Cardiac

Question 1

Conduction System of the heart

Answer 1

SA node
AV node
Bundle of His
Right and Left bundle branches
Purkinje fibers

Question 2

Aortic Heart sound

Answer 2

2cd intercostal space, RSB

Question 3

Pulmonic

Answer 3

2cd ISC, LSB

Question 4

Tricuspid

Answer 4

LLSB

Question 5

Mitral

Answer 5

Cardiac apex (5th ICS-LMCL)

Question 6

Erb’s Point

Answer 6

Area at which pulmonic and aortic sounds are best heard

Question 7

Cardiac Cycle

Answer 7

Normally, only the closing of the valves is auscultated
S1 = closure of the AV valves (mitral and tricuspid)
S2= closure of the semilunar valves (aortic and pulmonic valve)
Period between S1 and S2 = systole
period between S2 to the next S1 = diastole

the opening of the valves are only heard if the valves are damaged

Question 8

S3 heart sound

Answer 8

S3 may occur 120-170 msec after S2 (normally in children and young adults, otherwise can signal volume overload)

Question 9

S4 heart sound

Answer 9

S4 = extra heart sound before S1 (normal in children and young adults; otherwise indicative of a stiff ventricle)

Question 10

Blood Pressure

Answer 10

systolic blood pressure is the peak pressure in the arteries, regulated by stroke volume and compliance of blood vessels
Diastolic blood pressure is the lowest pressure in the arteries and depends on peripheral resistance
Pulse pressure = difference between the systolic and diastolic pressures
systolic blood pressure increases as distance from the heart increases

Question 11

physical exam components

Answer 11

inspection of the patient
assessment of blood pressure
Assesment of pulses
assessment of jugular venous pulse
percussion of the heart
palpation of the heart
auscultation of the heart
assessment for dependent edema

Question 12

Inspection

Answer 12

evaluate general appearance (any distress? how is their breathing)
inspect the skin (temperature, xanthomas, rash or asters nodes)
inspect the nails for - splinter hemorrhages and capillary refill

Question 13

inspection

Answer 13

inspect the facies (earlobe crease which is Lichstein’s sign)
inspect the eyes (xanthelasma or Marcus seniles)
Inspect the mouth (inspect the palate)

Question 14

Inspection

Answer 14

inspect the neck ( Turner’s syndrome - neck webbing and coarctation of the aorta) (Noonan’s syndrome - pulmonic stenosis)
Inspect the chest configuration (pacts excavated and precuts carinatum)
inspect the extremities (extra digits? atrial septa defects) (long slender fingers? = Marfan’s syndrome)

Question 15

Rule out orthostatic hypotension

Answer 15

make sure pt is recumbent for at least 5 minutes

Significant if greater than 20 mmHG drop plus symptomatic

Question 16

Rule out supravalular aortic stenosis

Answer 16

difference in blood pressure between both arms

Question 17

rule out coarctation of the aorta

Answer 17

compare BP in arms to BP in thighs

be suspicious if BP in arms I is higher than legs

Question 18

Rule out Cardiac Tamponade

Answer 18

Becks’s Triad = low BP, distended neck veins, muffled heart sounds

Pulsus paradoxus _exaggeration of the normal inspiratory fall in systolic pressure
normal fall is 5 mmhg with inspiration
greater than 10 mg; think cardiac tamponade

Question 19

Palpation and pulses

Answer 19

Arterial pulse is produced by the ejection of the blood into the aorta.
(assess radial pulse and carotid pulse, evaluate the characteristics of the pulse) (normal, diminished or bounding)

Question 20

Palpation and pulses

Answer 20

Jugular venous pulse provides direct information about the pressures in the right side of the heart

Question 21

evaluate the hepatojugular reflux

Answer 21

apply pressure of the liver (RUQ) are you able to grossly assess right ventricular function?
its with R ventricular failure have dilated sinusoids in the liver, that will become drained with compression
Maintain RUQ pressure for 10 seconds.
Normal response: increase in neck vein distention that resolves after a few seconds
Abnormal response: neck veins remain distended through entire compression

Question 22

evaluate the apical impulse (point of maximum implies PMI)

Answer 22

easiest if pt is sitting in position
5th ICS, Left MCL
a PMI that is laterally displaced or felt in two intercostal spaces is suggestive of cardiomegaly
In chronic lung disease, the PMI may be felt in the epigastric area

Question 23

Determine the presence of thrills

Answer 23

superficial vibratory sensations felt on the skin overlying an area of turbulence
Presence of thrill = loud murmur
Adds little to the diagnosis since the murmur will be able lot be auscultated

Question 24

Percussion

Answer 24

Performed at the 3rd, 4th and 5th ICS from the left anterior axillary line to the right anterior axillae line
percussion note is dull over the area of the heart
can be used to help determine cardiomegaly (greater than 10.c cm in the left 5th intercostal space)

Question 25

Auscultation

Answer 25

Bell of the stethoscope should be applied lightly to the skin. Best to hear low pitched sounds and AV stenosis murmurs The diaphragm of the stethoscope requires firm pressure (best for high pitched sounds, systolic events and regurgitant murmurs) Move through the points of auscultation with diaphragm first, then repeat with bell Four standard position for auscultation : supine, left lateral side, upright, upright and leaning forward. **pay attention to the influence of breathing on heart sounds**

Question 26

Pericardial Rub

Answer 26

Extra cardiac sounds of short duration Usually heard as one systolic and two diastolic (systolic component occurs during ejection and diastolic components occur during rapid filling and atrial contraction) Sounds like scratching on sandpaper Best heard in supine position with patient holding their breath in expiration

Question 27

Murmurs

Answer 27

Occurs when turbulent blood flow is present systolic murmurs occur with or after s1 and end before or with s2 Diastolic murmurs occur with or after s2 and end before or with s1 more significantly in pathology than systolic murmurs

Question 28

MR ASS

Answer 28

``` M – mitral R. – regurgitation A – aortic S - stenosis S - systolic ```

Question 29

MS ARD

Answer 29

``` M- mitral S- stenosis A- Aortic R- regurgitation D- diastolic ```

Question 30

describe any murmurs present

Answer 30

Timing, location, radiation, duration, intensity, pitch, quality, relationship to respiration, and relationship to body position

Question 31

Grading of murmurs

Answer 31

I : low intensity, difficult to hear II : low intensity, usually easily heard III : medium intensity, without a thrill IV : medium intensity, with a thrill V : loudest murmur that is heard with a stethoscope (and + thrill) VI : audible when stethoscope is removed from chest (and + thrill)

Question 32

Checking Edema

Answer 32

When peripheral venous pressure is high, pressure in the veins is distributed in a retrograde manner to the smaller vessels Edema of dependent areas occur and cause "pitting" edema ``` +1 = 2 mm depth and disappears rapidly +2 = 4 mm depth and disappears in 10-15 seconds +3 = 6 mm depth and may take more than 1 min to resolve +4 = 8 mm depth or more and may last 2-5 mins ```

Question 33

Chest pain

Answer 33

Probably the most important symptom of cardiac disease however can have many non cardiac origins "Angina Pectoris" is the true symptom of CHD - consequence of hypoxia to the myocardium which results in an imbalance of coronary supply and myocardial demand Levine's sign - clenching of the fist and placing it over the sternum

Question 34

Palpitations

Answer 34

Associated with a wide range of arrhythmias may be described as "fluttering" "skipped beats" "pounding" "jumping" "stopping" or "irregularity quite common and do not necessarily mean serious heart problems seek to rule out thryotoxicosis hypoglycemia fever anemia pheochromocytoma anxiety caffeine, tobacco and drugs

Question 35

Dyspnea

Answer 35

Shortness of breath "I can't get enough air" related to cardiac or pulmonary causes Paroxysmal nocturnal dyspnea (PND) - awakened from sound sleep and is markedly dyspneic and coughing -relatively specific for CHF Dyspnea on exertion - usually caused by CHF or pulmonary dx - attempt to quantify the dyspnea, especially over time

Question 36

syncope

Answer 36

fainting or the transient loss of consciousness due to inadequate cerebral perfusion can have cardiac and non cardiac causes determine the activity breeding the syncope determine position of the patient before fainting 40% of syncope episodes are vasovagal in nature

Question 37

Fatigue

Answer 37

Common symptom of decreased cardiac output patients with CHF and mitral valvular dx commonly complain of fatigue multiple possibilities for causation -anxiety and depression (most common) -anemia -chronic disease status

Question 38

Dependent edema

Answer 38

swelling of the legs its with CHF have symmetrical edema -less in the morning and with feet elevated -if accompanied by dyspnea, think CHF -Typically, the dyspnea will precede the swelling If edema is only one sided, think possible DVT -will also have accompanying tenderness, redness, and warmth

Question 39

cyanosis of the the lower extremities

Answer 39

termed "differential cyanosis" related to a right to left shunt from paint ductus arterioles (PDA) deoxygenated blood is pumped only to the lower extremities