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What is the area on the anterior chest overlying the heart & great vessels called?
Where is the Mediastinum and what does it contain?
Midthroacic cavity in the 2nd to 5th ICS, right sternal border to border to left MCL
Contains the heart & great vessels (aorta, pulmonary artery, inferior / superior vena cava)
Where is the base of the heart located?
Where is the apex located?
Apex is pointed and located at the bottom
5th ICS, 7 - 9 cm left of midsternal line (approximately at MCL)
How is the heart positioned?
Heart is rotated so that the right side is anterior & left side is poterior
What causes the apex shift to the left when the heart is enlarged?
- Hypertrophy of heart muscle
What are the structures of the heart?
What is the pericardium and what is it attached to?
Pericardium is the pericardial sac
It is attached to vessels, esophagus, sternum & pleura; anchored to the diaphragm
Where is the epicardial pacemaker placed in case of an emergency?
What does the Myocardium do?
A lot of muscle on the left side pumps blood throughout the body compared to the right side that pumps blood to the lungs.
What is the most inner part of the heart?
What kind of valve pushes the blood through one way?
What kind of valve depends on the pressure gradient of the heart?
- Open & close passively hearts
- Greater the volume, greater the pressure.
What are the atrioventricular valves?
- Left AV = Mitral (Bicuspid)
- Right AV = Tricuspid
What is the purpose of the tricuspid (right AV)?
Chordae tendinea attach the AV valves to papillary muscles & provide stability to valves during systole
Rupture of the chordae tendinea may be life threatening. When the chordae tendinea pulls away from the muscle, immediate death occurs.
What are the semilunar valves?
- Right = Pulmonic
- Left = Aortic
Which semilunar valve mostly pumps unoxygenated blood?
Pulmonic Semilunar Valve (Right)
Which semilunar valve pumps blood from the left ventricle to the aorta into the body?
Aortic Semilunar Valve (Left)
What are the 2 systems in the heart that work together?
Conduction System & Hemodynamic System
Which electrical system initiates & conducts heart beat?
Which system moves blood through the heart & vessels?
What is another word for electrical pathway?
What is the electrical tissue that starts the electrical process?
What is the intrinsic pacemaker?
How does conduction work?
It works like a spark that starts the heart beat & then it is transmitted across atria to the AV node, then to the Bundle of His & finally to the Perkinje fibers in the ventricles.
T/F. Pacemaker can be dormant if normal pacemaker works.
What reflects the electrical conduction through the heart?
Which wave depolarizes the atria?
Which wave spreads stimuli through the atria?
What does it mean when the P wave loos abnormal or absent?
SA node isn't firing properly or doesn't fire at all
At what rate should the SA node fire?
60 - 100 beats per minute (bpm)
What will happen if the heart rate is slower (less than 60)?
As the heartbeat is lower, the lower pacemakers (AV node / junctional node, which is 40 - 60 bpm) take over
What does it mean when the P wave increase?
SA node generates heartbeat.
What happens during the PR interval?
It is the time from stimulation of atria to stimulation of ventricles.
Firing of the SA nodes
The QRS complex is known for what 2 things?
- 1. Depolarization of ventricles
- 2. Spread of stimuli through ventricles
What 2 things is the T wave known for?
- 1. Repolarization of ventricles.
- 2. Resting phase
The U wave is known for what 2 things?
- 1. Final ventricular repolarization
- 2. Not always seen on EKG
What lies at the base of the heart?
- - Venous blood
- - Arterial blood
Which way does the flow of blood go?
Blood flows from higher to lower pressure gradients
Which way does the blood flow from the lower body?
Lower Body (abdomen, liver) -> Inferior Vena Cava -> Right Atrium
Which way does the blood flow from the head & neck?
Head & neck -> superior vena cava drains venous blood -> Right Atrium
What happens to the blood from the Right Atrium?
Right Atrium carries venous blood -> Tricuspid Valve -> Right Ventricle -> Pulmonary Semilunar Valve -> Pulmonary Arteries (unoxygenated blood) -> lungs / alveoli (oxygenate the blood) -> pulmonary veins (oxygenated blood) -> Left Atrium (arterial blood) -> Mitral Valve -> Left Ventricle -> Aortic Semilunar Valve -> Aorta -> Body
How does the blood move?
Blood moves by pressure gradients.
How can you get backward flow of blood?
Backflow of blood is caused when atrial pressure are excessively high.
What happens in the right side of the heart during backward flow?
- 1. No valves between right atrium & vena cava
- 2. If pressure in the right atrium is greater than vena cava, then blood back flows to the veins of the neck & PV system & results in distended neck veins & peripheral edema - which can lead to right valve disease, lung disease, etc.
What are some right-side heart failure signs?
Swelling in feet and legs
What happens in the left side of the heart during backward flow?
- 1. No valves are between the left atrium & pulmonary veins
- 2. If pressure in the left atrium is greater than the pulmonary veins, then blood back flows to the lungs & results in pulmonary congestions (ex. crackles / rales) - which can lead to right valve disease, Hypertension (HTN), defective aortic valve etc.
What sounds do you hear in fluid-filled lungs?
crackles / rales
How many breaths per hour is of the inspired spirameter?
10 breaths / hour
What consists of dead space?
Does the dead space have any function?
What is the equation for Cardiac Output?
CO = HR x SV
- increase heart rate leads to increase cardiac output
- Stroke Volume = amount of blood ejected w/ one heart beat (70 mL)
What is the normal rage of Cardiac Output?
4 - 6 L / min
What is another word for Preload?
Left Ventricular End Diastolic Volume (LVEDV)
What happens when the left ventricular volume increases? (preload)
- Causes more stretch on the myocardial muscle fibers at the end of diastole
What is the Frank Starling Law? (Preload)
Greater the stretch of muscle fibers, stronger the contraction
More stroke volume, more preload
- Give fluids until Stroke Volume starts to decrease
- If Cardiac Output is too low, give pt. diuretic
What is the goal of preload?
The goal is to maximize preload (volume) in order to maximize left ventricular contraction & cardiac output
What happens when the preload is excessive?
Excessive preload leads to decreased Cardiac Output & heart failure
What is artherosclerosis?
Plaque build-up which leads to not enough oxygen in blood & makes the muscle work harder
What are other words for Afterload?
What does the afterload do?
- Ventricles work harder & use more oxygen to pump but don't want to use more oxygen b/c can lead to myocardial infarction
- The opposing pressure in the ventricle must generate to open the aortic valve during systole, which increases SVR (afterload)
What does increased SVR (afterload) cause?
- Causes increased aortic pressures
What does excessive afterload increase?
Myocardial workload & oxygen consumption
What is the cause of excessive afterload?
May be caused by arteriosclerosis, HTN, sympathetic nervous system stimulation (stress - anything that causes stress on the sympathetic nervous system), excessive alcohol intake
What is arteriosclerosis?
Hardening of plaque in artery
What are heart sounds produced by?
Heart sounds are produced by closure of the valves
Which side are the valve sounds louder?
Louder on the left side (ex. mitral valve closure is louder than tricuspid & aortic valve closure is louder than pulmonic)
What are the 5 Valve Sites and where are they located?
- 1. Aortic Valve - 2nd ICS, right sternal border
- 2. Pulmonic Valve - 2nd ICS, left sternal border
- 3. Erbs Point - 3rd ICS, left sternal border (good location for referred sounds, place where murmurs radiate to)
- 4. Tricuspid Valve - 4th IC, left sternal border
- 5. Mitral Valve - 5th ICS, MCL
What do you when you are listening to valve sites?
- - Listen to all sites w/ diaphragm & bell of stethoscope
- - Listen for aortic murmurs (sitting & leaning forward is best)
- - Listen for extra heart sounds (left lateral decubitus position is best)
What happens in S1?
- - Mitral / tricuspid valves closes -> creates S1
- - Aortic / pulmonic valves open (when ventricular pressure exceeds aortic) -> ventricles contract & blood is ejected from ventricles
- - Ends diastole; begins systole
What happens in S2?
- - Aortic / pulmonic valves (semilunar) close -> creates S2
- - Mitral / tricuspid valves open
- - Rapid filling phase (passive initial filling of ventricles)
- - Atrial kick (atrial contraction ejects last 25% of SV into ventricles). AK is normal, but not the S4
- - End systole; begins diastole. Diastolic filling
What happens in S3?
- S1 ------- S2, S3
- "Ken ------- tucky"
- - Extra Heart Sounds (Gallops) - diastolic sounds
- - Heart Failure
- - Non-compliant Ventricle
- - Early diastole
- - Indicates ventricular resistance to early passive filling
- - Occurs in early diastole (immediately after S2)
What are the causes of S3?
- - Decreased ventricular compliance (early sign of HF)
- - High output conditions such as hyperthyroid, pregnancy, etc.
What happens to compliant ventricles?
Blood flows in freely
What happens in S4?
- S4, S1 ------- S2
- "Tenness ------- ee"
- - Extra Heart Sounds (Gallops) - diastolic sounds
- - Heart Failure
- - Indicates ventricular resistance to filing during the atrial kick
- - Occurs in late diastole (immediately before S1)
What are the causes of S4?
What consists of the Summation Gallop?
S3 & S4
What is Split S1?
- - Mitral valve closing before tricuspid valve due to higher pressures on the left
- - Uncommon since closure of tricuspid is usually too faint to hear
- - May be mistaken for S4
What is Split S2?
- - Common
- - Can be re-created
- - Aortic valve closing before pulmonic during deep inspiration
- - Changes in intrathoracic pressure w/ deep inspiration causes asynchronous valve closure
- - May be mistaken for S3 although S3 isn't affected by breathing patterns
- - Most prominent at 2nd ICS, left sternal border at peak inspiration (in contrast to S3 which is best heard at the apex)
What are murmurs?
Blowing / swooshing sound that occurs w/ turbulent flow through valves or great vessels
What causes murmurs?
- - Increased velocity (exercise)
- - Decreased viscosity (thin)
- - Decreased volume (anemia)
- - Defective valves (forward or backward flow)
- - Septal defects (ABN openings between chambers)
What are the Stenotic Murmurs?
- - Stenotic - narrow vessels / narrow valves
- - Blood flows through the narrow
- - Occurs when a valve is open
- - Prevents adequate forward flow through thick, stiff valves
- - Causes harsh murmurs
What are the Regurgitant Murmurs?
- - Regurgitant - blood goes the wrong way
- - Murmurs of insufficiency
- - Occurs when a valve is closed or not tightly closed
- - Also referred to as insufficiency
- - Results in backward flow due to poor valve closure
- - Causes turbulent sound
What are the Systolic Murmurs?
- - Heard in systole after S1
- - Aortic / pulmonic stenosis - when semilunar valves are open
- - Mitral / tricuspid insufficiency (regurgitant) - when A/V valves are closed
What are the Diastolic Murmurs?
- - Heard in diastole after S2
- - Mitral / tricuspid stenosis - when A/V valves are open
- - Aortic / pulmonic insufficiency (regurgitant) - when semilunar valves are closed
Determine what type of murmur you are hearing you must:
- 1. Know if you are in systole or diastole
- - One way to tell if you are in systole or diastole is to palpate the carotid pulse while listening to the heart sounds; if you feel the pulse immediately after you hear the heart sound, then you are in systole.
- 2. Identify at which valve site the murmur is the loudest
- 3. Know which valves are open & closed to determine if it's stenotic or regurgitant murmur
What are the characteristics of murmurs?
- - Timing
- - Systolic vs Diastolic
- - Early, mid, or late cycle
- - Entire cycle
- - Holodiastolic (between S2 & S1)
- - Holosystolic (between S1 & S2)
- - Intensity (graded 1 [soft] through 6 [loud])
- - Location (valve site)
What is an Innocent Murmur?
- - Functional murmur
- - No valve, cardiac or other pathology
- - Common in childhood (usually due to increased blood flow)
What is etiology of chest pain?
- - Cardiac (angina, MI, mitral valve prolapse)
- - Acute Coronary Syndrom until diagnosis w/ heart attack
- - Pulmonary (pneumonia, pleurisy, embolis)
- - Pericardial (pericarditis - pain with each heart beat after myocardial infarcation)
- - Musculoskeletal / chest wall (costochondritis, arthritis) - hurts w/ palpation
- - Gastrointestinal (may mimic MI) - ulcer, hiatal hernia, esophagitis, indigestion
- - Neurotic - anxiety
Describe heart symptoms (OLD CART).
- - Onset (at rest, with activity, after eating, etc).
- - Location (substernal, localized vs radiating)
- - Duration
- - Character (burning, sharp / stabbing, crushing, pressure, etc)
What is another word for angina?
What is angina (myocardial ischemia)?
- - Imbalance between oxygen supply & demand (thus, more common w/ exercise)
- - Lack of oxygen to heart muscle lead to heart attack b/c muscle dies
- - Symptoms: chest discomfort w/ or w/o radiation, SOB
- - Should resolve in couple of minutes w/ rest and / or treatment (NTG - nitroglycerin) -> may progress to myocardial infarction if not treated
- - Prolonged symptoms may indicate myocardial infarction
What does chest pain w/ hypertension mean in young adults?
Cocaine that leads to heart attacks
What is another word for heart attacks?
What are the symptoms of myocardial infarction?
- - Similar to angina
- - May have diaphoresis
- - Nausea and Vomiting
- - Palpitations
- - Sense of impending doom
What are the atypical symptoms of CAD?
- - SOB
- - Sharp chest pain
- - Fatigue
What are the risk factors for CAD?
- - Age (male > 45; female > 55, or postmenopausal)
- - HTN or hypertensive treatment
- - Smoking
- - Hyperlipidemia
- - Diabetes
- - Family history of premature CAD in 1st degree relative (male < 55; female < 65)
What is Shortness of Breath?
- - Dyspnea
- - DOE
- - PND
- - HF (lying down increases venous return & myocardial workload)
- - Orthopnea
What is a cough?
Back fluid into alveoli
Is there fatigue?
Sudden vs Gradual
What is syncope?
Fainting w/ no or decrease blood flow to brain
What can you detect with palpitations?
What is an edema & nocturia?
- - Dependent edema
- - Nocturia (recumbent position increases venous return to heart -> increase renal blood flow -> increases urinary output)
What can be the past history for the heart?
- - Cholesterol level
- - Murmurs
- - Congenital heart disease
- - Rheumatic fever
- - Swollen joints
- - Heart surgery
- - Last EKG
- - Stress test (ETT results)
- - etc.
What can be the family history for the heart?
- - HTN, CAD, DM, obesity, congenital heart disease, genetically transmitted disease
- - Ex. Hypertrophic cardiomyopathy is the leading cause of death in young athletes
What are some personal habits?
- - Diet (high fat, sodium)
- - Smoking (vasoconstricts - heart vessels & coronary arteries) - Increases heart rate, myocardial workload & oxygen consumption
- - ETOH (increases afterload) - cardiac depressant causing sympathetic compensatory response. Increase blood pressure.
- - Exercise (increases HDL, myocardial muscle tone) - Decrease plaque build-up
- - Medications (digitalis, diuretics, beta blockers, calcium channel blockers, etc.)
What is one objective data?
Assess for cyanosis or clubbing
What do you do with neck vessels?
- - Inspect
- - Palpate
- - Auscultate
- - Visualized at top of neck hear mandible
- - Palpate in lower 1/3 of neck between trachea & SCM muscle (avoids carotid sinus which slows HR)
- - Palpate one artery at a time
- - Pulse strength 2+ (diminished w/ decreased stroke volume)
- - Auscultate for bruits (coronary artery can be occluded) - over carotid w/ bell and makes swooshing sounds.
- - Indirect measure of RA pressure
- - Jugular veins reflect changes in filling pressures
- - No valves between jugular veins & right atrium
- - Increased right atrial pressure = increased JVD
- - External jugular vein (lies over SCM)
- - Internal jugular vein (IJV) - underneath & medial to SCM
- - More reliable than external jugular vein for measuring RA pressure (attached directly to SVC)
- - Can't see IJV (can only see waves or fluctuations)
- - Slightly rotate head to side (look for pulsations at the right base of the neck (caused by IJ moving SCM)
Differentiate between carotid & internal jugular vein
- Internal Jugular Veins
- - Pulsation visible but not palpable.
- - 2 undulating waves or fluctuations.
- - Palpable pulsation (one brisk pulsation wave)
Assessing Jugular Venous Distention & Jugular Venous Pressure
Raise HOB 30 - 45 degrees & locate top of the internal jugular pulsation in the right neck
What should be the central venous pressure?
Less than 5 cm
Jugular Venous Distention
Norms: 3-4 cm above sternal angle (measure with ruler)
Jugular Venous Pressure
- estimate of RA pressure
JVP = JVD + 5 cm (distance of right atrium from sternal angle)
- Norms: < 9 cm water
- More than 9 = more pressure on right side of the heart
Normal - when pressure is applied to liver border, jugular vein on right side of neck will distend for few seconds, then return to normal
Abnormal - jugular veins will remain elevated as long as pressure is applied to liver - suggestive of CHF
Positive HJR is sign of heart failure
What do you do with Precordium?
- - Inspect
- - Palpate
- - Auscultate
Where is the Apical Impulse (aka PMI) located?
- - Located at 4th or 5th ICS, left of MCL
- - Palpable in 1/2 of adults
- - Decreased w/ obesity & thick chest walls
- If shifted farther to the left, this may indicate cardiomegaly (enlarged heart)
What are Heaves (Lifts)?
- - Sign of myocardiohypertrophy (enlarged heart)
- - Sustained forceful thrusting of ventricle during systole
- - Visualized & palpated at the apex
- - Palpable vibrations
- - Purring cat
- - Associated with loud harsh murmurs
- - Palpate across precordium
Auscultating the Precordium
- - Rate: norm 60-100
- - Rhythm: regular; regular - irregular; irregular)
- - Heart sounds: listen to each valve w/ the diaphragm & bell
Auscultate hearts sounds
- S1 (loudest at apex)
- - Corresponds w/ R wave on ECG
- - Diminished wounds (pericardial effusion, obesity, emphysema)
- S2 (loudest at base)
- - Aortic valve sounds are best heard w/ the patient sitting & leaning forward
- Gallops (S3, S4)
- - Turn patient to left side, often more pronounced over apex by using bell
Rubs & clicks
- - Listen over the valve sites & note any radiation across precordium
Point of maximum inspection