Coeur Flashcards
What do you inspect in a heart examination?
Breathing : dyspnoea, orthopnoea
Chest shape : pectus carinatum, pectus excavatum
Skin : cyanosis, clubbed finger, oedema, scars
Circulation : pulse rate, congested jugular vein
Where do you palpate the apex ?
The apex is formed by the end of the left ventricle. It is normally located on the midclavicular line in the fifth intercostal space.
How is the vibration of the apex ?
Normal : brief movement towards the chest wall during systole
Enlarged heart : beat felt laterally on supine patient
What is the specific position of the heart ?
The superior border is located in the second intercostal space.
The inferior border is the fifth intercostal space.
The right border is the right parasternum line.
The left border is the left midclavicular line.
Where do you auscultate the heart ?
All = Aortic valve : right second intercostal space, parasternally
Patient = Pulmonary valve : left second intercostal space, parasternally
Take = Tricuspid valve : left fifth intercostal space, parasternally
Med = Mitral valve : left fifth intercostal space, at the midclavicular line
Where do you hear the heart sound ?
At Erb’s point, located in the third intercostal space, and the left lower sternal border.
There we can hear both S1 and S2. It is also where you can hear heart murmur.
Where is S1 and S2 the loudest.
S1 is heard the loudest at the apex where you can also hear its splitting.
S2 is heard the loudest at the base where you can hear the splitting.
What do you assess in the apex ?
The magnitude : number of intercostal space it can be palpable (normally 1).
The intensity : normal, forceful or attenuated
The length : short or long impulse
Normally S2 is louder than S1 in the second intercostal space. What could cause a decrease in S2 loudness / increase in S1 ?
Increased contractile force.
Shortened diastole.
Increased in the forward blood flow through the AV valve.
AV valve stenosis, blood faster to the ventricles.
Why would S1 decrease in loudness ?
Reduced contractile force.
Prolonged diastole.
Inability to close the valve.
What does the varying loudness of S1 mean ? What is the cause ?
Indication of atrioventricular dissociation : atria and ventricles activate independently form each other.
Caused by : premature beats, atrial fibrillation, complete atrioventricular block, ventricular tachycardia and cardiac tamponade.
What indicate the loudness of A2 and P2 ?
A2 louder : might be systemic hypertension, aortic valve greater closing force
P2 louder : might be pulmonary hypertension or atrial septal defect
A2 softer : less pliable artic valve or inability to close the valve.
What increase in splitting in S2 and S1 ?
Delayed electrical activation of the right ventricle or prolonged right ventricular contraction.
What is a reverse split of the heart ?
Also called paradoxical splitting. Refer to an audible separation of A2 and P2 during expiration only. Normally the separation can only be heard during inspiration.
What causes reverse split ?
Delayed electrical activation of the left ventricle or prolonged left ventricular contraction.
What cause the heart to be enlarged ?
Also called cardiomegaly.
It can be caused by disease that make the heart work harder which result in its muscle increasing and the space t dilate.
The most common cause of it is coronary heart disease (blockage of the coronary vessels limiting the amount of blood reaching the heart).
What cause clubbed finger ?
Chronically low blood level of oxygen
What are the five heart sounds ?
S1 : Isovolumetric contraction => closing of AV valve
S2 : isovolumic relaxation => closure of semilunar valve
S3 : early ventricular filing => normal in children but associated with ventricular dilatation
S4 : atrial contraction => stiff, low compliance ventricule
S5 : abnormal splitting
What does dyspnea may indicate ?
Cardiovascular problem : myocardial infraction, congestive heart failure, pericarditis
What does cyanosis indicate ?
Central cyanosis indicate inadequate oxygenation or abnormal haemoglobin.
Peripheral cyanosis indicate : low oxygen blood stagnation.
What scars suggest cardiac surgery ?
Mid-line sternotomy suggest a coronary artery bypass graft or valve replacement.
Below left/right clavicle with a bulge of the skin suggest an implantable pacemaker.
Why would the apex not be palpable ?
Obesity (thicker chest wall) or too light apex beat.
Emphysema, pericardial infusion, shock, dextrocardie.
Why would you percuss the heart ?
It has limited use. Only if the apex cannot be palpated or if the side of the heart isn’t clear. (The other border of the heart cannot be determined accurately with percussion).
Why do you not auscultate the valve at their anatomical location ,
Because the sound is conducted by the tissues (blood vessels and bones)
Where do you hear the splitting of S2 best ?
At P, but only during inspiration.
Where do you hear S3 best if present ?
At M.
What do you hear at Erb’s point ?
Both normal heart sounds are equal.
What’s the difference between pulse and heart rate
Pulse rate = heart rate
Heart rate measure the heartbeat of the heart.
Pulse rate measure the rate of the blood pressure pulses.
Would you change the area of auscultation if the apex is displaced ?
Yes but only the mitral valve. You will listen to it on the apex beat.
Where in time are located S1 and S2 ?
S1
Systole
S2
Diastole
Dextrocardia ?
Heart positioned on the right side of the chest.
What are the test on indication of the heart ?
Palpation :
- apex beat
- other pulsation
Percussion :
Auscultation :
- S3 and S4
- murmurs : turbulence in the bloodstream
- pericardial rub : audible friction
Assessment of CVP
Where else do you palpate for abnormalities ?
Left parasternal area 3rd-5th ICS
Epigastric space
Precordial space
Technique of heart percussion ?
Finger parallel to the ribs in 5th ICS. Patient supine.
Start anterior axillary line then move finger in medial direction until dull sound is heard.
What are S3 and S4 ?
Wall sounds made by vibration of the ventricular wall. Low pitched heard with the stethoscope bell.
Technique of auscultation on indication ?
Patient supine using the bell :
- left parasternal 4-5th ICS : S3/S4 RV sound
- left mid clavicular 4-5th ICS : S3/S4 LV sound
Left lateral recumbent position, using diaphragm :
- apex site : S1
Left lateral recumbent position, using bell :
- apex site : S3, S4
Seated using diaphragm :
- apex site : pericardial rub
What are the clinical significance of visible precordial pulsation ?
Apex beat seen outside the midclavicular line : enlarged heart
Left parasternal area : physiological in children
Epigastric pulsation : right ventricular hypertrophy or dilation
What is the clinical significance of the apex beat quality ?
Large magnitude or forceful beat : dilation, hypertrophy of LV
LV hypertrophy : prolonged beat with heave, double apical pulse (impaired filling due to stiffness)
Left parasternal or epigastric pulsation : volume/pressure overload
Fine vibration : change in blood flow => valve defect, ventricular septal defect
What is S3 ?
S3 : vibration of left/right ventricular wall
- just after S2
- early passive ventricular filling
- volume overload, impaired systolic function of LV
What is S4 ?
S4 : atrial contraction at the end of diastole due to ventricular wall rigidity
- just before S1
- late ventricular filling
- impaired diastolic LV function
What is an ejection murmur ?
Abnormal aortic / pulmonary valve.
High frequency clicking sound, audible in the second ICS. If it decrease in loudness on inspiration => pulmonary valve
What is a mid-systolic click ?
Mitral valve prolapse that may be accompanied by mitral insufficiency murmur.
What is an opening snap ?
Mitral stenosis.
High frequency clicking sound early in diastole. Audible near the apex, 3rd sound following A2 and P2
What is a tumor plop ?
Atrial tumor is displaced towards the ventricle
Early diastolic sound.
What do you assess in murmurs ?
Timing
Shape/configuration : crescendo, decrescendo, band shaped, crescendo-decrescendo
Loudness
Frequency : high, low, normal
Character : blowing harsh, musical
Location, radiation, timing : PMI (point of maximum intensity
Effect of particular actions : deep inspiration, standing up, squeezing the hand, Valsalva maneuver
How do you asses murmurs loudness ? (Scale)
Freeman and Levine scale :
1 : Soft, only audible in quiet surroundings
2 : soft, audible in normal surroundings
3 : loud
4 : loud with palpable vibration on chest wall
5 : very loud, audible with stethoscope off the chest
6 : extremely loud thrill, audible with naked ear near the chest
What are the different timing / duration of systolic murmurs ?
Mid systolic : start after S1 and before S2
Holosystolic / pansystolic : start at S1 and end at S2
Early systolic / ejection systolic : start with S1 and end before S2
End systolic : start after S1, ends with S2
Characteristics of physiological murmur ?
Relative stenosis of aortic / pulmonary valve.
Causes : pregnancy, anemia, fever, hyperthyroidism
Characteristics :
-early/mid systolic,
- PMI : high left ICS
- disappear when patient stand up or perform Vasalva maneuver
Characteristics of aortic stenosis ?
Systolic murmur with PMI in 2nd right ICS
- radiate to carotid artery
- S2 decrease in loudness
- palpable thrill
- sustainable apex beat
- delayed start of carotid pulsation
- fixed
The more severe the stenosis the more pressure on LV to open the valve and set blood column in motion.
Characteristics of pulmonary stenosis ?
Systolic murmur with PMI in 2nd right ICS
- crescendo-decrescendo
- radiate to the left side of the neck
Pressure overload on the right ventricle causing a wide splitting in S2.
Length of murmur correlated to the severity of stenosis
Characteristics of ventricular septal defect ?
Holosystolic murmur with PMI in left parasternal area
- harsh loud
- 2nd or 4th ICS depending on VSD location
- marked thrill
- central cyanosis
Leakage is normally from left to right.
Characteristics of mitral insufficiency or regurgitation ?
Systolic murmur with PMI at apex
- high frequency holosystolic murmur
- loudness increase in left lateral recumbent position
- radiate towards left axilla
Leakage begin in isovolumetric contraction phase continue into isovolumetric relaxation
Characteristics of tricuspid insufficiency or regurgitation ?
Systolic murmur with PMI in 4th-5th left ICS
- similar to mitral
- radiate towards right side of sternum and epigastrum
- respiration varying in loudness
Right ventricular overload cause wide split in S2
Aortic insufficiency or regurgitation ?
Holodiastolic with PMI in 3rd left ICS
- decrescendo
- high frequency, blowing
- most audible seated after expiration
Can be degenerative condition or aortic valve endocarditis
Characteristics of pulmonary insufficiency or regurgitation ?
Similar to aortic insufficiency murmur
- lower in frequency
- early diastolic murmur
Characteristics of mitral stenosis ?
Mid/end diastolic murmur with PMI at apex
- harsh low frequency sound
- more audible in left lateral recumbent position
Rheumatic heart disease : autoimmune response to streptococcal infection
What do you focus on for central venous pressure ?
If collapse point very high, likelihood of elevated CVP so higher risk of right sided heart failure or vascular overfilling
It is usually calculated using external jugular vein because it is easier to see but this one makes an angle => not direct to the heart contrely to the internal jugular vein.
What are the 5 Korotkoff sounds ?
1 : sharp tapping => systolic blood pressure
2 : swishing sound => blood flow
3 : softer thump
4 : muffled thump
5 : No sound anymore => diastolic blood pressure
