The PMI is also known as what?
(point of maximal impulse) or the apical pulse
Where is the PMI located?
Usually in the left 5th intercostal space
*if pregnant, it may be present in the 4th
Where is the apex and the base of the heart?
-The apex is at the bottom of the heart (PMI or AP)
-The base is the top of the heart
Where is S2 louder?
at the top or the base of the heart
Where is S1 louder?
at the bottom or the apex of the heart
What are the anatomical landmarks of the chest when discussing the cardiovascular system?
Midsternal line
Midclavicular line
Anterior axillary line
Midaxillary line
For CV, Which landmark divides the chest into two equal L/R sides?
Midsternal line
For CV, Which anatomical landmarks divide the L/R sides into two equal parts?
Midclavicular line
For CV, Which anatomical landmark is the the farthest away from the sternum?
Anterior axillary line (runs down the side of the body)
What is the sternal angle?
Where the menubrium and sternum come together? *where you measure for JVP
In CV, which anatomical landmark runs down the side of your body?
Midaxillary line
What is it called when the ventricles contract?
systole
What is it called when the ventricles refill?
diastole
WHen the RV pumps plood into the PA which valve is open?
pulmonic valve
WHen the LB pumps blood into the aorta, which valve is open?
aortic valve
Blood flows from the RA into the RV through what?
the tricuspid
Blood flows from the LA into the LV through what?
the mitral (bicuspid)
Where are the lubs and dubs?
The lub is directly before systole
The dub is after systole
When is it normal to hear an S3?
in children
An S4 may be heard in what type of patient?
an older patient
What are audible S3 and S4s indicative of in adults?
decreased ventricular compliance
Which section of the heart occupties the majority of the anterior cardiac surface?
RV
Which two sections of the heart are least likely to be identified on an exam?
RA and LA
What is the cause of the heart sounds?
The closing of valves makes vibrations
What are you hearing during S1?
mitral valve closing "lub
What are you hearing during S2?
aortic valve is closing "dub
S3 is also known as a what?
gallop
What are you hearing if you hear an S3?
diastolic filling - movement of blood against the ventricles
Describe what causes the pressure changes and valve openings for S1
-LA pressure is greater than LV pressure
-Blood then flows through MV into LV
-LV contracts so pressure is greater than LA
-MV shuts
Describe what causes the pressure changes and valve openings for S2
-LV pressure is greater than aortic pressure
aortic valve opens
-LV empties
-LV pressure drops below aortic pressure
-Aortic valve shuts
What is systolic blood pressure?
the maximum LV pressure
What creates your pulses?
pressure waves in the arteries
What is your pulse pressure?
Difference between systolic and diastolic
In people with heart failure, which valve is usually the first to go?
Mitral valve
An S3 sounds like what?
Kentucky
An S4 sounds like what?
Tennessee
What are you hearing if you hear an S4?
atrial contraction (pathologic indication of decreased ventricular compliance)
*expected with old people
If the S3 is dull and low-pitched, you should be able to hear it with which part of the stethoscope?
the bell
Where will you hear the S3 best?
PMI (Apex)
How/where is S4 best heard?
PMI with diaphragm
When a valve doesn't close well, what would you hear?
murmur
What are some causes of murmurs?
-Valve fails to close fully
-Valve leaks and regurgitates flow backward
-Abnormal narrowing that causes turbulent flow
With murmurs what do you want to note?
Timing - is it more systolic or diastolic
Children and young adults may have what kind of murmur?
Benign flow murmur
How do you know the difference between a murmur that is a problem and a benign flow murmur?
A benign flow murmur will change or disappear with position (would refer to a cardiac specialist to determine)
When might you hear a flow murmur in a child?
During a hyperdynamic state: FEVER
*murmur subsides when fever abates
What is the most common murmur?
mitral regurgitation
If you hear a continuous murmur in a child what would that be indicative of?
patent ductus arteriosus (exclusive to children)
What grade of a murmur is loud with a palpable thrill?
IV
What grade of murmur is faint?
II
What grad of murmur is loud with a palpable thrill, with stethoscope not on the chest?
VI
What grade of murmur is barely audible if listened to carefully?
I
What grade of murmur is moderately loud with no palpable thrill?
III
What grade of murmur is loud with palpable thrill and you barely need the stethoscope on the chest?
V
What are other things you want to note when describing a murmur?
Pitch: high, medium, low
Quality: blowing, harsh, rumbling, musical
Which node paces the heart?
SA node (60-100 bpm)
On an ECG, where is S1?
the top of the QRS complex
On an ECG, where is S2?
the end of the T wave
On an ECG, where is S3?
between the T wave and P wave (resting period)
On an ECG, where is S4?
the beginning of the QRS complex directly before S1
What is an index of Right heart pressure and cardiac function?
JVP
What would cause your JVP to fall?
loss of blood
What would cause your JVP to rise?
-R or L heart failure
-pulmonary HTN
-tricuspid stenosis
-Tamponade
What position should you be in to measure JVP?
45 degree angle with head turned to the left
How is JVP measured?
The height of the meniscus of the flutter of the internal jugular from the sternal angle.
What should the measurement of your JVP be?
less than 4 cm ANYTHING more is a problem
Hearing an S3 on someone over the age of 40 strongly suggests what?
CHF from volume overload of LV
What type of murmur would you be most likely to hear on an older adult?
mitral regurgitation
What are some CV changes in childbearing women?
-PMI may be slightly higher at 4th IC space
-Heart shifts up and left, apex moves laterally
-Venous hum is common during pregnancy
-Increase in blood volume
-Decrease in BP
With pregnant women what results due to the increase in blood volume?
the 30-40% increase increases stroke volume and cardiac output
What position should the patient be in for a CV exam?
supine with head elevated to 30*
Why is there a decrease in the BP of pregnant women?
peripheral vasodilation
In a child, which side of the heart has a higher pressure?
Right higher than Left in utero
An early midsystolic murmur, louder on left side would be what?
Carotid bruit
A murmur that is louder in diastole heard under the clavicle is called what?
venous hum
What is a normal change in heart rate/rhythm of a child that may speed up or slow down according to respirations?
Sinus dysrhythmia - normal finding
What type of murmur is heard early and midsystolic, on the mid/lower left sternal border?
Stills murmur
What type of murmur has to do with ejection in timing, and there is a crescendo/descrescendo between S1 and S2, and is heard on the upper left sternal border?
Pulmonary flow murmur
What complaint is the biggest cue to clue you in to a CV problem?
fatigue
What are other things you want to ask about on the CV ROS?
-Chest pain
-Palpitations/arrhythmias
-SOB
-Orthopnea
-dyspnea
-edema
-MI
-HTN
-Hyperlipidemia
-CAD
-Stroke
The JNC 7 assesses for what?
HTN
Where is the only place on the chest where pulsations would be normal?
PMI
JVP is not useful in what population?
children less than 12
Which pulse coincides with your S1?
Carotid
What are 3 descriptors of the upstroke of the carotid pulse?
Brisk
Delayed
Bounding
A brisk carotid pulse would mean what?
pulse is normal
A delayed upstroke on a carotid pulse would suggest what?
aortic stenosis
A bounding carotid pulse may suggest what?
aortic insufficiency
Other than inspect and palpate the carotid pulse with the patient's head elevated to 30*, what else do you want to do?
auscultate for bruits
What other position is helpful you if you couldn't palpate the PMI?
left lateral decubitus
What is usually easier to find when the patient is in Left Lateral Decubitus position?
-Palpate PMI
-Listen to the apex
-S3, S4 or murmurs not heard in other positions
At the apex, which is louder, S1 or S2?
S1>S2
At the base, which is louder, S1 or S2?
S2>S1
What is the order of positions for a CV assessment?
-Sup 30* (inspect/palpate)
-LLDecub (Palpate PMI, Listen with bell)
-Sup 30* (listen)
-Sitting, leaning forward (listen)
Space #1 is where?
Right 2nd intercostal space
What are you hearing in space #1?
aortic valve
Space #2 is where?
Left 2nd intercostal space
What are you hearing in space #2?
Pulmonic valve
Space #3 and 4 are where?
Left sternal border
What are you hearing in spaces #3 and 4?
tricuspid valve
Space #5 is where?
apex of the heart 5th intercostal space
What are you hearing in space #5?
mitral valve
If you have LV dysfunction, where would you most likely hear it?
Space #5
Which spaces do you listen to with the diaphragm?
All of them
Which spaces to listen to with the bell?
3, 4, and 5
What is a good way to distinguish between S1 and S2, while listening to heart sounds?
Keep your fingers on the carotid pulse, carotid pulse coincides with S1
What type of murmur is between S1 and S2?
Systolic murmur
Which type of murmur is between S2 and S1?
Diastolic murmur
Murmurs that coincide with the carotid pulse are what kind of murmurs?
systolic
What is it called when you have:
-Alternating loud and soft korotkoff sounds
-Force of arterial pulse alternates strong and weak
-Left sided heart failure
Pulsus alterans
What would help in hearing a systolic murmur of hypertrophic cardiomyopathy?
The sound would increase during the valsalva maneuver
A paradoxical pulse would indicate what?
-Tamponade
-pericardial restriction
Turbulent flow is also called what, and what does it indicate?
Bruits - indicates narrowing of the artery