Slide set 3 Flashcards
What sequence do you use to perform a heart exam
1-Inspection, 2-Palpation, 3-Auscultation
Skin inspection ABNLs
Cyanosis, Pallor, Edema, Clubbing
NL chest shape is
2:1 - wider:deep
ABNLs of the chest (5)
Pectus Excavatum Pectus Carinatum Barrel Chest
Thoracic kyphoscoliosis
Traumatic flai chest
Pectus excavatum charcteristics
AKA funnel chest Lower sternum is depressed Compresses heart/great vessels - causing murmurs
Pectus Carinatum characteristics
AKA Pigeon chest Sternum displaced anteriorly (increases A-P dia) Costal cartilage is depressed
What condition is associated with barrel chest
Aging COPD
Peripheral cyanosis represents what area
Extremities
Central cyanosis represents what area
Chest and mouth
Central cyanosis is involved with
R to L cardiac/pulmonary shunting
Pts with central cyanosis likely to have (2)
Hypoxemia and erythrocytosis
What D/O’s cause shunting
VSD, ASD, Pulm HTN, COPD, Congenital heart DZ in PEDS
Central cyanosis hypoxemia means
Deoxy blood is being circulated thru body
Pallor usually suggests
Inadequate Hgb
Best places to observe pallor (4)
Conjunctival vessels, lips, mucous membranes
Cardiogenic edema is usually
Bilateral and due to CHF esp. RHF
Where is clubbing typically seen
Congenital heart diseases
Palpate these (4)
JVP, BP, Pulses, PMI
JVP measurement assess
R sided heart fx (cnt tell if there is A-fib or stenosis)
JVP height is represents
Right atria pressure = Central venous pressure
NL JVP at highest site of pulsation is
less than or equal to 9cm to RA or 0-4cm to sternal angle
Where is the sternal angle in relation to right atrium
5cm above RA
JVD is
Persistant distention of internal (external sometimes) jugular veins
JVD is usually asscoaited with
Volume overload states like CHF
If you cant see this neck BV but can palpate it its
Carotid artery
If you can see it this neck BV but cant palpate its
Ext jugular vein
Distinguish JVP from carotid pulses
JVP fills from above, moves on inspiration, changes with posture
Wave forms of JVP (5)
A, C, V, X, Y
A wave corresponds to
RA pressure rise in Atrial contract, before S1 sound
A waves are absent in
A-fib
X descent corresponds to
Atrial relaxation - R vent contracts pullin RA down
X wave may be absent in
Severe tricuspid regurgitation, A-fib, R atrial ischemia
C wave represents
Tricuspid valve bowing into RA
V wave represents
After systole - venous pressure returns increasing atrial pressure
V wave is seen with
Severe tricuspid regurgitation, RVF, restrictive cardiomyopathy
Y descent represents
Reduced pressure with tricuspid opening - emptying RA during diastole
Factors impairing atrial emptying effect what waves
A and Y descent waves
Waves A and C represent what heart sound
S1
Wave V represents what heart sound
S2
Generally what causes increased pressures in RA
Increased Volume and Resistance/compliance conditions
Conditions increasing A waves
Conditions with increased resistance such as RVH, Pulm HTN, Complete heart block
Prominent X descent observed in what conditions
Constrictive pericarditis and tamponade
Kussmauls sign suggests
Impaired filling of right ventricle due to either fluid in pericardial space or uncompliant myocardium/pericardium
Kussmauls causes JVP to
Rise with inspiration
Hepato-jugular reflex concept with a pt having R-sided dysfx
Applying pressure to liver increases CVP, thus increasing RA pressure, and increasing JVP wave form intensity
BP symmetry includes taking BP where
L vs R and arms vs legs
Pulse pressure is
Difference between Systolic and Diastolic arterial pressure
Increased pulse pressure typically seen in
Aortic regurgitation or conditions increasing stroke volume or contractility
Narrowed pulse pressure typically seen in
Hypovolemia, severe LVF or severe mitral stenosis
Conditions that increase stroke volume
Anemia, thyrotoxicosis, arteriovenous fistulas
Full pulse exam includes (7)
Carotids Brachial Radialis
Purposes of palpating a pulse
Patency and LV contraction intensity
What pulse most accurately reflects aortic pulse
Carotid pulse
Exam each pulse for these 5 things
Rate, Rhythm, Strength, Contour, Symmetry
Normal pulse is characterized by
Rapid rise, short plateau, gradual descent
Dicrotic notch represents
A secondary upstroke of the aortic valve closure
ABNL pulses (6)
Hypokinetic Hyperkinetic Bisferiens pulse
Pulses Alternans
Pulses parvus et Tardus
Pulses Pradoxus
Hypokinetic pulse is related to
Decreased rate of 1.LV pressure development 2.LV SV
Hyperkinteic pulse is related to
Increased rate of 1.LV pressure development 2.Large LV SV with decreased peripheral resistance
Bisferiens pulse is
Pulse with two palpaable beats during systole
Bisferiens pulse is seen in
HOCM Aortic Stenosis and insufficiency Rapid ejection of an increased SV
Rapid ejection of an increased SV is related to
Exercise, Fever, PDA
Pulsus Alternans is
Variation of amplitude in alternate beats due to changing systolic pressures
Pulsus Alternans is seen in
Severely depressed cardiac function conditions
Pulsus Alternans can be confirmed by
Measuring the BP
Pulsus Pravus et Tardus is
Pulse with slow increase of pressure that is late and small in intensity
Pulsus Pravus et Tardus is associated w/
Aortic Stenosis
Pulsus paradoxus is
BP drops >10mmHg during inspiration
Pulsus paradoxus can be seen in
Cardiac Tamponade and others
PMI is palpated by
Having pt supine or in left lateral position and with hand over pts left lower chest wall
A NL PMI represents
the apex of the heart in the 4-5th ICS on MCL
What happens to PMI with LV hypertrophy
Lateral displacement
What two etiologies cause PMI displacement
Volume over load due to Cardiac Dilation Pressure overload due to Ventricular hypertrophy
Volume overload causes what type of PMI impulse
Hyperdynamic
Pressure overload causes what type of PMI impulse
Sustained apical impulse
What valvular pathologies cause cardiac dilation
AR and MR
What conditions cause hypertrophy
HTN and AS
Thrills represent
A palpable murmur
What grade is a palpable murmur usually
Grade IV to VI
Heave or lift is associated with
Large ventricle or HF
What positions for asuculatations (3)
Sitting, Supine, Left lateral
In what order are the concerns for auscultation
- NL heart sounds 2.ABNL heart sounds (S3, S4, clicks, snaps. 3.Murmurs
S1 sound is produced by
MTV closure
S1 is best heard where
Apex
S1 represents what phase
Beginning of systole
An increased S1 could mean
Shortened PR interval Mild Mitral stenosis High cardica output states (tachycardia)
A decreased S1 could mean
Prolonged PR interval (1st degree AV block) Mitral regurgitation Severe mitral stenosis Stiff Left ventricle
S2 sound is produced by
APV closure
S2 is best heard where
A2 - R 2nd ICS P2 - L 2nd ICS
Is A2 or P2 more intense?
A2
During S2 splitting which valve closes first?
A2
Variable widened S2 splitting during expiration and inspiration is caused by
R-BBB and Pulmonic Stenosis (sound intensity decreased
Fixed splitting of S2 that persists during expiration and inspiration is cause by
ASD
Paradoxical S2 splitting is when
A2 closes before P2
Paradoxical S2 splitting is caused by
L-BBB Aortic stenosis (decreased A2 intensity) Chronic HTN (increased A2)
S3 is also known as
Ventrical gallop (Slosh-ing-in S123)
S3 is best heard at
the cardiac apex in the left lateral decubitus
S3 intensity can be increased by
Increasing venous return (leg raise) Increasing arterial pressure/CO (handgrip)
S3 could mean dysfx of what
Ventricular dysfx esp >40yo
S4 is also known as
Atrial Gallop (A-stiff-wall S412)
S4 is best heard at
Cardiac apex
S4 is due to
Active atrial filling against a stiff noncompliant ventricle usually related to LVH
What causes LVH (4)
Chronic HTN Aortic Stenosis Hyertrophic cardiomyopathy
Opening snap occurs when
Early diastolic
Opening snap sounds like
A high pitched sound
Opening snap heard best where
Between the APEX and LSB
Opening snap is most commonly due to
Mitral Stenosis
What does it mean when A2 and OS interval is shortened
Worsening Mitral stenosis
Ejection clicks occurs when
Early to mid-systolic phase
Ejection clicks sounds like
Sharp high pitched sound
Early Ejection clicks due to
Stenotic valve reaches its macimum degree of opening (AS & PS & Pulm HTN)
Mid-systolic Ejection clicks due to
Sudden opening/regurgitation of MV or TV
Murmurs are defined as
Auditory vibrations due to turbulent blood flow
Murmurs are due to 1 of 2 things
ABNL blood flow across normal cardiac structure Normal blood flow across ABNL cardiac structure
Which type of murmur is almost always pathologic
Diastolic murmurs
Can systolic murmurs be pathologic or benign?
Yes
Describing a murmur (5)
Duration/timing Location Intensity
Pitch
Shape
Murmur pitch refers to
Frequency of the sound
A high frequency murmur suggests
Increased velocity of turbulent blood flow
A low freq murmur suggests
Reduced velocity of turbulent blood flow
Crescendo murmur described as
Building in intenstiy
Decrescendo murmur described as
Reducing intensity
Examples of a decrescendo murmur
Early diastolic murmur of aortic regurg
Crescendo-decrescendo is
“diamond-shaped” murmur of aortic stenosis
Holosystolic/pansystolic means
Unchanged character throughout murmur
MC Holosystolic/pansystolic are due to
Mitral regurgitation
Special manuevers are used to consider their effects on what?
Preload and Afterload
Preload is a function of venous return how?
Increased venous return equals increased preload Decreased venous return equals decreased preload
HOCM is an abbreviation for
Hypertrophic obstructive cardiomyopathy
HOCM is the exception to the rato of blood volume:murmur intensity rule- what is HCM more affected by?
Pressure gradient across the valve
Afterload is a function of systemic vascular resistance how?
Increased SVR equals increased afterload Decreased SVR equals decreased afterload
Systemic vascular resistance essentially means
BP of the aorta
Afterload exacerbates what type of murmur?
Regurgitant murmurs and reduces stenotic murmurs
Loud or diastolic murmurs are pathologic in nature usually?
Yes
