okayy Flashcards
The ____________ occupies most of the anterior cardiac surface.
Right Ventricle
The inferior border of the right ventricle lies below the junction of the _______ and _________.
Sternum; Xiphoid process
The base of the heart is at the ______ end.
superior
The apex of the heart is at the ______ end.
inferior
The base of the heart is located at the _______ intercostal space.
2nd
________ produces the apical impulse.
The apex on the left ventricle
The _________ is the external area of the body where the heart is located.
precordium
The PMI might not be readily felt in a ___________________.
healthy patient with a normal heart
The PMI is felt over the _________.
apex
The PMI can be palpated at the _______ intercostal space, _________ to the ___________ line.
5th; 7-9 cm lateral; midsternal
In supine patients, the diameter of the PMI may be as large as ________________.
a quarter (1 to 2.5 cm)
A PMI greater than ________ is evidence of ____________, or enlargement.
2.5 cm; left ventricular hypertrophy (LVH)
The PMI is also known as the ___________.
precordial impulse
Displacement of the PMI lateral to the _______________ suggests ___________ or enlargement.
midclavicular line; LVH
In patients with chronic obstructive pulmonary disease, the PMI may be in the ___________________ as a result of ___________.
xiphoid or epigastric area; right ventricular hypertrophy
Above the heart lie the _________.
great vessels
The ________ curves upward from the left ventricle to the level of the __________.
aorta; sternal angle
On the ________ border of the heart, the superior and inferior vena cava channel _________ from the upper and lower portions of the body into the ____________.
medial; venous; right atrium
Because of their positions, the tricuspid and mitral valves are often called _________ valves.
atrioventricular
The aortic and pulmonic valves are called __________ valves because each of their leaflets is shaped like a ____________.
semilunar; half moon
_______ is the period of ventricular contraction.
systole
The normal resting pressure of the left ventrical is _____ mm Hg, while the the normal peak pressure during contraction is _______ mm Hg.
5; 120
During systole, the aortic valve is _______.
open
Late in __________, ventricular pressure rises slightly during inflow of blood from _____________.
diastole; atrial contraction
During systole, the mitral valve is _______.
closed
During diastole, the aortic valve is _________ and the mitral valve is _________.
closed; open
Valves close in order to prevent __________.
backflow or regurgitation
The hear sounds S1 and S2 are heard when ___________.
the valves close
Closure of the ______ valve produces S1.
mitral (and tricuspid)
During ______ pressure in the blood filled left atrium slightly exceeds that in the relaxed left ventricle, and blood flows from left atrium to left ventricle.
diastole
Just before the onset of __________, atrial contraction produces a slight pressure rise in both chambers.
ventricular systole
During systole, the ________ starts to contract and __________ pressure rapidly exceeds __________ pressure, shutting the mitral valve.
left ventricle; ventricular; left atrial
Normally the _____________ corresponds to the systolic blood pressure.
maximal left ventricular pressure
As the __________ pressure continues to rise, it quickly exceeds the pressure in the aorta and forces the ________ open.
left ventricular; aortic valve
In some pathologic conditions, _________________ accompanies the opening of the aortic valve.
an early systolic ejection sound (Ej)
As the _____________ ejects most of its blood, ventricular pressure begins to fall.
left ventricle
When left ventricular pressure drops below aortic pressure, _________________.
the aortic valve shuts
________ produces the second heart sound.
aortic valve closure
Diastole begins when _______________.
the aortic valve shuts; S2
In ________, left ventricular pressure continues to drop and falls below left atrial pressure. The _____ opens.
diastole; mitral valve
____________ is usually silent, but may be audible as a pathologic opening snap (OS).
The mitral valve opening
Blood flows early in _______ from left atrium to left ventricle.
diastole
After the _____________, there is a period of rapid left ventricular filling.
mitral valve opens
In children and young adults, a third heart sound (S3) may arise from ________________________.
rapid deceleration of the column of blood against the ventricular wall
The 3rd heart sound is sometimes called ____________.
S3 gallop
In older adults, ________ usually indicates a pathologic change in ventricular compliance.
S3
Right ventricular and pulmonary pressures are ________________ than corresponding pressures on the left side.
significantly lower
Right-sided events usually occur ___________ than those on the left side of the heart.
slightly later
Instead of a single heart sound, you may hear two discernible components: ______ & _______.
A2 & P2
The split S2 occurs during ______, and is fused during ________.
inspiration; exhalation
_______ & _________ in the pulmonary vascular bed contribute to the “hangout time” that delays P2.
Distensibility; Impedence
Because the walls of veins ___________, the venous system has more capacitance than the arterial system and ______________.
contain less smooth muscle; lower systemic pressure
Of the two components of S2, ______ is normally louder.
A2
The ___________ can only be heard in the areas of the 2nd and 3rd left intercostal spaces, close to the sternum.
split S2
S1 can be heard at its loudest at ___________.
the apex
The split S1 can only be heard _____________________.
over the lower left sternal border
Splitting of S1 does not vary with ____________.
inspiration
Heart murmurs are distinguishable from heart sounds by their _______________.
longer duration
Heart murmurs are attributed to ____________.
turbulent blood flow
A ________ valve obstructs blood flow, and creates a characteristic murmur.
stenotic
A valve that does not fully close is usually the cause of a murmur called:
aortic regurgitation or insufficiency
Sounds and murmurs arising from the _______ are heard best at the cardiac apex.
mitral valve
Sounds and murmurs arising from the _______ are heard best at the left sternal border.
tricuspid valve
Sounds and murmurs arising from the _______ are heard best at the 2nd & 3rd left intercostal spaces (near the sternum).
pulmonic valve
Murmurs originating in the ________ may be heard anywhere from the right 2nd intercostal space to the apex.
aortic valve
Each normal electrical impulse of the heart is initiated in the __________.
sinus node
The ____________ acts as the cardiac pacemaker and automatically discharges an impulse about __________ times a minute.
Sinus node; 60-100
From the sinus node, the impulse travels through _______ to the _____________ (located low in the _________)
both atria; atrioventricular (AV) node; atrial septum
The electrical impulse is delayed at the ______ before passing down the bundle of his and its branches to the ______________.
AV Node; ventricular myocardium
During the conduction cycle, the _____ contract first, then the _______.
atria; ventricles
The ECG consists of _____ ______ leads in the ______ plane, and _____ ______ leads in the _______ plane.
6; limb; frontal; 6; chest/precordial; transverse
________ records the events of the electrical conduction system.
ECG
Electrical vectors ______________ a lead cause positive, or upward reflection.
approaching
Electrical vectors ______________ a lead cause negative, or downward deflection.
moving away from
When positive and negative vectors valance, they are _________, appearing as a _____________.
isoelectric; straight line
The ________ on an ECG represents atrial depolarization.
P wave
The ________ on an ECG represents ventricular depolarization.
QRS complex
The ________ on an ECG represents septal depolarization.
Q wave
The ________ on an ECG represents an upward deflection from ventricular depolarization.
R wave
The ________ on an ECG represents a downward deflection from ventricular depolarization.
S wave
The ________ on an ECG represents ventricular repolarization, or recovery.
T wave
The ___________ slightly precedes the myocardial contraction that it stimulates.
electrical impulse
_________ is the volume of blood ejected from each ventricle during 1 minute.
Cardiac output
heart rate X stroke volume =
cardiac output
________ is the volume of blood ejected with each heartbeat.
Stroke volume
Stroke volume depends on ________, _________, & _________.
preload; myocardial contractility; afterload
Preload refers to the load that ___________________________.
stretches the cardiac muscle before contraction
The volume of blood in the right ventricle at the end of diastole constitutes its __________ for the next beat.
preload
Right ventricular preload is increased by increasing __________________.
venous return to the right heart
Physiologic causes of increased preload include:
inspiration & increased volume of blood flow from exercise
The increased blood volume in a dilated right ventricle of congestive heart failure increases __________.
preload
Causes of decreased right ventricular preload include:
decreased left ventricular output, pooling of blood in the capillary bed or the venous system
_________ refers to the ability of cardiac muscle, when given a load, to shorten.
Myocardial contractility
Contractility increases when stimulated by the ________ and decreases when ____________________.
sympathetic nervous system; blood flow or oxygen delivery to the myocardium is impaired
_______ refers to the degree of vascular resistance to ventricular contraction.
afterload
The term _________ is now preferred over __________ because not all patients have volume overload on initial presentation.
heart failure; congestive heart failure
Sources of resistance to left ventricular contraction include:
the tone in the walls of the aorta, the large arteries, and the peripheral vascular tree, as well as the volume of blood already in the aorta.
Pathologic increase in preload is called ___________.
volume overload
Pathologic increase in afterload is called ___________.
pressure overload
Volume overload & pressure overload can be detected through:
palpation and auscultation
The pressure wave of blood that is ejected from the ______ is felt as the ___________.
left atrium; arterial pulse
The _______ travels quickly, many times faster than the actual blood.
pressure wave
Blood pressure in the arterial system peaks at _________ and falls to its trough at _________.
systole; diastole
The difference between the systolic and diastolic pressure is the ______________.
pulse pressure
Name 4 factors that influence arterial pressure:
1) Left ventricular stroke volume 2) Distensibility of the aorta and the large arteries 3) Peripheral vascular resistance 4) Volume of blood in the arterial system
The ____________ provide an important clinical index of right heart pressures and cardiac function.
jugular veins
_________ reflects right atrial pressure, which in turn equals central venous pressure (CVP) and _________________.
Jugular venous pressure; right ventricular end-diastolic pressure
The JVP is best estimated from the ________________.
right external jugular vein
The right external jugular vein is a useful and accurate method for estimating _________.
CVP
JVP falls with _________, and rises with ___________, ___________, _______________, and _____________.
blood loss; right or left heart failure; pulmonary hypertension; tricuspid stenosis; pericardial compression or tamponade
The internal jugular veins lie deep to the _______________ in the neck.
sternomastoid muscles
The venous jugular pulsations should not be confused with _____________.
the carotid artery
To estimate the level of the _________, find the highest point of oscillation in the internal jugular vein. Or, if necessary, the point above which the __________________________.
JVP; external jugular vein appears collapsed
The JVP is measured in vertical distance above the __________.
sternal angle
_________ is the bony ridge adjacent to the 2nd rib where the sternum meets the manubrium.
The sternal angle
Jugular venous pressure measured at more than _____ cm above the sternal angle, or more than ______ cm above the right atrium is considered elevated or abnormal.
4; 9
The sternal angle is approximately _______ cm above the right atrium.
5
The undulating pulsations of the internal jugular veins are composed of:
two quick peaks and two troughs
The 1st elevation of the internal jugular pulsation is the ________, the second elevation is the __________.
a wave; v wave
_______ occurs just before S1 and before the carotid pulse.
a wave
_______ reflects the slight rise in atrial pressure that accompanies atrial contraction.
a wave
The trough after the a wave is ___________.
x descent
The x descent begins with ____________.
atrial relaxation
________ occurs when the tricuspid valve is closed and the the atrium is filling, causing atrial pressure to rise.
v wave
________ occurs when the tricuspid valve opens, the blood drains into the right atrium, and atrial pressure drops.
y descent
The ___________ are the most obvious events in the normal jugular pulse.
two descents (x & y)
What is the sequence of jugular pulse?
atrial contraction (a wave), atrial relaxation (x descent), atrial filling (v wave), atrial emptying (y descent)
______ may affect the location of the apical impulse, the pitch of heart sounds and murmurs, the stiffness of the arteries, and blood pressure.
aging
The apical impulse is usually felt easily in _____________.
children & young adults
_______ & __________ may be more difficult to detect in older patients.
splitting of S2; apical impulse
At some time over the lifespan, almost everyone has a ______________.
heart murmur
Most murmurs occur without _____________________.
other evidence of cardiovascular abnormality
Mot murmurs may be considered ____________.
normal variants
Murmurs may originate in __________ as well as in the heart.
large blood vessels
The ___________ which is common in children, may still be heard through young adulthood.
jugular venous hum
A _________________ is innocent in children but suspicious for arterial obstruction in adults.
cervical systolic murmur
What are the four common or concerning cardiac symptoms?
Chest pain, palpitations, shortness of breath, and swelling/edema
Annual incidence of exertional angina is 1 per ________ in the population of 30 years or older.
1000
_________ is seen in 50% of patients with acute myocardial infarction.
Angina pectoris
__________ is classic exertional pain, pressure, or discomfort in the chest, shoulder, back, neck, or arm.
Angina pectoris
__________ is the 2nd leading cause of visits to the ED.
Chest pain
__________ is the 1st leading cause of visits to the ED.
Abdominal pain
Coronary heart disease currently affects _______ people in the US.
15 million
Of the 15 million people in the US with coronary heart disease, _______ have angina pectoris, and ______ have had a myocardial infarction.
9; 8
________ is the leading cause of death for both men and women, accounting for 1 ____ US deaths.
Coronary heart disease; 5
Death rates for coronary heart disease are highest amongst _______________.
African American men and women
__________ is used to refer to any of the clinical syndromes caused by acute myocardial ischemia, including unstable angina, non-ST elevation myocardial infarction, and ST elevated infarction.
Acute coronary syndrome
__________ presents with anterior chest pain, often tearing or ripping, often radiating into the back or neck.
Acute aortic dissection
________ involve an unpleasant awareness of the heartbeat.
Palpitations
Palpitations may result from _____________________, ___________________, or ___________________.
irregular heartbeat; rapid increase/decrease of heart rate; increased forcefulness of cardiac contraction
Palpitations do not necessarily mean ____________.
heart disease
The most serious dysrhythmias, such as ___________________ do not produce palpitations.
ventricular tachycardia
Sudden dyspnea occurs in ___________, _____________, and ___________.
pulmonary embolus; spontaneous pneumothorax; anxiety
Shortness of breath may represent __________, _________ or ________________.
dyspnea; orthopnea; paroxysmal nocturnal dyspnea
_________ is an uncomfortable awareness of breathing that is inappropriate to a given level of of exertion.
Dyspnea
________ is dyspnea that occurs when the patient is lying down and improves when the patient sits up.
Orthopnea
_________ is seen in left ventricular heart failure or mitral stenosis; also seen in obstructive lung disease.
Orthopnea
Orthopnea is typically quantified by ____________________.
the number of pillows that the patient uses for sleeping (only if the reason for sleeping upright is shortness of breath)
___________ describes episodes of sudden dyspnea and orthopnea that awaken the patient from sleep, usually 1 or 2 hours after going to bed, prompting the patient to sit up, stand up, or go to a window for air.
Paroxysmal nocturnal dyspnea (PND)
_________ is seen in left ventricular heart failure or mitral stenosis; may be mimicked by nocturnal asthma attacks.
Paroxysmal nocturnal dyspnea (PND)
_______ refers to accumulation of excessive fluid in the extravascular interstitial space.
Edema
___________ appears in the lowest body parts: the feet and lower legs while sitting or the sacrum when bedridden.
Dependent edema
Causes of _________ may be cardiac (congestive heart failure), nutritional (hypoalbuminemia), or positional.
Dependent edema
Interstitial tissue can absorb several liters of fluid, accommodating up to a ___% weight gain before ____________ appears
10; pitting edema
Edema occurs in ______ and ______ disease.
liver; renal
Cardiovascular disease affects _______ U.S. adults and includes __________, ___________, _______________, _______________, and _____________________.
80 million; hypertension; coronary heart disease; heart failure; stroke; congenital cardiovascular defects
Cardiovascular disease account for approximately ________ of all U.S. deaths.
one third
________ accounts for 35% of all myordial infarctions and strokes, 49% of all episodes of heart failure, and 24% of all premature deaths.
Hypertension
Blood pressure screening is recommended for ____________________________.
all people 18 years or older
Normal blood pressure is defined as:
below 120/80
Pre-hypertension is defined as __________, and warrants __________________.
120-139 (systolic) / 80-89 (diastolic); lifestyle change interventions
Stage 1 hypertension is defined as ____________, and warrants ____________.
140-159 (systolic) / 90-99 (diastolic); initiation of antihypertensive drug therapy
The blood pressure target for patients with diabetes and chronic kidney disease is ______________.
below 130/80
Individuals who are normotensive at 55 years have a _______% lifetime risk of developing hypertension.
90
More than 1 out of every _____ adults of the age 60 has hypertension.
2
For individuals aged 40 to 70 years, each increment of ____ mm HG in systolic BP or ______ mm Hg in diastolic BP doubles risk of CVD across the entire BP range from 115/75 to 185/115.
20; 10
Only _____ % of the young and middle-aged population is at low cardiovascular risk.
10-May
__________ leads to a gain of 5.8 to 9.5 years in life expectancy.
Low cardiovascular risk
Risk factors for hypertension include:
physical inactivity, microalbuminuria or estimated GFR less than 60 mL/min, family history of premature CVD (earlier than 55 in men, earlier than 65 in women), excess intake of dietary sodium, insufficient intake of potassium, and excess intake of alcohol.
AHA recommends screening for risk of CVD and stroke beginning at age _______.
20
AHA recommends “global absolute CHD risk estimation” for all adults aged _____ and over.
40
What are the risk factors that need to be checked for CHD?
Family history of CHD, smoking, diet, alcohol intake, physical activity, blood pressure, BMI, waist circumference, pulse (to detect atrial fibrillation), fasting lipoprotein profile, fasting glucose.
______ is the primary target of cholesterol lowering therapy.
LDL
________ is more closely correlated than _______ with risk factors for metabolic syndrome.
Waist circumference; BMI
________ reflects pressure in the right atrium, or central venous pressure, and is best assessed from pulsations in the ______________.
JVP; right internal jugular vein
Jugular veins and pulsations are not easily seen in ________________, so they are not useful for evaluating the cardiovascular system of this group.
children younger than 12 years
The usual starting point for JVP is to elevate the head of the bed to __________.
30 degrees
In hypovolemic patients, to see the JVP you will need to position the bed _____________.
lower, sometimes at 0 degrees
In hypervolemic patients, to see the JVP you will need to position the bed _____________.
higher (raise the head)
What are the steps for assessing JVP?
Make the patient comfortable, place head on a pillow, raise head of bed to 30 degrees, turn patient’s head to the left, using tangential lighting find the external jugular first, then the internal jugular, identify the highest point of pulsation in the right internal jugular, extend a ruler horizontally from this point, and a ruler vertically from the sternal angle, make a right angle between the two and measure the height, add 5 to the measurement to obtain JVP.
Increased JVP suggests _______________________.
right sided congestive heart failure (or less commonly, constrictive percarditis, tricuspid stenosis, or superior vena cava obstruction).
__________ pulsations are rarely palpable, while ________ pulsations are readily palpable.
Internal Jugular Pulsations; Carotid Pulsations
___________ pulsations have a soft, biphasic, undulating quality, usually with two elevations and two troughs per heart beat.
Internal Jugular Pulsations
__________ pulsations have a vigorous thrust with a single outward component.
Carotid pulsations
__________ pulsations are eliminated by light pressure on the veins just above the sternal end of the clavicle.
Internal Jugular Pulsations
__________ pulsations are not eliminated by light pressure.
Carotid pulsations
The height of _______ pulsations is changed with position.
Internal Jugular Pulsations
The height of _______ pulsations do not change with position.
Carotid pulsations
The height of _______ pulsations usually falls with inspiration.
Internal Jugular Pulsations
The height of _______ pulsations do not change with inspiration.
Carotid pulsations
In patients with ___________, venous pressure may appear elevated on expiration only; the veins collapse on inspiration. This finding does not indicate _____________.
obstructive lung disease; congestive heart failure
Venous pressure measured at greater than ____ cm above the sternal angle is considered elevated/abnormal.
3
An elevated _________ is 98% specific for an increased left ventricular end diastolic pressure and low left ventricular ejection fraction, and it increases risk of death from _________.
JVP; heart failure
If you cannot see pulsation in the internal jugular vein, look for the in the _____________.
external jugular vein and use the point above which the external collapses
You should observe JVP on the _____ side.
both (left & right)
____________ is the usual cause of unilateral distention of the external jugular vein.
Local kinking or obstruction
Systole occurs between _____ & _____.
S1; S2
Diastole occurs between ______ & ______.
S2; S1
When feeling jugular venous pulsations: the ____ wave just precedes S1 and the _______ pulse. The ____ descent can be seen as a systolic collapse. The _____ wave almost coincides with S2. The _____ descent follows ______ early in diastole.
a; carotid; x; v; y; S2
Prominent _____ waves are seen in increased resistance to right atrial contraction, as in tricuspid stenosis (also in first-degree atrioventricular block, supraventricular tachycardia, junctional rhythms, pulmonary hyertension, and pulmonic stenosis).
a
Absent a waves are seen in ______________.
atrial fibrillation
Large ____ waves are seen in tricuspid regurgitation & constrictive pericarditis.
v
The _____________ provides valuable information about cardiac function and is especially useful for detecting stenosis or insufficiency of the aortic valve.
carotid pulse
A ____________ carotid artery may produce a unilateral pulsatile bulge.
tortuous and kinked
Causes of decreased carotid pulsations include:
decreased stroke volume and local factors in the artery such as atherosclerotic narrowing or occlusion.
To assess amplitude and contour of the right carotid artery:
use right index and middle fingers or left thumb, press just inside the medial border of the sternomastoid muscle
Never press ________ at the same time, this may induce syncope.
both carotids
Pressure on the _______ may cause a reflex drop in pulse rate or blood pressure.
carotid sinus
When palpating the carotid artery, the __________ correlates reasonably well with the pulse pressure.
amplitude of the pulse
Small, thready or weak carotid pulse is seen in ________.
cardiogenic shock
Bounding carotid pulse is seen in ____________.
aortic insufficiency
Delayed carotid upstroke is seen in __________.
aortic stenosis
Normal carotid upstroke occurs between _____ & ______.
S1; S2
Which is normally shorter: systole or diastole?
systole
_________ may radiate to the neck and sound like a carotid bruit.
Aortic valve murmur
During palpation of the carotid artery, you may detect humming vibrations, or __________ that feel like the throat of a purring cat.
thrills
You should auscultate the carotid arteries for _________, a __________ sound of vascular rather than cardiac origin.
bruit; murmur-like
If the carotid artery is inaccessible, you should use the _______ artery.
brachial
During the heart exam, the clinician should stand on the patient’s _______ side.
right
Which heart sound is usually louder at the base?
S2
Which heart sound is usually louder at the apex?
S1
At a heart rate of about _______ bpm, the durations of systole and diastole become indistinguishable.
120
Both the carotid upstroke and apical impulse occur during __________.
systole (just after S1)
Sounds or murmurs coinciding with the carotid upstroke and apical impulse are _________.
systolic
Sounds or murmurs occurring after the carotid upstroke and apical impulse are _________.
diastolic
_______ is decreased in a first degree heart block.
S1
________ is decreased in aortic stenosis.
S2
_________ may accompany loud, harsh, or rumbling murmurs as in aortic stenosis, patent ductus arteriosus, and ventricular septal defect.
Thrills
__________ is when a patient’s heart is found on the right side.
dextrocardia
In ___________ the heart, liver, and stomach are all on the opposite sides.
situs inversus
A right sided heart with a normally placed liver and stomach is usually associated with ______________.
congenital heart disease
You should use _________________ to check for thrills.
the ball of your hand placed firmly against the chest
How do you determine S1 and S2 by palpation only?
Place your right hand on the chest wall, and your left fingers on the carotid. The carotid upstroke occurs between S1 and S2.
The aortic area of the heart is located where?
right 2nd intercostal space
The pulmonic area of the heart is located where?
left 2nd intercostal space
The right ventricular area is located where?
left sternal border
The left ventricular area is located where?
apex of the heart
Where should you assess the right ventricle?
the right ventricular area (left sternal border) and subxiphoid area
Name some pathological conditions that could produce a more prominent PMI:
enlarged right ventricle, dilated pulmonary artery, or aneurysm of the aorta
The apex beat is palpable in only ________ % of healthy adults in the supine position, and ______ % of healthy adults in the left lateral decubitus position.
25-40; 50
If you cannot find the apical impulse, what should you do?
Ask the patient to roll onto their left side (left lateral decubitus position) and/or ask the patient to exhale completely and hold.
