List the areas of questioning to address during the health history of the cardiovascular system.
Chest pain, dyspnea, orthopnea, cough, fatigue, cyanosis or pallor, edema, nocturia, past cardiac history, family cardiac history, personal habits (cardiac risk factors)
What are the major risk factors associated with heart disease?
genetic, environmental and lifestyle factors: hypertension, smoking, serum cholesterol, obesity, type 2 DM.
How can these risk factors be assessed?
Obesity can be assessed by BMI test. Normal 18.5-24.9. Cholesterol normal- 120-200 mg abnormal- anything above 200.
Carotid artery pulsation
higher and medial to medial to muscle, brisk, localized, one wae per cycle, does not vary, palpable, no pressure changes, unaffected by position change.
Jugular vein pulsation
lower, more lateral, under or behing sternomastoid muscle, undulant and diffuse, two visible waves per cycle, varies with respiration. Its level descends during inspiration when intrathoacic pressure is decreased, not palpable, light pressure change at th
What is a bruit?
A bruit is a blowing, swishing sound indicating blood flow turbulence.
What does finding a bruit indicate?
Indicated turbulence due to a local vascular cause, such as atherosclerosis narrowing.
How do you assess for a carotid bruit?
Keep the neck in neutral position, lightly apply the bell of the stethoscope over the carotid artery at three levels 1. Angle of jaw 2. Midcervical area and 3.base of the neck. Ask to take a deep breath, exhale and hold it briefly while you listen so that
What is an apical impulse?
An apical pulse is a pulsation created as the left ventricle rotates against the chest wall during systole.
How is apical impulse assessed?
Point of maximal impulse (PMI)- using one finger pad, Ask the person to exhale then hold it. Patient may have to roll halfway to the left and it will displace it farther to the left.
What is the location of the apical impulse as a young child and as an older child/adult? What are the normal characteristics of the apical impulse?
Normal characteristics are at the fourth of fifth intercostal space and medial. Size should be 1x2 cm with a normal gentle tap amplitude and short normally first half of systole duration. In children it is at 4th ICS and adults it is 5th ICS.
Is there any other pulsations (besides apical impulse) that should be normally visible and/or palpable?
There shouldn't be any other visible or palpable pulsations.
What are the auscultation areas where you listen (traditional method) and their locations? In what order do you listen?
Aortic valve- 2nd ICS, right sternal border
Pulmonic valve- 2nd ICS, left sternal border
Erb's Point- 3rd ICS, left sternal border
Tricuspid valve- 5th ICS, left lower sternal border
Mitral valve- 5th ICS, Midclavicular line
What causes the heart sounds?
The closing of the AV and semilunar valves.
Describe the characteristics of the first heart sound and its intensity at the apex of the heart and at the base of the heart.
S1- "LUB"- Loudest at the apex and softer at the base.
What causes S1 heart sound?
the closing of the mitral and tricuspid valves.
What causes the first heart sound? What is the reason for the different intensity of the first heart sound at the apex and base? Which valve closes first?
S1 is louder at the apex because the AV valves are closer to the apex. The mitral valve closes before the tricuspid valve.
Describe the characteristics of the second heart sound and its intensity at the apex of the heart and at the base of the heart
S2- "Dub"- is the loudest at the base.
What is the reason for the different intensity of the second heart sound at the apex and base?
The closing of the semilunar valves causes the sound. It is louder at the base since the semilunar valves are closer to the base
What causes the second heart sound? Which valve closes first?
The aortic valve closes before the pulmonic valve although it combines to make one sound.
Explain the physiologic mechanism for normal splitting of S2. In what location on the heart would you expect to hear a split S2?
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.
How long should you take to count the apical pulse?
Auscultate for 60 seconds.
Define the third heart sound. When in the cardiac cycle does it occur? Describe its intensity, quality, location in which it is heard, and the method of auscultation. When is an S3 sound normal? When is an S3 sound abnormal?
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 adul
Define 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. When is S4 sound normal? When is an S4 sound abnormal?
It is heard right before S1 late in diastole and sounds like ventricular filling. Sounds like "da LUB-dub". It can be heard on the apex in the left lateral position. It is normal in people over the age of 40-50. Usually heard after exercise with no CV dis
Grading scale of the murmur.
-Grade 1. Barely audible
-Grade 2. Clearly audible, but faint
-Grade 3. Moderately loud, easy to hear
-Grade 4. Loud, associated with a thrill palpable on the chest wall
-Grade 5. Very loud, heard with one corner of the stethoscope lifted off the chest wa
What is an innocent or functional murmur?
Murmurs sometimes heard in children. Common first few days of life (usually grade 1 or 2. Many children have murmurs without heart disease.