dextrocardia
location of heart in right hemithorax, either by displacement from disease or congenital mirror-image reversal
S1
First heart sound, “Lubb”
Closure of the atrioventriclar valves (systole)
S2
Second heart sound, “Dubb”
Closure of semilunar valves (diastole)
S3
Passive filling of the ventricle during diastole
S4
Contraction of atria to complete filling of ventricle
Split S2
A2 then P2
Same events occur first on left, then right
Depolarization
Spread of stimulus through the heart muscle
Repolarization
Return of the stimulated heart to a resting state
P wave
spread of a stimulus through the atria (atrial depolarization)
PR Interval
The time from initial simulation of the atria to initial simulation of the ventricles
0.12-0.20 second
QRS Complex
Spread of a stimulus through the ventricles (ventricular depolarization)
Less than 0.10 second
ST segment and T wave
Return of stimulated ventricle muscle to a resting state (ventricular repolarization)
U wave
small deflection sometimes seen just after the T wave
QT Interval
Time elapsed from the onset of ventricular depolarization until the completion of ventricular repolarization. The interval varies with the cardiac rate.
Fetal heart circulation
Umbilical vessels compensate for nonfunctioning lungs
Blood flows right to left atrium via foramen ovale
Right ventricle pumps blood through the patent ductus ateriosus
Changes of fetal circulation at birth
Closure of ductus arteriosus within 24 to 48 hours after birth
Maternal cardiac
Blood volume increases 40-50%, mainly due to increase in plasma volume
CO increases 30-40%
Anginal CP
Substernal, provoked by effort, relieved by rest
Pleural CP
Precipitated by breathing or coughing, sharp, present during respiration, absent when breath held
Esophageal CP
Burning, substernal, occasional radiation to shoulder, nocturnal, usually lying flat
Relieved with food, antacids
CP from peptic ulcer
Infradiaphragmatic and epigastric, nocturnal occurence and daytime attack relieved by food
Biliary CP
Under right scapula, occurs after eating
Will trigger angina more often than mimic it
Arthritis/Bursitis
Lasts for hours, local tenderness and/or pain with movement
Cervical
Assc with injury, provoked by activity, painful on palpation/movement
Musculoskeletal CP
Provoked by movement, particularly twisting or costochondral bending, assc with focal tenderness
Psychoneurotic
After anxiety, poorly described, located intramammary region
Cardiac Inspection
Apical Impulse-miclavicular, 5th left intercostal
Look for cyanosis, venous distension
Heave or Lift
Vigorous apical impulse, forceful, widely distributed, fills systole or is displaced laterally and downward
Thrill
fine, palpable, rushing vibration, palpable murmur
Usually related to defect in closure of semilunar valves (aortic or pulmonic stenosis)
Aortic Valve Area
2nd right intercostal space at right sternal border
Pulmonic Valve Area
2nd left intercostal space, left sternal border
Second pulmonic area
3rd left intercostal space, left sternal border
Tricuspid area
4th left intercostal space, lower left sternal border
Mitral (apical) area
Apex of heart in 5th left intercostal space, midclavicular
Mitral Stenosis
Bell at apex, left lateral ducbitus
Narrowed valve restricts forward flow, forceful ejection into ventricle
Aortic Stenosis
Aortic area, ejection sound 2nd right intercoastal
Restricts forward flow, forceful ejection into aorta
Subaortic Stenosis
Apex, left sternal border
Fibrous ring below aortic valve
Pulmonic Stenosis
Pulmonic area, radiates left and into neck, thrill in 2nd and 3rd intercostals
Restricts forward flow, almost always congenital
Tricuspid Stenosis
Bell, tricuspid area
Restricts forward flow, forceful ejection
Mitral Regurgitation
Apex, high pitched, parasystolic murmur transmitted to left axilla
Valve incompetence allows backflow from ventricle to atrium
Mitral Valve Prolapse
Apex and left lower sternal border. Listen with patient upright
prolapses into atrium later in systole, develops into a holosystolic murmur
Aortic Regurgitation
Diaphragm, patient sitting and leaning forward
Austin Flint heard with bell, 2nd intercostal
Valve incompetence allows backflow into aorta
Pulmonic regurgitation
Valve incompetence allows backflow from PA into ventricle
Difficult to distinguish on physical exam
Tricuspid regurgitation
Left lower sternum, holosytolic murmur
Valve incompetence allows backflow from ventricle to atrium
Heart rates of children
Newborn 120-170 1 year 80-160 3 years 80-120 6 years 75-115 10 years 70-110
Systolic ejection murmur in pregnany
heard in pulmonic area in over 90%
Should not be louder than grade II
Bacterial endocarditis
bacterial infection of endothelial layer of heart and valves
fever, murmur, neuro dysfunction
Janeway lesions, osler nodes
CHF
Heart fails to propel blood
Systolic CHF= narrow pulse pressure
Diastolic CHF= wide pulse pressure
Pericarditis
Sudden inflammation of pericardium
Can result in cardiac tamponade, friction rub
Cardiac Tamponade
Excessive accumulation of fluids/blood between pericardium
Constrains cardiac relaxation, impairs access of blood to right heart, Becks triad
Becks Triad
JVD, hypotension, muffled heart sounds
Cor Pulmonale
Enlargement of right ventricle secondary to pulmonary malfunction
Usually chronic= COPD
Acute cause= PE, ARDS
Crackles, cyanosis, parasternal systolic heave
Myocardial Infarction
Ischemic myocardial necrosis by abrupt decrease in coronary blood flow
S4, thready pulse, soft systolic blowing apical murmur
Myocarditis
Focal or diffuse inflammation of the myocardium
Results from infection, toxin, autoimmune
Cardiac enlargement, murmurs, pulsus alternans, gallop rhythms
Tetralogy of Fallot
4 defect: VSD, pulmonic stenosis, dextroposition of the aorta, right ventricular hypertrophy
“Tetralogy Spell”=paroxysmal dypnea, loss of conciousness and central cyanosis
Ventricular Septal Defect
Opening between left and right ventricles
30-50% close spontaneously
Holosystolic murmur, s/s chf
Patent Ductus Arteriosus
Failure of ductus arteriosus to close after birth
Blood flows through ductus during systole and diastole, increases pulmonary pressure and workload on right heart
Atrial Septal Defect
Congenital Defect in septum dividing left and right atria
Brief, early, rumbling murmur
Acute Rheumatic Fever
Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection
Mitral regurg, aortic insufficiency, CHF, friction rub
Kawasaki Disease
Inflammation in walls of small and medium-sized arteries throughout the body, including coronaries
Diagnosis: Fever 5+ days and 4/5 of the following
Painless bulbar conjunctival lesion without exudate
Changes in extremities (erythema, edema, desquamation)
Polymorphous erythematous rash of trunk and extremities
Changes in lips and oral cavitiy, “strawberry” tongue
Cervical lymphadenopathy, usually unilateral
Atherosclerotic Heart Disease
deposition of cholesterol, complex inflammatory process
Senile Cardiac Amyloidosis
Amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease
s/s heart failure. small. thickened left ventricle
Aortic Sclerosis
Thickening and calcification of aortic valves
Midsystolic ejection murmur