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Anatomy of the heart in reference to the chest
How is the PMI produced, where is it located and what is its size? Where is it heard the easiest?
- Location: left border of the heart and is usually found in the 5th interspace 7cm to 9 cm lateral to the midsternal line.
- Measures < 2.5 cm
- Heard best in children and YA - bc as the chest deepens in its AP diameter, the impulse gets harder to find.
What area is called the base of the heart?
R and L 2nd interspaces close to the sternum
tapered inferior tip of the LV
Is the RA identifiable during examination?
- ventricular contraction
- AV valves closed
- Semilunar valve open for ejection of blood
- Ventricular relaxation - ventricle fills up with blood coming from atrium
- AV valves open
- Semilunar valve close to prevent regurgitation
1st heart sound defines?
- duration of systole - ventricular contraction
- closure of the AV valves
2nd heart sound defines?
- duration of diastole - ventricular relaxation
- Semilunar valve close.
What is the ejection sound? ( Ej)
In some pathologic conditions, opening of the aortic valve is accompanied by an early systolic ejection sound.
Maximal left ventricular pressure corresponds to?
systolic blood pressure
Pathologic opening snap
heard when mitral valve is closing if the valve leaflet motion is restricted for example in mitral stenosis
What is S3 and when is it usually heard?
- 3rd heart sound, heard in children and young adults
- may come from rapid descent of blood agaisnt the ventricular wall
When is S3 called an S3 gallop and why?
- in older adults
- indicates a pathologic change in ventricular compliance
What is S4 and when is it heard?
- 4th HS
- coincidates with late diastolic filling to the ventricle due to atrial contraction
- (atrial kick?)
- comes right before S1 of the next beat
- reflects something is wrong with ventricular compliance. - usually blood being forced into a stiff/hypertrophic ventricle.
- heard seldom in YA - unless they are well conditioned athletes, also heard in healthy older people.
How are RP compared to LP, and R sided events and L sided events?
- R sided events occur slightly later than those on the left
How and when do heart sounds split? - A2 and P2
For what population it is harder to hear and why?
- Bc R and L side events do not occur at the same time, R occur later than L
- Closure of Aorta valve (A2) is heard before closure of Pulmonic valve ( P2)
- S2 is split at inspiration
Harder to hear in elderly due to AP diameter increase
What happen to A2 and P2 during expiration?
fuse into one single sound = S2
What happens to A2 and P2 during inspiration?
-S2 may split into 2 audible sounds --> A2 and P2.
Comparing A2 and P2? (sound pitch and reason, location of sound?)
- A2: louder due tot he HP of the aorta, heard throughout the precordium, heard 1st
- P2: softer due to the lower P in the pulmonary artery- heard best in the L2/3 interspace closes to the sternum
Where should you search for splitting of the heart sound?
2nd and 3rd left interspaces close to the sternum
S1 split sounds?
- Mitral: louder, can be heard throughout precordium and heard best at the apex.
- Tricuspid: heard best at lower left sternal border - where split S1 is often best heard too
Where is the best area to hear a split S1
lower left sternal border - when tricuspid valve closes
Can the earlier louder mitral component mask the tricuspid one?
Is splitting always detectable?
Does splitting S1 vary with respirations?
how are heart murmurs distinguishable from heart sounds?
They are longer
What are murmurs?
- systolic murmurs (bruits) - turbulent blood flow that are for the most part innocent in children but worrisome in adults.
- in children are frequently heard just above the clavicle.
What may cause murmurs?
- attributed to turbulent blood flow and may be innocent ( young adults)
- valvular heart disease ( aortic stenosis, aortic regurgitation or insufficiency --> regurgitant murmur)
What is a "flow murmur"?
- innocent systolic murmur heard best in children, teens and YA.
- felt to reflect pulmonic blood flow.
- heard best in the 2nd to 4th left interspaces
- murmurs heard in pregnant women late in pregnancy or during lactation.
- It is due inc blood flow in the breast
- mostly heard on the 2nd and 3rd interspace on either side of sternum
- both systolic and diastolic ( sometimes systolic is easier to heard bc it is louder.
What is the jugular venous hum?
murmur that is common in children and may stil be heard through YA
Heart sounds - and murmur locations.
- Aortic -->R 2nd interspace/ from R 2nd to apex area
- Pulmonic --> L 2nd / from L 2nd and 3rd close to the sternum
- Tricuspid --> L 5th interspace/ Lower L border
- Mitral --> L 5th interspace mid- clavicular
Pathway of the electrical impulse that causes the heart to contract?
- electrical impulse --> initiated in sinus node ( right atrium) - cardiac peacemaker- ht beats
- AV nodes --> bundle of His ( ventricular myocardium) - contraction occur, 1st atria and then ventricles.
ECG and the pathway of the electrical impulse that contracts the heart?
When is an ECG required?
- small P wave --> atrial depolarization ( contraction) - pR interval
- QRS: ventricular depolarization ( relaxation)
- T wave: ventricular repolarization or recovery (duration relates to QRS)
Rqd: when ss of irregular heart action is seen except for atrial defibrillation that can be dx at the bedside
- volume of blood ejected
- = HR* SV
volume of blood ejected from each ventricle during 1 min
What is preload and what increases it?
load that stretches muscle prior to contraction. - volume of blood in ventricle after diastole.
IVR in right heart = right preload increase
- Ex: inspiration, high volume of blood that runs through the heart from exercising muscles
myocardial contractility, what is it? when does it increase and decrease?
- ability for heart muscle to contract/shorten
- inc: when stimulated by sympathetic nervous system
- dec: blood flow or oxygen delivery to myocardium is impaired.
vascular resistance against which the ventricle must contract - if arterial walls are narrowed ( artherosclerosis) - afterload may increase
What is the difference between systolic and diastolic pressure called?
What are the principle factors that influence blood pressure?
- Distensibility of the aorta and the large arteries
- Peripheral vasc resistance, particularly at the arteriorlar level
- Volume of blood in the arterial system
What does pressure in the jugular veins reflect?
- RAP/ CVP - indication of fluid status in patient
- the oscillation reflects the changing pressures within the RA. -
Where are the internal jugular veins located and are they visible?
they lie deep to the sternomastoid muscles in the neck, and are not visible
Can JVP be measured in children?
No bc the internal jugular vein is not visible in children less than < 12 - not a useful way to evaluate CV system in this age group.
How should we go about finding the pulsation of the JVP?
feel for internal jugular vein pulsation - do not mix with carotid artery pulsation. If they cannot be identified, those from the external jugular veins can be used - but are less reliable
How do we measure JVP?
- Find highest point of oscillation in the internal jugular vein or, if necessary the point above which the external jugular vein appears collapsed.
- usually measured in vertical distance above sternal angle - the bony ridge adjacent to the second rib where the manubrium joins the body of the sternum.
What is the best position to measure the JVP?
HOB @ 60 = top of internal jugular vein is easily visible - so vertical distance between the sternal angle or RA and the top of the internal jugular vein can now be measured
HOB @ 30 - too low bc point of oscillation is above the jaw so not visible
HOB@ 90 - too high - veins are barely discernable above the clavicle making measurement untainable
The height is the same on all 3 points, it is all about the way you position the patient.
What is considered an elevated or abnormal JVP?
> 4 cm above the sternal angle or > 9 cm above the RA
What is the composition of the internal jugular vein composition?
- a wave: slight rise in atrial pressure that comes with atrial contraction -> occurs before heart sound and the carotid pulse. ( atrial contraction)
- x descent: starts with atrial relaxation - goes through ventricular contraction ( atrial relaxation) - occurs just before 1st HS -
- v wave: as atria is filling up with blood it starts to contract --> peak in pressure in atria ( atrial filling)
- y descent: tricuspid valve opens, blood in atria goes into ventricle, pressure in the atria decreases. ( atrial emptying) - follows 2nd heart sound
What are the SS of angina pectoris?
exertional chest pain w/ radiation to left side of the neck and down the left arm
What are the ss of aortic dissection?
sharp pain radiating through the back or into the neck
Define Orthopnea - what does it suggest? How is it quantified?
- Dyspnea that occurs when the pt is lying down - that suggests LVHF or mitral stenosis, obstructive lung diseaseIt is quantified by the # of pillows someone uses for sleeping or by the fact that the pt needs to sleep sitting up
- Treatment: Patient needs to sit up.
Paroxysmal nocturnal dyspnea? - what does it suggest?
- SOB that awakens the pt from sleep usually 1-2 hrs after going to bed
- suggests: LVHF or mitral stenosis - may be mimicked by asthma attack.
When should cholesterol be tested in adults?
starting age 20 or older every 5 years
Ideal cholesterol level?
- LDL< 100
- HDL between 40 and 60
- Total cholesterol < 200
- w/ 1 RF < 160
- W/ 2 or + < 140
- CHD < 100
What are xanthomas?
- lipid containing nodules on the skin as an indication of high blood cholesterol
- search for them in pts with family hx of high cholesterol.
- they are present around the eyelids, over extensor tendons, occasionally as small eruptive papules on the extremities, buttock and trunks.
Difference between JVP and carotid pulsation
- Internal Jugular Pulsations
- - Rarely Palpable
- - Soft,rapid with 2 elevation and troughs/ min
- - Pulsation eliminated by light pressure
- - Level of pulsations changes with position, dropping as the pt becomes more upright
- - Level of the pulsations usually descends w/ inspiration
- - PalpableVigorous thrust w/ single outward component
- - Not eliminated by pressure
- - Level of pulsation does not change with position
- - Level of pulsations not affected by inspiration
If JP cannot be found in internal and external vein what should PCP do?
- Use point above which the external jugular veins appear to collapse. Measure the vertical distance of this point to the sternal angle.
- Make this observation on each of the neck.
What does unilateral jugular vein distention indicate?
local kinking or obstruction
What are thrills and bruits? How are they assessed? Where are they heard?
- - humming vibration when palpating the carotid artery
- - What to do? listen over both carotid with the diaphragm for bruits --> (murmur like sound more vascular of origin than cardiac)
What does a bruit suggest in a middle age adult?
May suggest aortic stenosis
Where is S1 louder than S2 and vice versa? why?
- S1 louder at apex
- S2 louder at base
Why do patient position themselves in LLD position? If you cannot find the pulse?
- if PMI is hard to palpate
- low pitched extra sounds may be heard ( S3, S4, OS, or diasolic murmurs)'
- If you cannot find pulse, ask patient to exhale fully and then hold expiration for a seconds
- Can also detect soft diastolic murmur coming from aortic regurgitation.
Where is the RV area located?
Left sternal border in 3,4,5th interspaces
Where would you percuss for cardiac dullness?
3rd, 4th, 5th and 6th interspace on the left... going from resonance to dullness.
What do we measure with the diaphragm?
- S1, S2, loud sounds -
- murmurs of the aortic and mitral regurgitation
- pericardial friction rubs
What do you listen to with the bell?
- Softer sounds - S3, S4
- murmur of mitral stenosis
What are 2 of the most important positions to listen to aortic regurgitation and mitral stenosis?
- LLD - bell on PMI
- Sit and lean forward - listen along left sternal border and at the apex with diaphragm - listen to aortic murmurs.
Difference between systolic and diastolic murmurs?
- - between S1 and S2
- - coincide with carotid upstroke
- - between S2 and S1
How are murmurs graded?
- 1- lowest intensity, often inaudible if inexperienced
- 2- Low intensity, heard immediately w/ stetho
- 3 - Medium , no thrill
- 4- Medium , has palpable thrill
- 5- Loudest intensity with stethoscope partly off chest, has thrill
- 6- heard without stethoscope, has thrill
What to do when you hear a murmur?
- 1- Grade it - thrill or no thrill? heard with stetho or without?
- 2- Locate it. - in relations to the location of the heart sounds - is it aortic? pulmic? tricuspid? or mitral?
- 3- Examine area that it is originating from. Let's say it is pulmonic, the size of the RV should be assessed by carefully palpating the Left parasternal border - bc pulmonic stenosis or atrial septal defects may cause such murmur. - You always want to check the chamber of the heart that is behind - so it does not back up.
- Listen to splitting on second heart sound, try to hear the presence ofd any ejection sound4- Listen to murmur after patient sits up.
- 5- Look for signs of anemia, hyperthyroidism, or pregnancy - these conditions may cause this type of murmur.
- 6- If all findings are normal, pt has innocent murmur.
What are ejection clicks?
Ejection clicks are high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves. They are heard just after the first heart sound. The sounds occur in the presence of a dilated aorta or pulmonary artery or in the presence of a bicuspid or flexible stenotic aortic or pulmonary valve. Ejection clicks may also be called ejection sounds. The diastolic correlate of the ejection click is the opening snap, which occurs at maximal opening of a flexibly stenotic mitral or tricuspid valve.
What are a couple of techniques the NP can use to assess form prolapsed mitral valve or hypertrophic cardiomyopathy from aortic stenosis?
- Standing and squatting
- Vasalva maneuver
How do you screen for PAD?
ABI- which can detect 50% or greater stenoses of 50% or more in major vessels in the leg.
How is the ABI measured, and how is it calculated?
ABI consist of measuring the systolic BP with Doppler ultrasonography in each arm, dosalis pedis, posterior tibial pulses.
ABI calculated on both R and L by dividing the higher right ankle pressure by the higher right arm pressure and the higher left ankle pressure by the higher left arm pressure.
- 0.90-1.30 --> normal
- 0.41-0.90 --> mild to moderate PAD
- 0.00– 0.40 --> severe peripheral vascular disease w/ critical leg ischemia
What is the Allen test and what does it assess?
assures patency of ulnar artery - pt should rest hands in lap, and palms up.
- Ask patient to make a tight fist with one hand, then compress both radial and ulnar
- arteries, ask pt to open hands, hands pale, release arteries, hands flush.
- Intermittent claudication progressing to pain at rest
- Pulses decrease or absent
- Color: pale esp on elevation, dusky red on dependence
- Temp: cool
- Edema: No
- Skin changes: atrophy, thin, hiny, loss of hair over the foot and toes, nails thickened and ridged
- Ulceration: if present on toes or points of trauma on feet
- Gangrene ( necrosis) may develop
- Pain: present on dependency
- Pulse: normal - may be difficult to feel through edema
- Color :normal or cyanotic on dependency. Petechaie and then brown pigmentation appear with chronicity
- Temp: normal
- Edema: present
- Skin changes: brown pigmentation around the ankles, stasis dermatitis, thickening of the skin, narrowing of the leg as scarring develop.
- Ulceration: if present, it is at side of ankle
- Gangrene: does not develop.