Week 5: Cardiovascular Exam Flashcards
What is the flow of the heart from right to left
Blood comes through inferior and superior vena cava, right atrium to the right ventricle, then to the pulmonary artery to the lungs (right side of heart goes to lung) pulmonary vein to left atrium to left ventricle to aorta to the heart.
What is S1 and S2
S1: closure of tricuspid and mitral valve
S2: close of pulmonic and aortic valve
P wave:
atrial depolarization
PR:
atrial depolarization complete
QRS:
ventricular depolarization begins, atria repolarize
ST segment:
ventricular depolarization is complete
T wave:
ventricle repolidatszation
Post T wave:
ventricular repolarization completes
Apical pulse:
5th ICS @ approximately the MCL (mid clavicular line)
Where is the base and apex?
Base is top of the heart, apex is at the bottom of heart.
Common/Concerning S/sx
Chest pain Shortness of breath, dyspnea, orthopnea or paroxysmal nocturnal dyspnea Dizziness - anemia? Palpitations Racing heart Exercise/activity intolerance Fainting/Syncope or Near Syncope Cyanosis/pallor Extreme Fatigue Edema
Questions to ask for cardiac issues
Symptoms worse with activity?
Any recent medication changes (new meds, change in dose etc)
Hydration- how much fluid do you drink each day (24 hr fluid recall)
Accompanying symptoms
Has this happened before?
How long has it been going on?
Recent travel or activity changes?
Increased stress?
Caffeine intake?
PMH:Family History, social history (smoking drug use), medication, allergy, decongestion, over the counter meds
Lifestyle, diet exercise habit
Quality of life: how is this affecting the things you like to do, where do you want to be? If they snore?- sleep apnea
Cardiac Assessment Steps
Inspect: color, work of breathing/dyspnea (w or w/out exertion), abdominal girth/ascites, edema, clubbing, nutritional status, chest diameter
Palpate: thrill (murmur, may be a incompetent valve), heave (englarge heart, is it working heart? Can you feel it move), PMI (is it displaced - large heart?), chest wall tenderness, edema
Auscultate: all major areas: APETM (aortic, pulmonic, erb’s point, tricuspid, mitral valve), S1, S2, extra heart sounds, murmurs
Orthostatic Vital Signs - what is significant?
What is significant?
Pulse ↑by 20 beats per minute
SBP ↓20 mmHg or DBP ↓10 mmHg
Inspection for cardiac
How does the patient appear? Color, Dyspnea Is there a visible heave? Thorax shape? Large abdomen? Ascites? Can you see the PMI? JVD?
PALPATION: Chest Wall
Using the finger pads, palpate for heaves or lifts from abnormal ventricular movements
Using the ball of the hand, palpate for thrills, or turbulence transmitted to the chest wall surface by a damaged heart valve
Palpate the chest wall in the:
Aortic
pulmonic,
left sternal border
apical areas
Thrill
Turbulent vibration
Heave:
feel apex due to enlarged heart
Assessing the Point of Maximal Impulse (PMI) or “Apical Pulsation”
Inspect the left anterior chest for a visible PMI
Using your finger pads, palpate at the apex for the PMI . . . Where? Just to the left of the 5th intercostal space; 9cm from midsternal line
Tapping — normal
Sustained — suggests LV hypertrophy from hypertension or aortic stenosis
Diffuse — suggests a dilated ventricle from congestive heart failure or cardiomyopathy
Locate the PMI by interspace and distance in centimeters from the mid-sternal line
S1: (lub)
Closure of AV valves (Mitral, Tricuspid) Begins systole
Loud at apex
S2: (dub)
Closure of semilunar valves (Aortic, Pulmonic)
Ends systole
Loud at base
Auscultation: APETM
aortic area- 2nd right interspace- aortic area
pulmonic area - 2nd left interspace
erb’s point - third intercostal space
tricuspid area - lower left sternal border
mitral area - apex
diaphragm is best for detecting ____
high-pitched sounds like S1, S2, and also S4 and most murmurs
bell is best for detecting ______
low-pitched sounds like S3 and the rumble of mitral stenosis
Split S2: aortic valve closes before pulmonic valve is heard at?
Heard at LSB @ 3rd ICS (Erb’s point)
third heart sound (S3):
ventricular filling sound, early diastole
Immediately after S2- heard best @ apex or LSB (low pitched, does not change w/ inspiration0
Fourth heart sound (S4):
ventricular filling sound, late diastole
Immediately before S1
Murmurs:
turbulent blood flow through a stenotic, or incompetent valve
Grade: loudness and thrill
I: softer than S1/S2, very faint
II: equal to S1/S2, heard immediately (easy to hear)
III: louder than S1/S2, moderately loud
IV: louder than S1/S2, w/palpable thrill
V: louder than S1/S2, palpable thrill, heard w/part of stethoscope on chest wall
VI: very much louder than S1/S2, palpable thrill, heard w/out the stethoscope
ASD or VSD
Describing Murmurs
Timing: during systole or diastole, late, early or holo (pan)
Pitch: high, medium, low
Quality (harsh, musical, soft, blowing, or rumbling)
Harsh (AS)
Rumbling (MS)
Location: area heard best
Radiation: neck, back, axillae?
Murmurs & Location
Leaning left, mitral stenosis
Leaning forward, pericarditis, aortic regurgitation
Valsalva maneuver: squatting - Aortic stenosis
Standing: hypertrophic myopathy - systolic murmur
Pericarditis
Inflammation of the pericardium
Etiology can be infectious or noninfectious
Infective Endocarditis
Infection of the endocardial surface of heart; may include one or more heart valves, mural endocardium, or a septal defect
Causes severe valvular insufficiency
MVP (Mitral Valve Prolapse)
Displacement or prolapse of mitral valve leaflets into the left atrium during systole
Can lead to mitral regurgitation (MR)
Considerations for Infants/Children- cardiac
Blood oxygenated through placenta until birth, so FO & DA open to feed blood to aorta/systemic circulation
Patent FO- closes @ 1 hour after birth
Patent DA- closes 10-15 hours after birth
Infant heart is more horizontal (apex @ 4th ICS), reaches 5th ICS @ 7yo
Growth, feeding, activity, fam Hx?
Pediatric sized stethoscope
Know normal HR ranges
Innocent/functional murmurs common in 30% of infants/children
Considerations for Older Adults - for cardiac
Lifestyle greatly affects CV health over time
Increase in systolic hypertension- due to?
Decrease in diastolic pressure» increased pulse pressure
LV wall thickness increases
Decrease in compensation w/activity/exercise
Dysrhythmias, ECG changes
Inc risk of orthostatic hypotension
Inc in systolic murmurs
