dextrocardia
condition of the heart on the right side, either rotated, displaced or mirror image
apical impulse usually felt
fifth left intercostal space at mid clavicular line
what side is more forward in the chest
right side
what happens during systole
the ventricles contact; ejecting blood from left of heart through aortic valve to aorta and right side of heart through pulmonic valve to pulmonary artery
what happens during diastole
the ventricles dilate; draws blood into ventricles as atria contract
S1
the first heart sound "Lubb"; as systole begins ventricular pressure rises and forces mitral(bicuspid) and tricuspid valve closed, preventing back flow.
S2
the second heart sound "dubb"; pressure in ventricles fall below aortic and pulmonary artery and the aortic and pulmonary valves close.
The end of systole
SPLIT S2
A2 is produced by the aortic valve closing, P2 by the pulmonic valve closing. A2 will be before P2 because the pressure in the right side of the heart is slightly less than the left so it takes longer.
Heard best during inspiration
S3
the filling of the ventricle, not a normal sound
Gallop, right after S2
S4
when atria contracts ensuring ejection; a stiff wall
increased resistance to filling because of loss of compliance of the ventricular walls; or increased stroke volume of high out-put states
Right before S1
When you have a HR of 68-72 ventricular systole is _______ than diastole.
ventricular systole is shorter than diastole
When your HR increases what happens to the length of systole and diastole.
the two phases of the cardiac cycle tend to approximate each other in length
The heart lies more _________ in infants and young children
horizontally
During pregnancy the hear is shifted how
shifted toward a horizontal position and there is a slight axis rotation
A through examination of the heart requires a patient to assume what positions
Sitting erect
leaning forward
lying supine
Left lateral recumbent positions
Apical impulse can be made visible by having the patient
sit up, bringing the heart closer to the anterior wall
What would an apical impulse indicate that is more widely distributed, fills systole or displaced laterally and downward
increased cardiac output
Left ventricular hypertrophy
A lift along the left sternal border may indicate
Right Ventricular hypertrophy
Displacement of apical impulse to right without a loss or gain in thrust suggest
dextrocardia
diaphragmatic hernia
distended stomach or
pulmonary abnormality
What is a thrill
Fine palpable rushing vibration, palpable murmur grade IV or greater.
Generally indicates turbulence or disruption of expected blood flow, due to defect of closer of one of the valves
Thrill in systole felt at suprasternal notch &/or second and third right intercostal space most likely
Aortic Stenosis
Thrill in systole at suprasternal notch &/or second and third left intercostal space most likely
Pulmonic Stenosis
Thrill in systole at fourth left intercostal space most likely
Ventricular septal defect
Thrill in systole at Apex most likely
Mitral regurgitation
Thrill in systole at left lower sternal border most likely
Teatralogy of Fallow
Thrill in systole at left upper sternal border, often with extensive radiation
Patent ductus arteriousus
Thrill in diastole in right sternal border most likely
Aortic Regurgitation
Thrill in diastole at Apex most likely
Aneurysm of ascending aorta
Mitral Stenosis
Aortic Valve area
second right intercostal space at right sternal border
Pulmonic Valve area
Second left intercostal space at left sternal border
Erb's Point, Second Valve area
Third left intercostal space at left sternal border
Tricuspid valve area
fourth left intercostal space at left sternal border
Mitral valve area
Fifth left intercostal space at the midclavicular line
Where is a split 2 best heard
pulmonic auscultatory area
S1 best heard where
at the apex
S2 best heard at
aortic and pulmonic area
Splitting S2 is pathological when
it is fixed; unaffected by respiration
large atrial septal defects
ventricular septal deftect with R to L shunting
R ventricular failure
S3 can be heard better if
filling pressure is increased or ventricular compliance is reduces.
Heard best in left lateral position
Raising the legs does what
Increases Venous Return
An isometric grip does what
Increases arterial pressure, increases after load
increases mitral regurgitation
What is and when does paradoxic splitting of S2 occur?
Occurs when closure of aortic valve is delayed, so P2 occurs before A2.
Left Bundle Branch Block
A wide splitting of S2 is indicative of
Right Bundle branch block
Stenosis delays pulmonic valve closer
Pulmonary HTN delays ventricular emptying
Mitral regurgitation induces early closure of aortic valve
The two main causes of Heart Murmurs are:
1. Stenosis of a valve; harder to open, so hear when you normally do not.
2. Regurgitation: valves no longer fit together tightly and allow blood to flow backwards.
Other causes of Heart Murmurs
High output demands (anemia, pregnancy)
structural defects other than valve (hole in septum)
diminished strength of contraction of Heart
altered blood flow through major blood vessels near heart
Obstructive disease (atheroscleortic dz)
Mitral Stenosis PE findings
Heard best at apex, does not radiate
Diastolic rumble, more intense in early and late diastole.
Opening Snap following S2
Palpable thrill at apex in diastole common
Mitral Regurgitation PE findings
Heard best at apex, radiates to left axilla/ subscapular region
Holosystolic murmur, may obliterate S2
Prominant S3
displaced apical impulse
mitral valve prolapse PE findings
Heard best at apex & left lower sternal border
easily missed in supine position
Mid-systolic click, high pitched
Late systolic murmur may follow (MR)
Click will occur earlier while standing/ Valsalva (decreased afterload)
Click will occur later while squa
Aortic Stenosis PE findings
Heard over Aortic area, radiates along left sternal border and to carotid with palpable thrill
Mid-Systolic ejection murmur;
crescendo-decrescendo
murmur shifts depending of severity of disease
Aortic Regurgitation PE findings
Best patient seated bent forward, aortic area/ erb's point
Early Diastolic blowing murmur
Widened pulse pressure
low diastolic pressure
Water-Hammer (corrigan) pulse
Sub-aortic Stenosis PE findings
Fibrosis Ring 1-4 cm below aortic valve causes murmur
Murmur fills systole; crescendo-decresendo
thrill often palpable during systole at apex and right sternal border
jugular venous pulses prominant
Pulmonic Stenosis
Systolic ejection murmur
radiates to left and into neck
S4 common in R ventricular hypertrophy
thrill in second and third intercostal spaces
Pulmonic Regurgitation
Difficult to distinguish from aortic regurgitation
Echo definitive in high pressure, but less definitive in low pressure
Tricuspid Stenosis
Diastolic rumble along left sternal boarder
increases with inspiration
jugular venous pulse prominent especially a wave. slow fall of v wave
Tricuspid Regurgitation
Heard best at left lower sternum
Holosystolic murmur, over right ventricle
Increases with inspiration (increased volume in R ventricle with negative pressure)
Systolic c-V wave in jugular venous pulsations
hypertrophic cardiomyopathy
Valsalva; increases (decreases venous return, decrease preload)
Squatting to standing; increases
standing to squatting; decreases
Leg elevation; decreases (increased venous return, increases preload)
A murmur from what type of shunt can be increased by hepatic reflex
Right to left shunt; due to increasing right atrial pressure
A murmur from what type of shunt will be decreased by hepatic reflex
Left to Right shunt; due to increasing right atrial pressure will disappear brefiely
Patent ductus arteriousus may be associate with what type of murmurs
murmur extends past S2 and occupy diastole and machine like quality
disappear in first 2-3 days of life when closes
sinus arrhythmia
physilogic during childhood.
Heart rate varies in cyclic pattern usually faster on inspiration and slower on expiration.
Normal newborn heart rate
120- 170 bpm
Normal 1 year old heart rate
80 -160 bpm
Normal 3 year old heart rate
80-120 bpm
Normal 6 year old heart rate
75 - 115 bpm
Normal 10 year old heart rate
70-110 bpm
What abnormal heart sound is more common in older adults?
S4, decreased left ventricular compliance
Bacterial Endocarditis
bacterial infection of the endothelial layer of the heart and valves.
S/S: Fever, fatigue, murmur, sudden onset of congestive heart failure.
PE: neurologic dysfuntion, janeway lessions; painful small erythematous or hemorrhagic macules on palms and soles
Congestive Heart Failure
Heart fails to propel blood forward with its usual force, resulting in congestion in pulmonary or systemic circulation.
Right or
Left sided systolic HF; narrow pulse pressure
Left sided diastolic HF; wide pulse pressure
Most helpful clinical finding in Left sided heart failure
Jugular venous distension
Pericarditis
Sudden inflammation of the pericardium
S/S; sharp stabbing chest pain, movement/inspiration aggravate pain, pain relieved by leaning forward
PE; friction rub on ascultation
Cardiac Tamponade
excessive accumulation of effused fluids or blood between the pericardium.
S/S; chest pain relieved by sitting upright and leaning forward, difficultly breathing, snycope, pale/gray or blue skin, palpitations, rapid breathing
PE;
Becks triad: 1. jugular v
Cor Pulmonale
Enlargement of right ventricle secondary to pulmonary malfunction.
Chronically caused by COPD
Acutly by acute respiratory distress syndrome
S/S; fatigue, tachypena, exertional dyspnea, cough, hemoptysis
PE; pulmonary disease, wheezes & crackles on auscult
Sick Sinus Syndrome
Arrhythmias caused by a malfunction of sinus node.
Tetralogy of Fallot
Four abnormalities:
1. stenotic pulmonary valve
2. ventricular septal defect
3. overriding aortic valve
4. hypertrophy of right ventricle
S/S; dyspnea with feeding, poor growth, exercise intolerance, paroxysysmal dyspnea with loss of consciousness & centr
Ventricular Septal Defect
opening between the left and right ventricles; many small defects close spontaneously during first 2 years of life
s/s: recurrent respiratory infections, large rapid breathing, poor growth and symptoms of CHF
PE; holosystolic murmur heard best along left
Atrial Septal Defect
congential defect int he septum dividing the left and right atrium.
S/S; often asymptomatic, heart failure rarely in children,but can occur in adults.
PE; systolic thrill, systolic ejection murmur over pulmonic area, may have breif rumbling early diastoli
Patent Ductus Arteriosus
failure of the ductus arteriosus to close after birth.
S/S; small shunt can be asymptomatic and larger one dyspnea on exertion.
PE; dilated pulsatile neck vessels, wide pulse pressure, harsh, loud continuous murmur heard at 1-3 intercostal space with mach
Kawaski Disease
Condition causing inflammation in walls of small and medium-sized arteries throughout the body including coronary arteries.
S/S; fever, lasting longer than 5 days, conjunctivitis, strawberry tongue, cervical lymphadenopathy, erythemia of palms and soles,
Pre-eclampsia
Hypertension after 20th week of pregnancy and presence of proteinurea
> 160 mmHg systolic, >110 mmHg diastolic
eclampsia
Hyptertension after the 20th week of pregnancy and presence of proteinurea with seizures with no other identifiable cause
> 160 mmHg systolic, >110 mmHg diastolic
Raynaud Phenomenon
exaggeration of digital arterioles usually to cold exposure.
Most common in young healthy women
s/s: area feels cold/achy white and blue with cold exposure and red with reprofusion
Secondary raynaud phenomenon
associated with underlying connective tissue disorder, scleroderma or systemic lupus.
PE; ulcers on tips of digits, can appear smooth shiny & tight from loss of subcutaneous tissue
Temperal arteritis (Giant Cell arteritis)
Inflammatory disease of the branches of the aortic arch including temporal arteries.
Can lead to ischemia of supplied structures (masseter, tongue or optic nerve).
S/S; flue like (low grade fever, malasie, anorexia), polymyalgia of hips/ shoulders, headac
List the measurements for edema
1+: slight pitting (2mm), no visible distortion disappears rapidly
2+:Somewhat deeper than 1 (4mm), no readily detectable distortion, disappears 10-15 sec
3+:notably deep pit (6mm) last longer than 1 min, dependent extremity looks fuller and swollen
4+: v
JVP distension
Normal value >9 cm
If cant see its under 5 cm
Calculate the number and add 5 cm
hepato-jugular reflex
exaggerated when right heart failure is present
apply pressure to liver, increase in JVP with pressure, decreases when released
Watter Hammer (Corrigan) Pulse
greater amplitude than expected, a rapid rise to a narrow sumit and sudden descent.
Patent ductus arteriosus
aortic regurgitation
Paradoxic Pulse
exaggerated decrease >10mmHg in amplitude of pulsation during inspiration and increased amplitude during expiration.
Premature cardiac contraction
Tracheobronchial obstruction
bronchial asthma
emphysema
pericardial effusion
constrictive pericarditis
Pulsus bisferiens
two main peaks.
Aortic stenosis combined with aortic insufficency
pulsus alterans
Alteration of small and large amplitude
Left ventricular failure; more significant if pulse is slow
Jugular veins reflect what
the right side of the heart and offer clues to its compensation.
Level of jugular venous pulse indicates Right Atrial pressure.
Jugular A wave
First most prominent wave, result of a brief back flow of blood to vena cava during Right Atrial contraction.
Jugular C wave
transmitted impulse from vigorus backward push produced by closer of the tricuspid valve during ventricular systole.
Jugular V wave
Increased volume and concomitant increased pressure in right atria, after c wave late in ventricular systole
Jugular X slope
after C wave, caused by passive atrial filling
Jugular Y slope
After v wave, open tricuspid valve and rapid ventricular filling