Ch15 cardiac exam Flashcards
start with health history
-chest pain: MI
-low cardiac sx’s: dyspnea, HF sx’s, syncope
older woman with history of HTN and comorbidities (DM 2) sus with ACS.. most likely to report…
unusual fatigue
older WOMEN early warning sx’s of acute MI…
unusual fatigue
sleep disturbances
SOB
indigestion
anxiety
chest pain (only 30%)
ACS in elderly > 75 years old symptoms..
dyspnea
syncope, weakness, confusion
chest pain/pressure (< 50%)
left sided heart valve diseases
more common than right sided since it carries more pressure to entire body
Mitral valve and aortic valve disease more common than pulmonic and tricuspid
examine what area that is the left ventricle?
point of maximum impulse (PMI)
-5th ICS, MCL
size of impulse: nickel
gentle tap of 1 finger, single impulse (1/3 of systole)
displaced PMI?
usu laterally = increased LV volume
PMI unusually forceful, sustained?
pressure overload, HTN
best position to palpate PMI
put pt in left lateral decubitus position enhancement
consider thick chest wall, obesity, COPD (barrel chest)
increase AP diameter in COPD changes
might not hear PMI
S1 best heard where?
apex of heart with diaphragm
-beginning of systole
“LUB dub”
put finger on carotid to feel for upstroke = that is systole (vs diastole)
S2 heard where?
marks end of systole
heard best at the base with diaphragm
lub DUB
physiologic split S2
benign normal finding in 30 year olds or younger
-split INCREASES on pt INSPIRATION (have pt breathe in and hold, the split opens. then blow out and split should close)
-widening of normal interval b/t aortic and pulmonic components of 2nd heart sound
-best heard in pulmonic region
pathologic split S2
-fixed split (NO changes in inspiration, from uncorrected septal defect)
OR
-paradoxical split, closes with inspiration (delay aortic closure like LBBB)
-in pulmonic region
resolves when tx underlying condition
S3 heart sound
-heart sound DOESN’T MEAN heart failure
-early diastole
-hooked onto S2, low pitched with using bell
-lub dub-DUB
-need sx’s like dyspnea
S4 heart sound
POOR diastolic function (mostly from poor HTN control, recurrent MI)
-heard late in diastole “hooked” in front of S1
soft, low pitch (use bell)
-DUB-lub dub
-goes away with tx of underlying condition
failure to open adequately
stenosis
failure to close adquately
incompetent valves = regurgitant murmurs
systolic murmurs.. benign or pathologic?
either
diastolic murmurs.. benign or pathologic?
always pathologic
Systolic murmurs
MR PEYTON MANNING AS MVP
-mitral regurgitation
-physiologic murmur
-aortic stenosis
-mitral valve prolapse
diastolic murmurs
ARMS
-aortic regurgitation
-mitral stenosis
grading murmurs
sound of blood flow/turbulent
I: very faint
II: quiet but immediate heard
III: moderately loud w/o thrill (as loud as S1 or S2)
IV: loud with thrill (FEEL/vibration on palpation)
V: very loud with thrill
VI: audible without stethoscope
murmur characteristic
harsh:
rumble:
blowing:
musical:
harsh: aortic stenosis (bell & diaphragm)
rumble: mitral stenosis (low “bowling ball” = bell)
blowing: aortic regurgitation (high = diaphragm)
musical: still’s murmur
systolic murmurs are ONLY benign IF…
all of these:
-negative history (chst pain, syncope, dsypnea etc)
-grade 2 or less
-no radiation beyond precordium (to carotids, axilla, abdomen)
-S1, S2 intact
-no heave or thrill when palpating PMI
-PMI WNL
auscultate supine/squatting preferred to hear murmur then do listen again to stand
or when supine to standing, radiation disappear when standing
systolic murmurs pathologic IF…(refer)
ANY of these: (get echocardiogram)
-abnormal hx
-Grade 3-6
-radiation to neck, axilla, other locations
-S1, S2 obliterated
-with thrill or heave
-PMI displaced
-increases in intensity with supine to stand position change
harsh systolic murmur, radiates to the neck
delayed carotid upstroke
assume it came off aortic valve!!
aortic stenosis
which murmur heard best in mitral area?
mitral valve prolapse
delayed carotid upstroke
when S1 sound is not simultaneosus to the pulse of the carotid
carotid bruit vs radiating murmur
carotid bruit: usually softer, unilateral, different sound/tone than chest
radiating murmur: usu louder, bilateral, same sound and timing as chest
holosystolic murmur that radiates to axilla
mitral regurgitation
mid systolic click, late systolic murmur
murmur moves forward with position change from supine to stand
mitral valve prolapse
usu in women with mild pectus excavatum
get echo
if hear murmur, must get diagnosis by getting an ___ before managing
echo!
louder when standing and quieter when squating
mitral valve prolapse
low pitche descrendo-crescendo rumbling diastolic murmur, best heard at apex
mitral stenosis
