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)
Categories by which heart sounds are classified
Pitch, intensity, duration, timing (in cardiac cycle)
Normal heart sounds S1 vs. S2 comparison
Where is S1 best heard?
Comparison of sound S1/S2?
Toward apex
S1 is lower in pitch and longer than S2
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
Reasons for lounder S1
Systole begins too early:
Blood veolicty increased (anemia, fever, hyperthyrodism, anxiety, exercise)
Stenosis of mitrial valve
Degree of opening of the S1 valve (and loudness of the S1)
Decrease
Complete heart block
Gross disruption of rhythm
Increase of overlying, tissue, fat
Pulmonary hypertension
Fibrosis and calcification e.g. due to RF
S2 increase in loudness causes
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.
S2 decrease in loudness
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
Which sound is heard later in physiologic splitting in S2?
Pulmonary valve
S3 “Ken-TUCK-y”
Cause
Timing
Quality
When lounder?
Vibration of ventricle during passive
diastole
Quiert, low pitched, difficult to hear
Increased filling pressure or decreased ventricular compliance
S4 “TEN-nes-see”
Cause
Timing
When louder?
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
What makes S3 and S4 easier to hear?
Increasing venous return (e.g. raising leg or grip hand)
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
Murmur definition
Prologned extra sound during sys or diastole
Due to disruption of the blood flow
Forward blood restriction in valve
Stenosis
Allowing backward flow of blood through valve
Regurgitation
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
Innocent murmurs another name
Population where heard
Description
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
Benign murmur
The result of a structural anomaly that is not severe enough to cause a clinical problem
DDx systomic murmurs
Right-sided chambers
Inspiration-increase
Expireation-decrease
DDx systomic murmurs
Hypertrophic
Valsalva - Increase
DDx systomic murmurs
Cardiomyopathy
Squatting to standing (rapidly for 30 seconds) - Increase
Standing to squatting (rapidly) - Decrease
Passive leg elevation to 45 degrees, patient supine - Decrease
DDx systomic murmurs
Mitral regurgitation
Handgrip - Increase
DDx systomic murmurs
VSD
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
DDx systomic murmurs
Aortic Stenosis
No maneuver distinguishes this murmur; the diagnosis can be made by exclusion
Irregular rate in repeated pattern likely cause
sinus dysrhythmia
Irregular rhytms possible cause
heart disease or conduction system impairment
Infancy purplish plethora symptom of
Polycythemia
Infancy ashen white color symptom of
Shock
Infancy central cyanosis symptom of
Congential heart disease
Cyanosis of hands and feet without central cyanosis
Important?
Acrocyanosis
Dissapears after few days/hours after birth
Cyanosis at birth suggestion
transposition of the great vessels, tetralogy of Fallot, tricuspid
atresia, a severe septal defect, or severe pulmonic stenosis
Cyanosis that appears after the neonatal period causes
pure pulmonic stenosis, Eisenmenger complex,
tetralogy of Fallot, or large septal defects
Most murmurs in infancy
Innocent - transition from fetal to pulmonic circulation
Heart rate vs. age
Sign of heart failure in infants
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
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)
Congestive Heart Failure
Description
Pathophysiology
Subjective
Objective
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
Pericarditis
Description
Pathophysiology
Subjective
Objective
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
Cardiac Tamponade
Description
Pathophysiology
Subjective
Objective
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
Cor Pulmonale
Description
Pathophysiology
Subjective
Objective
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
Myocardial Infraction
Description
Pathophysiology
Subjective
Objective
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
Myocarditis
Description
Pathophysiology
Subjective
Objective
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
Causes of syncope
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
Conduction distrubances
Description
Pathophysiology
Subjective
Objective
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
Tetralogy of fallot
Description
Pathophysiology
Subjective
Objective
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
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
Acute Rheymatic Fever
Description
Pathophysiology
Subjective
Objective
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
Major Jones Criteria
Minor Jones Criteria
Carditis, Polyarthiritis, Chorea, Erythema maginatum, Subcutaneus Nodules
Fever, Arthalgia, Preious RF, Acute Phase Reaction, Prolonged PR
Kawasaki Disease
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
Kawasaki Disease Diagnostic Characteristics
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
Artherosclerotic Heart Disease
Description
Pathophysiology
Subjective
Objective
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
Mitral Insufficiency/Regurgitation
Description
Pathophysiology
Subjective
Objective
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
Angina
Description
Pathophysiology
Subjective
Objective
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
Senile Cardiac Amyloidosis
Description
Pathophysiology
Subjective
Objective
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
Aortic Sclerosis
Description
Pathophysiology
Subjective
Objective
DESCRIPTION
Thickening and calcification of aortic valves
SUBJECTIVE
Does not usually cause symptoms
OBJECTIVE
Midsystolic (ejection) murmur
