Cardiology Flashcards
Surface landmarks
Midsternal line, midclavicular line, anterior axillary line, midaxillary line
Circulation
SVC and IVC —> RA —> RV —> pulmonary arteries —> LA —> LV —> aorta, aortic arch
Auscultation
R sternal border 2nd ICS - aortic valve
L sternal border 2nd ICS- pulmonary valve
L sternal border 3rd ICS- Erb’s Point (pulmonic and aortic valve)
L sternal border 4th ICS- Tricuspid valve
L mid-clavicular line - 5th ICS- mitral valve
“All physicians eagerly take money”
Systole - S1, Lub
Ventricles contract
R ventricle pump blood into pulmonary artery. Pulmonic valve open
L ventricle pumps blood into aorta. Aortic valve is open.
Tricuspid and mitral valve close
Diastole (S2, Dub)
Ventricles Relax
Blood flow from RA to RV. Tricuspid valve is open
Blood flow from LA to LV. Mitral valve is open.
Pulmonic and aortic valves closed
Preload, contractility, afterload, CO, BP
Preload —> volume overload (stretch)
Contractility: ventricles contract during systole
Afterload —> pressure overload
Cardiac output: SV x HR
Blood pressure: CO x SVR
Systolic blood pressure
Presssure generated by LV during systole, when LV ejects blood into aorta
Pressure waves in arteries create pulses
Diastolic blood pressure
Pressure generated by load remaining in arteries during diastole (ventricles relax)
Blood pressure
Select proper cuff size. Position patient properly. Make sure there is brachial pulse. Apply cuff correctly. Assess blood pressure for hypertension
Jugular venous pressure (JVP)
Jugular veins reflect right atrial pressure
Measure the distance of the topmost point of JV pulsation above sternal angle.
3-4 cm normal
High JVD suggests CHF, SVC/IVC blockage, tricuspid stenosis
Carotid pulse
Auscultate listening for bruits. Then palpate upstroke. Don’t palpate both sides at the same time.
Brisk- normal
Delayed- suggest aortic stenosis
Bounding- suggest aortic insufficiency
Palpate the chest wall
Finger pads- palpate for heaves and lifts from abnormal ventricular movements
Use ball of hand- palpate for thrills
Chest wall- aortic, pulmonic, left parasternal, and apical areas
Thrills- turbulence transmitted to chest wall surface by damaged heart valve ***** TQ!!!
Assess Point of Maximal Impulse (PMI)
Tapping- normal
Sustained- suggest LV hypertrophy from HTN or aortic stenosis
Diffuse- suggest dilated ventricle from CHF or cardiomyopathy
Assess- location, amplitude, duration and diameter
When examining a patient for PMI, which of the following is least important to assess?
Rhythm
Auscultation of the heart
Listen in 6 listening areas for S1 and S2 using diaphragm of stethoscope then the bell
Diaphragm
Best for detecting high pitched sounds like S1, S2, and S4 and most murmurs
Bell
Best for detecting low pitched sounds like S3 and rumble of mitral stenosis
Identify and describe murmurs - cause, timing, Dx, duration, pitch
Murmur: sounds from turbulent blood flow. Caused by stenosis or regurgitation of valves
Timing: are the murmurs systolic or diastolic?
Dx by palpating carotid upstroke (occur in systole) as you listen
Determine duration- early/mid/late systole or diastole
Pitch- high, medium or low pitched
Murmur shape
Crescendo, decrescendo, or both (diamond shaped), or plateau (machinery)
Crescendo-decrescendo (both) murmur —> aortic stenosis
Plateau - holosystolic murmur of mitral regurgitation
Murmur intensity
Grade 1: very faint, heard only after listener tuned in w/ stethoscope
Grade 2: quiet, heard immediately after placing stethoscope on chest
Grade 3: moderately loud
Grade 4: loud with palpable thrill
Grade 5: very loud with thrill, heard with stethoscope partly off chest
Grade 6: very loud with thrills heard without stethoscope
Grade 4-6 must have accompanying thrill ***** TQ!!!
Ex. Harsh 2/6 medium-pitched holosystolic murmur heard at the apex describes
Mitral regurgitation
Soft bowing 3/6 decrescendo diastolic murmur heard at lower left sternal border describes
Aortic regurgitation
Midsystolic click
Mitral valve prolapse
Main cause of PMI displacement
Pregnancy, cardiac enlargement, cardiomyopathy, ischemic heart disease
Systolic murmur
Occur between S1 and S2. Associated with ventricular ejection. Coincide with carotid upstroke. May indicate valve disease
Diastolic murmur
Occur between S2 and S1. Associated with ventricular relaxation and filling. Caused by aortic/pulmonic regurgitation or mitral/tricuspid stenosis
Speeding of heart during inspiration
Sinus arrhythmia. Speeds up with inspiration, slows down with expiration. Heart sounds normal. S1 may vary with heart rate
Splitting of S2 heart sounds ***** TQ!
Happens when RV filling time increases during inspiration. Increases RV ejection time. Causes delay of closing pulmonic valve. Hear both pulmonic and aortic closing separating, P2 and A2. During expiration, 2 sounds fuse into a single sound
Found at 2nd and 3rd ICS close to sternum
Cause of S3
Hearing sound of rapid LV filling when mitral valve opens
Causes- common in children, young adults, pregnancy
Adults- indicate changes in ventricular compliance, decreased myocardial contractability, CHF, volume overload
Cause of S4
Atrial contraction. Indicate decrease ventricular compliance. Left side caused by HTN, CAD, aortic stenosis. R side caused by pulmonary HTN or pulmonic stenosis
Systolic murmurs
Between S1 and S2
Midsystolic - after S1 up to S2. Goes from soft to louder to softer. Caused by blood across semilunar valves ie aortic stenosis
Pansystolic- begin at S1, ends at S2. Occur with regurgitatant flow across M/T valve ** TQ!!
Late systolic, opening snap- mid to late systole, persists to S2. Caused by mitral valve stenosis/prolapse
Diastolic murmurs
Occur after S2
Early- start after S2 (no gap). Fades before S3. Caused by regurgitant blood flow across semilunar valves ie Aortic regurgitation
Mid- after S2 (short gap). Fade before S1. Caused by turbulent flow across M/T valves
Late- starts late in diastole, continues to S1 (no gap)
Functional Murmur
Short, early, midsystolic, decrease in intensity with actions that reduce LV volume. When standing, BP, SV, LV volume decrease. Squatting, opposite happens. Can identify prolapsed mitral valve, distinguish hypertrophic cardiomyopathy from aortic stenosis
Viscero-somatic reflexes: T1-T5 on left side
Mitral valve prolapse
Mid to late systolic click
Opening snap
Caused by anxiety, panic attacks, coffee
Accentuate findings with valsalva maneuver
PMI
5th interspace midclavicular line, 8 cm lateral to midsternal border
Palpitations-
Palpitations- atrial fibrillation (irregularly irregular), paroxysmal supraventricular tachycardia (regular, rapid, sudden, offset), sinus tachycardia
Dyspnea (SOB)
Dyspnea (SOB)- pulmonary embolus, spontaneous pneumothorax, anxiety
Paroxysmal nocturnal dyspnea (SOB when sleeping)
Paroxysmal nocturnal dyspnea (SOB when sleeping). Left ventricular heart failure, mitral stenosis
Edema
Edema (excessive fluid in interstitial tissue spaces)- renal and liver disease
Dependent edema
Dependent edema- CHF, hypoalbuminemia
Chest pain. Dx meaning-
Chest pain. Dx meaning- angina pectoris, MI, coronary heart disease, aortic aneurism
