cardiovascular system Flashcards
Heart’s Surface Projections:
- Right ventricle = most anterior heart structure
- left ventricle: left lateral border
Apical pulse/point of maximal impulse:
- Normal: 1 to 2.5 cm diameter; brisk and tapping
- PMI > 2.5 cm suggests LV hypertrophy
- location: 5th intercostal space, 7-9 cm lateral to midsternal line
- Displacement of the PMI indicates LVH, ventricular dilatation, or HF
- dextrocardia: PMI on RIGHT side of chest
Great vessels:
- pulmonary artery
- aorta
- vena cava
PMI palpation
palpation:
- Normal: 1 to 2.5 cm diameter; brisk and tapping
- PMI > 2.5 cm suggests LV hypertrophy
- location (supine): 5th intercostal space, 7-9 cm lateral to midsternal line
- duration: during systole
- Displacement of the PMI indicates LVH, ventricular dilatation, or HF
- dextrocardia: PMI on RIGHT side of chest
location:
- if you can’t feel supine -> move pt to LLD
S3 sounds: pathological sounds of HF
S3 : abrupt deceleration of inflow across the mitral valve
- can be normal in kids + young adults
- adults: pathological “S3 gallop” -> indicative of SYSTOLIC HF
- Occurs at beginning of diastole following S2
- s3 = Rapid ventricular Filling/Distension
- auscultate: bell in LLD at apex
S4 sounds: pathological sounds of HF
S4: increased LV end diastolic stiffness which decreases compliance
- s4 = atrial contraction
- Occurs after atrial contraction at the end of diastole before S1 (active ventricular filling)
- Atrial blood striking ventricle
- Is indicative of DIASTOLIC HF*
- auscultate: bell in LLD at apex
S1 and S2 heart sounds
S1:
- Mitral & Tricuspid Valve closure at the beginning of systole
- Represents systolic “LUB”
S2:
- Aortic & Pulmonary Valve closure at the beginning of diastole/end of systole
- Represents diastolic “DUB”
Splitting of S2 sounds
normal S2 sound: closure of aortic valve (A2) + closure of pulmonic valve (P2)
- A2 LOUDER due to higher pressure than P2
splitting:
- check LEFT 2nd ICS with bell*
- inspiration: split sound; expiration: fuse together again
- Mechanism: inspiration = increased right heart filling DELAYS the closure of the pulmonic valve (P2) -> audible splitting
- ask pt to breathe quietly and then slightly more deeply than normal
potential causes:
- pulmonic stenosis
- RBBB
Heart Murmurs: definition, stenosis vs regurgitation
Definition: heart sounds distinguished by their pitch and LONGER duration
- caused by TURBULENT BLOOD FLOW
- indicate valvular heart ds
Stenosis = abnormally narrow orifice that obstructs blood flow
Regurgitation = improperly closing valves allow blood to flow backward
what corresponds?
Pulse: origin and mechanism
Origin: LV* pumping blood out through the aorta into the arterial tree
Mechanism:
- pressure wave created by the pumping of blood = pulse felt
- pressure wave travels FASTER than actual movement of blood
Pulse pressure + factors that affect BP
PP: systolic BP - diastolic BP
Factors Affecting Blood Pressure:
- LV stroke volume
- Distensibility of the aorta and the large arteries
- PVR: arterioles
- Volume of blood in the arterial system
———-
physical activity; emotional state; pain; noise; environmental temperature; use of coffee, tobacco, and other drugs; and even time of day.
JVP: location to measure + where to estimate; oscillations
JVP = crucial indicator of right atrial pressure and cardiac function**
- closely parallels pressure in R atrium/central venous pressure
- related to volume in the venous system**
- point at which the external jugular vein appears collapsed
Location:
- best to measure: pulsations from R INTERNAL jugular vein: direct alignment with R atrium + SVC
- can also use external jugular vein
- lies beneath SCM muscle: can see oscillations at neck surface
Estimation: Measure the highest point of the vein’s oscillation above the sternal angle to estimate JVP
- best at 45 degree incline
Oscillations in the jugular veins during the cardiac cycle represent:
- changes in the right heart during filling and emptying
- atrial contractions
JVP: PE
Position: 30-45 degrees (relaxes SCM) and turn pt head so you can look at RIGHT side
Measure:
- find external jugular vein and observe internal jugular venous pulsations
- Identify the highest point of pulsation in the right jugular vein
- measure VERTICAL DISTANCE from sternal angle to the highest point of pulsation
- JVP > 3 cm = ABNORMAL
JVP: when is it increased vs decreased
Decreased: BLOOD LOSS
Increased:
- pulmonary HTN (R heart strain)
- acute + chronic HF
- tricuspid stenosis
- AV dissociation
- pericardial effusion/tamponade
pt complains of Chest Pain: DDx
MC sx of CAD*
Aortic dissection: Anterior chest pain, often tearing or ripping and radiating into the back or neck
ACS: unstable angina, non-STEMI, and STEMI
- exertional angina
- typical vs atypical chest pain
- nausea/vomit
- pain: upper back, neck, jaw
PE!!!
importantto get a pts baseline level of activity to gauge the severity of the chest pain and guide management
- EKG
- stress test
- echo
- CT angiography
typical chest pain
Typical
- Men
- Mid-sternal or left sided
- Squeezing, tightness, pressure
- “elephant sitting on chest”
- Levine sign – clenches fist over sternum
- Radiation: Left arm
atypical chest pain
Atypical
- Females
- elderly (over 65)
- diabetes/ immunocompromised
- pain: jaw, back, right shoulder; may not be in chest
- Radiation: Right or bilateral arms
- paroxysmal nocturnal dyspnea
pt complains of palpitations…. define, ddx, next steps
Definition: unpleasant awareness of heart beat
- palpitations DOES NOT EQUAL heart ds
- vtach = NO PALPITATIONS
DDX:
- hyperthyroidism
- anxiousness
Next steps:
- have pt describe the palpitation: skipping, racing, fluttering, pounding, stopping, irregular, rapid
- teach pt how to take their pulse* so they know for subsequent episodes
- get an EKG* (afib?)
pt complains of sudden dyspnea
PE
spontaneous pneumothorax
anxiety
Heaves vs thrills
Heaves:
- SUSTAINED impulses that LIFT your finger pads
- MC: enlarged ventricles; others: ventricular aneurysm
Thrills: turbulent flow
- BUZZING/VIBRATIONS felt with ball of your hand
- higher grade murmur
- AS: thrills in carotid artery
palpating the heart: RV
RV: 30 degree angle + supine
- pt must exhale + hold breath
- use tips of fingers on 3-5th ICS
- parasternal movement: pulmonary HTN, pulmonic stenosis
special maneuver: valsalva
valsalva: bear down, have pt flex abdomen against hand
-initial strain: increases the thoracic pressure -> increases BP = decreased venous return to heart
- HOCM: only systolic murmur that increases
- DECREASES PRELOAD
special maneuver: isometric hand grip
INCREASES AFTERLOAD ***
- increases vascular resistance = increase afterload
Murmurs:
- all stenotic murmurs are quieter EXCEPT MS
- regurgitant murmurs LOUDER: mitral regurgitation and aortic regurgitation ***
How does inspiration and expiration affect murmurs
Inspiration:
- increases RIght sided murmurs
Expiration:
- increases LEft sided murmurs
- increases AS murmurs
Grading systolic cardiac murmurs:
Grade 1/6:
- Softer in volume than S1 and S2
- very faint
- not heart in all positions
Grade 2/6:
- Equal in volume to S1 and S2
- soft
- heard immediately in all positions
Grade 3/6:
- Louder in volume than S1 and S2
- NO thrill
Grade 4/6:
- Louder in volume than S1 and S2
- with palpable thrill
Grade 5/6:
- Louder in volume than S1 and S2
- thrill: heard when the stethoscope is partly off the chest
Grade 6/6:
- Louder in volume than S1 and S2
- thrill: heard with stethoscope entirely off the chest
List the systolic murmurs: midsystolic, holosystolic, late systolic
if DM = MS; then systolic murmurs are MR + opposites (AS + PS)
Mitral regurgitation/tricuspid regurgitation
opposite: AS + PS
Midsystolic: HAPA are MID
- HOCM
- AS
- PS
- ASD
holosystolic:
- MR/TR
- VSD
late systolic murmur: MVP
List the diastolic murmurs: early diastolic, mid-late diastolic, rare
DM = MS (diastolic murmurs = mitral stenosis + the oppoisites (AR + PR)
mitral stenosis/tricuspid stenosis (mid-late)
aortic regurgitation/pulmonic regurgitation
Early diastolic = early didatic wants austin to do APA format:
- AR
- PR
-Austin Flint: low pitched murmur in AR at apex
rare: patent ductus arteriosus
