Chapter 12: Heart

Question 1

Physical exam heart

Answer 1

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

Question 2

heart FMH

Answer 2

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

Question 3

Heart PMH/SMH

Answer 3

Employment
Tobacco use
Nutritional status/diet/weight
Alcohol consumption
Hypercholesterolemia/elevated triglycerides
Exercise
Substance abuse

Question 4

heart HPI

Answer 4

Onset and duration, character, location, severity, associated symptoms, treatment, medications

Question 5

Heart PMH

Answer 5

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

Question 6

Preg pt hx

Answer 6

History of cardiac disease or surgery
Dizziness/syncope
Signs and symptoms of heart disease

Question 7

Older adult heart hx

Answer 7

Common symptoms of cardiovascular disorders
Factors once heart disease has been diagnosed

Question 8

Infant heart hx

Answer 8

Maternal health during pregnancy

Feeding intolerance
-Tires easily
-Sweating while feeding
-Cyanosis

Cyanotic spells
-TET spells

Breathing difficulty

Failure to grow

Question 9

Children and adolescent hx

Answer 9

Tires easily
Exercise intolerance
Syncope
Chest pain/palpitations
Shortness of breath
Headaches/nosebleeds
Unexplained joint pain/swelling/ rash
Surgical repair of congenital heart disease

Question 10

Inspection of heart

Answer 10

Apical Impulse: visible at about the midclavicular line in the fifth left intercostal space

Pulsations, heaves, or lifts

Question 11

Heart palpation

Answer 11

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

Question 12

Heart percussion

Answer 12

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.

Question 13

Auscultation of heart

Answer 13

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

Question 14

Heart sounds

Answer 14

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

Question 15

Heart sounds

Answer 15

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

Question 16

Physical exam rhythm disturbance

Answer 16

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

Question 17

Abnormalities in Heart Rates and Rhythms

Answer 17

Conduction disturbances
-Proximal to bundle of His or diffusely throughout conduction system

Sick sinus syndrome
-Arrhythmias caused by a malfunction of the sinus node

Question 18

Physical exam for infant

Answer 18

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.

Question 19

Physical exam children

Answer 19

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

Question 20

Preg pt physical exam

Answer 20

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

Question 21

Older adult physical exam

Answer 21

Apical impulse is difficult to find.

S4 is more common in older adults.

ECG changes

Question 22

Heart abnormalities

Answer 22

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

Question 23

Heart abnormalities in infants and children

Answer 23

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

Question 24

Heart abnormalities in older adults

Answer 24

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

Question 25

A third heart sound is created by:

Atrial contraction
Ventricular contraction
Diastolic filling
Regurgitation between the right and left ventricles

Answer 25

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.

Question 26

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.

Answer 26

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.

Question 27

A palpable rushing vibration over the base of the heart is called a:

Heave.
Lift.
Thrill.
Thrust.

Answer 27

ANS: C

Rationale: A thrill is a fine, palpable, rushing vibration; it is a palpable murmur.

Question 28

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.

Answer 28

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.

Question 29

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

Answer 29

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.

Question 30

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.

Answer 30

ANS: A

Rationale: In the elderly, the anteroposterior diameter of the chest can increase thus making it difficult to assess heart sounds.

Question 31

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.

Answer 31

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.

Question 32

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?

Answer 32

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

Question 33

Identify reported signs of cardiac chest pain that Mr. Davis is experiencing.

Answer 33

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.

Question 34

Identify and list the cardiac risk factors for Mr. Davis.

Answer 34

ANS: Hypertension, smoking history, caffeinated coffee consumption, and family history of myocardial infarction.

Question 35

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.

Answer 35

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.