Mosby 14 Flashcards

1
Q

Position of heart with respect to costal cartilages

A

3rd to 6th

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2
Q

The area overlying heart

A

Precordium

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3
Q

Upper portion of heart

Lower portion of heart

A

Base

Apex

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4
Q

Relationship of heart position to tallness

A

The more tall the more central/vertical vs. left/horizontal

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5
Q

Mirror image heart (right)

A

Dextrocardia

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6
Q

Somach and heart on right side

A

Sinus inversus

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7
Q

Apical pulse of left ventricle position

A

5th intercostal space @ midclavicular line

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8
Q

Infancy

Size of left/right atrium

Extra connections

Arrangement of heart

A

Equal unlike adult

ductus arterisus, foramen ovale

More horiztonal than adults

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9
Q

Pregnancy

Change in blood volume

Which part

When start/edn

Heart position change

A

Increases 50%

Plasma

Starting in first timester and peaking in 30th week, 3-4wks after delivery

Rotations towards horizontal axis

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10
Q

Hemodynamic Changes during pregnancy

A
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11
Q

Pressure or choking sensation substernally or into the neck

Cause?

A

Angina

strenuous physical activity, eating, exposure to intense cold, windy weather, or exposure to
emotional stress

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12
Q

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

A

precordial catch

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13
Q

Ddx for chest pain

A

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)

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14
Q

Anginal pain

Characteristic

A

Substernal; provoked by effort, emotion, eating; relieved by rest
and/or nitroglycerin; often accompanied by diaphoresis,
occasionally by nausea

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15
Q

Pleural pain

Characteristic

A

Precipitated by breathing or coughing; usually described as
sharp; present during respiration; absent when breath held

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16
Q

Esophageal Pain

characteristics

A

Burning, substernal, occasional radiation to the shoulder;
nocturnal occurrence, usually when lying flat; relief with food,
antacids, sometimes nitroglycerin

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17
Q

Pain from a peptic ulcer

characteristics

A

Almost always infradiaphragmatic and epigastric; nocturnal
occurrence and daytime attacks relieved by food; unrelated
to activity

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18
Q

Biliary pain

characteristics

A

Usually under right scapula, prolonged in duration; often
occurring after eating; will trigger angina more often than
mimic it

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19
Q

Arthritis/bursitis

characteristics

A

Usually lasts for hours; local tenderness and/or pain with
movement

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20
Q

Cervical pain

characteristics

A

Associated with injury; provoked by activity, persists after
activity; painful on palpation and/or movement

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21
Q

Musculoskeletal (chest) pain

characteristics

A

Intensified or provoked by movement, particularly twisting or
costochondral bending; long lasting; often associated with
focal tenderness

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22
Q

Psychoneurotic pain

characteristics

A

Associated with/after anxiety; poorly described; located in intramammary region

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23
Q

DDx comparison

Angina pectoris

muscoskeletal

gastrointestinal

A
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24
Q

HPI Chest pain description: onset and duration

A

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

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25
Q

Chest pain description: character

A

aching, sharp, tingling, burning, pressure, stabbing, crushing, or clenched
fist sign

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26
Q

HPI Chest pain description: location

A

radiating down arms, to neck, jaws, teeth, scapula; relief with rest or position
change

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27
Q

HPI Chest pain description: Severity

A

interference with activity, need to stop all activity until subsides, disrupts
sleep, how severe on a scale of 0 to 10

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28
Q

HPI Chest pain description: Associated symptoms

A

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)

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29
Q

HPI Chest pain description: treatment

A

rest, position change, exercise, nitroglycerin, digoxin, diuretics, beta-blockers,
angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, nonsteroidal
antiinflammatory drugs, antihypertensives

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30
Q

HPI Fatigue

Associated Symptoms

Medications causing

A

dyspnea on exertion, chest pain, palpitations, orthopnea, paroxysmal
nocturnal dyspnea, anorexia, nausea, vomiting

beta-blocker

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31
Q

HPI Cough

character

medications

A

dry, wet, nighttime, aggravated by lying down

ACE inhibitors

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32
Q

HPI related to cariovascular (general)

A

Chest pain

Fatigue

Cough

Difficulty breathing

Loss of conciousnes

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33
Q

HPI Questions regarding difficulting breathing

A

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

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34
Q

HPI Loss of consciousness’

associated symptoms

A

palpitation, dysrhythmia,
unusual exertion, sudden turning of neck (carotid sinus effect), looking upward (vertebral
artery occlusion), change in posture

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35
Q

PMH Cardio

A

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

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36
Q

FH Cardio

A

Long QT syndrome
Diabetes
Heart disease
Dyslipidemia
Hypertension
Obesity
Congenital heart defects

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37
Q

SH

A

Emplyoment w/ physical, env hazards (e.g. heat/stress)

Tabacoo

Nutritional status

Diet

Weight

Alcohol

Releaxation

Hobbies

Exercise

Sexual activity

Illegal drugs

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38
Q

Risk factors for cardiac disease

A

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

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39
Q

Concers for infants related to cardiovascular disease

A

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

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40
Q

Concers for chidren related to cardiovascular disease

A

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)

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41
Q

Concers for pregnant women related to cardiovascular disease

A

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

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42
Q

Concers for chidren related to cardiovascular disease

A

◆ 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

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43
Q

NIH recommendation for cholesterol

total

LDL

LDL after MI

A

200 mg/dL

100 mg/dL

70 mg/dL

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44
Q

Lifestyle changes to improve cardio

A

LDL levels

Diet

Exercise

No smoking

Monitor BP, glucose, inflamatory, lipids anually

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45
Q

Non-cardio signs of heart failure

A

Crackles in the lugs

Engorgement of liver

Peripheral edema

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46
Q

Influencing factors during cardiovascular exam:

General?

Skin?

Abdominal region?

Eye?

A

◆ Effect of a barrel chest or pectus deformity
◆ Xanthelasma
◆ Funduscopic changes of hypertension
◆ Ascites or pitting edema
◆ Abdominal aortic bruit

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47
Q

What is the indication of downward displaced and stronger apical impulse?

A

Left vencticular hypertrophy

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48
Q

What is the indication of lift of apical impulse along sternal border

A

Righte ventricular hypertrophy

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49
Q

The point at which the apical
impulse is most readily seen or felt

A

point of maximal impulse (PMI)

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50
Q

Cause Loss of thrust for apical impulse

A

overlying fluid or air or to displacement beneath the sternum

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51
Q

Cause for displacement to the right without a loss or gain in thrust for apical impulse

A

dextrocardia, diaphragmatic
hernia, distended stomach, or a pulmonary abnormality

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52
Q

What is thrill

Indication for what?

A

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

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53
Q

Why percussion is not useful for cardio?

How heart borders can be estabilished then?

A

Heart is more maleable than chest and it will conform shape

Chest radiograph

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54
Q

Five ascultatory areas

A

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

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55
Q

Where is split S2 beast hear at

A

Pulmonic valve area: second left intercostal space at the left sternal border (during inspiration)

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56
Q

Categories by which heart sounds are classified

A

Pitch, intensity, duration, timing (in cardiac cycle)

57
Q

Normal heart sounds S1 vs. S2 comparison

A
58
Q

Where is S1 best heard?

Comparison of sound S1/S2?

A

Toward apex

S1 is lower in pitch and longer than S2

59
Q

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

A
60
Q

Reasons for lounder S1

A

Systole begins too early:

Blood veolicty increased (anemia, fever, hyperthyrodism, anxiety, exercise)

Stenosis of mitrial valve

61
Q

Degree of opening of the S1 valve (and loudness of the S1)

Decrease

A

Complete heart block

Gross disruption of rhythm

Increase of overlying, tissue, fat

Pulmonary hypertension

Fibrosis and calcification e.g. due to RF

62
Q

S2 increase in loudness causes

A
Systemic hypertension (S2 may ring or boom), syphilis of the aortic valve, exercise, or
excitement accentuates S2

Pulmonary hypertension, mitral stenosis, and congestive heart failure accentuate P2

The valves are diseased but still fully mobile; the component of S2 affected depends on
which valve is compromised.

63
Q

S2 decrease in loudness

A

A shocklike state with arterial hypotension causes loss of valvular vigor.
The valves are immobile, thickened, or calcified; the component of S2 affected depends on which valve is compromised.
Aortic stenosis affects A2.
Pulmonic stenosis affects P2.
Overlying tissue, fat, or fluid mutes S2 giving

64
Q

Which sound is heard later in physiologic splitting in S2?

A

Pulmonary valve

65
Q

S3 “Ken-TUCK-y”

Cause

Timing

Quality

When lounder?

A

Vibration of ventricle during passive

diastole

Quiert, low pitched, difficult to hear

Increased filling pressure or decreased ventricular compliance

66
Q

S4 “TEN-nes-see”

Cause

Timing

When louder?

A

vibration in the valves, papillae, and ventricular walls

late diastole (presystole) * can be confused with s1

elderly, increased resistance because of loss of complance of ventricular walls

67
Q

What makes S3 and S4 easier to hear?

A

Increasing venous return (e.g. raising leg or grip hand)

68
Q
A
69
Q

Wide splitting causes

A

DELAYED PULMONIC CLOSURE

right bundle branch block

stenosis of pulmonary valve

pulmonary hypertension delays emptying

mitral regurgitation (cause early closure of aortic valve)

70
Q

Fixed splitting causes

A

WHEN OUTPUT OF RIGHT VENTRICLE IS GREATER THAN OF THE LEFT

Large atrial septal defect

ventricular septal defect

left-to-right shunting

71
Q

Paradoxic (reversed) splitting

A

AORTIC VALVE IS DELAYED

72
Q

Extra Heart Sounds examples

A

Pericardial friction rub

73
Q

Murmur definition

A

Prologned extra sound during sys or diastole

Due to disruption of the blood flow

74
Q

Forward blood restriction in valve

A

Stenosis

75
Q

Allowing backward flow of blood through valve

A

Regurgitation

76
Q

First Heart Sound

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
77
Q

Second Heart Sound

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
78
Q

Third Heart Sound

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
79
Q

Fourth Heart Sound

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
80
Q

Quadruple rhythm

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
81
Q

Summation gallop

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
82
Q

Ejection sounds

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
83
Q

Systolic Click

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
84
Q

Open Snap

Preferable position of patient

Area for auscultation

Endpiece

Pitch

Effects of respiration

External Influences

Cause

A
85
Q

Classification of murmur: timing and duration

A
86
Q

Classification of murmur: intensity

A
87
Q

Classification of murmur: pattern

A
88
Q

Classification of murmur: quality, location, radiation, respiratiory phase

A
89
Q

Mitrial Stenosis

Detection

Findings

Description

A

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

90
Q

Aortic Stenosis

Detection

Findings

Description

A

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

91
Q

Subaortic Stenosis

Detection

Findings

Description

A

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

92
Q

Pulmonary Stenosis

Detection

Findings

Description

A

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

93
Q

Tricuspid Stenosis

Detection

Findings

Description

A

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

94
Q

Mitrial Regurgitation

Detection

Findings

Description

A

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

95
Q

Mitral Valve Prolapse

Detection

Findings

Description

A

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

96
Q

Aortic Regurgitation

Detection

Findings

Description

A

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

97
Q

Pulmonic Regurgitation

Detection

Findings

Description

A

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

98
Q

Tricuspid Regurgitation

Detection

Findings

Description

A

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

99
Q

Innocent murmurs another name

Population where heard

Description

A

Still murmurs

Younger (blood flowing from large chamber to blood vessels)

They are usually grade I or II, usually midsystolic, without radiation, medium pitch, blowing, brief, and often accompanied by splitting of S2

100
Q

Benign murmur

A

The result of a structural anomaly that is not severe enough to cause a clinical problem

101
Q

DDx systomic murmurs

Right-sided chambers

A

Inspiration-increase

Expireation-decrease

102
Q

DDx systomic murmurs

Hypertrophic

A

Valsalva - Increase

103
Q

DDx systomic murmurs

Cardiomyopathy

A

Squatting to standing (rapidly for 30 seconds) - Increase
Standing to squatting (rapidly) - Decrease
Passive leg elevation to 45 degrees, patient supine - Decrease

104
Q

DDx systomic murmurs

Mitral regurgitation

A

Handgrip - Increase

105
Q

DDx systomic murmurs

VSD

A

Transient arterial occlusion (sphygmomanometer placed on each of patient’s upper arms and simultaneously inflated to 20 to 40 mm Hg above patient’s previously recorded blood pressures; intensity noted after 20 seconds) _ increase

Inhalation of amyl nitrate (three rapid breaths from a broken ampule) (Not routinely recommended) - decrease

106
Q

DDx systomic murmurs

Aortic Stenosis

A

No maneuver distinguishes this murmur; the diagnosis can be made by exclusion

107
Q

Irregular rate in repeated pattern likely cause

A

sinus dysrhythmia

108
Q

Irregular rhytms possible cause

A

heart disease or conduction system impairment

109
Q

Infancy purplish plethora symptom of

A

Polycythemia

110
Q

Infancy ashen white color symptom of

A

Shock

111
Q

Infancy central cyanosis symptom of

A

Congential heart disease

112
Q

Cyanosis of hands and feet without central cyanosis

Important?

A

Acrocyanosis

Dissapears after few days/hours after birth

113
Q

Cyanosis at birth suggestion

A

transposition of the great vessels, tetralogy of Fallot, tricuspid
atresia, a severe septal defect, or severe pulmonic stenosis

114
Q

Cyanosis that appears after the neonatal period causes

A

pure pulmonic stenosis, Eisenmenger complex,
tetralogy of Fallot, or large septal defects

115
Q

Most murmurs in infancy

A

Innocent - transition from fetal to pulmonic circulation

116
Q

Heart rate vs. age

A
117
Q

Sign of heart failure in infants

A

infant’s liver may enlarge before there is any suggestion of moisture in the lungs, and that the left lobe of the liver may be more distinctly enlarged than the right

118
Q

Bacterial Endocarditis

Description

Pathophysiology

Subjective

Objective

A

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)
119
Q

Congestive Heart Failure

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Heart fails to propel blood forward with its usual force, resulting in congestion in the pulmonary or systemic circulation

PATHOPHYSIOLOGY

Decreased cardiac output causes decreased blood flow to the tissues
May be left or right sided
Left sided is characterized as systolic or diastolic
Diastolic CHF is result of advanced glycation cross-linking collagen and creating a stiff ventricle unable to dilate actively
Diastolic CHF occurs in older adults whose tissue is exposed to glucose for a longer period of time and in individuals with diabetes mellitus

SUBJECTIVE

Fatigue
Orthopnea
Breath difficulty, shortness of breath
Edema

OBJECTIVE

Symptoms can develop gradually or suddenly with acute pulmonary edema
Systolic CHF has a narrow pulse pressure
Diastolic CHF has a wide pulse pressure

120
Q

Pericarditis

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Sudden inflammation of the pericardium

PATHOPHYSIOLOGY

If persists the pericardial effusion may increase and result in cardiac tamponade

SUBJECTIVE

Initially, chest pain is sharp or stabbing
Movement or inspiration may aggravate the pain
Pain may be most severe when supine, relieved when leaning forward

OBJECTIVE

Scratchy, grating, triphasic friction rub on ascultation, comprises ventricular systole, early diastolic ventricular filling, and late diastolic atrial systole
Easily heard just left of the sternum in third and fourth intercostal spaces

121
Q

Cardiac Tamponade

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Excessive accumulation of effused fluids or blood between the pericardium

PATHOPHYSIOLOGY

Seriously constrains cardiac relaxation, impairing access of blood to the right heart
Common causes: pericarditis, malignancy, aortic dissection, and trauma

SUBJECTIVE DATA

Anxiety, restlessness
Chest pain
Difficulty breathing
Discomfort, sometimes relieved by sitting upright or leaning forward
Syncope, light-headedness
Pale, gray, or blue skin
Palpitations
Rapid breathing
Swelling of the abdomen or arms or neck veins

OBJECTIVE

Beck’s triad (jugular venous distention, hypotension, and muffled heart sounds)
Chronically and severely involved pericardium may also scar and constrict, limiting cardiac filling; heart sounds are muffled, blood pressure drops, the pulse becomes weakened and rapid, and paradoxic pulse becomes exaggerated

122
Q

Cor Pulmonale

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Enlargement of the right ventricle secondary to pulmonary malfunction

PATHOPHYSIOLOGY

Usually chronic, occasionally acute
Chronic common cause: chronic obstructive pulmonary disease
(COPD)
Acute causes: massive pulmonary embolism and acute respiratory distress syndrome (ARDS)
Results from chronic pulmonary disease; alterations in pulmonary circulation leads to pulmonary arterial hypertension, which imposes a mechanical load on right ventricular emptying

SUBJECTIVE

Fatigue
Tachypnea
Exertional dyspnea
Cough, hemoptysis

OBJECTIVE

Evidence of pulmonary disease
Wheezes and crackles on auscultation
Increase in chest diameter
Labored respiratory efforts with chest wall retractions
Distended neck veins with prominent A or V waves
Cyanosis
Left parasternal systolic heave
Loud S2 exaggerated in the pulmonic region

123
Q

Myocardial Infraction

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Ischemic myocardial necrosis caused by abrupt decrease in coronary blood flow to a segment of the myocardium

PATHOPHYSIOLOGY

Most commonly affects left ventricle
Atherosclerosis and thrombosis are the common underlying causes

SUBJECTIVE

Deep substernal or visceral pain that often radiates to the jaw, neck, and left arm
Discomfort may be mild, especially in older adults or patients with diabetes mellitus

OBJECTIVE

Dysrhythmias are common
S4 is usually present
Distant heart sounds
Soft, systolic, blowing apical murmur
Thready pulse
Blood pressure varies, although
Video/Animation hypertension is usual in the early phases

124
Q

Myocarditis

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Focal or diffuse inflammation of the myocardium

PATHOPHYSIOLOGY

Results from infectious agents, toxins, or autoimmune diseases such as amyloidosis

SUBJECTIVE

Initial symptoms vague
Fatigue
Dyspnea
Fever
Palpitations

OBJECTIVE

Cardiac enlargement
Murmurs
Gallop rhythms
Tachycardia
Dysrhythmias
Pulsus alternans

125
Q

Causes of syncope

A

CANADA

  • *C Cardiac:** valve stenosis, Stokes-Adams attacks, other conduction disturbances
  • *A Arteriovenous:** “steal” syndromes
  • *N Nervous:** psychologic, autonomic, vagal, coughing
  • *A Anemia**, altered blood (CO)
  • *D Drugs**, diabetes, alcohol, poisons
  • *A Altitude**, acute fevers
126
Q

Conduction distrubances

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Conduction disturbances either proximal to the bundle of His or diffusely throughout the conduction system

PATHOPHYSIOLOGY

May result from a variety of causes: ischemic, infiltrative, or, rarely, neoplastic
Antidepressant drugs, digitalis, quinidine, and many other medications can be precipitating factors

SUBJECTIVE

Transient weakness
Syncope
Cardiac syncope may occur acutely without warning; sometimes diminished sensibility, a “gray-out” instead of a “black-out,” may precede the event
Strokelike episodes
Rapid or irregular heartbeat

OBJECTIVE

Labile heart rates
Rhythm disturbances

127
Q

Tetralogy of fallot

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Four cardiac defects: ventricular septal defect, pulmonic stenosis, dextroposition of the aorta, and right ventricular hypertrophy

PATHOPHYSIOLOGY

Surgical correction is recommended, currently initiated after the first “spell”

SUBJECTIVE

Dyspnea with feeding, poor growth, exercise intolerance
Paroxysmal dyspnea with loss of consciousness and central cyanosis (tetralogy spell)

OBJECTIVE

Parasternal heave and precordial prominence, systolic ejection murmur over the third intercostal space, sometimes radiating to the left side of the neck; a single S2 is heard (Fig. 14-24)
Older children develop clubbing of fingers and toes

128
Q

Ventricular Septal Defect

Description

Pathophysiology

Subjective

Objective

A

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

129
Q

Patent Ductus Arteriosus

Description

Pathophysiology

Subjective

Objective

A

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

130
Q

Atrial Septal Defect

Description

Pathophysiology

Subjective

Objective

A

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

131
Q

Acute Rheymatic Fever

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection

PATHOPHYSIOLOGY

Characterized by a variety of major and minor manifestations
May result in serious cardiac valvular involvement of mitral or aortic valve; tricuspid and pulmonic are not often affected
Affected valve becomes stenotic and regurgitant
Children between 5 and 15 years of age are most commonly affected
Prevention—adequate treatment for streptococcal pharyngitis or skin infections—is the best therapy

SUBJECTIVE

Fever
Inflamed swollen joints
Flat or slightly raised, painless rash with pink margins with pale centers and a ragged edge (erythema marginatum)
Aimless jerky movements (Sydenham chorea or St. Vitus dance)
Small, painless nodules beneath the
skin
Chest pain
Palpitations
Fatigue
Shortness of breath

OBJECTIVE

Murmurs of mitral regurgitation and aortic insufficiency
Cardiomegaly
Friction rub of pericarditis
Congestive heart failure

132
Q

Major Jones Criteria

Minor Jones Criteria

A

Carditis, Polyarthiritis, Chorea, Erythema maginatum, Subcutaneus Nodules

Fever, Arthalgia, Preious RF, Acute Phase Reaction, Prolonged PR

133
Q

Kawasaki Disease

A

DESCRIPTION

Condition causing inflammation in walls of small and medium-sized arteries throughout the body, including coronaryn arteries

PATHOPHYSIOLOGY

Named after Dr. Tomisaku Kawasaki, the physician who first identified the disease in 1967
Also called mucocutaneous lymph node syndrome because it also affects lymph nodes, skin, and mucous membranes
Frequently (80% of the time) affects infants and children under 5 years of age

SUBJECTIVE

High fever, lasting longer than 5 days
Conjunctivitis
Cracked, red, and inflamed lips
Strawberry tongue, white coating on tongue or prominent papillae on the back of the tongue
Cervical lymphadenopathy
Erythema of the palms of the hands and soles of the feet
Joint pain (arthralgia) and swelling, frequently symmetric
Irritability
Tachycardia

OBJECTIVE

Diagnosis is usually made based on the patient having most of the classic symptoms

134
Q

Kawasaki Disease Diagnostic Characteristics

A

Fever of at least 5 days’ duration together with four of the following five findings:
• Painless bulbar conjunctival injection without exudate
• Changes in extremities including erythema, edema, and desquamation
• Polymorphous (macular, morbilliform, or target lesions) erythematous rash of the trunk and extremities.
• Changes in the lips and oral cavity including diffuse oral or pharyngeal mucosal erythema; erythematous, dry/fissured, or swollen lips; red “strawberry” tongue
• Cervical lymphadenopathy (≥1.5 cm in diameter), usually unilateral

135
Q

Artherosclerotic Heart Disease

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Caused by deposition of cholesterol, other lipids, and by a complex nflammatory process

PATHOPHYSIOLOGY

Leads to vascular wall thickening and narrowing of the lumen

SUBJECTIVE DATA

May be asymptomatic
Angina pectoris, shortness of breath, palpitations
Family history of close relatives with atherosclerotic disease, early death, or dyslipidemia

OBJECTIVE

Dysrhythmias and congestive heart failure

136
Q

Mitral Insufficiency/Regurgitation

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Abnormal leaking of blood through the mitral valve, from left ventricle into left atrium

SUBJECTIVE

Acute mitral regurgitation has symptoms of decompensated congestive heart failure
Shortness of breath
Pulmonary edema
Orthopnea
Paroxysmal nocturnal dyspnea
Decreased exercise tolerance
Chronic compensated mitral regurgitation may be asymptomatic
Patients may be sensitive to small shifts in intravascular volume and are prone to develop congestive heart failure

OBJECTIVE

High-pitched pansystolic murmur radiating to axilla
May also have a third heart sound

137
Q

Angina

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Pain caused by myocardial ischemia

PATHOPHSYIOLOGY

Occurs when myocardial oxygen demand exceeds supply
Can be recurrent or present as initial incidence

SUBJECTIVE

Substernal pain or intense pressure radiating to the neck; jaws; and arms,
particularly the left
Often accompanied by shortness of breath, fatigue, diaphoresis, faintness, and syncope

OBJECTIVE DATA

No definitive examination findings suggest angina
Tachycardia, tachypnea, hypertension, and/or diaphoresis
Ischemia may lead to presence of crackles due to pulmonary edema or a reduction in the S1 intensity or an S4
Physical examination may suggest other comorbidities that place the patient at higher risk for anginal symptoms, such as COPD, xanthelasma, hypertension, evidence of peripheral arterial disease, abnormal pulsations on palpation over precordium, murmurs or arrhythmias

138
Q

Senile Cardiac Amyloidosis

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in the heart

PATHOPHYSIOLOGY

Heart contractility may be reduced
Causes heart failure

SUBJECTIVE

Palpitations, lower extremity edema, fatigue, reduced activity tolerance

OBJECTIVE

Pleural effusion
Arrhythmia
Lower extremity edema
Dilated neck veins
Hepatomegally or ascites
Electrocardiography or echocardiography shows small, thickened left ventricle; right ventricle may also be thickened

139
Q

Aortic Sclerosis

Description

Pathophysiology

Subjective

Objective

A

DESCRIPTION

Thickening and calcification of aortic valves

SUBJECTIVE

Does not usually cause symptoms

OBJECTIVE

Midsystolic (ejection) murmur