Mosby 14 Flashcards
Position of heart with respect to costal cartilages
3rd to 6th
The area overlying heart
Precordium
Upper portion of heart
Lower portion of heart
Base
Apex
Relationship of heart position to tallness
The more tall the more central/vertical vs. left/horizontal
Mirror image heart (right)
Dextrocardia
Somach and heart on right side
Sinus inversus
Apical pulse of left ventricle position
5th intercostal space @ midclavicular line
Infancy
Size of left/right atrium
Extra connections
Arrangement of heart
Equal unlike adult
ductus arterisus, foramen ovale
More horiztonal than adults
Pregnancy
Change in blood volume
Which part
When start/edn
Heart position change
Increases 50%
Plasma
Starting in first timester and peaking in 30th week, 3-4wks after delivery
Rotations towards horizontal axis
Hemodynamic Changes during pregnancy
Pressure or choking sensation substernally or into the neck
Cause?
Angina
strenuous physical activity, eating, exposure to intense cold, windy weather, or exposure to
emotional stress
sudden, sharp, relatively brief pain that does not radiate, occurs most often at rest, and is unrelated to exertion and may not have a discoverable cause
precordial catch
Ddx for chest pain
Cardiac
• Typical angina pectoris
• Atypical angina pectoris, angina equivalent
• Prinzmetal variant angina
• Unstable angina (acute coronary syndrome)
• Coronary insufficiency
• Myocardial infarction
• Nonobstructive, nonspastic angina
• Mitral valve prolapse
Aortic
• Dissection of the aorta
Pleuropericardial Pain
• Pericarditis
• Pleurisy
• Pneumothorax
• Mediastinal emphysema
Gastrointestinal Disease
• Hiatus hernia
• Reflux esophagitis
• Esophageal rupture
• Esophageal spasm
• Cholecystitis
• Peptic ulcer disease
• Pancreatitis
Pulmonary Disease
• Pulmonary hypertension
• Pneumonia
• Pulmonary embolus
• Bronchial hyperreactivity
• Tension pneumothorax
Musculoskeletal
• Cervical radiculopathy
• Shoulder disorder or dysfunction (e.g., arthritis, bursitis, rotator cuff injury, biceps tendonitis)
• Costochondral disorder
• Xiphodynia
Psychoneurotic
• Illicit drug use (e.g., cocaine)
Anginal pain
Characteristic
Substernal; provoked by effort, emotion, eating; relieved by rest
and/or nitroglycerin; often accompanied by diaphoresis,
occasionally by nausea
Pleural pain
Characteristic
Precipitated by breathing or coughing; usually described as
sharp; present during respiration; absent when breath held
Esophageal Pain
characteristics
Burning, substernal, occasional radiation to the shoulder;
nocturnal occurrence, usually when lying flat; relief with food,
antacids, sometimes nitroglycerin
Pain from a peptic ulcer
characteristics
Almost always infradiaphragmatic and epigastric; nocturnal
occurrence and daytime attacks relieved by food; unrelated
to activity
Biliary pain
characteristics
Usually under right scapula, prolonged in duration; often
occurring after eating; will trigger angina more often than
mimic it
Arthritis/bursitis
characteristics
Usually lasts for hours; local tenderness and/or pain with
movement
Cervical pain
characteristics
Associated with injury; provoked by activity, persists after
activity; painful on palpation and/or movement
Musculoskeletal (chest) pain
characteristics
Intensified or provoked by movement, particularly twisting or
costochondral bending; long lasting; often associated with
focal tenderness
Psychoneurotic pain
characteristics
Associated with/after anxiety; poorly described; located in intramammary region
DDx comparison
Angina pectoris
muscoskeletal
gastrointestinal
HPI Chest pain description: onset and duration
sudden, gradual, or vague onset, length of episode; cyclic nature;
related to physical exertion, rest, emotional experience, eating, coughing, cold temperatures,
trauma, awakens from sleep
Chest pain description: character
aching, sharp, tingling, burning, pressure, stabbing, crushing, or clenched
fist sign
HPI Chest pain description: location
radiating down arms, to neck, jaws, teeth, scapula; relief with rest or position
change
HPI Chest pain description: Severity
interference with activity, need to stop all activity until subsides, disrupts
sleep, how severe on a scale of 0 to 10
HPI Chest pain description: Associated symptoms
anxiety; dyspnea; diaphoresis; dizziness; nausea or vomiting;
faintness; cold, clammy skin; cyanosis; pallor; swelling or edema (noted anywhere,
constant or at certain times during day)
HPI Chest pain description: treatment
rest, position change, exercise, nitroglycerin, digoxin, diuretics, beta-blockers,
angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, nonsteroidal
antiinflammatory drugs, antihypertensives
HPI Fatigue
Associated Symptoms
Medications causing
dyspnea on exertion, chest pain, palpitations, orthopnea, paroxysmal
nocturnal dyspnea, anorexia, nausea, vomiting
beta-blocker
HPI Cough
character
medications
dry, wet, nighttime, aggravated by lying down
ACE inhibitors
HPI related to cariovascular (general)
Chest pain
Fatigue
Cough
Difficulty breathing
Loss of conciousnes
HPI Questions regarding difficulting breathing
aggravated by exertion (how much?)
worsening or remaining stable
lying down or eased by
resting on pillows (how many? or sleep in a recliner?)
paroxysmal nocturnal dyspnea
HPI Loss of consciousness’
associated symptoms
palpitation, dysrhythmia,
unusual exertion, sudden turning of neck (carotid sinus effect), looking upward (vertebral
artery occlusion), change in posture
PMH Cardio
Cardiac surgery or hospitalization
Rhythm disorder
Acute Rheumatic feverl unexplained fever, swollen joins, Sydenham chorea (St. Vitus dance), abdominal pain, skin rash (erythema marginatum)
or nodules
Chronic illness: hypertension, bleeding disorder, hyperlipidemia, diabetes, thyroid dysfunction,
coronary artery disease, obesity, congenital heart defect
FH Cardio
Long QT syndrome
Diabetes
Heart disease
Dyslipidemia
Hypertension
Obesity
Congenital heart defects
SH
Emplyoment w/ physical, env hazards (e.g. heat/stress)
Tabacoo
Nutritional status
Diet
Weight
Alcohol
Releaxation
Hobbies
Exercise
Sexual activity
Illegal drugs
Risk factors for cardiac disease
• Gender (men more at risk than women; women’s risk is increased in the postmenopausal years and with oral contraceptive use)
• Hyperlipidemia
• Elevated homocysteine level
• Smoking
• Family history of cardiovascular disease, diabetes, hyperlipidemia, hypertension, or sudden death in young adults
• Diabetes mellitus
• Obesity: dietary habits including an excessively fatty diet
• Sedentary lifestyle without exercise
• Personality type: intense, compulsive behavior with feelings of hostility; negative
emotions, pessimistic attitude, failure to share emotions
Concers for infants related to cardiovascular disease
◆Tiring easily during feeding
◆ Breathing changes: more heavily or more rapidly than expected during feeding or defecation
◆ Cyanosis: perioral during eating, more widespread and more persistent, related to crying
◆ Weight gain as expected
◆ Knee-chest position or other position favored for rest
◆ Mother’s health during pregnancy: medications taken, unexplained fever, illicit drug use
Concers for chidren related to cardiovascular disease
◆ Tiring during play: amount of time before tiring, activities that are tiring, inability to keep
up with other children, reluctance to go out to play
◆ Naps: longer than expected
◆ Positions: squatting instead of sitting when at play or watching television
◆ Headaches
◆ Nosebleeds
◆ Unexplained joint pain
◆ Unexplained fever
◆ Expected height and weight gain (and any substantiating records)
◆ Expected physical and cognitive development (and any substantiating records)
Concers for pregnant women related to cardiovascular disease
◆ History of cardiac disease or surgery
◆ Dizziness or faintness on standing
◆ Indications of heart disease during pregnancy, including progressive or severe dyspnea,
progressive orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, syncope with exertion,
and chest pain related to effort or emotion
Concers for chidren related to cardiovascular disease
◆ Common symptoms of cardiovascular disorders: confusion, dizziness, blackouts, syncope,
palpitations, coughs and wheezes, hemoptysis, shortness of breath, chest pains or chest
tightness, impotence, fatigue, leg edema: pattern, frequency, time of day most
pronounced
◆ If heart disease has been diagnosed: drug reactions: potassium excess (weakness, bradycardia,
hypotension, confusion); potassium depletion (weakness, fatigue, muscle cramps,
dysrhythmias); digitalis toxicity (anorexia, nausea, vomiting, diarrhea, headache, confusion,
dysrhythmias, halo, yellow vision), interference with activities of daily living; ability
of the patient and family to cope with the condition, perceived and actual; orthostatic
hypotension
NIH recommendation for cholesterol
total
LDL
LDL after MI
200 mg/dL
100 mg/dL
70 mg/dL
Lifestyle changes to improve cardio
LDL levels
Diet
Exercise
No smoking
Monitor BP, glucose, inflamatory, lipids anually
Non-cardio signs of heart failure
Crackles in the lugs
Engorgement of liver
Peripheral edema
Influencing factors during cardiovascular exam:
General?
Skin?
Abdominal region?
Eye?
◆ Effect of a barrel chest or pectus deformity
◆ Xanthelasma
◆ Funduscopic changes of hypertension
◆ Ascites or pitting edema
◆ Abdominal aortic bruit
What is the indication of downward displaced and stronger apical impulse?
Left vencticular hypertrophy
What is the indication of lift of apical impulse along sternal border
Righte ventricular hypertrophy
The point at which the apical
impulse is most readily seen or felt
point of maximal impulse (PMI)
Cause Loss of thrust for apical impulse
overlying fluid or air or to displacement beneath the sternum
Cause for displacement to the right without a loss or gain in thrust for apical impulse
dextrocardia, diaphragmatic
hernia, distended stomach, or a pulmonary abnormality
What is thrill
Indication for what?
fine, palpable, rushing vibration, a palpable murmur, often, but not always, over the base of the heart in the area of the right or left second intercostal space
indicates turbulence or a disruption of the expected blood flow related to some
defect in the closure of one of the semilunar valves (generally aortic or pulmonic stenosis),
pulmonary hypertension, or atrial septal defect
Why percussion is not useful for cardio?
How heart borders can be estabilished then?
Heart is more maleable than chest and it will conform shape
Chest radiograph
Five ascultatory areas
◆ 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: at the apex of the heart in the fifth left intercostal space at the
midclavicular line
Where is split S2 beast hear at
Pulmonic valve area: second left intercostal space at the left sternal border (during inspiration)
Normal heart sounds S1 vs. S2 comparison
Location where sounds are heard the best
1st sound
1st sound split
2nd sound
Physiological 2nd sound split
3rd sound (entricular gallop)
4th sound (atrial gallop)
summation gallop
Wide splitting causes
DELAYED PULMONIC CLOSURE
right bundle branch block
stenosis of pulmonary valve
pulmonary hypertension delays emptying
mitral regurgitation (cause early closure of aortic valve)
Fixed splitting causes
WHEN OUTPUT OF RIGHT VENTRICLE IS GREATER THAN OF THE LEFT
Large atrial septal defect
ventricular septal defect
left-to-right shunting
Paradoxic (reversed) splitting
AORTIC VALVE IS DELAYED
Extra Heart Sounds examples
Pericardial friction rub
First Heart Sound
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Second Heart Sound
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Third Heart Sound
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Fourth Heart Sound
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Quadruple rhythm
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Summation gallop
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Ejection sounds
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Systolic Click
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Open Snap
Preferable position of patient
Area for auscultation
Endpiece
Pitch
Effects of respiration
External Influences
Cause
Classification of murmur: timing and duration
Classification of murmur: intensity
Classification of murmur: pattern
Classification of murmur: quality, location, radiation, respiratiory phase
Mitrial Stenosis
Detection
Findings
Description
DETECTION
Heard with bell at apex, patient in left lateral decubitus position
FINDING
Low-frequency diastolic rumble, more intense in early and late diastole, does not radiate; systole usually quiet; palpable thrill at apex in late diastole common; S1 increased and often palpable at left sternal border; S2 split often with accented P2; opening snap follows P2 closely Visible lift in right parasternal area if right ventricle hypertrophied Arterial pulse amplitude decreased
DESCRIPTION
Narrowed valve restricts forward flow; forceful ejection into ventricle Often occurs with mitral regurgitation Caused by rheumatic fever or cardiac infection
Aortic Stenosis
Detection
Findings
Description
DETECTION
Heard over aortic area; ejection sound at second right intercostal border
FINDINGS
Midsystolic (ejection) murmur, medium pitch, coarse, diamond shaped,* crescendodecrescendo; radiates along left sternal border (sometimes to apex) and to carotid with palpable thrill; S1 often heard best at apex, disappearing when stenosis is severe, often followed by ejection click; S2 soft or absent and may not be split; S4 palpable; ejection sound muted in calcified valves; the more severe the stenosis, the later the peak of the murmur in systole Apical thrust shifts down and left and is prolonged if left ventricular hypertrophy is also present
DESCRIPTION
Calcification of valve cusps restricts forward flow; forceful ejection from ventricle into systemic circulation Caused by congenital bicuspid (rather than the usual tricuspid) valve, rheumatic heart disease, atherosclerosis May be the cause of sudden death, particularly in children and adolescents, either at rest or during exercise; risk apparently related to degree of stenosis
Subaortic Stenosis
Detection
Findings
Description
DETECTION
Heard at apex and along left sternal border
FINDINGS
Murmur fills systole, diamond shaped, medium pitch, coarse; thrill often palpable during systole at apex and right sternal border; multiple waves in apical impulses; S2 usually split; S3 and S4 often present Arterial pulse brisk, double wave in carotid common; jugular venous pulse prominent
DESCRIPTION
Fibrous ring, usually 1 to 4 mm below aortic valve; most pronounced on ventricular septal side; may become progressively severe with time; difficult to distinguish from aortic stenosis on clinical grounds alonea
Pulmonary Stenosis
Detection
Findings
Description
DETECTION
Heard over pulmonic area radiating to left and into neck; thrill in second and third left intercostals space
FINDINGS
Systolic (ejection) murmur, diamond shaped, medium pitch, coarse; usually with thrill; S1 often followed quickly by ejection click; S2 often diminished, usually wide split; P2 soft or absent; S4 common in right ventricular hypertrophy; murmur may be prolonged and confused with that of a ventricular septal defect
DESCRIPTION
Valve restricts forward flow; forceful ejection from ventricle into pulmonary circulation Cause is almost always congenital
Tricuspid Stenosis
Detection
Findings
Description
DETECTION
Heard with bell over tricuspid area
FINDINGS
Diastolic rumble accentuated early and late in diastole, resembling mitral stenosis but louder on inspiration; diastolic thrill palpable ov er right ventricle; S2 may be split during inspiration Arterial pulse amplitude decreased; jugular venous pulse prominent, especially a wave; slow fall of v wave
DESCRIPTION
Calcification of valve cusps restricts forward flow; forceful ejection into ventricles Usually seen with mitral stenosis, rarely occurs alone Caused by rheumatic heart disease, congenital defect, endocardial fibroelastosis, right atrial myxoma
Mitrial Regurgitation
Detection
Findings
Description
DETECTION
Heard best at apex; loudest there, transmitted into left axilla
FINDINGS
Holosystolic, plateau-shaped intensity, high pitch, harsh blowing quality, often quite loud and may obliterate S2; radiates from apex to base or to left axilla; thrill may be palpable at apex during systole; S1 intensity diminished; S2 more intense with P2 often accented; S3 often present; S3-S4 gallop common in late disease If mild, late systolic murmur crescendos; if severe, early systolic intensity decrescendos; apical thrust more to left and down in ventricular hypertrophy
DESCRIPTION
Valve incompetence allows backflow from ventricle to atrium Caused by rheumatic fever, myocardial infarction, myxoma, rupture of chordae
Mitral Valve Prolapse
Detection
Findings
Description
DETECTION
Heard at apex and left lower sternal border; easily missed in supine position; also listen with patient upright
FINDINGS
Typically late systolic murmur preceded by midsystolic clicks, but both murmur and clicks highly variable in intensity and timing
DESCRIPTION
Valve is competent early in systole but prolapses into atrium later in systole; may become progressively severe, resulting in a holosystolic murmur; often concurrent with pectus excavatum
Aortic Regurgitation
Detection
Findings
Description
DETECTION
Heard with diaphragm, patient sitting and leaning forward; Austin- Flint murmur heard with bell; ejection click heard in second intercostal space
FINDINGS
Early diastolic, high pitch, blowing, often with diamondshaped midsystolic murmur, sounds often not prominent; duration varies with blood pressure; low-pitched, rumbling murmur at apex common (Austin-Flint); early ejection click sometimes present; S1 soft; S2 split may have tambour-like quality; M1 and A2 often intensified, S3-S4 gallop common In left ventricular hypertrophy, prominent prolonged apical impulse down and to left Pulse pressure wide; waterhammer or bisferiens or Corrigan pulse common in carotid, brachial, and femoral arteries (see Chapter 15)
DESCRIPTION
Valve incompetence allows backflow from aorta to ventricle Caused by rheumatic heart disease, endocarditis, aortic diseases (Marfan syndrome, medial necrosis), syphilis, ankylosing spondylitis, dissection, cardiac trauma
Pulmonic Regurgitation
Detection
Findings
Description
DETECTION/FINDINGS
Difficult to distinguish from aortic regurgitation on physical examination
DESCRIPTION
Valve incompetence allows backflow from pulmonary artery to ventricle Secondary to pulmonary hypertension or bacterial endocarditis
Tricuspid Regurgitation
Detection
Findings
Description
DETECTION
Heard at left lower sternum, occasionally radiating a few centimeters to left
FINDINGS
Holosystolic murmur over right ventricle, blowing, increased on inspiration; S3 and thrill over tricuspid area common In pulmonary hypertension, pulmonary artery impulse palpable over second left intercostal space and P2 accented; in right ventricular hypertrophy, visible lift to right of sternum Jugular venous pulse has large v waves
DESCRIPTION
Valve incompetence allows backflow from ventricle to atrium Caused by congenital defects, bacterial endocarditis (especially in IV drug abusers), pulmonary hypertension, cardiac trauma
Heart rate vs. age
Bacterial Endocarditis
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Bacterial infection of the endothelial layer of the heart and valves
PATHOPHYSIOLOGY
Individuals with valvular defects, congenital or acquired, and those who use intravenous drugs are particularly susceptible
SUBJECTIVE
Fever, fatigue
Murmur
Sudden onset of congestive heart failure
OBJECTIVE
Signs of neurologic dysfunctions Janeway lesion (small erythematous or hemorrhagic macules appearing on the palms and soles) Osler nodes (appear on the tips of fingers or toes and are caused by septic emboli)
Ventricular Septal Defect
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Opening between the left and right ventricles
PATHOPHYSIOLOGY
Significant number (30% to 50%) of small defects close spontaneously, during the first 2 years of life
SUBJECTIVE
Recurrent respiratory infections
If large VSD, rapid breathing, poor growth, symptoms of congestive heart failure
OBJECTIVE
Arterial pulse is small, and jugular venous pulse is unaffected
Holosystolic murmur, often loud, coarse, high-pitched, and best heard along the left sternal border in the third to fifth intercostal spaces
Distinct lift is often discernible along left sternal border and the apical area
A smaller defect causes a louder murmur and a more easily felt thrill than a large one
Patent Ductus Arteriosus
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Failure of the ductus arteriosus to close after birth
PATHOPHYSIOLOGY
Blood flows through the ductus during systole and diastole, increasing pressure in the pulmonary circulation and consequently workload of the right ventricle
SUBJECTIVE
Small shunt can be asymptomatic; a larger one causes dyspnea on exertion
OBJECTIVE
Dilated and pulsatile neck vessels
Wide pulse pressure
Harsh, loud, continuous murmur heard at the first to third intercostal spaces and the lower sternal border, with a machine-like quality
Murmur is usually unaltered by postural change, unlike murmur of a venous hum
Atrial Septal Defect
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Congenital defect in the septum dividing the left and right atria
SUBJECTIVE DATA
Often asymptomatic
Heart failure rarely occurs in children but can often occur in adults
OBJECTIVE
Diamond-shaped systolic ejection murmur often loud, high pitched, and harsh, heard over the pulmonic area
May be accompanied by a brief, rumbling, early diastolic murmur
Does not usually radiate beyond the precordium
Systolic thrill may be felt over the area of the murmur, along with a palpable parasternal thrust
S2 may be widely split
Sometimes murmur may not sound particularly impressive, especially in overweight children; if there is a palpable thrust and radiation to the back, it is more apt to be significant
