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NURS 503 > Heart murmurs and dysrhythmias > Flashcards

Heart murmurs and dysrhythmias Flashcards

1
Q

What is infective endocarditis (IE)?

A

Caused by microbial infection (bacterial) within the endothelium of the heart → vegetations form and adhere to endothelial structures

  • Heart valves must often affected
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2
Q

What are the three classifications of IE?

A

Acute → death occurs within days to <6 weeks

Subacute → death occurs within 6 weeks to 3 months

Chronic → death occurring later than 3 months

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3
Q

Causes of IE

A
  • Native valve endocarditis (most common)
  • Prosthetic valve endocarditis
  • Injection drug users
  • Healthcare associated endocarditis
    • Symptoms within 48 hours of hospital admission
  • Cardiac implantable device
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4
Q

IE clinical presentation

A
  • Generalized fatigue, malaise, weakness
  • Night sweats
  • Fever, chills
  • Weight loss, anorexia
  • N/V
  • S. aureus infection → abrupt onset that prompts the patient to seek early medical attention
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5
Q

IE physical examination

A
  • Heart murmurs
  • Cerebral emboli can lead to neurologic findings → headache, CN involvement
  • Roth spots in eyes, changes in visual acuity
  • Osler nodes: painful nodules on fingers and toe pads
  • Janeway lesions: non tender, hemorrhagic macules on palms and soles of feet
  • Splinter hemorrhages on nails
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6
Q

IE diagnostic studies

A
  • Three blood cultures from different venipuncture sites
  • CBC w/ diff, RF, circulating immune complexes
  • BUN, creatinine
  • UA
  • Chest x-ray
  • EKG
  • Echocardiogram
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7
Q

True/false: Specialty consultation and immediate referral to the ED is warranted for patients presenting with fever and suspicion of IE

A

True

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8
Q

IE management

A
  • Antibiotics (based on culture/sensitivity)
    • Prophylaxis before dental procedures → amoxicillin 2 g 30-60 minutes before procedure
  • Repeat blood cultures after treatment
  • Work with specialist (ID, cardiology, cardiac surgery)
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9
Q

IE surgery indications

A
  • Failure of antibiotic therapy
  • Development of refectory CHF
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10
Q

Antibiotic alternatives for IE management if patients are allergic to amoxicillin

A
  • Cephalexin
  • Clindamycin
  • Azithromycin
  • Clarithromycin
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11
Q

What factors help providers distinguish murmurs from one another?

A
  • Timing (most important)
    • Delineates division between systolic and diastolic murmurs
  • Location
  • Radiation
  • Intensity (Grade)
  • Quality
  • Pitch
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12
Q

What mnemonic is helpful in identifying the features of murmurs?

A

SCRIPTS + response to physiologic maneuver

Site (location)

Character (quality)

Radiation

Intensity (grade)

Pitch

Timing

Shape

+

Response to physiologic maneuver

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13
Q

Grades I through III of murmurs

A
  • Grade I → barely audible
  • Grade II → soft but easily heart
  • Grade III → loud
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14
Q

Grades IV through VI of murmurs

A
  • Grade IV → loud and associated with a thrill
  • Grade V → audible with the stethoscope barely touching the chest
  • Grade VI → audible without a stethoscope
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15
Q

How would you distinguish a systolic from diastolic murmur with palpation?

A

If you put your fingers on the carotid and hear the murmur at the same time you feel a pulse = systolic

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16
Q

What seven valvular/heart defects are considered a systolic murmur?

A

Please sneak away slowly, Mr. Tiger

  • Pulmonic stenosis
  • Aortic stenosis
  • Mitral regurgitation
  • Tricuspid regurgitation

Plus

  • Ventricular septal defect (VSD)
  • Hypertrophic cardiomyopathy
  • Benign or innocent murmurs
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17
Q

Do diastolic murmurs have a good prognosis?

A

Diastolic murmurs are not good

  • Will always involve cardiology
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18
Q

What five valvular/heart defects are considered diastolic murmurs?

A

Arms parts

  • Aortic regurgitation
  • Mitral stenosis
  • Pulmonic regurgitation
  • Tricuspid stenosis

Continuous murmurs

  • Patent ductus arteriosus (PDA)
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19
Q

Common complaints associated with valvular disorders

A
  • Chest pain
  • Palpitations
  • Dizziness
  • Syncope or near syncope
  • Fatigue
  • Exercise intolerance
  • Dyspnea
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20
Q

Physical examination components when assessing patients with valvular heart defects

A
  • Inspection and palpitation of chest wall
    • PMI, heaves, lifts, thrills
  • Auscultation of S1, S2, S3, S4, murmurs
  • Position change noted (squatting/standing)
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21
Q

Valvular heart defect diagnostic studies

A
  • EKG
  • Chest x-ray
  • Transthoracic echocardiogram (TTE) with 2D imaging and doppler
  • Stress test
  • Cardiac catheterization
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22
Q

What test is the gold standard test for initial evaluation of patients with suspected/known VHD?

A

Transthoracic echocardiogram (TTE)

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23
Q

General VHD management

A
  • Aortic valve replacement (AVR)
  • Surgical replacement and transcatheter aortic valve replacement (TAVR)
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24
Q

Pharmacologic therapy for patients with mitral regurgitation

A
  • Beta blocker
  • ACE inhibitors or ARBs
  • Aldosterone antagonist
  • Vasodilator therapy
  • Anticoagulation
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25
Q

What is characteristic of an aortic stenosis murmur?

A

Harsh, crescendo-decrescendo

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26
Q

What is a common cause of aortic stenosis?

A

Rheumatic fever (2nd most common cause)

  • Mitral valve is usually involved
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27
Q

What is the usual course (progression) of aortic stenosis?

A

Prolonged asymptomatic period (until 5th or 6th decade of life) then rapid deterioration at onset of symptoms

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28
Q

Common associated symptoms of aortic stenosis

A
  • Angina
  • Syncope → exertion, preceded by dizziness
  • HF (LV will enlarge and fail) → dyspnea
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29
Q

Aortic stenosis physical exam findings

A
  • Squatting increases murmur, standing resolves it
  • Loudest at right upper sternal border and carotids (will hear murmur at the same time)
  • Narrow pulse pressure (systolic - diastolic pressure)
  • ECG and chest x-ray normal
  • Cardiomegaly appears late on echo
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30
Q

What is characteristic of an aortic regurgitation murmur?

A

Loud, blowing, high pitched

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31
Q

What is the usual course (progression) of aortic regurgitation?

A

Prolonged asymptomatic period even with exertion, then will develop decreased exercise tolerance

  • Very late course will lead to CHF
32
Q

Aortic regurgitation clinical presentation

A
  • Angina
  • CHF
  • Dizziness
  • Atypical chest pain (aware of heartbeat and pounding when lying down)
  • Palpitations d/t tachycardia or premature heartbeats
33
Q

Aortic regurgitation physical exam findings

A
  • Murmur heard best with patient in seated position slightly leaning forward and breath held after expiration
  • Water hammer pulse → bounding and forceful, wide and quick
  • PMI displaced downward and to the left
34
Q

Aortic regurgitation imaging findings

A
  • X-ray → late findings demonstrate large and dilated LV
  • EKG → LVH
35
Q

What is the most common cause of mitral stenosis?

A

Rheumatic fever

36
Q

What is characteristic of a mitral stenosis murmur?

A

Low pitched, diastolic rumble

37
Q

Mitral stenosis symptoms

A
  • Dyspnea (most common)
  • Atrial fibrillation → risk for thrombus formation
  • Hemoptysis
  • Right ventricular hypertrophy
38
Q

Mitral stenosis physical exam findings

A
  • Loud S1
  • Apical diastolic murmur that radiates toward the axilla
  • Chest x-ray → enlarged left atrium
  • EKG → atrial fibrillation
39
Q

What is characteristic of a mitral regurgitation murmur?

A

Pansystolic (holosystolic) blowing, musical

40
Q

Most common cause of mitral regurgitation

A

Mitral valve prolapse

41
Q

Mitra regurgitation physical exam findings

A
  • PMI displaced laterally
  • Murmur heard at apex with radiation to axilla and sternum (grade 2+)
  • Chest x-ray → LV and left atrium enlargement
  • EKG → atrial fibrillation
42
Q

What is characteristic of a mitral valve prolapse murmur?

A

Late systolic, honking, mid systolic “click”

43
Q

What is the most common VHD that predisposes patients to infective endocarditis?

A

Mitral valve prolapse

44
Q

Mitral valve prolapse symptoms

A
  • Palpitations (PACs, PVCs more common with exercise)
  • Chest pain → severe stabbing pain at apex
  • Dyspnea
  • Dizziness
  • Numbness
45
Q

Mitral valve prolapse physical exam findings

A
  • Mid systolic “click” at apex and left sternal border
  • Late systolic click (later in course)
    • Worse with standing
    • Quieter with squatting
46
Q

What is the difference between aortic stenosis and MVP in terms of making the murmur better or worse?

A

AS → squatting makes the murmur worse (louder)

MVP → squatting makes the murmur quieter

47
Q

True/false: CHD is the leading cause of morbidity and mortality within the first year of life in infants

A

True

  • Developmental alterations leading to CHD occur in the 2nd or 8th weeks of gestation
48
Q

If left to right shunting in CHD cyanotic or acyanotic?

A

Acyanotic → oxygenated blood from the left side of the heart goes to the right due to higher pressures

  • Blood is still oxygenated before it does to systemic circulation
49
Q

What are the three left-to-right shunts (acyanotic)?

A
  • Atrial septal defect (foramen ovale)
  • Ventricular septal defect
  • PDA
    • Persistent connection between the aorta and pulmonary artery
50
Q

Atrial septal defect (foramen ovale) symptoms

A

Symptoms become more common in late adolescence or early childhood

  • Fatigue
  • Exertional dyspnea
  • Frequent URIs or PNA
51
Q

Atrial septal defect physical exam findings

A
  • Murmur heard at 2-3 years old
  • Mild left anterior chest bulge or palpable lift at left sternal border
  • Wide split S2
52
Q

Atrial septal defect (foramen ovale) management

A
  • Small defects close spontaneously and larger defects require intervention
53
Q

True/false: Majority of ventricular septal defects close spontaneously by age 4

A

True

54
Q

Ventricular septal defect symptoms

A

Symptoms began at 6 months

  • Small defect may be asymptomatic at birth
55
Q

Ventricular septal defect physical exam findings

  • Small VSD
A

Harsh, high pitched, grade II-IV/VI holosystolic murmur at LLSB

56
Q

Ventricular septal defect physical exam findings

  • Large VSD
A
  • Low pitched, grade II-V/VI holosystolic murmur at LLSB
  • Diastolic hum at apex
  • Thrill along LSB
  • S3 and S4 gallop if CHF present
57
Q

Ventricular septal defect management

A
  • Infants with small defects and no CHF symptoms can be monitored every 6 months for the first year of life, then every other year
  • Larger defects with symptoms of CHF require meds, SBE prophylaxis, proper nutrition, surgery
58
Q

PDA clinical findings

A
  • Asymptomatic if PDA is small
  • Symptoms of CHF may be present in the first week of life in larger PDAs (evident by 3 months)
59
Q

What is characteristic of a PDA murmur?

A

Machine like murmur

  • Normal closure occurs in the first 12-72 hours after birth
  • Permanent closure in 2-3 weeks in term infants
60
Q

PDA physical exam findings

A
  • Postnatal period → soft systolic murmur heard along LSB, under clavicle, and in the back
  • After first week of life: harsh, rumbling, continuous machinery murmur at left intraclavicular fossa
    • Thrill at base
61
Q

PDA management

A
  • Large shunts require surgery
  • Indomethacin or ibuprofen given to preterm infants to encourage closure
  • Asymptomatic infants with small PDA followed for spontaneous closure or transcatheter device closure
62
Q

What are the three right-to-left shunts (cyanotic)?

A

Unoxygenated blood goes from the right to left side of the heart then to systemic circulation

  • Tetralogy of fallot
  • Transposition of the great arteries
  • Tricuspid atresia
63
Q

What is tetralogy of fallot? What defects are associated with this?

A

Combination of four anatomic cardiac defects → right ventricular outflow tract obstruction

  • Pulmonary valve stenosis
  • Right ventricular hypertrophy
  • VSD
  • Aorta that overrides the ventricular septum
64
Q

Tetralogy of fallot clinical findings

A

Depends on the degree of right ventricular outflow obstruction and presence of PDA

  • Cyanosis
  • Dyspnea (“TET” spells)
  • Poor weight gain
65
Q

Tetralogy of fallot physical exam findings

A
  • Cyanosis
  • Dyspnea
  • Harsh systolic ejection murmur at left mid to upper sternal border
  • Holosystolic murmur at LLSB
  • Sternal lift
  • Palpable thrill
66
Q

Tetralogy of fallot management

A
  • Surgery (not compatible with life)
  • TET spell management → Cradled in knee-chest position, soothed, given supplemental oxygen or morphine sulfate SQ
67
Q

What is transposition of the great arteries?

A

Aorta is at the RV and pulmonary artery is at the LV (opposites)

  • Incomplete septation and migration of the truncus arteriosus during fetal development
68
Q

Transposition of the great arteries clinical findings

A
  • Cyanosis within 1 hour of birth
  • CHF symptoms
  • Large for gestational age infants
69
Q

Transposition of the great arteries management

A

Immediate referral to cardiac care center

70
Q

What is tricuspid atresia?

A

Small right ventricle without access from the right atrium

  • Transposition of the great arteries occur in 50% of these patients
71
Q

Tricuspid atresia clinical findings

A
  • Cyanosis
  • Increased respiratory rate
  • Fatigue with effort of crying or feeding
  • Poor weight gain
72
Q

Tricuspid atresia physical exam findings

A
  • Early systolic murmur
  • Single S2
  • Cyanosis
  • Hepatomegaly
73
Q

Tricuspid atresia management

A

Specialist involvement

74
Q

What is an example of an obstructive cardiac lesion?

A

Coarctation of the aorta

  • Narrowing of a small or large segment of the aorta
75
Q

Coarctation of the aorta clinical findings

A
  • Apparent at 6 weeks with tachypnea, poor feeding, cool lower extremities
  • At 3-5 years old, will have HTN and murmur
76
Q

Coarctation of the aorta physical exam findings

A
  • Upper extremity HTN with lower extremity hypotension
  • Absent or wear distal pulses
  • Bounding brachial, radial, carotid pulses
  • Symptoms of CHF
  • Systolic ejection murmur in left infraclavicular region with transmission to back
  • Palpable ventricular heave at apex
  • Gallop rhythm

NURS 503 (10 decks)

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