Chapter 12: Heart Flashcards
Physical exam heart
Inspect precordium for:
-Apical impulse
-Pulsations
-Heaves or lifts
Palpate the precordium to detect:
-Apical impulse
-Thrills, heaves, lifts
Percuss to determine heart size.
Auscultate heart for:
-Rate
-Rhythm
-S1
-S2
-Splitting
-S3 and/or S4
-Extra heart sounds
Assess murmur characteristics:
-Timing
-Duration
-Pitch
-Intensity
-Pattern
-Quality
-Location
-Radiation
-Variation with respirations
heart FMH
Congenital heart disease, prolonged Q-T syndrome, Marfan syndrome, diabetes, heart disease, dyslipidemia, hypertension, obesity, MI < 50 years of age, sudden unexplained cardiac death, other cardiac risk factors
Heart PMH/SMH
Employment
Tobacco use
Nutritional status/diet/weight
Alcohol consumption
Hypercholesterolemia/elevated triglycerides
Exercise
Substance abuse
heart HPI
Onset and duration, character, location, severity, associated symptoms, treatment, medications
Heart PMH
Congenital heart disease
Kawasaki disease
Rhythm disorder -Prolonged Q-T
Cardiac surgery and hospitalization
Acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism
Chronic illness
Preg pt hx
History of cardiac disease or surgery
Dizziness/syncope
Signs and symptoms of heart disease
Older adult heart hx
Common symptoms of cardiovascular disorders
Factors once heart disease has been diagnosed
Infant heart hx
Maternal health during pregnancy
Feeding intolerance
-Tires easily
-Sweating while feeding
-Cyanosis
Cyanotic spells
-TET spells
Breathing difficulty
Failure to grow
Children and adolescent hx
Tires easily
Exercise intolerance
Syncope
Chest pain/palpitations
Shortness of breath
Headaches/nosebleeds
Unexplained joint pain/swelling/ rash
Surgical repair of congenital heart disease
Inspection of heart
Apical Impulse: visible at about the midclavicular line in the fifth left intercostal space
Pulsations, heaves, or lifts
Heart palpation
Apex, up the left sternal border, base, down the right sternal border, into the epigastrium or axillae if the circumstance dictates
Apical impulse
-Heave or lift
-Point of maximal impulse (PMI)
-Thrill
Carotid artery
Heart percussion
Percussion has limited value in defining borders of heart or determining its size.
Left ventricular size is better judged by the location of the apical impulse.
Right ventricle tends to enlarge in the anteroposterior diameter rather than laterally.
Obesity, unusual muscular development, and some pathologic conditions can easily distort the findings.
Chest radiograph is far more useful in defining the heart borders.
Auscultation of heart
Aortic valve area
Second right intercostal space at the right sternal border
Pulmonic valve area
Second left intercostal space at the left sternal border
Second pulmonic area
Third left intercostal space at the left sternal border
Tricuspid area
Fourth left intercostal space along the lower left sternal
border
Mitral (or apical) area
Apex of the heart in the fifth left intercostal space at the midclavicular line
Assess overall rate and rhythm
Frequency
Intensity
Duration
Pathology
Heart sounds
Basic heart sounds
S1 or S2 most distinct
Splitting
S3 and S4 difficult to hear
Extra heart sounds
Gallops
Mitral snaps
Ejection clicks
Friction rubs
Heart murmurs
Timing and duration, pitch, intensity, pattern, quality, location and radiation, respiratory phase variations
Heart sounds
Intense 1st sound: heard best at apex
Split 1st sound: heard best at tricuspid
Intense second sound: heard best at base
Physiologic splitting s2: heard best at base
3rd sound (vent. Gallop): heard after s2, heard best at apex
4th sound (atrial gallop): heard before s1, heard best at apex
Summation gallop: s3&s4, heard best at apex
Physical exam rhythm disturbance
Determine the regularity of the heart rhythm.
If irregular, determine if there is a consistent pattern.
-Irregular but occurring in a repeated pattern may indicate sinus arrhythmia, a cyclic variation of the heart rate
Abnormalities in Heart Rates and Rhythms
Conduction disturbances
-Proximal to bundle of His or diffusely throughout conduction system
Sick sinus syndrome
-Arrhythmias caused by a malfunction of the sinus node
Physical exam for infant
Examine newborn at birth and at 2 to 3 days of life for signs of circulatory transition.
Examine cardiac function examination, including skin, lungs, and liver.
Inspect color of skin and mucous membranes.
Look for enlargement of heart if dyspneic.
Heart sounds are difficult to assess; vigor
and quality are indicators of heart function.
Heart rates vary with eating, sleeping, and waking.
Murmurs are common until 48 hours of age.
Palpate peripheral pulses.
Physical exam children
Heart rate is more variable in childhood; varies with age
Sinus arrhythmias are normal in childhood
-Regular, irregularities in heart beat
Innocent murmurs of childhood
-Murmur changes with position or respiration
-Usual occur during systole
-No other abnormalities noted
-Nonradiating to other parts of chest
-Low amplitude
-Still murmur: best heard at the lower left sternal border and changes with position.
Pathologic murmurs of childhood
-Blowing, squeaky, or a whooshing sound
-Louder, harsher sound
-Holosystolic
-Does not change with position change
-May be accompanied by clicks or rubs
-Sound transmits to other parts of the chest and back
Child with known heart disease:
-Weight gain or loss
-Developmental delays
-Cyanosis
-Clubbing of fingers or toes
Preg pt physical exam
Heart rate and blood volume increase in pregnancy; pulse is 10% to 30% faster by end of third trimester.
Fourth heart sound is abnormal.
Clubbing, cyanosis, neck vein distension, diastolic murmur=abnormality
Older adult physical exam
Apical impulse is difficult to find.
S4 is more common in older adults.
ECG changes
Heart abnormalities
Angina
Pain caused by myocardial ischemia
Bacterial endocarditis
Bacterial infection of the endothelial layer of the heart and valves
Congestive heart failure
Heart fails to propel blood forward with its usual force, resulting in congestion in the pulmonary or systemic circulation
Pericarditis
Inflammation of the pericardium
Cardiac tamponade
Excessive accumulation of effused fluids or blood between the pericardium and heart
Cor pulmonale
Enlargement of the right ventricle secondary to chronic lung disease
Myocardial infarction
Ischemic myocardial necrosis caused by abrupt decrease in coronary blood flow to a segment of the myocardium
Myocarditis
Focal or diffuse inflammation of the myocardium
Heart abnormalities in infants and children
Ventricular septal defect
Opening between the left and right ventricles
Tetralogy of Fallot
Ventricular septal defect, pulmonic stenosis, dextroposition of the aorta, right ventricle hypertrophy
Patent ductus arteriosus
Failure of the ductus arteriosus to close after birth
Atrial septal defect
Congenital defect in the septum dividing the left and right atria
Acute rheumatic fever
Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection
Heart abnormalities in older adults
Atherosclerotic heart disease
Narrowing of small blood vessels that supply blood and oxygen to the heart
Senile cardiac amyloidosis
Amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in the heart
A third heart sound is created by:
Atrial contraction
Ventricular contraction
Diastolic filling
Regurgitation between the right and left ventricles
ANS: C
Rationale: Diastole is a relatively passive interval until ventricular filling is almost complete. Diastole occurs when the ventricle is filling with blood from the atria and the filling sometimes produces a third heart sound, S3.
Your patient has complaints of shortness of breath and decreased exercise tolerance. On examination you note a high-pitched, pansystolic murmur radiating to the axilla. You diagnose this as:
Aortic regurgitation.
Aortic stenosis.
Mitral stenosis.
Mitral regurgitation.
ANS: D
Rationale: Mitral regurgitation has symptoms of decompensated congestive heart failure, including shortness of breath, pulmonary edema, and orthopnea. Objective data include a high-pitched pansystolic murmur radiating to the axilla and possibly a third heart sound.
A palpable rushing vibration over the base of the heart is called a:
Heave.
Lift.
Thrill.
Thrust.
ANS: C
Rationale: A thrill is a fine, palpable, rushing vibration; it is a palpable murmur.
Mr. Fox is an 84-year-old who visits the nurse practitioner for symptoms of weakness, decreased energy, and unintended weight loss. Mr. Fox tells the nurse practitioner “I just don’t seem to bounce back like I once did. My body seems to succumb to stress more easily than before.”
Mr. Fox most likely has:
Angina.
Congestive heart failure.
Aortic regurgitation.
Frailty syndrome.
ANS: B
Rationale: Congestive heart failure can leave the patient feeling fatigued. Decreased energy levels and unintended weight loss are also indicative of congestive heart failure because the heart is using extra energy to pump blood to the body.
Mr. Fox is an 84-year-old who visits the nurse practitioner for symptoms of weakness, decreased energy, and unintended weight loss. Mr. Fox tells the nurse practitioner “I just don’t seem to bounce back like I once did. My body seems to succumb to stress more easily than before.”
The nurse practitioner uses the FRAIL scale to further assess Mr. Fox. Which finding is consistent with criteria of the FRAIL scale?
Weight loss of greater than 50%
Ability to climb one flight of stairs
Ability to walk two blocks
One documented illness
ANS: B
Rationale: FRAIL stands for fatigue, resistance, ambulation, illness, and loss of weight. The ability to climb one flight of stairs is a criteria of the FRAIL scale.
Mr. Fox is an 84-year-old who visits the nurse practitioner for symptoms of weakness, decreased energy, and unintended weight loss. Mr. Fox tells the nurse practitioner “I just don’t seem to bounce back like I once did. My body seems to succumb to stress more easily than before.”
Mr. Fox’s increased anteroposterior diameter of the chest makes it difficult for the nurse practitioner to assess Mr. Fox’s:
Heart sounds.
Respirations.
Pulse.
Capillary refill.
ANS: A
Rationale: In the elderly, the anteroposterior diameter of the chest can increase thus making it difficult to assess heart sounds.
Brent Davis is a 65-year-old white man who is being transferred to your unit after having failed an outpatient diagnostic test known as a Cardiolyte treadmill stress test. For the past 5 years, Mr. Davis has been physically active and routinely walked 4 or 5 miles per day. He also enjoyed playing golf as well as working out with a trainer at the local gym two or three times per week. Recently, he has only been able to walk “a quarter of a mile” before experiencing “chest pain that radiates to my jaw.” This chest pain, which he rated as a 7 of 10 on the pain scale, would slowly go away when activity was stopped. In addition, he also experienced shortness of breath with the chest pain.
Name the organs located in the thoracic cavity and identify the normal physiologic processes for these organs.
During the admission of Mr. Davis to the telemetry unit, you must clinically reason and differentiate the patient’s history and assessment to determine the reason behind his “chest pain that eases when I stop walking.” What questions are pertinent to ask Mr. Davis?
Identify reported signs of cardiac chest pain that Mr. Davis is experiencing.
The following information is obtained during the history portion of his admission:
White man, age 65 years, with a 10-year history of hypertension that is controlled with Bystolic 20 mg every morning. He smoked 2 packs of cigarettes per day for 40 years but no longer smokes. He rarely consumes alcoholic beverages. He does drink 6 to 8 cups of caffeinated coffee every day. His height is 74 inches with a weight of 195 pounds. His father died from an acute myocardial infarction. His mother had a long history of hypertension and died from a hemorrhagic stroke.
Identify and list the cardiac risk factors for Mr. Davis.
Before performing a cardiac examination on Mr. Davis, identify specific abnormal objective findings related to his complaint of “chest pain” that would help focus your assessment.
Clinical update: After undergoing a diagnostic and interventional cardiac catheterization, Mr. Davis had two stents placed in his circumferential coronary artery. He is discharged home the following day without any further complaints of chest pain after receiving the interventional treatment and teaching.
Name the organs located in the thoracic cavity and identify the normal physiologic processes for these organs.
ANS: The chest, or thorax, is a structure of bone, cartilage, and muscle capable of movement as the lungs expand. It consists anteriorly of the sternum, manubrium, xiphoid process, and costal cartilages; laterally, of the 12 pairs of ribs; and posteriorly, of the 12 thoracic vertebrae. The primary muscles of respiration are the diaphragm and the intercostal muscles. The diaphragm is the dominant muscle. It contracts and moves downward during inspiration, lowering the abdominal contents to increase the intrathoracic space.
The pleural cavities include the right and left lungs. Respirations with the lungs keep the body adequately supplied with oxygen and protected from excess accumulation of carbon dioxide. Respiration involves the movement of air back and forth from the alveoli in the lungs to the outside environment, gas exchange across the alveolar-pulmonary capillary membranes, and circulatory system transport of oxygen to and carbon dioxide from the peripheral tissues.
The heart is positioned behind the sternum and the contiguous parts of the third to the sixth costal cartilages. Its function is to circulate oxygenated blood to the body and nonoxygenated blood to the lungs. The heart is further divided into the right and left sides of the heart as well as into four chambers with four valves, which normally permit flow of blood in one direction only.
The closing of the valves makes the “heart sounds.”
Portions of the great vessels include the aorta, superior and inferior venae cavae, pulmonary arteries, and pulmonary veins. The aorta carries oxygenated blood out of the left ventricle to the body. The pulmonary artery, which leaves the right ventricle and divides almost immediately into right and left branches, carries deoxygenated blood to the lungs. The superior and inferior venae cavae carry deoxygenated blood from the upper and lower body, respectively, to the right atrium. The pulmonary veins return oxygenated blood from the lungs to the left atrium.
During the admission of Mr. Davis to the telemetry unit, you must clinically reason and differentiate the patient’s history and assessment to determine the reason behind his “chest pain that eases when I stop walking.” What questions are pertinent to ask Mr. Davis?
ANS: Students should clinically reason to determine if findings in other body systems are related to the chief complaint of “chest pain.”
Onset and duration of pain: sudden, gradual, vague, length, related to physical exertion, rest, coughing, cold temperature, does it awaken him at night, and so on
Character: aching, sharp, tingling, burning, pressure
Location: radiates down the arms to the neck, jaws, teeth, and scapula; relief with rest or position
Severity: interferes with activity; needs to stop all activity until subsides; severity of 7 on a scale of 0 to 10
Associated symptoms, treatment, and medications used
Identify reported signs of cardiac chest pain that Mr. Davis is experiencing.
The following information is obtained during the history portion of his admission:
White man, age 65 years, with a 10-year history of hypertension that is controlled with Bystolic 20 mg every morning. He smoked 2 packs of cigarettes per day for 40 years but no longer smokes. He rarely consumes alcoholic beverages. He does drink 6 to 8 cups of caffeinated coffee every day. His height is 74 inches with a weight of 195 pounds. His father died from an acute myocardial infarction. His mother had a long history of hypertension and died from a hemorrhagic stroke.
ANS: Pain while walking only a short distance that is resolved with rest.
Identify and list the cardiac risk factors for Mr. Davis.
ANS: Hypertension, smoking history, caffeinated coffee consumption, and family history of myocardial infarction.
Before performing a cardiac examination on Mr. Davis, identify specific abnormal objective findings related to his complaint of “chest pain” that would help focus your assessment.
Inspection: note visibility and palpable impulses, cyanotic skin, nail beds for cyanosis and capillary refill, and jugular venous distention.
Palpation: feel and identify the apical impulse and its location, which should be at the point of maximal impulse (PMI); determine if there is a presence of a heave or lift, which could represent left ventricular hypertrophy.
Feel for a thrill: a fine palpable rushing vibration that could represent cardiovascular valve murmurs.
Percussion: recognize that it does have a limited use but could potentially be used to determine heart size.
Auscultation: auscultate heart sounds in the five cardiac areas. Listen for the basic heart sounds of S1 and S2. Listen to the rhythm, paying particular attention to the potential of splitting heart sounds, presence of an irregular heart rate, presence of bruit, and cardiac rate.
Objective findings related to Mr. Davis’ concern of “angina” as supported by vital signs of P = 120, R = 30, B/P = 160/89, and T = 99. Skin is warm and dry but was diaphoretic while Mr. Davis complained of “chest pain.” Pulse was irregularly, irregular.
