Cardiac Exam

Question 1

Pericardium

Answer 1

Location: fibrous sac that holds the heart; contains the heart, roots of great vessels, and pericardial fluid
Function: protects, lubricates, and fixes heart in place

Question 2

Right Ventricle

Answer 2

Ventricles receive blood from atria and strongly pump it out during systole. Muscular. Oomph of heart.
Location: Right bottom of heart
Function: Receives blood from RA, pumps to lungs via pulmonary artery

Question 3

Left Ventricle

Answer 3

Location: Left bottom of heart
Function: Receives blood from LA, pumps blood to aorta/body

Question 4

Right Atrium

Answer 4

Atria receive blood from the circulation (body & lungs) and drain into ventricles. Thin walled, reservoirs
Location: Top right of heart
Function: receives deoxygenated blood from the body/vena cavae

Question 5

Left Atrium

Answer 5

Location: Left top of heart
Function: receives oxygenated blood from the pulmonary circulation via pulmonary veins

Question 6

Aortic Valve

Answer 6

Location: Between LV and ascending aorta
Function: forced open in systole, prevents blood from flowing backward from the aorta into the LV (3 leaves)

Question 7

Pulmonic Valve

Answer 7

Location: Between RV and pulmonary artery
Function: forced open in systole, prevents blood from flowing backward from the pulmonary artery into the RV (3 leaves)

Question 8

The great vessels

Answer 8

Superior Vena Cava
Inferior Vena Cava
Pulmonary Artery
Pulmonary Veins
Aorta
Function: bring blood to and from heart

Question 9

Apex

Answer 9

Location: lower ‘tip’ of the heart; most downward, forward aspect of the heart. Tip of the LV; behind the 5th left intercostal space, midclavicular, just below nipple
muscle fibers in apex are primarily responsible for regulating ventricle contraction and play role in transmitting signals from atrial nodes

Question 10

Base

Answer 10

Location: opposite the apex; most posterior section. LA, and some of the RA, and inferior and superior vena cava and pulmonary veins

Question 11

Precordium

Answer 11

Location: area on the anterior chest overlying the heart and lower thorax
Function: where heart contraction can be palpated and auscultated

Question 12

Tricuspid Valve

Answer 12

Location: 3 leaves, separates RA and LV
Function: Deoxygenated blood from the IVC collects in the RA, tricuspid valve opens on diastole and allows blood to flow in the RV

Question 13

Mitral Valve

Answer 13

Location: 2 leaves, separates the LA from the LV
Function:regulate blood flow from LA to LV

Question 14

Blood flow through heart during Systole

Answer 14

Semilunar valves (aortic and pulmonary) open when ventricles contract; blood flows to pulmonary artery via the RV and to aorta via the LV; ventricular contraction and atrial refilling (occurs about the same time)

Question 15

Blood flow through the heart during Diastole

Answer 15

Atrioventricular valves (tricuspid and mitral) open, blood flows into the ventricles, passively, ventricles fill, atria contract to eject remaining blood

Question 16

Wigger’s Diagram

Answer 16

DRAW

Question 17

Preload

Answer 17

the initial stretching of the cardiac myocytes prior to contraction

Question 18

Afterload

Answer 18

can be thought of as the ‘load’ that the heart must eject blood against closely related to aortic pressure

Question 19

Systole

Answer 19

the part of the cardiac cycle during which the heart contracts, particularly the ventricles, resulting in a forceful flow of blood into both the systemic and pulmonary circulations

Question 20

Diastole

Answer 20

the time between two contractions of the heart when the muscles relax, allowing the chambers to fill with blood; diastole of the atria precedes that of the ventricles; diastole alternatives, usually in a regular rhythm, with systole.

Question 21

S1

Answer 21

Produced by the closure of the mitral and tricuspid valves
Indicates beginning of systole
Loudest over the apex of the heart (use diaphragm)

Question 22

S2

Answer 22

Produced by the closure of the aortic and pulmonic valves
Indicates beginning of diastole
Loudest at pulmonic and aortic valves (use diaphragm)

Question 23

S3

Answer 23

Passive filling of ventricles during diastole

Best heard in left lateral decubitus position

Question 24

S4

Answer 24

Second phase of ventricular filling

Contraction of atria to insure all blood was drained into vesicles

Question 25

Murmur

Answer 25

caused by abnormal turbulent flow when a valve is stenotic or damaged

Question 26

Bruit

Answer 26

an unexpected audible swishing sound or murmur over an artery or vascular organ

Question 27

Point of maximal impulse (PMI)

Answer 27

Usually generated by the apex, but it may be produced by an enlarged or hypertrophied RV, a dilated aorta or pulmonary artery or an LV wall motion abnormality

Question 28

Thrill

Answer 28

palpable murmur

Question 29

Heave/lift

Answer 29

Can be caused by a number of abnormalities. Heave (more pronounced lift) Lift (RV hypertrophy)

Question 30

Situs inversus/ dextrocardia

Answer 30

the inversion or transposition of the body viscera so that the heart is on the right and the liver is on the left; the chest and abdominal contents become mirror images of the usual

Question 31

S3 Gallop

Answer 31

S3 may be heard if blood volume transferred is abnormally large, as in Mitral regurgitation. S3: the sound the ventricle makes when it is forced to dilate beyond its normal range due to volume overload in the atria (ex: heart failure). Conditions of high cardiac output (ex: thyrotoxicosis, severe anemia) can also cause an S3 gallop

Question 32

Rub

Answer 32

A sound audible through the stethoscope, resulting from the rubbing of opposed inflamed serous surfaces (pericarditis)

Question 33

Click

Answer 33

classic finding in mitral valve prolapse. Usually heard during mid or late systole, accompanied with a late systolic murmur indicate of mitral regurgitation

Question 34

Snap

Answer 34

Commonly associated with aortic stenosis (or MV stenosis).

Question 35

Ejection Sounds

Answer 35

The opening of the semilunar valves is usually silent. Abnormal dilation or calcification of the aortic and pulmonic valves can cause an abnormal early systolic ejection sound as they open during systole.

Question 36

Electrical conduction system of the heart & Cardiac cycle

Answer 36

See objectives

Question 37

Surface anatomy pertinent to Internal structures of the heart

Answer 37

See Picture**Aortic, pulmonic, Erb's point, tricuspid, and mitral focuses

Question 38

Inspection (CV Exam)

Answer 38

``` Acute cardiac distress (cyanosis, diaphoresis, pallor, temp., difficulty breathing, anxiety, Levine's sign - clutching fist over chest) Chronic heart conditions (clubbing, xanthelasma - yellow, waxy deposits on extremities and around eyes do to increased cholesterol, Obesity or coarction - underdeveloped lower extremities) Apical impulse (not normally seen while supine, may need light) ```

Question 39

Auscultation (CV Exam)

Answer 39

- Listen to all areas with patient upright, supine and left lateral recumbent. - Upright: leaning forward = best to hear S2 and aortic murmurs - LL recumbent = best to hear S1, mitral murmurs, and low-pitched diastole filling sounds - Bell and Diaphragm - 5 locations: Aortic, pulmonic, Erb's, Tricuspid, and Mitral

Question 40

Palpation (CV Exam)

Answer 40

Patient elevated 30 degrees, carotid pulse to detect timing of systole, palpate PMI (apical pulse) Checking for lifts, heaves, thrills

Question 41

Assessment of cardiac rate and rhythm

Answer 41

Rate/Rhythm Assess during auscultation, compare with peripheral arterial pulse. S1 and S2 to determine rhythm

Question 42

Percussion (CV Exam)

Answer 42

Not greatly helpful in determining borders do to chest distortion Can attempt by listening to change from resonant to dull

Question 43

Fixed splitting

Answer 43

Splitting of sounds A2 and P2 that is wide and there is no variation with respirations. Examples: atrial septal defect and right ventricular failure

Question 44

Paradoxic splitting

Answer 44

during respiration there is a delay in the closure of the aortic valve (A2) creating an inconsistent movement of A2 and P2. The sounds are separate during expiration and sound closer together during inspiration. Example: Left bundle branch block.

Question 45

Chest pain

Answer 45

Many differential dx's! Angina pectoris (pressure sensation sub-sternal), Levine's sign (ischemic pain), When associated with breathing (pleuritic chest pain), In children seldom due to cardiac problem, When it's a constant all day ache or a sharp jab that lasts 1-2 seconds (generally not related to heart)

Question 46

Fatigue

Answer 46

Worse with exertion, unable to keep up with peers, persistent chronic hypoxia, body working hard to compensate

Question 47

Dyspnea

Answer 47

Difficult/ labored breathing w/shortness of breath, worse with exertion, better w/ rest or propped up pillow, increases w/ severity of pulmonary and cardiovascular disease

Question 48

Diaphoresis

Answer 48

Often with anxiety, sympathetic response to stress, seen in MIs

Question 49

Syncope

Answer 49

Fainting, temporary loss of consciousness, brief lack of blood flow to brain, also associated with palpations, exertion, dysrhythmia, sudden neck turn, change in posture, common CV symptom in older patients, seen in hypovolemia, low BP, bradycardia, and valve stenosis

Question 50

Cyanosis

Answer 50

Due to hypoxia, nails (peripheral cyanosis occurs first), Periorbital (in kids esp. during eating), also in kids: characteristic of congenital heart defects allowing mix of arterial and venous blood or prevented oxygenated blood

Question 51

Cough

Answer 51

Dry, wet, nighttime, worse lying down, maybe associated with vascular disease

Question 52

Orthopnea

Answer 52

Shortness of breath that begins or increases with lying down, relieved by sitting or standing. Ask if patient sleeps with pillows propping, associated with heart failure

Question 53

Claudication

Answer 53

Pain, burning, fatigue in legs/butt, occurs with walking, better with rest, symptoms of narrowing of artery or blockage, may be able to hear bruit (atherosclerosis is the most common cause of arterial blockage which can cause claudication)

Question 54

Paroxysmal nocturnal dyspnea

Answer 54

Sudden onset of shortness of breath after a period of sleep, issues with pulmonary function related to CV disease, congestion, better with sitting up

Question 55

Xanthelasma

Answer 55

Yellow, waxy deposits around eyes, occurs with extreme hypercholesterolemia, hyperlipidemia, which are related to CV health risks

Question 56

Additional organ system to examine CV complaint

Answer 56

Respiratory and Peripheral Vascular Musculoskeletal (shoulder joint dysfunction, xiphoidynia), GI system (heartburn, peptic ulcer, cholecystitis), Psychoneurotic (anxiety, drug use, herpes zoster)

Question 57

Hypotension

Answer 57

low blood pressure

Question 58

Postural/ orthostatic hypotension

Answer 58

abnormal decrease in blood pressure from sitting to standing; decrease >20mmHg systolic or >10 diastolic

Question 59

Hypertension - systolic/diastolic

Answer 59

high blood pressure Stage 1: >140/90 - 159/99 Stage 2: >160/100

Question 60

Normotension

Answer 60

Normal blood pressure

Question 61

Murmur - Timing and duration

Answer 61

Between S1 and S2, or S2 and S1? | Short or prolonged:

Question 62

Murmur - Pitch

Answer 62

High, medium, or low? Bell or diaphragm?

Question 63

Murmur - Intensity

Answer 63

Grade 1: faint, intermittent Grade 2: quiet but easy to hear Grade 3: moderately loud, no palpable thrill Grade 4: loud, PALPABLE THRILL Grade 5: loud, palpable thrill, can hear with stethoscope barely touching chest Grade 6: very loud, palpable thrill, can hear with stethoscope off chest

Question 64

Murmur - Pattern

Answer 64

Crescendo: increased blood velocity Decrescendo: decreased blood velocity Square/plateau: constant intensity

Question 65

Murmur - Location

Answer 65

Where is it auscultated best?

Question 66

Murmur - Radiation

Answer 66

Do you hear it only over the specific valve or elsewhere? Sound generally transmitted in direction of blood flow

Question 67

Murmur - Respiratory phase variations

Answer 67

Impacted by inspiration/expiration? Variation of intensity, quality, timing? (If venous issue, variation increase with inspiration and decrease with expiration)

Question 68

Superior Vena Cava

Answer 68

Routes deoxygenated blood from the head/neck/upper extremities into the RA

Question 69

Inferior Vena Cava

Answer 69

Routes deoxygenated blood from the abdomen/pelvis/lower extremities into the RA

Question 70

Pulmonary Artery

Answer 70

Routes deoxygenated blood from the RV to the lungs

Question 71

Pulmonary Veins

Answer 71

Routes oxygenated blood from the lungs to the LA

Question 72

Aorta

Answer 72

Routes oxygenated blood from the LV to the body; ascending - arch - descending - thoracic - abdominal

Question 73

Heart valves

Answer 73

``` Try Pulling My Aorta Tricuspid Pulmonic Mitral Aortic ```

Question 74

Aortic focus

Answer 74

best for hearing the aortic valve, heard over the 2nd right intercostal space at the right intercostal border. S2 is heard well here

Question 75

Pulmonic focus

Answer 75

Best for hearing the pulmonic valve, located at the left 2nd intercostal space at the left sternal border. S2 is heard well here

Question 76

Erb's point

Answer 76

located at the 3rd left intercostal space, where S2 is BEST heard

Question 77

Tricuspid focus

Answer 77

4th left intercostal space, where tricuspid valve is BEST heard

Question 78

Mitral focus

Answer 78

5th left intercostal space in the midclavicular line. This is where the apex is located and where S1 is BEST heard

Question 79

S4 Gallop

Answer 79

Ventricle isn't expanding as it fills, and atrium gives one last 'kick' to try and force blood out ('kick' = S4) If the ventricle is stiff and non-compliant (ex: left ventricular hypertrophy secondary to longstanding severe hypertension, MI, or cardiomyopathies) then the pressure wave gradient generated as the atria contract generates an S4 sound. Ex of right sided S4: pulmonary hypertension, pulmonary stenosis

Question 80

PMI

Answer 80

- If anywhere other than apex = abnormal - provides estimation for size of heart - assess location, diameter, amplitude and duration - palpable during systole (should have less duration)

Question 81

Physiologic Splitting

Answer 81

During inspiration, slight delay in the closure of the P2 component.