Cardiovascular Module Flashcards
Mid-sternal line
An imaginary line drawn down the center of the anterior chest from the center of the manubrial notch superiorly to the center of the xyphoid process inferiorly.
The Right and Left Parasternal Lines
Vertical imaginary lines on the anterior surface which parallel the mid-sternal line; they are drawn along side the sternum through the junctions of the costal cartilages with the sternum.
The Right and Left Mid-clavicular Lines
Imaginary vertical lines which parallel the midsternal line and which are drawn on the anterior chest wall from the mid-point of each clavical to the mid-point of each anterior costal margin. They pass through the nipples and are sometimes referred to as the nipple lines
The Left Anterior Axillary Line
An imaginary vertical line which parallels the mid- sternal line and is drawn through the left anterior axillary fold
The Left Mid-axillary Line
an imaginary vertical lines which parallels the mid- sternal line and is drawn from the apex of the left axilla to the lateral costal margin
The Angle of Louis
A bony prominence located on the anterior surface of the sternum which marks the junction of the manubrium and the body of the sternum. It is located approximately 5 cm below the manubrial notch. It also marks the site where the second rib (actually the second costal cartilage) meets the sternum
The Right and Left Second Intercostal Spaces
The interspaces which lie immediately below the right and left second ribs respectively.
The Left Third, Fourth, and Fifth Intercostal Spaces
the interspaces immediately below the left third, fourth, and fifth ribs respectively.
When auscultating the heart, it is necessary to identify each of the
heart sounds separately. This is accomplished by noting the location (on the anterior wall) where the sound is heard and by recognizing the cadence of the sounds by their timing
To understand this timing sequence of cardiac sounds, it is helpful to “visualize” the cardiac cycle as
a clock face with the cardiac sounds being audible at specific “times” on the clock
Choosing the S1 as a starting point, the S1 is heard at the
12 o’clock position
The S1 is a combination sound composed of the closing sounds of the
right and left atrio-ventricular valves (mitral and tricuspid) at the onset of ventricular systole. Normally the 2 components are heard simultaneously and are heard as one sound
The S2 sound is normally heard at the
4 or 5 o’clock position on the clock face
The S2 sound is composed of 2 separate sounds consisting of the
closing of the semilunar valves (aortic and pulmonic) at the beginning of ventricular diastole.
The S2 sound is normally heard either as one sound or 2 separate sounds depending on
the time in the respiratory cycle (inspiration or expiration) they are being auscultated
S2 sound: The filling of the right ventricle during its diastole takes a little longer when the patient is
inspiring. Therefore, it contains a little more blood at the beginning of its next systole. This will cause the right ventricle to take a bit longer to empty during the next systole and the pulmonic valve will close a fraction of a second later than the aortic
This slightly delayed closure of the pulmonic valve will create a slight separation in the 2 components of the S2 sound and this is referred to as
splitting of the second heart sound. Since this is a normal phenomenon, it is referred to “physiologic splitting” of S2 and the 2 components of S2 are referred to as A2 and P2
During the expiratory phase of respiration, the right and left ventricle take
about the same amount of time to fill and the same amount of time to empty
The 2 components (A2 and P2) of the S2 will occur simultaneously and will be heard as
one sound
The S3 sound is normally heard (if at all) at the
7 o’clock position on the clock face
S3 consists of the sound created by the
vibration of the ventricular wall during the passive phase of ventricular diastole (when blood is simply flowing from the atria)
S3 occurs early in ventricular diastole before the
atria contract
The S3 sound can be a normal finding or it may represent
a pathological condition
The S4 sound is normally heard (if at all) at the
11 o’clock position on the clock face
S4 occurs very late in the ventricular diastolic phase and is produced by the
vibration of the semilunar (aortic and pulmonic) valves generated by the contraction of the atria known as the “atrial kick”
S4 is heard a fraction of a second before the normal
S1 and is frequently confused for a splitting of the S1 heart sound
The S4 can be a normal finding but most often it represents a
pathological condition
The time intervals between the main cardiac sounds (S1 and S2) are also named
intervals
The period of time b/t the S1 and S2 is referred to as the
systolic interval
The period of time b/t the S2 and the next S1 is referred to as the
diastolic interval
Any event (such as a murmur) occurring during these intervals is referred to as
either a systolic event or a diastolic event
There are traditionally five areas on the anterior chest wall that are designated for special attention during cardiac evaluation:
1. The Aortic Area
located in the second right intercostal space at the sternal border
There are traditionally five areas on the anterior chest wall that are designated for special attention during cardiac evaluation:
2. The Pulmonic Area
located in the second left intercostal space at the sternal border
There are traditionally five areas on the anterior chest wall that are designated for special attention during cardiac evaluation:
3. ERB’s Point
located in the third intercostal space at the sternal border
There are traditionally five areas on the anterior chest wall that are designated for special attention during cardiac evaluation:
4. The Tricuspid Area
located in the fourth left intercostal space at the sternal border
There are traditionally five areas on the anterior chest wall that are designated for special attention during cardiac evaluation:
5. The Mitral (or Apical) Area
located in the fifth left intercostal space at the left mid-clavicular line
Inspection of the heart usually begins with the patient lying
supine with the entire anterior chest revealed. Inspecting the anterior chest while the patient is sitting upright is also acceptable.
Identify the surface topographical features that will be required to locate
the anatomical structures of importance
Notice the location of the cardiac apex usually marked by the point of
maximal impulse or apical impulse
Use of a penlight to direct a beam of light across the anterior chest will help in locating this point
it is typically located in the 5th left intercostal space at the mid-clavicular line
More precisely, in an adult, the PMI is located
10 cm lateral to the mid-sternal line
Note the diameter (in cm) of the impulse and note the
intensity (forcefulness) of the deflection it creates on the anterior chest wall
A PMI may not be visible in patients with
large amount of chest muscularity, obese patients, and women with large breasts
Excessive intensity of the PMI or a PMI diameter greater than 3cm suggests
either volume overload or pressure overload conditions of the left ventricle
The location of a normal PMI may be shifted upward and to the left in
pregnancy and downward and medially in patients with emphysema
Palpation is best performed with the proximal parts of the
fingers or the entire hand
The patient should be supine and the room should be
warm and comfortable to prevent any shivering by the patient
Palpation is performed for pulsations, for
generalized motions (Heaves or lifts), the point of maximal impulse (PMI), and thrills
Pulsations- palpate for pulsations in the
sternoclavicular, aortic, pulmonic, left sternal border, and epigastric area
When palpating pulsations, note the location,
rhythm, amplitude, duration and any associated findings. Pulsations may be normal or abnormal.
Generalized motion- palpate for an area of forward motion of a relatively large
segment of the anterior chest wall (usually extending over two or three interspaces). These are called heaves or lifts and (if present) will be located along the right or left sternal borders and are associated with right ventricular function
Also note the presence of a retraction (a backward motion) of the
anterior chest wall. This is also noted along the left sternal border and usually involves an area covering several ribs and interspaces and extends for several cm to the left of the left parasternal line
A retraction may be a normal finding in patients with a
thin and supple chest wall (children) but in adults it is usually a sign of ventricular enlargement
Point of Maximal Impulse (PMI) - palpate the area near the
5th left interspace at the mid-clavicular line for the “apical impulse” more correctly referred to as the “point of maximal impulse”
PMI - note the location, amplitude (force),
duration, rhythm, and diameter of the impulse
PMI
Note: this pulsation may be easier to detect with the patient
sitting up. Also, in females, the breast may cover this area preventing identification of the PMI
Thrills - palpate the same areas noted above for pulsations to note the presence of
thrills. In addition, palpate the left axillary area.
Thrills are actually palpable murmurs and are
vibrations on the surface of the chest wall caused by turbulent blood flow within the heart
Thrills
Touch the skin lightly with the bases of the fingers for the best
sensitivity to detect these vibrations
Note the location, amplitude, radiation, and timing to the cardiac cycle
(this is done by correlating the thrill with the carotid pulse)
Note: any turbulence that can produce a palpable thrill will be
easily heard on auscultation as a murmur or bruit
The key points to be made about cardiac auscultation are to be
systematic in the approach and to be un-hurried
The heart is capable of producing a variety of
normal and abnormal sounds that vary in pitch from high to low
Both the bell and diaphragm are necessary for
adequately hearing of all of these possible sounds
Cardiac sounds are heard both at the locations of the structures (valves)
which create them and also in the direction of the blood flowing through those structures
As a result, auscultation should be performed at the
5 cardiac areas and also in several “in b/t” areas corresponding to the direction of blood flow from these 5 main areas
When listening to the cardiac sounds, select and concentrate on each of the
segments of the cardiac cycle while “blocking out” all of the other sounds
For example, at each location on the chest wall, listen only to the
S1 sound for several heart beats, then listen to the S2 sound for several beats, then listen to the systolic interval for several beats, and finally the diastolic interval for several beats
During the intervals, listen for
S3s and S4s or any other sounds (clicks, opening snaps, murmurs)
Auscultate all areas with both the
bell and diaphragm of the stethoscope and do this with the patient in the supine, sitting up, and leaning forward and the left lateral decubitus positions
During cardiac auscultation, instruct the patient to breath
normally
Auscultation can begin at the base of the heart and move
toward the apex or at the apex of the heart and move toward the base
Movements of the stethoscope should “inch” along this route,
moving to new positions only a few centimeters at a time
The valves snapping shut make the 2 basic heart sounds often called
“lub-dub”
As you listen to a patient’s chest, you want to hear a crisp
“lub” followed by an equally crisp “dub” with a brief moment of silence in between each lub-dub
The 1st heart sound, or lub, is
S1
S1 is produced when the
tricuspid and mitral valves simultaneously close
S1 marks the onset of
systole, or ventricular contraction
The simultaneous closing of the pulmonic and aortic valves produces
S2 or dub
S2 marks the end of
systole
The brief silent period between S2 and S1 represents
diastole, or ventricular relaxation
During diastole the ventricles
fill with blood coming from the atria
As you assess a patient’s heart sounds, any new whoosh, plop, or an extra lub or dub may indicate
a change in the patient’s condition and should prompt you to contact the physician
S1 is normally softer than
S2, except over the apex, where S1 is louder
Since S1 is in sync with the carotid pulse,
palpating the pulse helps to distinguish lub from dub
If you hear a quick “lu-lub”, S1 may be split, meaning that
the mitral valve closed just before the tricuspid. A split may be normal, but it can also occur in the presence of a bundle-branch block
If you hear a “du-dub” it means S2 is split, which occurs when the
aortic valve closes before the pulmonic valve. A split S2 is often normal and heard on inspiration
A ventricular gallop is produced when a
third heart sound, called S3, occurs early in diastole
S3 is heard as a low-pitched “Plop” right after
dub, when there should be silence
The cadence created by S3 resembles the word
Ken-tuc-ky, where S1 represents “Ken”. S2 carries the accent on “tuc” and S3 is the “ky”
While a ventricular gallop may be normal in children and young adults, it is abnormal in
patients over the age of 30
In adults, the sudden appearance of an S3 may indicate
ischemia or heart failure
The S3 is caused by the vibration of non-compliant
ventricles as they resist the rapid filling of the early phase of diastole
S3 is heard best over the apex, using the
bell of the stethoscope. it helps to have the patient hold his breath for a moment as you listen. It also helps to have him supine or in the left-side lying position
An atrial gallop is produced by a
fourth heart sounds, called S4
S4 is another low-pitched sound heard best over the
apex
S4 is heard late in diastole
just prior to S1
The presence of S4 creates a rhythm that sounds like the word
Ten-nes-see
S4 represents the “Ten”, S1 represents
“nes: and S2 carries the accent on the syllable “see”
S4 is normal in
infants and children and common in the elderly
In adults, however, S4 often occurs after an
MI
S4 is also linked to
aortic stenosis, myocardial ischemia, heart failure, and hypertension. Its caused when stiff and over distended ventricles are forced to accept blood from the atria during late diastole, when the atria exert their final squeeze, called the atrial kick
Like the third heart sound, S4 is heard best when you use the
bell of the stethoscope and the patient is in a supine position while holding his breath
Murmurs are either high or low pitched sounds that usually last
longer than normal heart sounds
Murmurs are most often caused by a
stiffened valve that leaves only a narrow passage for blood to get through or by a weak, floppy valve that allows blood to backflow
A murmur can also be caused by blood flowing turbulently through a hole in the
septal wall.
