Lecture Two (Adult heart)-Exam 2 Flashcards
What is the overview of the cardiovascular system: examining the heart and blood vessels? (7)
- Anatomy of the heart and great vessels
- The heart as a pump; blood pressure
- Beginning the examination with the vital signs: blood pressure and heart rate
- Jugular venous pressure (JVP) and pulsations; carotid pulse
- Chest wall and apical impulse/PMI
- Auscultation: S1 and S2; S3 and S4
- Auscultation:describing cardiac murmurs
What are the surface landmarks do we need to know?
Count interspaces: Identify your …
o Midsternal line
o Midclavicular line
o Anterior axillary line
o Midaxillary line
Identify different lines
What are the different interspaces?
Heart Murmurs
- Distinct heart sounds distinguished by what?
- Attributed to turbulent blood flow and usually indicate what?
- Distinct heart sounds distinguished by their pitch and their longer duration
- Attributed to turbulent blood flow and usually indicate VALVULAR HEART DISEASE
Heart murmurs: What may be represented in young adults?
may represent “innocent” flow murmur, especially young adults
What is stenosis and regurgitation?
- Stenosis: stenotic valve has abnormally narrowed orifice that obstructs blood flow; such as aortic stenosis
- Regurgitation: Valves closing abnormally, result in regurgitation. Blood leaks backward in a retrograde direction and produces a regurgitant murmur
What must you do to identify murmurs accurately?
- Learn where they are heard best on the chest wall
- Their timing in systole or diastole
- Their descriptive qualities (machine like, etc)
Fill in
What does jugular veins provide?
provide index of right heart pressures and cardiac function
What are common or concerning symptoms of CVS? (5)
*Chest Pain
* Palpitations
*Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea
*Swelling (edema)
*Fainting (syncope)
For chest pain, what is the range of causes?
- Range of causes
- Cardiac
- Pulmonary
- MSK: see if you can reproduce it
- Outside of the thoracic cavity
For Chest pain-OLD CARTS:
What is the onset and duration?
For Chest pain-OLD CARTS: Character?
For Chest pain-OLD CARTS: Location and radiation?
- Location: Substernal, precordial, epigastric (if locatized then less serious)
- Radiation: Jaw, teeth, down arms, into back, scapula or neck
What are the associated symptoms of chest pain (OLD CARTS)
What occurs in aortic dissection?
*Anterior chest pain, often tearing or ripping and radiating into the back or neck, occurs in acute aortic dissection
*Tearing, ripping = aortic dissection
What are palpitations? What are various descriptions?
An unpleasant awareness of the heartbeat.
Various descriptions
* Rapid beating, skipping, stopping, extra beating, flip-flop
* Regular or irregular?
* Fast or slow?
* Precipitating factors? (SVT)
* Associated with fainting, dizziness, CP, dyspnea or anxiety?
* Duration?
What can palpitations be associated with? (not heart disease)
- Anxiety
- Hyperthyroid (women over 40)
- Electrolyte imbalance (high or low potassium)
- Drug or stimulant
What is dyspnea? What are causes?
Dyspnea is an uncomfortable awareness of breathing that is inappropriate to a given level of exertion.
* Cardiac or pulmonary
* Sudden dyspnea occurs in pulmonary embolus,
spontaneous pneumothorax, and anxiety
What is orthopnea? How is it quantified?
Orthopnea is dyspnea that occurs when the pt is supine and improves when sits up
* Quantified by the number of pillows pt uses for sleeping or by the fact that the pt needs to sleep sitting up (recliner)
What is Paroxysmal Nocturnal Dyspnea(PND)
awakens pt suddenly about 1-2 hours after falling asleep due SOB
Orthopnea and PND can be caused by what?
caused LV heart failure, mitral stenosis, obstructive lung disease
What is edema?
Accumulation of excessive fluid in the extravascular interstitial space
Interstitial tissue can absorb how much before pitting edema appears?
Interstitial tissue can absorb up to 5 L of fluid, accommodating up to a 10% weight gain, before pitting edema appears
- Edema can be what?
- What are associated symptoms?
Can be systemic to local
Location, timing, and setting of the swelling and any
associated symptoms:
* Rings tight on fingers?
* Eylids puffy or swollen in morning?
* Have to let belt out?
* Rapid weight changes? (>2 lb rapid wt gain will occur prior to visible edema)
If a patient is swollen in the morning or the swelling is pass the ankle, do you need to look at?
Cardiac
What are edema casues?
- Cardiac: right or left ventricular dysfunction, pulmonary hypertension
- Pulmonary: obstructive lung disease
- Nutrition: hypoalbuminemia
- Nephrotic syndrome (rings and eyes)
- Positional: dependent edema
- Anasarca: severe generalized edema extending to the sacrum and abdomen
What do you need to know about past medical history with CVS?
Prior Cardiac
* Previous hospitalizations and Rx.
* Myocardial infarctions/angina
* Arrhythmias, bradycardia, pacemaker insertion
* Heart Failure
* Syncope or new seizures
* Cardiac Surgery
* Congenital heart disease
* Rheumatic Fever
* Valvular heart disease /MVP
* Heart Murmurs diagnosed in past
For PMH, what are some other vascular diseases?
- Carotid Artery disease: common and stenosis in carotid artery
- Peripheral Vascular Disease
- Embolic or Thrombotic CVA
- Abdominal or Thoracic Aneurysms
- Varicose veins
- Previous Deep Venous Thrombosis-> emergency, onset of calf pain, worst when pushing on calf
What are some chronic illnesses you need to know about for PMH?
- Chronic Illnesses * HTN
- DM
- Hyperlipidemia
- Thyroid Disease
- Neoplastic disease
- Chronic lung disease
- Chronic renal (need dialysis) or hepatic disease
- Pulmonary Hypertension
- Pulmonary Emboli
What should we know about for family history (CVS)?
What are the key components of the CV examination? (big overview)
Key components of the CV exam
- What do you need to note and measure?
- What do you estimate?
- What do you auscultate?
- What do you need to palpate?
- Note general appearance and measure blood pressure and heart rate.
- Estimate the level of jugular venous pressure.
- Auscultate the carotids (bruit) one at a time. (BEFORE PALPATE to not dislodge anything)
- Palpate the carotid pulse including carotid upstroke (amplitude, contour, timing) and presence of a thrill.
Key components of the CV exam
- What do you need to inspect?
- What do you need to palpate (not carotid)?
- Inspect the anterior chest wall (apical impulse, precordial movements).
- Palpate the precordium for any heaves, thrills, or palpable heart sounds.
- Palpate and locate the PMI or apical impulse
Key components of the CV exam
- What do you need to auscultate (not carotid)?
- What do you need to distinguish?
- Auscultate S1 and S2 in five positions from the base to the apex.
- Auscultate and recognize abnormal sounds in early diastole, including an S3 and OS of mitral stenosis and an S4 later in diastole.
- Distinguish systolic and diastolic murmurs, using maneuvers when needed. If present, identify their timing, shape, grade, location, radiation, pitch, and quality.
- How is the JVP best assessed?
- When does it fall and increase?
JVP best assessed from the pulsations in the right internal jugular vein
* JVP falls with loss of blood or decreased venous vascular tone
* JVP increases with right or left heart failure, pulmonary hypertension, tricuspid stenosis, AV dissociation, increased venous vascular tone, and pericardial compression or tamponade
For measuring the JVP: what do you need to find and how is it measured?
- Find the highest point of oscillation of the IJV
- JVP is measured in vertical distance above the sternal angle
* Bony ridge located around T4 adjacent to the second rib
What are the steps for measuring the JVP?
How does JVP change with differing angles of bed?
Not much
What are we looking for with JVP?
JVP measured at >3 cm above the sternal angle, or more than 8 cm in total distance above the right atrium, is considered elevated above normal.
What is this?
distended neck vein
* common with increase JVP in heart disease
Carotid arteries: What is the order? How do you perform the exam?
- Auscultation BEFORE palpating
- Auscultate both the carotid arteries to listen for a
bruit - Bruit is a murmur-like sound from turbulent arterial blood flow
- Ask the patient to stop breathing for about 10 seconds
- Listen near upper end of the thyroid cartilage below the angle of the jaw
What is a bruit?
Bruit is a murmur-like sound from turbulent arterial blood flow
- How should you palpate the carotid arteries?
- What do we need to note and avoid doing?
- Pt should be at 30 degrees
- Palpate the carotid, medial to relaxed SCM, roughly level of cricoid cartilage
* Note carotid upstroke, its amplitude and contour, and the presence or absence of thrills
* Avoid pressing on the carotid sinus, adjacent to the top of the thyroid cartilage - NEVER PALPATE BOTH CAROTID ARTERIES AT THE SAME TIME
- What are you inspecting?
- What can you do to help you?
- Inspect the anterior chest for apical impulse or PMI
- Shine a tangential light across the chest wall over the cardiac apex to make more visible
What are you feeling for in palpations? (precordium)
- Heave
- Thrill
- Apical impulse and PMI
What are heaves and thrills? What causes them?
.