PD_heart W

(The carotid pulse) Carotid artery ________ causes ∼10% of ischemic strokes and ________ the risk of CHD. The prevalence of ________ carotid stenosis in the United States is ∼1% for stenoses occluding 75% to 90% of the lumen, and ________ significantly with age. The 5-year risk of ________ stroke from asymptomatic stenoses of over 70% is ∼5%..

-stenosis -doubles -asymptomatic -increases -ipsilateral

(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

(The carotid pulse) Causes of decreased pulsations include: (1) decreased ________ from shock or MI. (2) local atherosclerotic ________.

-stroke volume -narrowing or occlusion

(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

(The carotid pulse) Thrills (vibrations) in aortic stenosis are transmitted to the carotid arteries from the ________ notch or ________ intercostal space.

-suprasternal -2nd right

(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

(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

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

(The Splitting of Heart Sounds) The S2 heart sound splits into what two heart sounds?

A2 P2

(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

(Surface projections of heart & Great Vessels) Rarely, in ________ and ________, the PMI is located on the right side of the chest.

-situs inversus -dextrocardia

(Swelling; Assessing cardiac symptoms) ________ edema appears in the lowest body parts: - the feet and lower legs when sitting. - or the sacrum when bedridden.

Dependent

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

(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

carotid pulse is weak in__ pulse is bounding in __ carotid upstroke is delayed in __

cardiogenic shock aortic reguritation delayed in aortic stenosis

(Events in the Cardiac Cycle) what does S1 and S2 respond to

closure of mitral valve closure of aortic valve

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

The terms heart failure with preserved ejection fraction (EF) and heart failure with reduced EF are now preferred to "________ heart failure" because of differences in treatment.

congestive

(Shortness of breath; Assessing cardiac symptoms) Sudden dyspnea occurs in: (1) pulmonary ________ (2) ________ pneumothorax (3) anxiety

embolus spontaneous

(Assessing cardiac symptoms) For chest symptoms, be systematic as you think through the range of possible cardiac, pulmonary, and ________ etiologies.

extrathoracic

(Jugular Venous Pressure) - Although the JVP accurately predicts elevations __ in heart failure, - its prognostic value for heart failure outcomes and mortality is ________.

fluid volume unclear

(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

(Follow-up of bruit; The carotid pulse) Use the diaphragm of the stethoscope to detect ________ frequency sounds of arterial bruits better than the bell. -----

higher

(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

(Cardiac Chambers, Valves, and Circulation) What does the S4 sound correspond with?

increased left ventricular end diastolic stiffness which decreases compliance

(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

(The carotid pulse) palpating carotid and jugular at same time produce

induce syncope

(The Splitting of Heart Sounds) right side cardiac event occur __ than the left side

later

(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 ___ 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 side - Left lateral decubits - apex - forward - exhale

---

left side- left decubitus closer

(Shape of murmur) Crescendo murmur grows _____.

louder i.e presystolic murmur of mitral stenosis in normal sinus rhythm

(The Splitting of Heart Sounds) A2 is __, reflecting __, heard through

louder, reflect high pressure in aorta heard through precordium

(Follow-up of bruit; The carotid pulse) Note that higher-grade stenoses may have ________ frequency or even absent sounds, more amenable to detection with the bell of stethoscope. ----

lower

(The carotid pulse) Why wouldn't you want to press on the carotid sinus while examining carotid pulsations?

may cause reflex bradycardia or lowered BP

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

(Ausculatory Sounds) The systolic click of mitral valve _____ is the most common extra sound.

prolapse

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

(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.

(The carotid pulse) -If you detect thrills (vibrations) during palpation of carotid artery, proceed to auscultation. - Listen for ________ ------

*bruit* Note: - At this point you'd want the to Tell patient stop breathing for 15 secs - and listen with diagphragm at thyroid cartilage below jaw where common carotid artery bifurcates.

(Detection of Point of maximal impulse; effects of position) A PMI >________ cm is evidence of left ventricular hypertrophy (LVH) from ________ or ________.

-2.5 -hypertension -aortic stenosis.

(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 carotid pulse) -Alternately loud and soft Korotkoff sounds or a sudden doubling of the apparent heart rate as the cuff pressure declines signals ________. - Placing the patient in the __ position may accentuate this finding

- *pulsus alternans* - right Note: - Rhythm = regular - arterial pulse force alt. due to alt. strong & weak ventricular contractions. - almost always indicates severe LV dysfunction. - best felt at radial or femoral arteries. - will hear double beat when measuring diastolic P. with pressure cuff.

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.

(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

--

- EARLY DIASTOLE subsequent to S2

--

- 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

(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

(Chest pain; assessing cardiac symptoms) Both men and women with acute coronary syndrome usually present with the classic symptoms of ________ angina. However, women, particularly those over age ________, are more likely to report atypical symptoms that may go unrecognized, such as: - ________ - neck - jaw pain - dyspnea - ________ - nausea or vomiting - fatigue making careful history taking especially important.

-exertional -65 -upper back -paroxysmal nocturnal dyspnea

(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

*PARADOXICAL PULSE* -The pressure when Korotkoff sounds are first heard is the ________ systolic pressure during the respiratory cycle. -The pressure when sounds are heard throughout the cycle is the ________ systolic pressure. -A difference between these levels of ≥________ mm Hg to ________ mm Hg constitutes a paradoxical pulse, found MOST commonly in: (1) *acute ________* (2) *________ pulmonary disease.* -It also occurs in: (3) pericardial tamponade (4) constrictive pericarditis (5) acute pulmonary embolism.

-highest -lowest -10 mmHg to 12 mmHg -asthma -obstructive

(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 M.Ischemia, which include: (1) ________ angina (2) non-ST elevation MI (3) ST elevation MI.

-coronary -unstable

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) 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

(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

(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

(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

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

(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

--: --

-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

(Review of Blood Pressure) -Evidence of ________ reliability of clinic blood pressure measurements. -Multiple ________ measurements improve precision, especially when using: (1) automated home (2) ambulatory blood pressure readings, -which are more reliable, accurate, and better correlated with ________ outcomes than clinic readings.

-poor -averaged -cardiovascular

(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

(Point of maximal impulse) Displacement of the PMI lateral to the midclavicular line or >10 cm lateral to the midsternal line occurs in?

(1) LVH (2) ventricular dilatation from MI (3) heart failure

(The carotid pulse) *Causes of BRUITS include:* (1) atherosclerotic luminal ________ (2) ________ carotid artery (3) ________ carotid arterial disease (4) aortic ________ (5) ________ of hyperthyroidism (6) ________ compression from thoracic outlet syndrome. Bruits do NOT correlate with clinically significant underlying disease.

(1) atherosclerotic luminal stenosis (2) tortuous carotid artery (3) external carotid arterial disease (4) aortic stenosis (5) hypervascularity of hyperthyroidism (6) external compression from thoracic outlet syndrome.

(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

(Cardiac Chambers, Valves, and Circulation) In most adults over age 40 years, the diastolic sounds of ________ and ________ are pathologic, and are correlated with heart failure and ________.

- S3 - S4 - acute myocardial ischemia

(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

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

---

- 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

(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

(Events in the Cardiac Cycle) What causes the S2 sound?

- closure of aortic valve close to the end of systole.

(Events in the Cardiac Cycle) What causes the S1 sound?

- closure of mitral valve at beginning of systole.

(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

(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

(Chest pain; assessing cardiac symptoms) Causes of chest pain in the ________ of coronary artery disease on angiogram include (which require special tests): (1) ________ coronary dysfunction (2) abnormal cardiac ________ Roughly half of ________ with chest pain and normal angiograms have ________ coronary dysfunction.

-absence -microvasculature -nocioception -women -microvascular

(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.

(The carotid pulse) What are the assessment characteristics of carotid pulse? (4)

Note: Carotid Upstroke is between S1 and S2.

What are the Steps for Measuring the Jugular Venous Pressure? (5 Steps and some maths)

Note: Round measurement to nearest cm

(Shape of murmur) _____ murmur: Has the same intensity throughout.

Plateau Note: pansystolic murmur of mitral regurgitation.

(Diastolic murmurs) Early diastolic murmur: - when does it start and end? - gap present?

Reflects regurgitant flow across incompetent semilunar valves.

(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"

(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

(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

(Cardiac Chambers, Valves, and Circulation) What does the S3 sound correspond with?

an abrupt deceleration of inflow across the mitral valve

(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

(The Splitting of Heart Sounds) P2 is __, reflect __

soft, reflect lower pressure in pulmonary artery

(Shape of murmur) Decrescendo murmur grows _____.

softer i.e early diastolic murmur of aortic regurgitation.

(The JVP and Volume Status) elevation if 3cm above__ and 8 cm above__ is considered elevated above normal

sternal angle right atrium

(Events in the Cardiac Cycle) normally maximal left ventricular pressure corresponds to

systolic pressure

Murmurs with grades 4 through 6 require the added presence of a palpable _____.

thrill

(The carotid pulse) A tortuous and kinked carotid artery may produce a ________ pulsatile bulge.

unilateral