The Heart Flashcards
The apical impulse, known as the point of maximum impulse, is normally found in the
5th intercostal space
Location of aortic sound
Second intercostal space, right sternal border
Location of pulmonic sound
Second intercostal space, left sternal border
Location of tricuspid sound
Left lower sternal border
Location of mitral sound
Cardiac apex (5th intercostal space, mid-clavicular line).
The area at which pulmonic sounds or aortic sounds are best heard is
Erb’s point (third left intercostal space).
The first heart sound (S1) is produced by the
Closure of the AV (tricuspid and mitral) valves.
The second heard sound (S2) is produced by the
Closure of the semilunar valves.
An “opening snap” refers to the sound made when
A narrow AV valve opens.
It occurs during diastole
An “ejection click” sound is produced by
A stenotic semilunar valve opening.
It occurs during systole
The sequence of opening and closing of the four valves is as follows:
Mitral valve closes
Tricuspid valve closes
Pulmonic valve opens
Aortic valve opens
Aortic valve closes
Pulmonic valve closes
Tricuspid valve opens
Mitral valve opens
The mitral component of S1 occurs as a result of the
Closure of the mitral valve when the left ventricular pressure rises to more than the left atrial pressure; it is written as M1
The tricuspid component of S1 occurs as a result of
Closure of the tricuspid valve when right ventricular pressure rises to more than right atrial pressure.
Isovolumetric contraction is
The time between the closure of the AV valves and the opening of the semilunar valves.
Ejection is
The time between the opening and the closing of the semilunar valves.
The incisura is the point at which
Ejection is completed and the aortic and left ventricular curve separate.
It is simultaneous with the aortic component, or closure of the aortic valve.
The time between the closure of the semilunar valves and the opening of the AV valves is called
Isovolumic contraction
At the end of diastole __ and the additional 20% of ventricular filling occur.
Atrial contraction
Mnemonics for remembering the cadence and characteristics of the third and fourth sounds are:
SLOSH-ing-in (S1, S2, S3)
A-STIFF-wall (s4, S1, S2)
Splitting of the first heart sound may be heard in the
Tricuspid area
Physiological splitting occurs as a result of:
Inspiration.
Intrathoracic pressure lowers, causing more blood to be drawn from the superior and inferior vena cavae into the right chambers of the heart.
Sinus arrhythmia occurs as a result of
An increase in heart rate with inspiration; it is a reflex tachycardia.
The anacrotic notch is a
Noth in the arterial pulsation toward the end of the rapid ejection period.
The positive wave that follows the dicrotic notch is called the
Dicrotic wave
In the arterial pulse, the percussion wave occurs
Earlier than the dicrotic notch and is associated with the rate of flow in the artery.
It occurs during peak velocity of flow.
The tidal wave is the
Second wave in the arterial pulse and is occurs during peak systolic pressure.
Blood pressure depends on
The volume of blood ejected
The velocity of blood
Distensibility of the arterial wall
Viscosity of the blood
Pressure within the vessel after the last ejection
The jugular venous pulse provides direct information about the pressures in the _ side of the heart because the jugular system is in direct continuity with the __.
Right side of the heart
Is in direct continuity with the right atrium.
If ther is no stenoic lesion at the pulmonic or mitral valves, the right ventricle will
Directly monitor the pressures in the left atrium and left ventricle.
The most common cause of right sided heart failure is
Left sided heart failure.
The “a” wave of the jugular venous pulse is produce by
Right atrial contraction.
It occurs 90 msec after the P wave.
The “x” descent is caused by
Atrial relaxation
In the jugular venous curve, the drop in right atrial pressure is terminated by the
“C” wave.
The “c” wave involves
Closing of the tricuspid valve secondary to right ventricular contraction.
The “x prime” descent involves
An increase in the size of the atrium, causing a fall in its pressure.
An increase in right atrial filling pressure causes the shape of the
“V” wave.
A drop in right atrial pressure produces the
“Y” descent.
Angina pectoris the true symptom of
Cardiac heart disease
Angina is commonly the consequence of
Hypoxia of the myocardium resulting from imbalance of coronary supply and myocardial demand.
Characteristics of angina
Retrosternal, diffuse pain
Felt on the left arm and jaw
Is described as aching, dull, pressing, squeezing, viselike
Is mild to sever and last minutes.
It is precipitaed by effort, emotion, eating and cold
It is relieved by rest and nitroglycerin.
Characteristics that are not indicative of angina:
Left inframmary localized pain or pain in the right arm
Sharp, shooting, cutting and excruciating pain
Lasts seconds, hours or days
Is due to respiration, posture and motion, and is relieved by nonspecific methods.
Extrasystoles are commonly caused by
Bradyarrhythmias
Atrial premature beats are most commonly caused by
Heart block
Nodal premature beats are most commonly caused by
Heart block
Ventricular premature beats are msot commonly caused by
Drugs
Tachyarrhythmias are most commonly caused by
Bronchodilators
Paroxysmal supraventricular tachycardia is most commonly caused by
Digitalis
Atrial flutter is msot commonly cuased by
Antidepressants
Atrial fibrillation is most commonly caused by:
Smoking
Multifocal atrial tachycardia is most commonly caused by
Caffeine
Ventricular tachycardia is msot commonly caused by
Thyrotoxicosis
Cardiac causes of dyspnea include
Left ventricular failure
Mitral sentosis
Pulmonary causes of dyspnea are:
Obstructive lung disease
Asthma
Restrictive lung disease
Pulmonary embolism
Pulmonary hypertension
A common emotional cause of dyspnea is
Anxiety
A common high-altitude exposure cause of dyspnea is
Decreased oxygen pressure
A common anemia cause of dyspnea is
Decreased oxygen carrying capacity.
Cardiac causes of syncope include
Decreased cerebral perfusion secondary to cardiac rhythm disturbance
Left ventricular output obstruction
Metabolic causes of syncope
Hypoglycemia
Hyperventilation
Hypoxia
Psychiatric causes of syncope
Hysteria
Neurologic causes of syncope include
Epilepsy
Cerebrovascular disease
Orthostatic hypotension causes syncope by the following mechanisms:
Volume depletion
Antdepressant medications
Antihypertensive medications
Vasovagal response causes syncope by
Vasodepression
Micturition causes syncope due to
A visceral reflex (vasodepressor)
Coughing can cause syncope due to
Chronic lung disease
The carotid sinus can cause syncope by
A vasodepressor response to carotid sinus sensitivity.
Mitral stenosis is an important cause of
Hemoptysis
Differential cyanosis, a type of cyanosis found only in the lower extremities, is related to a
Right-to-left shunt through a patent ductus arteriosus.
Prehypertension includes a blood pressure of
120-139/80-89
Stage 1 hypertension is defined as a blood pressure reading of:
140 - 159/90-99
Stage 2 hypertension is defined as a blood pressure reading of
160/100
How to rule out orthostatic hypertension
After the patient has been recumbent for at least 5 minutes, measure the baseline blood pressure and pulse. Then have the patient stand, and repeat the measurements immediately.
How to rule out supravalvular aortic stenosis
If hypertension is detected in the right arm, place the cuff on the left arm and determine the auscultatory pressure. In a healthy patient, there should not be a difference in blood pressures.
How to rule out coarctation of the aorta
Measure blood pressure in the lower extremity, then the upper extremity. In a healthy patient, a leg systolic blood pressure should be higher than in the arm.
How to rule out cardiac tamponade.
Paradoxical pulse
Have the patient breathe as normally as possible. Inflate the blood pressure cuff until no sounds are heard. Deflate the cuff until sounds are heard in expiration only. Continue to deflate the cuff until sounds are heard during inspiration. If the difference in these pressures exceeds 10 mm Hg, a marked pulsus paradoxus is present and cardiac tamponade may be the cause.
To palpate the carotid artery
Place your index and third fingers on the patient’s thyroid cartilage and slip them laterally between the trachea and the sternocleidomastoid muscle.
An anacrotic notch is indicative of
Aortic stenosis
A waterhammer (Corrigan’s notch - looks like a smooth hump) and the bisiferiens hump (double humps) are indicative of
Aortic regurgiation
Alternans (alternating low and high peaks) are indicative of
Congestive heart failure
Paradoxical (two high peaks, two low peaks, then two high peaks, etc) are indicative of
Tamponade
Constructive pericarditis
Chronic obstructive lung disease
Features of the jugular pulse
Not palpable
Soft, undulating
Inspiration and sitting up decrease the height of wave forms
Valsalva maneuver increase the height of wave forms
Features of the carotid pulse
Palpable, vigorous sound with multiple waveforms.
Inspiration, sitting up and the valsalva maneuver have no effect on the pulse.
Percussion of the heart is performed at the
3rd, 4th and 5th intercostal spaces from the left anterior axillary line.
Palpating for localized motion involves
Having the patient lie down so that all four main cardiac areas can be palpated.
The presence of a systolic impulse in the second intercostal space to the left of the sternum is suspect for pulmonary hypertension.
Palpating for generalized motion involves
Palpating for any large area of sustained outward motion (called a heave or lift).
A parasternal rock is indicative of a large right ventricle.
Thrills are
Superficial vibratory sensations felt on the skin overlying an area of turbulence.
The presence of a thrill indicates a loud murmur.
The supine position is used for auscultating
All areas
The left lateral decubitus position is used, listening with the BELL, to auscultate the
Mitral area
The upright position is used for listening to __ and the upright, leaning forward position is used for _
Upright only - all areas
Upright, leaning forward - listening with the diaphragm at the base positions.
In the supine position, auscultate and evaluate the
S1, S2 and systolic murmurs in all areas
At the left lateral decubitus, auscultate and evaluate the
Diastolic events at apex with the bell of the stethoscope
In the upright position, auscultate/evaluate the
S1, S2
Systolic murmurs in all areas
Diastolic murmurs in all areas
In the upright, leaning forward position, auscultate/evaluate the
Diastolic events at the base with a diaphragm of a stethoscope.
The intensity of murmurs is graded from I to VI, based on increasing loudness. Sounds I - III are:
I: not heard by inexperienced listeners
II: audible to inexperienced listeners
III: medium intensity without a thrill
The intensity of murmurs is graded I to VI, based on increasing loudness. Murmurs IV - VI are heard as:
IV: medium intensity with a thrill
V: loudest murmur that is audible when the stethoscope is placed on the chest; associated with a thrill.
VI: loudest intensity; audible when stethoscope is removed from chest; is associated with a thrill.
The factors that are responsible for the intensity of S1 are:
The rate of rise of ventricular pressure
The condition of the valve
The position of the valve
The distance of the heart from the chest wall
The conditions that change the intensity of S2 are
Changes in systolic pressure
Condition of the valve
Calcification or fibrosis of the semilunar valves can affect the heart sounds.
Midystolic clicks are not
Ejection clicks.
Ejection murmurs appear diamond shaped and are described as:
Crescendo-decrescendo.
They begin slightly after S1 and end before S2.
High pitched murmurs heard during S3 are indicative of volume overload. These murmurs are also known as
Regurgitation
Incompetence
Insufficiency
Diastolic murmurs begin after S2 with the opening of the
AV valve.
Mitral stenosis and tricuspid stenosis are examples of this type of murmur.
Sounds heard during the early systolic phase of the cardiac cycle are
Ejection clicks
Aortic prosthetic valve opening sounds
Sounds heard during the midsystolic to late systolic are
Midsystolic click
Rub
Sounds heard during the early diastolic cardiac cycle are
Opening snap
S3
Mitral prosthetic valve opening sound
Tumor plop
Sounds heard during the mid-diastolic cardiac cycle are
S3
Summation gallop
Sounds heard during the late diastolic cardiac cycle are
S4
Pacemaker sound
The sounds of aortic stenosis are
Medium pitched and harsh.
Associated signs with aortic stenosis are
Decreased A2
Ejection click
S4
Narrow pulse pressure
Slow rising delayed pulse
The sounds associated with mitral regurgitation are
High, blowing with a holosystolic shape.
Associated signs of mitral regurgitation are
Decreased S1
S3
Laterally displaced diffuse PMI
Sounds associated with mitral stenosis are:
Low, rumbling, decrescendo.
Signs associated with mitral stenosis are
Increased S1
Opening snap RV rock
Presystolic accentuation
Sounds associated with aortic regurgitation are
High, blowing, decrescendo
Signs associated with aortic regurgiation are
S2
Laterally displaced PMI
Wide pulse pressure
Bounding pulses
Austin flint murmur
Systolic ejection murmur
Features of pulmonic stenosis murmur
Located in the pulmonic area and radiates to the neck.
It is diamond shaped, has a medium pitch and is of harsh quality.
Features of tricuspid regurgitation
Located in the tricuspid area and radiates to the right of the sternum.
It is holosystolic and has a high, blowing noise.
Features of ventricular septal defect
They are located in the tricuspid area and radiate to the right of the sternum.
They are holosystolic, high and harsh sounding.
Features of venous hum murmur
Above the clavicle and radiates to the right neck.
It is a continuous, high, roaring and humming sound.
Features of an innocent murmur
It is widespread and has minimal radiation.
It is diamond shaped, and has a medium, twanging and vibratory quality sound.
