Cardiac Flashcards
(66 cards)
1
Q
What is Dyspnea?
A
Shortness of breath
2
Q
What is Orthopnea?
A
Shortness of breath with lying down
3
Q
What is Paroxysmal Nocturnal Dyspnea – PND
A
Waking up suddenly from sleep with SOB
4
Q
What is Peripheral edema?
A
Swelling in the legs
5
Q
What is Claudication?
A
Pain in the calves with walking
6
Q
What is the BP goal in patients with diabetes or chronic kidney disease?
A
< 130/80 mmHg
Note:
Categorization is based on whichever category is higher – if systolic is prehypertension and diastolic is stage 1 hypertension, the patient has stage 1 hypertension
7
Q
What is a normal breathing rate?
A
Normal adult is 14 – 20 respirations (or less)
Infant rate may be as high as 44
8
Q
Temperature averages
A
- Oral temperature: 98.6 F (37 C)
- Fluctuates throughout the day
- Morning, may be 96.40F
- Evening, may be 99.10F
- Fever is > 100 F (often stated as > 100.4 F)
9
Q
How do Rectal, Axillary, and Tympanic temp differ?
A
- Rectal temp is higher 0.7-0.9 F
- Axillary temps are lower by about 1 F
- Tympanic temp measures core temp – usually higher than oral temp by ≈ 1.4 F
- May be lower if cerumen in auditory canal
-In general – rectal and tympanic are 1 degree higher than oral, axillary is 1 degree lower
10
Q
Anatomy of the heart… Base and Apex
A
-Superior aspect, where the great vessels originate is “base”of the heart
- Inferiolateral tip of left ventricle is termed cardiac “apex”
- Produces apical impulse, which is normally the point of maximal impulse (PMI)
11
Q
What are the valves of the heart?
A
Atrioventricular valves
- Mitral
- Tricuspid (3 cusps)
Semilunar valves
- Aortic
- Pulmonic
12
Q
What are you looking for when inspecting the chest wall and neck during a Cardiac exam?
A
Inspect the chest wall for:
-Apical impulse –> Point of maximal impulse (PMI)
Inspect the neck for :
- Jugular venous distention (JVD)
- Jugular venous pulsations
13
Q
Define a murmur
A
Heart sounds that are produced as a result of turbulent blood flow
14
Q
Thrill (or vibration)
A
- A palpable murmur, usually due to vibrations that accompany loud murmurs
- May be caused by vigorous blood flow through any narrowed opening (e.g. aortic stenosis, ventricular septal defect, etc.)
15
Q
Lift (or Heave)
A
- When the cardiac impulse (e.g. apical impulse) feels more vigorous than normal and can be felt through the chest wall
- May be caused by ventricular hypertrophy or hyperdynamic ventricular activity
16
Q
What is the precordium?
A
-Precordium - front of the chest wall that overlays the heart and epigastrium
- Will be palpating apex and Left Sternal Border (LSB) and base
- Examine with pt supine or in left lateral decubitus position (on left side)
17
Q
What are you looking for when you palpate the precordium?
A
- Examine for PMI (point of maximal impulse) –> In “normal” patient, this will be the apical impulse (located at apex)
- Apical Impulse: represents pulsation of the left ventricle (normally the PMI)
18
Q
How do you palpate the precordium?
A
1) Place right hand on chest, with heel of hand on lower sternum and fingertips at apex
2) Locate apical impulse (normally at 5th ICS in MCL)
– Note location and size
- If apical impulse is lateral to MCL or larger than 2.5 cm diameter (or width of 1 intercostal space), suggests left ventricular enlargement
- Apical impulse (apex beat) palpable in 25-40% of healthy adults in supine position; palpable in 50% in left lateral decubitus position
19
Q
What are you looking for when you palpate at the Left Sternal Border (LSB) and Base?
A
- Check for lifts (heaves) and thrills (vibrations)
- RVH will show a “parasternal lift” at LSB
20
Q
Describe percussion (Special test) during a Cardiac exam
A
-Percussion can give an estimate of cardiac size
- Begin at about 5th ICS in the midaxillary line and percuss medially; listen for onset of dullness (the heart)
- “LBCD 2 cm lateral to MCL in 5th ICS” AKA “left border of cardiac dullness is 2 cm lateral to the midclavicular line in the 5th ICS”
-More useful/evident with cardiac pathology –>
cardiomegaly, pericardial effusion, etc.
21
Q
Give me the steps for the Cardiac exam we have to do for our practical.
A
- With patient seated
1) Auscultate heart with diaphragm (4 areas / 5 locations)
2) Auscultate heart with bell (4 areas / 5 locations) - With patient supine
3) Inspect chest wall for PMI (with verbalization)
4) Palpate precordium –> area overlying heart and lower chest /epigastrium (with verbalization)
5) Auscultate heart with diaphragm (4 areas / 5 locations)
6) Auscultate heart with bell (4 areas / 5 locations)
7) Verbalize palpation of axillary lymph nodes
22
Q
Which part of the Stethoscope do you use to detect the different “Sounds” (S)
A
- Diaphragm best for high pitch sounds (S1, S2)
- Bell best for low pitch sounds (S3, S4 if present)
23
Q
What are the Body Positions during the Cardiac exam?
A
- Sitting
- Sitting, leaning forward
- Supine
- Left lateral decubitus
- Standing and squatting
24
Q
Better to describe location of auscultation of the “cardiac areas”
A
Aortic – 2nd ICS, RSB Pulmonic – 2nd ICS, LSB Second Pulmonic – 3rd ICS, LSB (Erb’s Point) Tricuspid – 4th and 5th ICS, LSB Mitral (apex) – 5th ICS, MCL
25
How do you conduct auscultation while sitting/leaning forward?
Sitting up:
- Ask patient to breathe quietly
- Auscultate in the 4 cardiac regions (5 locations)
Sitting, leaning forward (Special test)
- Ask patient to exhale completely and stop breathing in exhalation
- Auscultate with diaphragm and bell at base (and LSB and apex)
- Accentuates soft aortic murmurs (e.g. aortic regurg)
26
How do you conduct auscultation while Supine/L. lateral decubitus?
Supine:
- Examine all 4 areas with the diaphragm and the bell
- Inch – don’t jump – your way through the exam
L. lateral decubitus (Special test)
- Brings L. ventricle close to chest
- Place bell lightly on apical impulse (apex)
- Accentuates L. sided S3, S4 (low pitch) and mitral murmurs (e.g. mitral stenosis)
27
What produces the First Heart Sound (S1)?
- Closure of mitral and tricuspid valves during Systole
- Contraction of ventricles --> aortic and pulmonic valves forced open and blood is ejected into arteries --> Closure of mitral and tricuspid valves produces the S1 sound “lub”
- Best heard at the Apex
- Carotid upstroke occurs just after S1
28
What produces the Second Heart Sound (S2)?
- Closure of the aortic and pulmonic valves during Diastole
- Relaxation of heart
- Ventricles start to refill mitral and tricuspid valves open
- Closure of the aortic and pulmonic valves produces the S2 sound “dub”
- Best heard at the base
- Carotid upstroke occurs before S2
- S1 –> carotid upstroke –> S2)
29
Describe Splitting of S2 during inspiration
* **Normal split during inspiration***
- Listen in 2nd and 3rd ICS (pulmonic area)
- Inspiration increases R. heart filling → increases R. ventricle stroke volume → R. ventricle ejection is longer compared to left
- “Physiologic splitting of S2”
- You hear S1 first and instead of hearing S2 after that, you hear a "splitting," which is comprised of the Aortic valve closing then the Pulmonary valve closing RIGHT after.
- S1 + (A2+P2)
30
Describe Splitting of S2 during expiration
- Listen in 2nd and 3rd ICS (pulmonic area)
- Split heard during expiration suggests pathology
- Pathologic splits due to delay in closure of pulmonic valve:
- Pulmonic stenosis
- Right ventricular heart failure
- Right bundle branch block
31
Describe the Third Heart Sound (S3)
- Low-pitch sound created in early diastole by early passive rapid filling of the ventricles with blood from the atria
- S3 is produced by the rapid distension of the ventricular walls, causing vibration
- Low-pitch, heard best with bell at apex
- Sounds like: “FUCK…you’re screwed”
- S1 + S2 + S3 = ventricular gallop rhythm
32
When would one hear the Third Heart Sound (S3)?
- May be normal in children / young adults
- In adults (>40), usu. indicates pathologic change of ventricular compliance (e.g. assoc. with congestive heart failure)
33
Describe the Fourth Heart Sound (S4)
- Sound created by 2nd phase of ventricular filling as the ATRIA CONTRACT and eject blood into the ventricles (during the “atrial kick”)
- S4 may be produced during this phase, as the rush of blood causes vibration of valves, papillary muscles, and ventricular walls
- Low pitch, best heard with bell, at apex
- Sounds like “well FUCK…you”
- S1+S2+S4 = atrial gallop rhythm
34
When would one hear the Fourth Heart Sound (S4)?
- Uncommon in healthy adults
- But may be normal for some older individuals (if no other heart disease)
- Pathologic due to resistance to ventricular filling; stiffness of heart muscle (reduced compliance)
- HTN, CAD, Aortic Stenosis, Cardiomyopathy
- Right-sided S4 from pulmonary HTN or pulmonary stenosis
35
What are some Irregular Rhythms that can be heard during Cardiac auscultation?
1) Rhythmically or sporadically irregular
2) Regularly irregular
3) Irregularly irregular
4) Irregular rhythms may also be fast or slow
36
Give me an example of something that would cause a Rhythmically or sporadically irregular beat
- Premature atrial contractions (PAC’s)
| - Premature ventricular contractions (PVC’s)
37
Describe and give me an example of something that would cause a Regularly irregular beat
-Variation between two R-R intervals is > 0.04 with the appearance of a repeating pattern (second degree blocks)
38
Describe and give me an example of something that would cause a Irregularly irregular beat
- Variation between two R-R intervals is > 0.04 with no repeating pattern
- Atrial fibrillation
39
Give me an example of something that would cause a Irregular rhythms may also be fast or slow beat
-Atrial fibrillation with rapid ventricular response
40
Valvular stenosis
- occurs when a heart valve becomes narrowed
- This prevents the valve from fully opening and therefore obstructs blood flow – causing turbulent flow through the valve
41
Valvular regurgitation (insufficiency)
- occurs when the leaflets do not close completely, letting blood leak backward across the valve
- This backward flow is referred to as “regurgitant flow”
42
Mitral valve prolapse (MVP)
- due to ballooning of the mitral leaflet(s) into the left atrium during systole
- Mid-late systolic “click(s)” are often present
- Variable pitch
- Mitral regurgitation may also occur
- Common condition > 5% of general population; usually benign
43
Valvular sclerosis
-hardening / thickening of a valve (e.g. aortic sclerosis)
- Recall that stenosis is narrowing of the valve
- Sclerosis and stenosis can occur together
44
Septal defect
is a hole in the septum separating chambers of the heart
45
Patent ductus arteriosus
occurs when a neonate’s ductus arteriosus fails to close after birth
Results in abnormal connection between the aorta and pulmonary artery
46
Coarctation of the aorta
- A narrowing of part of the aorta.
| - Congenital (present at birth)
47
Hypertrophic cardiomyopathy (HCM)
- A portion of the heart muscle becomes hypertrophied (thickened) without any obvious cause
- Autosomal dominant inheritance
- Well-known as the leading cause of sudden cardiac death in young athletes
- Many with HCM live normal, healthy life
48
What are the Cardiac auscultation Murmur characteristics
1. Timing (where in the cardiac cycle, e.g. mid-systolic)
2. Location and radiation (where murmur is heard best and where it radiates – “classically” an aortic murmur is heard best at the aortic position)
3. Shape (e.g. crescendo-decrescendo)
4. Intensity (gradation – how loud)
5. Pitch (e.g. high)
6. Quality (e.g. harsh)
7. Response to maneuvers
49
What are the Cardiac auscultation Gradations of murmurs
Grade 1/6: Barely audible in quiet room
Grade 2/6: Quiet but clearly audible
Grade 3/6: Moderately loud
Grade 4/6: Loud, associated with thrill
Grade 5/6: Very loud, heard with stethoscope
partially off chest; obvious thrill
Grade 6/6: Very loud, heard with stethoscope
entirely off the chest, obvious thrill
50
Define Systolic murmurs
occur between S1 and S2 and are associated with ventricular ejection (systole)
1. Aortic and pulmonic stenosis (these valves open during systole)
2. Mitral and tricuspid regurg (these valves closed during systole)
51
Describe Mid-systolic murmurs
- typically have a crescendo-decrescendo character (start softly, become loudest near mid-systole, followed by decrease in sound amplitude
- Can result from aortic or pulmonic stenosis
52
Describe Holosystolic (sometimes called pansystolic)
- have a high amplitude throughout systole
| - Can result from mitral or tricuspid regurgitation or from ventricular septal defect
53
Describe Innocent systolic murmurs
- Result from turbulent blood flow, but no valvular narrowing or obstruction
- There is no evidence of cardiac disease
- Usually grade 1-2, rarely 3/6
- May decrease or disappear with sitting
- Common in children and young adults
- Physiologic in pregnancy, anemia, fever, hyperthyroidism (hyperdynamic states / increased flow across valves)
54
Describe Still’s murmur (aka vibratory murmur)
- A Innocent systolic murmurs
- Common benign pediatric heart murmur (usu. heard in children ages 2-5 – usu. Disappears with age)
- Cause unknown, but no assoc. heart defect
- Mid-systolic
- Best heard at lower LSB
- Louder when patient is supine
- Low pitch, musical quality
55
Describe Diastolic murmurs
-Occur after S2 and are associated with ventricular relaxation and filling (diastole)
- Aortic and pulmonic regurgitation
- Mitral and tricuspid stenosis
- Majority of diastolic murmurs are due to aortic regurg
- They can occur early (e.g., regurgitation), mid-diastolic, or late diastolic (e.g., stenosis)
- Almost always indicate valvular disease (vs some systolic murmurs which can occur with normal valves)
56
Summary of Systolic murmurs
```
Systolic
Aortic or pulmonic stenosis
Mid-systolic
Mitral or tricuspid regurg (insufficiency); VSD
Holosystolic
```
57
Summary of Diastolic murmurs
Diastolic
Aortic or pulmonic regurg (insufficiency)
Early diastolic
*Majority of diastolic murmurs in US are aortic regurg
Mitral or tricuspid stenosis
Mid to late diastolic
58
What effect does a squatting valsalva maneuver (Release Phase) have on the cardio vascular system?
- Increases left Vent volume (from increased venous return)
| - Increased vasculature tone (from increased blood pressure)
59
What effect does a squatting valsalva maneuver (Release Phase) have on Mitral Valve Prolapse?
- Decreases the prolapse of the valve
- Delays click
- Murmur shortens
60
What effect does a squatting valsalva maneuver (Release Phase) have on Hypertrophic Cardiomyopathy?
- Decreased outflow obstruction
| - Decreased intensity of murmur
61
What effect does a squatting valsalva maneuver (Release Phase) have on Aortic stenosis?
- Increase flood volume ejected
| - Increased intensity of murmur
62
What effect does a standing valsalva maneuver (Strain Phase) have on the cardio vascular system?
- Decreased left Vent volume (from Decreased venous return)
| - Decreased vasculature tone (from Decreased blood pressure)
63
What effect does a standing valsalva maneuver (Strain Phase) have on Mitral Valve Prolapse?
- Increases the prolapse of the valve
- Click moves earlier
- Murmur lengthens
64
What effect does a standing valsalva maneuver (Strain Phase) have on Hypertrophic Cardiomyopathy?
- Increase outflow obstruction
| - Increase intensity of murmur
65
What effect does a standing valsalva maneuver (Strain Phase) have on Aortic stenosis?
- Decreased flood volume ejected
| - Decreased intensity of murmur
66
Cardiac abbreviations. RRR, NSR, MRG, ICS, m in a circle
```
RRR= regular rate and rhythm
NSR= normal sinus rhythm
MRG= murmurs, rubs, gallops
ICS= intercostal space
m in a circle = murmur
```
