Chapter 19: Heart and neck vessels

Define apical impulse and describe its normal location, size, and duration

Apical pulse: pulsation created as the left ventricle rotates against chest wall during systole. Location: the 4th or 5th interspace, and bear or medial to midclavicular line Size: normally 1x2 cm Amplitude: normally a short, gentle tap Duration: short, normally occupies only first half of systole

Define bruit and discuss what it indicates

Bruit: blowing, swishing sound indicating blood flow turbulence from a local vascular cause and is a marker for artherosclerotic disease

Explain the mechanism producing normal first and second heart sounds

First heart sound (S1) occurs with closure of the AV valves and this signals the beginning of systole. The mitral component of the first sound slightly precedes the tricuspid component, but you usually hear these two components fused as one sound. You can hear S1 over all the precordium but usually loudest at the apex. Second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. The aortic component of the second sound (A2) slightly precedes the pulmonic component. Although it is heard over all the precordium, S2 is loudest at the base.

Discuss the characteristics of an innocent or functional murmur

Innocent- no valvular or pathological cause. Functional- increased blood flow to the heart (anemia, pregnancy, fever, hyperthyroidism).

Define the third heart sound. When in the cardiac cycle does it occur? Describe its intensity, quality, location in which it is heard, and method of auscultation

Low pitched sound that occurs in early diastole. You will hear this sound at the apex in the left lateral position. Use the bell of the stethoscope. Normal in children and young adults. It is abnormal when it persists in a person. Usually abnormal in adults over the age of 40 and can be an early sign of heart disease or congested heart failure.

List the characteristics to explore when you hear a murmur, including the grading scale of murmurs

Pattern: crescendo, decrescendo-depends on blood flow pressure Quality: musical, blowing, harsh, rumbling Location: PMI or valve area, intercostal space, on the neck, back, or axilla Radiation: Heard in the quality of blood flow Posture: may disappear with posture change Grading: 1-difficult, need quiet; 2-audible but faint; 3-easy to hear; 4-loud, thrill palpable on chest; 5-loud with only part of stethoscope off; 6-loud with stethoscope off

Define preload and after load.

Preload: venous return that builds during diastole. It is the length to which the ventricular muscle is stretched at the end of diastole just before contraction Afterload: opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure

Define pulse deficit and discuss what it indicates

Pulse deficit: apical-radial pulse Signals a weak contraction of the ventricles. It occurs with A-Fib, premature beats, and HF

Explain the physiologic mechanism for normal splitting of S2 in the pulmonic valve are

Splitting of the S2 can happen during inspiration. It is heard when the aortic valve closes earlier than the pulmonic valve. Instead of it sounding like "dub" it sounds like "T-Dub". You can hear it only in the pulmonic valve area.

Describe the characteristics of the second heart sound and its intensity at the apex of the heart and at the base

S2- "Dub"- is the loudest at the base.

Differentiate a physioligic S3 from a pathologic S3

The S3 may be normal (physiological) or abnormal (pathological). The physiological S3 is heard frequently in children and young adults; it occasionally may persist after age 40 years, especially in women. The normal S3 usually disappears when the person sits up. In adults, the S¬3 is usually abnormal. The pathological S3 is also called a ventricular gallop or an S3 gallop, and it persists when sitting up. The S3 indicates decreased compliance of the ventricles, as in heart failure.

Describe the fourth heart sound. When in the cardiac cycle does it occur? Describe its intensity, quality, location in which it is heard, and method of auscultation

The S4 is a ventricular filling sound. It occurs when the atria contract late in diastole. It is heard immediately before S1. This is a very soft sound, of very low pitch. You need a good bell, and you must listen for it. It is heard best at the apex, with the person in left lateral position.

List the major risk factors for heart disease and stroke as identified in the text

The major risk factors for heart disease and stroke are hypertension, smoking, high cholesterol, obesity, and diabetes. Physical inactivity, family hist of heart disease, and age are other risk factors

Define venous pressure and jugular venous pulse

Venous pressure - the pressure exerted on the walls of the veins by the circulating blood Jugular Venous Pulse - The pulse in the right internal jugular vein at the root of the neck; pressure of right atrium

Describe the characteristic of the first heart sound and intensity at the apex of the heart and at the base

You can hear s1 all over the precordium, but it is usually loudest at the apex. Intensity depends on (1) position of AV valve at the start of systole (2) structure of the valve leaflets, and (3) how quickly pressure rises in the ventricle "pub"

State 4 guidelines to distinguish from S2

• S1 is the start if systole and thus serves as the reference point for the timing of all other cardiac sounds; usually you can identify S1 instantly because you hear a pair of sounds close together (lub-dup), and S1 is the first of the pair • S1 is louder than S2¬ at the apex; S2 is louder than S1 at the base • S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel is pulse is S1 • S1 coincides with the R wave (the upstroke of the QRS) complex) if the person is on an ECG monitor

Explain the position of the valves during each phase of the cardiac cycle

Diastole- AV valves (i.e. tricuspid and mitral) are open Systole- AV valves shut producing S1. Aortic valves open to eject blood rapidly. then some back flow from psi equalizing b/t aorta and ventricles causes aortic valve to shut Diastole again- all 4 valves closed, mitral valve opens and diastolic filling begins again

Describe the effect of respiration on heart sounds

First heart sound (S1) occurs with closure of the AV valves and this signals the beginning of systole. The mitral component of the first sound slightly precedes the tricuspid component, but you usually hear these two components fused as one sound. You can hear S1 over all the precordium but usually loudest at the apex. Second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. The aortic component of the second sound (A2) slightly precedes the pulmonic component. Although it is heard over all the precordium, S2 is loudest at the base. Decrease stroke volume=decrease ventricular systole-aortic valley closes early=split s2