Cardiac: What do you listen for with the client in LLD?
mitral stenosis, S3, S4 - with bell
Cardiac: What do you listen for with the client leaning forward?
Aortic regurgitation murmurs - with diaphragm. "breathe in, breathe out, hold"
What heart sounds do you hear with the diaphragm?
high pitched: S1, S2, murmurs of AR and MR, AS, friction rubs, VSD
What heart sounds do you hear with the bell?
low pitched: S3, S4, diastolic murmurs (e.g. MS)
Cardio: what are the characteristics of sounds to be described?
Frequency (pitch) Intensity (loudness) Duration Timing (systole, diastole)
What are the valves of the heart?
Atrioventricular: tricuspid & mitral/bicuspid Semilunar: pulmonic & aortic
Name the areas of the heart
RV is most of anterior chest
Base is superior aspect of heart at R & L 2nd IS
Xiphoid process is good landmark for RV.
Tell me about a normal PMI
4th or 5th interspace, 7-9cm lateral to midsternal (at or just medial to midclavicular)
Supine diameter: 1-2.5 (about a quarter)
Tell me about an abnormal PMI
Larger than 2.5cm (evidence of LVH, or enlargement, as seen in HTN and AS)
Lateral to midclavicular or >10cm lateral to midsternal (LVH)
Xiphoid/epigastric area (COPD)
varies with respiration
normal HSs, though S1 may vary with the HR
Atrial or nodal premature contractions
Rhythm: atrial/nodal beat before next expected heart beat. Pause. Rhythm resumes
Heart Sounds: S1 may differ in intensity from normal S1. S2 may be decreased.
PVC (sporadic or regularly irregular)
Rhythm: ventricular beat comes before next expected beat. Pause. Rhythm resumes.
Heart Sounds: S1 may differ from normal, S2 may be decreased. Both likely split.
Afib & Aflutter w/varying AV block (Irregularly irregular)
Rhythm: ventricular rhythm is totally irregular, though possible short runs of regular-seeming
Heart Sounds: S1 varies in intensity
decrease in pulse's amplitude on quiety inspiration (st palpable, but possibly need BP cuff)
Systolic pressure decreases >10mmHg during inspiration
Causes: pericardial tamponade, exacerbatins asthma & COPD, st in constrictive pericarditis
pulse alternates in amplitude beat to beat even though rhythm is basically regular (must be).
Indicates LV failure, usually accompanied by S3
Normal Pulse Pressure
~30-40 mmHg pulse pressure
small, weak pulse
Pulse pressure diminished, upstroke may feel slowed, peak prolonged
causes: decreased SV (HF, hypovolemia, severe AS); increased peripheral resistance (exposure to cold and severe HF)
Large, bounding pulse
pulse pressure increased, rise and fall may feel rapid, peak brief
Causes: increased stroke volume, decreased peripheral resistance, or both (fever, anemia, hyperthyroidism, AR, AV fistulas, PDA); increased stroke volume d/t slow HRs (bradycardia, complete heart block); decreased compliance/increased stiffness of aortic walls (aging, atherosclerosis)
Usually MVP (systolic ballooning into LA from both leaflet redundancy & elongations of chordae tendineae)
Mid to late systolic
High pitched, often followed by MR murmur
several positions recommended: supine, seated, squatting, standing (squatting delays click & murmur, standing moves them closer to S1)
very early diastolic sound
stenotic mitral valve
listen with diaphragm medial to apex along lower left sternal border
intermittently irregular beats
e.g., ectopic beats - PAC, PVC
Continuously irregular beats
a.k.a. "regularly irregular"
Afib: palpittions that warrant ECG
Superior view of heart valves
What happens during diastole (+atrial kick)
AV valves open, passive flow (about 75% of volume) move into relaxed ventricles, then atria contract & active flow accounts for about 25% into ventricles (atrial kick)
isovolumic phase of ventricular systole
interval between closing of AV valves and opening of semilunar valves
ECG: define p, qrs, t, u
p: atrial depolarization
qrs: ventricular depolarization
t: ventricular repolarization
u: ventricular diastole
6 limb leads, 6 precordial leads
CAD risk factors for women
DM, smoking, HTN, obesity
questions you ask if chest pain
O: when did pain start? having pain now?
L: where is pain located? Does it radiate?
D: how long have you had pain?
C: what does it feel like? Pressure, tightness, heaviness, stabbing? Associated symptoms?
A: aggravates/alleviates? rest? Nitro?
R: travel to any part of your body?
T: when did you notice? Intermittent or persistent?
characteristics: squeezing, discomfort, burning, stabbing
Associated symptoms: cough
Relieved by: rest or nitrogylcerin
Special considerations on pediatric cardiac exam
Listen in at least 2 positions
S3 heard through thin chest walls
S4 indicates poorly compliant ventricles - always abnormal
murmurs: should disappear when supine, be systolic, not be assoc w/clicks, rubs, or other sx
school age: may disappear w/sitting