Chapter 11 - Heart Flashcards
Major categories of heart disease
- Coronary
- HTN
- Rheumatic
- Bacterial endocarditis
- Congenital
Which type of heart disease is the MC?
Coronary
Why is bacterial endocarditis still a problem?
Despite abx, # of cases are increasing d/t IV street drug use
Circulation system consists of a ___ pressure delivery system and a ___ pressure return system
High delivery (left) Low return (right)
Most of the anterior cardiac surface is the ____ ventricle
Right
The RA forms a narrow border from the ___ to ___ ribs to the ___ of the sternum
3rd-5th Right
Where is the apex of the heart located?
5th ICS at midclavicular line
What is the apical impulse also known as?
Point of maximum impulse (PMI)
4 classic auscultatory areas and where they are
- Aortic = 2ICS-RSB (right sternal border)
- Pulmonic = 2ICS-LSB
- Tricuspid = LLSB
- Mitral = 5ICS-MCL (midclavicular line)
Also Erb’s point (3rd ICS) - best for aortic/pulmonic
What are the only sounds that should be heard normally?
Closing of the valves (S1 and S2)
What does S1 indicate?
Closing of the AV valves (lub)
What does S2 indicate?
Closing of the semilunar valves (dub)
When can opening of the valves be heard?
Only when they are damaged
Define “opening snap” and when it occurs
Sound of an AV valve opening when it is stenotic
*Diastole
Define “ejection click” and when it occurs
Sound of a SL valve opening when it is stenotic
*Systole
How do the pulmonic and aortic valves open/close in relation to each other?
Pulmonic opens first, but closes last
When does isovolumetric contraction occur?
Between closure of AV valves and opening of the SL valves
Ejection is defined as:
Time between opening and closing of SL valves
Incisura/Dicrotic notch =
The point at which ejection is completed and the aortic and left ventricular curves separate
When does isovolumetric relaxation occur?
Between closure of SL valves and opening of AV valves
Define S3
Third heart sound - end of ventricular filling
*Mainly heard in children/young adults
What does an S3 in 30+ yos indicate?
Ventricular volume overload (could be from regurg/CHF)
Define S4
4th heart sound - atrial contraction/additional ventricular filling
*Normal in children/young adults
What does an S4 in 30+ yos indicate?
Noncompliant/stiff ventricle (from pressure overload/CAD)
What are gallop sounds?
S3 and S4
The ___ heart sound is loudest at the cardiac apex
S1
The ___ heart sound is loudest at the base
S2
Splitting of the first heart sound may be heard in the ___ area
Tricuspid
What is sinus arrhythmia?
Normal finding!
Reflex tachycardia during inspiration that compensates for decreased LV volume
Anacrotic pulse and what causes it?
Small, slow rising, delayed pulse with a notch or shoulder on the ascending limb
*Aortic stenosis
Pulse pressure =
Difference in systolic and diastolic pressures
Systolic blood pressure is ____ in the legs compared to the arms
Greater in the legs (Poiseuille’s law)
MC cause of R heart failure is:
Left heart failure
Components of jugular venous pulse:
a wave x descent c wave v wave y descent
Define “a wave”
- Part of jugular venous pulse
- Signifies right atrial contraction
Define “x descent”
- Part of jugular venous pulse
- Atrial relaxation
Define “c wave”
- Part of jugular venous pulse
- Tricuspid valve closure (RV contraction)
Define “v wave”
- Part of jugular venous pulse
- Increase in RA pressure due to filling
Define “y descent”
- Part of jugular venous pulse
- Drop in RA pressure due to opening of tricuspid valve
What does a normal jugular venous pulse wave show?
Only a and v waves
What is the true symptom of coronary heart disease?
Angina pectoris
How is angina caused?
- Hypoxia of myocardium
- Imbalance between supply and demand
Why does PND occur?
Supine position increases intrathoracic blood volume and a weakened heart may be unable to handle this
What symptom is often associated with PND?
Orthopnea (need more pillows to sleep, sitting up more)
What is trepopnea?
Rare form of positional dyspnea
Dyspnea occurs while lying on R or L side
Define syncope
Transient loss of consciousness from inadequate cerebral perfusion
What is the MC type of fainting?
Vasovagal syncope
Carotid sinus syncope
A/w a hypersensitive carotid sinus
MC in older adult population
Tight shirt collar or turning the neck causes it
What is the MC heart-related cause of hemoptysis?
Mitral valve stenosis
Differential cyanosis
Cyanosis only in lower extremities (Related to R-L shunt)
How should the patient be positioned for PE of the heart?
- Supine with examiner on the right side of the bed
- HOB may be elevated slightly
Xanthoma
- Stony-hard, slightly yellow masses
- Found on extensor tendons and fingers
- Pathognomonic for familial hypercholesterolemia
Primary biliary cirrhosis
- Rare progressive and often fatal liver disease
- Mostly women
- Pruritus is common symptom
- Xanthomata develop in 15-20% pts
- LDL can be as high as 1000-1500 mg/dL
- Antimitochondrial antibody is present in 90%
Eruptive xanthomata
- Chest, butt, abdomen, back, face, arms
- Seen in familial disturbances of fat metabolism (HLD types I-IV)
- Happen as a result of high TG levels
Erythema marginatum in a febrile pt is indicative of:
Acute rheumatic fever
Reddened areas that are disc shaped with raised edges
Osler’s nodes
- Painful lesions that occur in tufts of fingers and toes
- Pts with infective endocarditis
Splinter hemorrhages
- Small reddish brown lines in nail bed
- A/w infective endocarditis
What is infective endocarditis a/w?
Osler’s nodes
Splinter hemorrhages
IV street drug use
Palatal petechiae
Lichtstein’s sign
An oblique crease in ear lobe (often bilaterally)
Pts 50+ yo with significant CAD
Xanthelasma
Yellowish plaques on the eyelids
*Less specific than the xanthoma
Arcus seen in patients eyes less than 40 yo could indicate:
Hypercholesterolemia
What is often seen in the eyes of Marfan’s syndrome patients with aortic regurg?
Displacement of lens
What is commonly seen in the eyes of someone with infective endocarditis?
Conjunctival hemorrhage
Hypertelorism and what is it often a/w?
- Widely set eyes
- A/w congenital heart disease (esp. pulmonic and supravalvular aortic stenosis)
Webbing is seen in what patients?
Turner’s syndrome
Noonan’s syndrome
What heart problem may Turner’s syndrome patients have?
Coarctation of the aorta
What heart problem may Noonan’s syndrome patients have?
Pulmonic stenosis
Korotkoff sounds
- Heard when assessing BP
- Low-pitched sounds originating in the vessel
- Related to turbulence produced by partially occluding an artery with the cuff
BP should be recorded to the nearest ___ mm Hg
5 mm Hg
Masked HTN
Normal BPs in a medical facility, but actually have much higher BPs throughout the day
*Opposite of white coat HTN and more serious
How to test for supravalvular aortic stenosis?
- Take BP in both arms
- BP will differ between arms
How to test for coarctation of aorta?
- Take BP in arms and then legs
- If legs BP is lower than suspect COA
How to test for cardiac tamponade?
- If low BP and rapid/feeble pulse, necessary to r/o
- Marked paradoxical pulse (exaggerated fall in systolic pressure during normal inspiration) could indicate tamponade
Normal pulsus paradoxus
Approx 5 mm Hg fall in systolic BP during inspiration
Waterhammer (Corrigan’s) pulse and what causes it?
- Rapid and sudden systolic expansion
- Aortic regurge
Bisferiens pulse and what causes it?
- Double peaked pulse with a midsystolic dip
- Aortic regurge
Alternans pulse and what causes it?
- Alternating amplitude of pulse pressure
- Congestive heart failure
How is the jugular venous pulse evaluated?
ONLY ON THE RIGHT SIDE!
Straighter vessel than on the left
Hepatojugular reflex
Applying pressure over liver allows assessment of RV function
*Pts with R heart failure show further distension of neck veins
Where is percussion of the heart performed?
3rd-5th ICS from left anterior axillary line to right
*Dullness = heart
How to palpate PMI?
- Patient sitting
- Examiner on right side of bed
- 5th ICS-MCL
What is a RV rock and what does it suggest?
- Sustained L parasternal impulse a/w lateral retraction
- Suggests large RV
Heart auscultation with the bell of stethoscope allows you to hear which sounds?
LOW pitched sounds (press lightly)
-Gallop rhythms, murmur of AV stenosis
Heart auscultation with the diaphragm of stethoscope allows you to hear which sounds?
HIGH pitched sounds (press firmly)
-Valve closure, systolic events, regurge murmurs
Which areas should be listened for S3 and S4 sounds?
- Apex
- LLSB
- With the BELL
How should you auscultate for mitral stenosis murmur?
- Patient turned onto L side
- Listen at apex with BELL (low pitch)
How should you auscultate for aortic regurg?
- Patient sits up and leans forward
- Exhale and hold breath
- Listen w/DIAPHRAGM 2nd and 3rd ICS on both sides
Most murmurs or sounds originating in the R side of the heart are accentuated with ____
Inspiration
Holosystolic/pansystolic murmurs
Occur throughtout systole
Grading of murmur intensity
I = lowest, often not heard by inexperienced listeners II = low III = medium w/o a thrill IV = medium w/ a thrill V = loudest; a/w a thrill VI = loudest, audible w/o stethoscope, a/w thrill
Pericardial rub components =
1 systolic (during ejection) 2 diastolic (during rapid filling and atrial contraction)
Pericardial rubs are best heard how?
With pt sitting while holding breath in expiration
Quantification of pitting edema
1+ = 2 mm in depth, disappears rapidly 2+ = 4 mm in depth, disappears 10-15 sec 3+ = 6 mm in depth, may last more than 1 minute 4+ = 8+ mm, may last 2-5 mins
How should edema be evaluated in patients who are bedridden?
Dependent area will most likely be the sacrum not the shins
Arc of coaptation
- Angle through which the AV valve closes
- Wider arc = louder S1
Longer PR interval = ____ S1
Softer
Why is S1 softer than normal in very obese or COPD patients?
Heart is “further” away so S1 is softer
The distance the heart is from the chest affects which heart sound?
S1
Any condition that increases systolic pressure increases the intensity of which heart sound?
S2
What causes wide splitting of S2?
- Delayed RV systole
- Shortened LV systole
What causes paradoxical splitting of S2?
Delayed LV emptying (delayed closure of aortic valve)
Fixed splitting of S2 indicates?
Atrial septal defect
Midsystolic clicks
NOT ejection clicks (early systole)
MC condition a/w midsystolic clicks = prolapse of mitral/tricuspid valves
Blowing murmurs
Large gradients w/variable flow volumes
Rumbling murmurs
Small gradients that depend on flow
Harsh murmurs
Large gradients and high flow
Ejection murmurs
- Turbulence across a SL valve during systole
- Diamond shaped and crescendo-decrescendo
- Ejection click may precede the murmur
