) shape (2) maximal intensity, (3) direction of radiation (4) grade of intensity (5) pitch (6) quality
(Swelling; Assessing cardiac symptoms) Causes of edema are frequently of the following origins: (1) ________: - Right or left ventricular dysfunction - Pulmonary HTN (2) ________: - Obstructive lung disease (3) ________: - Hypoalbuminemia (4) POSITIONAL.
- CARDIAC - PULMONARY - NUTRITIONAL
(The Splitting of Heart Sounds) ________ and ________ in the pulmonary vascular bed contribute to the "hangout time" that delays P2.
- Distensibility - impedance
What stage of the cardiac cycle does the Y descent occur?
- EARLY DIASTOLE subsequent to S2
What stage of the cardiac cycle does the X descent occur?
- LATE SYSTOLE just before S2 Note: BTW this waveform is the MOST prominent of JVP pulse curve
(The JVP) An elevated JVP is: HIGHLY correlated with: (1) ________ and (2) ________ heart failure. Also, Correlated with: - tricuspid ________ - ________ pulmonary HTN - SVC obstruction - cardiac ________ - ________ pericarditis
-acute -chronic -stenosis -chronic -tamponade -constrictive
(Aortic Area—The Right 2nd Interspace) A pulsation here suggests a dilated or _____ aorta. A palpable S2 can accompany _____ hypertension
-aneurysmal -systemic
(Systolic murmurs) Midsystolic murmurs can be FUNCTIONAL murmurs: - They are short and _____ in intensity with maneuvers that reduce LV _____: (1) standing (2) sitting up (3) Valsalva maneuver These murmurs are often heard in _____ patients and are not pathologic. Early systolic murmurs are uncommon.
-decrease -volume -healthy
(Apical impulse or PMI; Cardiac examination) In ________, a rare congenital transposition of the heart, the heart is situated in the RIGHT chest cavity and generates a RIGHT-sided apical impulse. Use percussion to help locate the heart border, the liver, and stomach.
-dextrocardia -percussion
(Apical impulse) A _____ sustained _____-amplitude (hypokinetic) impulse is seen in heart failure and dilated cardiomyopathy.
-diffuse -low
(Apical Pulse Diameter) -In the left lateral decubitus position, a _____ PMI with a diameter >_____ cm signals LV enlargement. - a diameter of >_____ cm makes LV overload almost 5 times more likely
-diffuse -3 -4
(Shortness of breath; Assessing cardiac symptoms) What 3 symptoms can shortness of breath suggest?
-dyspnea -orthopnea -paroxysmal nocturnal dyspnea
(The Splitting of Heart Sounds) S1 also has two components: (1) an ________ mitral sound and a (2) ________ tricuspid sound.
-earlier -later
(Valsava) In patients with severe heart failure, blood pressure remains _____ and there are _____ sounds during the phase 2 strain phase, but NOT during phase 4 release, termed "the square wave" response. This response is highly correlated with _____ overload and _____ LVEDP and pulmonary capillary wedge pressure, in some studies outperforming brain natriuretic peptide.
-elevated -Korotkoff -volume -elevated
(Variation in heart sound - S1) S1 is DIMINISHED in: (1) _____-degree heart block (2) _____ bundle branch block (3) MI due to _____ ventricular contraction. (4) acute aortic _____.
-first -left -weak -regurgitation Note: (in acute aortic regurgitation where Early mitral valve closure occurring before ventricular contraction )
(Review of Blood Pressure) It is important to have patients unclothed arm at the proper level. At ________ arm levels, the blood pressure recordings will be lower. At ________ levels, the blood pressure recordings will be higher.
-higher -lower
(Apical Pulse Location) Lateral displacement from the midclavicular line makes: - _____ left ventricular volume - and a _____ left ventricular EF 5 and 10 times more likely, respectively.
-increased -low
Midsystolic ejection murmurs may be: (1) _____—without any detectable physiologic or structural abnormality (2) _____—from physiologic changes in body metabolism (3) _____—arising from structural abnormalities in the heart or great vessels
-innocent -physiologic -pathologic
(Variation in heart sound - S1) Varying S1 INTENSITY: (1) in _____ heart block - when atria and ventricles are beating independently of each other (2) in any totally _____ rhythm (e.g., atrial fibrillation). In these situations, the mitral valve is in varying positions _____ being shut by ventricular contraction. Its _____ sound, therefore, varies in loudness.
-complete -irregular -before -closure
(Chest pain; assessing cardiac symptoms) Acute ________ syndrome is increasingly used to describe the clinical syndromes caused by acute MI, which include: (1) ________ angina (2) non-ST elevation MI (3) ST elevation MI.
-coronary -unstable
(The heart; Positing the patient) To assess the *Point of Maximal Impulse (PMI)* and *extra heart sounds such as S3 or S4*: (1) ask the patient to turn to the left side, termed the ________ position—this brings the ventricular ________ closer to the chest wall. (2) To bring the left ventricular outflow tract closer to the chest wall and improve detection of aortic regurgitation, have the patient sit up, lean ________, and ________.
- Left lateral decubits - apex - forward - exhale
After palpalation, where should the normal apical impulse be located?
- Locate horizontal line = 4th or 5th intercostal space - Locate vertical line = midclavicular line Note: -first supine then left lateral ducubitis
(The JVP) In patients with obstructive lung disease, the JVP can appear: (1) ________ on expiration (2) but the veins ________ on inspiration. This finding does NOT indicate heart failure.
- elevated - collapse
(Right ventricular area - Left Sternal border in 3rd, 4th, 5th interspace) -In obstructive pulmonary disease, hyperinflation of the lungs may prevent palpation of the _____ RV in the left parasternal area. -The RV impulse is readily palpated high in the _____ where heart sounds are also more audible
- hypertrophied - epigastrium
- Right-sided heart murmurs generally increase with _____ - left-sided murmurs generally increase with _____ .
- inspiration - expiration
(Jugular Venous Pressure) The JVP is best assessed from pulsations in the: - right ________ jugular vein, which is directly in line with the ________ vena cava and right atrium
- internal - superior
(Jugular Venous Pressure) -The dominant movement of the JVP is ________, coinciding with the ________ - descent waveform. -In contrast, the dominant movement of the carotid pulse, often confused with the JVP, is ________.
- inward - X- descent - outward
(Auscultation; Cardiac Exam) How can you enhance the detection of - mitral stenosis - S3 and S4 with stethoscope?
- left lateral decubitus position (which brings the LV closer to the chest wall) - Place BELL of stethoscope lightly on the apical impulse
(The Splitting of Heart Sounds) Instead of a hearing a single heart sound for S2, you may hear two discernible components: First from ________, or A2, and the second from ________, or P2.
- left-sided aortic valve closure - right-sided closure of the pulmonic valve
(Auscultation; Cardiac Exam) Heart sounds and murmurs that originate in the four valves radiate widely. Use anatomical _____ rather than valve _____ to describe your findings.
- location - area
(The Splitting of Heart Sounds) The earlier louder ________ component may mask the later softer ________ sound, however, and splitting is not always detectable.
- mitral - tricuspid
(Radiation or Transmission from the Point of Maximal Intensity.) The murmur of aortic stenosis often radiates to the _____ in the direction of arterial flow, especially on the _____ side. In mitral regurgitation, the murmur often radiates to the axilla, supporting transmission by bone conduction.
- neck - right - axilla - bone
(Heart Murmurs) Heart murmurs are distinct heart sounds distinguished by their ________ and their longer ________.
- pitch - duration
Characteristics of late systolic murmur: 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.
- prolapse - click - regurgitation
(Auscultation; Cardiac Exam) How can you enhance the detection of - Soft diastolic decrescendo murmur of Aortic regurgitation with stethoscope?
- sit up, lean forward, exhale completely, - and briefly stop breathing after expiration.
(PALPATION; Cardiac examination) What are heaves and lifts? Cause?
- sustained impulses that rhythmically lift your fingers - usually produced by an enlarged LA, RA, LA, or LV - and maybe produced by by ventricular aneurysms. Note: - use fingerpads or palms or hand
(The Splitting of Heart Sounds) Using surface anatomy where should you listen for the splitting of S2 on the patient?
- the 2nd and 3rd left interspaces close to the sternum.
(Chest pain; assessing cardiac symptoms) Classic exertional pain, pressure, or discomfort in the chest, shoulder, back, neck, or arm in angina pectoris, is seen in ________% of patients with acute ________. Atypical descriptors also are common, such as cramping, grinding, pricking or, rarely, tooth or jaw pain.
-18 -MI
(PMI; LV area; Cardiac examination) The apical impulse represents the brief early pulsation of the ________ ventricle as it moves ________ during contraction and contacts the chest wall. In most examinations the apical impulse is the ________; however, pathologic conditions such as: (1) RV hypertrophy (2) dilated pulmonary artery (3) aortic aneurysm - may produce a pulsation that is ________ prominent than the apex beat.
-left -anteriorly -PMI (Point of maximal impulse) -more
Intensity of Murmur An identical degree of turbulence would cause a _____ murmur in a thin person than in a very muscular or obese person. Emphysematous lungs may _____ the intensity of murmurs.
-louder -diminish
(Midsystolic murmurs) - Midsystolic murmurs tend to peak near _____ and usually stop _____ S2. - The crescendo-decrescendo or "diamond" shape is not always audible, but the gap between the murmur and _____ helps to distinguish midsystolic from pansystolic murmurs.
-mid systole -before -S2
(Location of timing of cardiac findings) (1) ID the anatomical location of cardiac findings in terms of interspaces and distance of the PMI from midclavicular line. (2) ID timing of impulses, sounds, murmurs in relation to cardiac cycle.
-midclavicular -timing
(Palpable S3 and S4) - A brief early to _____ impulse represents a palpable S3. - an outward movement just _____ S1 signifies a palpable S4.
-middiastolic -before
(Systolic murmurs) Systolic murmurs are typically either _____ or .____.
-midsystolic -pansystolic
(Variation in S2 heart sound) FIXED SPLITTING of S2: - wide splitting that does _____ vary with respiration, often due to: (1) _____ right ventricular systole - seen in atrial septal defect (when the pulse is regular) (2) _____ ventricular failure.
-not -prolonged -right
(Shortness of breath; Assessing cardiac symptoms) PAROXYSMAL NOCTURNAL DYSPNEA describes: - episodes of sudden dyspnea and ________ that ________ the patient from sleep, usually 1 or ________ hours after going to bed, prompting the patient to sit up, stand up, or go to a window for air.
-orthopnea -awaken -2
(Variation in S2 heart sound) WIDE SPLITTING of S2: - increase in the usual splitting of S2 during inspiration that _____ throughout the respiratory cycle. caused by: (1) _____ closure of the pulmonic valve (pulmonic stenosis & R. bundle block) (2) _____ closure of the aortic valve (mitral regurgitation).
-persists -delayed -early
(Cardiac examination) During the INSPECTION process: - Pay attention to location of the ________. - or less commonly ________ movements of left-sided S3 or S4
-point of maximal impulse. -ventricular
(Apical Pulse Duration) A SUSTAINED high-amplitude impulse significantly increases the likelihood of LVH from the _____ overload seen in HTN. If such an impulse is displaced LATERALLY, consider _____ overload.
-pressure -volume
(Right ventricular area) A sustained left parasternal movement beginning at S1 points to: (1) Pressure overload from _____ HTN (2) Pulmonic _____ (3) Chronic _____ volume overload of an atrial septal defect.
-pulmonary -stenosis -ventricular
(Cardiac examination) During the PALPATION process: - Where should palpate? (4)
(1) 2nd right interspace (2) 2nd left interspace (3) along the sternal border (4) the apex
(Assessing cardiac symptoms) Patient describes palpitations as: - rapid regular beating of sudden onset and offset What could this suggest?
(possible paroxysmal supraventricular tachycardia)
(Assessing cardiac symptoms) Patient describes palpitations as: - Transient skips and flip-flops What could this suggest?
(possible premature contractions)
(Assessing cardiac symptoms) Patient describes palpitations as: - Rapid regular rate of <120 bpm - especially if gradually starting and stopping . What could this suggest?
(possible sinus tachycardia).
Systolic Clicks: -Caused by? -Heard in what phase? -Always mediastinal? -Where can you hear it? - High or low pitch? - best heard with what part of stethoscope - often followed by what sound? - does it vary?
- Mitral valve prolapse (abnormal systolic ballooning of mitral valve into LA) - Heard mid or late-systole - Can be extrathoracic or mediastinal origin - Can have multiple at or medial to apex and lower left sternal border - High pitched - best heard with diaphragm of stethoscope - Often followed by late systolic murmur - it varies with positions i.e. VALSAVA
(The Splitting of Heart Sounds) Splitting occurs with respiration of the ________ sound but not the ________ sound.
- S2 - S1
(Apical Pulse Amplitude) After palpation, what is the normal amplitude of apical impulse?
- Small brisk and tapping Note: Other potential findings: - Brisk & tapping (hyperkinetic is normal in kids) - diffuse - sustained
(Palpitations; Assessing cardiac symptoms) What are palpitations?
- Unpleasant awareness of heartbeat Side Note: - dont always suggest a problem - anxious and hyperthyroid pts may report this - most serious dysrhytmias like ventricular tachycardia dont have palpitations. (i.e. skipping, racing, fluttering, pounding, or stopping of the heart)
Early Ejection Sounds: - What kinds? - when does it occur? - Coincident with pathological halting of? - High or low pitch? - Clicking quality? - Best heart with part of stethoscope? - Indicates disease?
- aortic ejection and pulmonic ejection sounds
(Variation in S2 heart sound) PARADOXICAL SPLITTING of S2: - Splitting that _____ on expiration and _____ on inspiration. - Closure of the aortic valve is abnormally delayed so that A2 _____ P2 in expiration. -Normal inspiratory delay of P2 makes the split _____. -The most common cause is _____ bundle branch block
- appears - disappears - follows - disappear - left
(Jugular Venous Pressure) Why not use the right EXTERNAL jugular vein instead of left for JVP?
- can be used but - route from the vena cava is more tortuous - and examination can be impaired by kinking and obstruction at base of neck and by obesity - Difficult to see in children under 12 y/o
(The Splitting of Heart Sounds) Note that because walls of veins contain less smooth muscle, the venous system has more ________ than the arterial system and ________ systemic pressure.
- capacitance - lower
(PALPATION; Cardiac examination) What are thrills? Cause? What' s the next step if this is felt?
- check for a buzzing or vibratory sensation - caused by underlying turbulent flow. - follow up with auscultation
(Ausculatory Sounds) Persistent splitting results from _____ closure of the pulmonic valve or _____ closure of the aortic valve. A loud P2 points to pulmonary _____.
- delayed - early - hypertension
What effect does valsave manuever have on systolic click? - Squatting/ release phase - Standing/ Strain phase
- delays the click and murmur due to increased venous return - moves them closer to S1
(The JVP) An elevated JVP is >95% specific for an increased: (1) left ventricular end ________ pressure. (2) and low left ventricular ________. - although its role as a predictor of hospitalization and death from heart failure is less clear.
- diastolic - EF
(Variation in heart sound - S1) SPLITTING S1 sound: - _____ closure of the tricuspid valve increases splitting of S1 - best heard along the _____ left sternal border where the tricuspid component, often too faint to be heard, becomes audible. A prominent split S1 occurs when right _____ contraction is delayed, as in: (1) right bundle branch block (2) left premature contractions. This split may sometimes be heard at the apex, but must be distinguished from an _____, an aortic _____ sound, and an early systolic click.
-Delayed -lower -ventricular -S4 -ejection
(Palpitations; Assessing cardiac symptoms) If there are symptoms or signs of irregular heart action, obtain an ________. - This includes ________ fibrillation, which causes an "irregularly irregular" pulse often identified at the bedside.
-ECG -atrial
(Shortness of breath; Assessing cardiac symptoms) Orthopnea and PND occur in: (1) ________ ventricular heart failure (2) Mitral ________ (3) ________ lung disease
-Left -stenosis -Obstructive Note: PND = paroxysmal nocturnal dyspnea
(Cardiac examination) When patient is in left lateral decubitus position. You listen to the apex with the bell of the stethoscope. The accentuated findings may include ________-pitched extra sounds such as: - S3 - ________ - ________ rumble of mitral stenosis
-Low -opening snap -diastolic
(Location of timing of cardiac findings) Since the carotid upstroke always occurs in systole immediately after ________ heart sound. - sounds or murmurs COINCIDING with the upstroke are systolic - sounds or murmurs FOLLOWING the carotid upstroke are diastolic.
-S1 -systolic -diastolic NOTE: Palpation of the carotid artery during auscultation is an invaluable aid to the timing of sounds and murmurs.
(Auscultation; Cardiac Exam) The diaphragm is better for picking up the relatively high-pitched sounds (1) _____ and _____ heart sounds (2) the murmurs of aortic and mitral _____ (3) _____ friction rubs.
-S1 and S2 -regurgitation -pericardial
(Swelling; Assessing cardiac symptoms) ________ is severe generalized edema extending to the sacrum and abdomen.
Anasarca
(Cardiac examination) While the patient is sitting, leaning forward, and fully exhaled, you noted: - *Soft descrescendo higher-pitched diastolic murmur* What may this suggest?
Aortic regurgitation
Describe continuous murmurs
Congenital patent ductus arteriosus and AV fistulas, common in dialysis patients, produce continuous murmurs that are nonvalvular in origin. Venous hums and pericardial friction rubs also have both systolic and diastolic components.
(Events in the Cardiac Cycle) Which sound can be heard in some pathologic conditions that accompanies the opening of the aortic valve?
Early systolic ejection sound (Ej)
How should you palpate to find apical impulse?
Palpate in left lateral decubitis position - Find Apical impulse - Use fingertips to find tune assessment Palpate apical impulse with one finger - Assess location, diameter, durating of apical impulse
What effect does inspiration and expiration have on right ventricular preload?
Inspiration - increased expiration - decreased
What are the Steps for Measuring the Jugular Venous Pressure? (5 Steps and some maths)
Note: Round measurement to nearest cm
(Diastolic murmurs) Early diastolic murmur: - when does it start and end? - gap present?
Reflects regurgitant flow across incompetent semilunar valves.
(Shape of murmur) _____ murmur: Has the same intensity throughout.
Plateau Note: pansystolic murmur of mitral regurgitation.
(Location of timing of cardiac findings) Comparing S1 and S2 heart sounds: - ________ is diminished in first-degree heart block. - ________ is diminished in aortic stenosis.
S1 S2
(Jugular venous pulse & Pulsations) When do you hear the S1 and S2 sounds in the jugular pulsation curve?
S1 - After "a wave" S2 - After "x descent"
(Events in the Cardiac Cycle) Which heart sounds define the duration of diastole and systole?
S1 and S2
(Auscultation; Cardiac Exam) The bell is more sensitive to the: low-pitched sounds of: (1) _____ and _____ heart sounds (2) the murmur of mitral _____
S3 and S4 stenosis
(Events in the Cardiac Cycle) In older adults, an what is the S3 sound sometimes called?
S3 gallop
(Pulmonic Area—The Left 2nd Interspace) A prominent pulsation here often accompanies dilatation or increased flow in the pulmonary _____. A palpable S2 points to increased pulmonary _____ pressure from pulmonary _____
artery artery hypertension
(Location of timing of cardiac findings) How do you ID the timing of the paired heart sounds S1 and S2 based on auscultation alone?
The relatively long diastolic interval after S2 separates one pair from the next.
(Diastolic murmurs) late diastolic murmur: - when does it start and end? - gap present?
Turbulent flow across AV valves
(Diastolic murmurs) mid diastolic murmur: - when does it start and end? - gap present?
Turbulent flow across AV valves
(Jugular Venous Pressure) Note that the height of the venous pressure as measured from the sternal angle is similar in all three positions (30°, 60°, 90°), but your ________ to measure the height of the column of venous blood, or JVP, differs according to how you position the patient.
ability
(Chest pain; assessing cardiac symptoms) Anterior chest pain, often tearing or ripping and radiating into the back or neck, occurs in acute ________.
aortic dissection
(Location of timing of cardiac findings) - S1 is usually louder than S2 at the ________. - S2 is usually louder than S1 at the ________.
apex base
(Shortness of breath; Assessing cardiac symptoms) Paroxysmal nocturnal dyspnea may be mimicked by nocturnal ________ attacks.
asthma
(Thee JVP!) Absent a waves of the JVP pulse curve signal ________.
atrial fibrillation.
(Assessing cardiac symptoms) When assessing cardiac symptoms, it is important to quantify the patient's ________ level of activity.
baseline
In patients with carotid obstruction, kinking, or thrills, assess the pulse in the ________ artery.
brachial
(Shape of murmur) Decrescendo murmur grows _____.
softer i.e early diastolic murmur of aortic regurgitation.
Murmurs with grades 4 through 6 require the added presence of a palpable _____.
thrill
(Jugular Venous Pressure) - Although the JVP accurately predicts elevations in fluid volume in heart failure, - its prognostic value for heart failure outcomes and mortality is ________.
unclear