ryan clin skills 3

R ventricle

what is the most anterior structure of the heart?

when there is a noticeable difference between right and left sided events

when does splitting of heart sounds occur?

right

___ sided events occur slightly later

junction of the sternum and xiphoid process

where does the inferior border of the RB lie?

base of heart

what surface of the heart is where the RV joins the pulmonary artery?

sternal angle

at what level is the base of the heart?

behind

where is the left ventricle located in relation to right ventricle?

apex

what part of the heart produces the point of maximal impulse?

R 2nd ICS

where can the aortic valve be best auscultated?

L 2nd ICS

where can the pulmonic valve be best auscultated?

lower L sternal border

where can the tricuspid valve be best auscultated?

apex/5th ICS, midclavicular line

where can the mitral valve be best auscultated?

cardiac cycle

what is the process of valvular function and heart muscle contraction that allows blood to flow in the right direction?

distal vasculature

what aids in blood flow?

AV

systole involves closure of the ____ valves (S1)

semilunar

diastole involves closure of the ___ valves (S2)

EKG

what is the electrical system of the heart best evaluated by?

depolarization occurs during S2 and atria contract

what happens when SA node fires electrical conduction through atria?

depolarization occurs during S1 and ventricles contract

what happens after the electrical impulse travels through the bundle of his and bundle branches and purkinje fibers?

ventricle heart pressure

clinically, what do we care about most in regard to heart pressure gradients since it dictates pulse?

ejection fraction

what is the percentage of ventricular volume ejected at each heart beat?

60%

what is the normal ejection fraction?

Exertional pain, pressure of discomfort in the chest, shoulder, back, neck, arm

what is the typical MI and associated symptoms common with CAD?

cramping or grinding pain, tooth or jaw pain, SOB, fatigue, nausea or vomiting without pain

what are atypical sx of CAD?

retrosternal, knife-like pain, worse when lying down and with deep inspiration

describe pericarditis

tearing or ripping sensation, radiates to the back between the shoulder blades, pts rapidly lose consciousness and decline

describe dissecting aortic aneurysm

often sharp and worse on inspiration, more likely to have SOB, hemoptysis, LOC

describe pulmonary embolism

palpitations

what might be described as skipping, racing, fluttering, extra beat, pounding, or stopping?

uncomfortable awareness to breathing that is inappropriate to level of exertion

what is dyspnea?

dyspnea when supine and improves with elevation

what is orthopnea?

by number of pillows they need in bed or sleeping in a recliner

how do you quantify orthopnea?

episodes of dyspnea that wakes pt from sleep

what is paroxysmal nocturnal dyspnea (PND)?

5L

interstitial fluid can accumulate up to ___ of fluid before pitting edema occurs

neurologic, CV, or other source

what can fainting/syncope be from?

that it is cardiac in nature

if syncope is abrupt onset/offset, what should you think?

head to SVC to R heart

what does the jugular v drain blood from?

R atrial pressure (jv)

what does the jugular v reflect?

R atrial pressure

what correlates with central venous pressure and RV end-diastolic pressure?

fluid overload states

what causes jugular vein distension?

distance from R atrium to venous pulsations

what is jugular vein pressure?

pressure changes in the cardiac cycle

what causes jugular venous pulsations?

R internal jugular v

where is jugular venous pressure (JVP) best assessed?

R external jugular v

what other vessel can be used to assess JVP besides R internal jugular v?

deep to SCM

where is the R internal jugular vein located?

fluid status

what does the level of pulsations measured in the neck correlate with?

laying at 30 degrees, head turned slightly to left, tangential lighting

how should you position a pt to assess JVP?

between SCM attachments

where should you look for pulsations of internal jugular v?

1. find point of highest pulsation and place index card on it

2. identify sternal angle and place ruler perpendicular to it

3. measure where the index card crosses over

4. add 5cm

describe how to measure JVP

it is the distance from sternal angle to center of the R atrium

why do you add 5cm when measuring JVP?

6-8cm

what is WNL when measuring JVP?

hypervolemia

if JVP is measured as >8cm, what is it called?

acute and chronic heart failure, tricuspid stenosis, pulmonary HTN, SVC obstruction, cardiac tamponade, constrictive pericarditis

what is hypervolemia seen with?

hypovolemia

if JVP is measured as <5cm, what is it called?

elevated JVP on expiration and vein collapse on inspiration

what can COPD cause in terms of JVP?

diaphragm

what part of stethoscope is bruit of carotids best heard with?

atherosclerotic stenosis

what is bruit most often caused by?

stroke

what can bruit lead to?

carotids

where might murmurs from the heart radiate to?

amplitude

what is strength of the beat in carotids?

speed of upstroke, summit, and downstroke

what is the contour of the pulse wave in carotids?

brisk

describe normal contour of pulse wave in carotids

varied peak, bisferiens/double systolic peak, bigeminal, rapid rise or collapse

what are abnormal contours of pulse wave in the carotids?

rhythm is regular but the force of the pulse alternates

describe pulsus alternans

severe left ventricular dysfunction

what does pulsus alternans indicate?

alternating loud and soft Korotkoff sounds or sounds double as the cuff pressure declines

what might be heard with pulsus alternans when taking BP?

increased pulse pressure with double pulse peak

what is biferiens pulse?

aortic diseases, particularly aortic regurgitation and hypertrophic obstructive cardiomyopathy

what is bisferiens pulse often seen in?

large drop in systolic blood pressure during inspiration with correlating decrease in pulse amplitude during inspiration

what is paradoxical pulse?

pericardial tamponade, COPD or asthma exacerbations and constrictive pericarditis

what is paradoxical pulse seen in?

abnormal heart rhythm with extra, premature contraction between each normal beat

what is bigeminal pulse?

normal, decreased

with a bigeminal pulse, the regular beats have ___ amplitude and the extra beats are typically ___ in amplitude

electrical abnormality/arrhythmia that affects ventricles

what is the cause of a bigeminal pulse?

water hammer pulse

what is a hyperkinetic/bounding pulse aka?

elevated pulse amplitude with rapid upstroke and descent

describe a hyperkinetic/bounding pulse

fever, anemia, systolic HTN, cirrhosis, aortic or mitral regurgitation, patent ductus arteriosus

what are the pathologic causes of a hyperkinetic/bounding pulse?

stress, exercise, pregnancy

what are the physiologic causes of hyperkinetic/bounding pulse?

point of maximal impulse

what does PMI stand for?

left border of heart/apex

what does PMI locate?

fourth or fifth ICS, midclavicular line

what is the location of apical impulse/PMI?

1-2.5cm

what is the diameter of apical impulse/PMI in supine pts?

body habitus and positioning

the apical impulse/PMI may not be palpable or visible due to...

pulsations

what are visible chest wall impulses?

heart enlargement

what causes lateral displacement of PMI?

hypertrophic cardiomyopathy

what causes double impulse in apical region?

RV hypertrophy or AAA

what causes epigastric and subxiphoid movement?

shortly after

when should the carotid pulse occur in relation to S1?

left lateral decubitus position

PMI is best noted with a pt in what position?

sustained impulse from enlarged ventricle

what are heaves?

palm or finger pads

what are heaves best felt with?

buzzing or vibration sensation due to turbulent blood flow

what are thrills?

ball of hand

what are thrills best felt with?

apex

where are S3 and S4 best felt at?

pregnancy, heart failure, cardiomyopathy, ischemic heart disease, thoracic deformities

displaced apical impulse may be seen in...

hypertrophic cardiomyopathy (d)

what might a double apical impulse be seen with?

high pitched sounds

what sounds is the diaphragm best for?

diaphragm

S1 and S2 can be best heard with what part of the stethoscope?

aortic and mitral regurgitation and pericardial friction rubs

what are examples of sounds that can be heard with the diaphragm?

throughout the pericardium

where should the diaphragm be used first?

light pitch sounds

what sounds is the bell best for?

bell

light pressure should be used when using what side of the stethoscope