Phys Di II - Exam 2 (Cardio)

Heart position

in mediastinum btw medial/lower border of lungs

3rd to 6th intercostal cartilage

Dextrocardia

heart positioned to the right (rotated/displaced/mirror image)

Sinus inversus

if heart and stomach are placed on right

liver on left

Pericardium

tough, double walled, fibrous sec encasing and protecting heart

fluid btw inner and outer layers (low-friction)

Epicardium (inner layer of pericardium)

thin outermost muscle layer covering heart

Myocardium

thick, muscular middle layer (pumping)

Endocardium

innermost layer, lining chambers and covering valves

Atrioventricular valves (AV)

tricuspid - 3 cusps, separates R atrium + ventricle

mitral/bicuspid - 2 cusps, separates L atrium + ventricle

Semilunar valves (SL)

pulmonic valve - 3 cusps, separates R ventricle + pulmonary artery

aortic valve - 3 cusps, separates L ventricle + aorta

Systole

ventricles contract

tricuspid and mitral valves close

aortic and pulmonic valves open

aortic and pulmonic valves close

Closure of what valves is the first heart sound (S1 - Lub, start of systole)

tricuspid and mitral

Closure of what valves is the second heart sound (S2 - Dub, start of diastole)

aortic and pulmonic

Diastole

tricuspid and mitral valves close

blood moves from atria to ventricles passively

atria contract

What makes the third heart sound (S3)

blood moving from atria to ventricles

What makes the fourth heart sound (S4)

contraction of atria for complete emptying

What is the order in which electrical activity runs through the heart

Sinuatrial node (SA)

AV node

Bundle of His

Purkinje fibers

P wave

atrial depolarization (spread of stimulus through atria)

PR interval

time from initial stimulation of atria to initial stimulation of ventricles

QRS complex

ventricular depolarization (spread of stimulus through ventricles)

atrial repolarization

ST segment and T wave

ventricular repolarization

U wave

repolarization of purkinje fibers (small deflection sometimes seen just after T wave)

QT interval

time elapsed from onset of ventricular depolarization until completion of ventricular repolarization

Infant heart characteristics

more horizontal and apex is higher

(adult heart by age 7)

Pregnant women cardio changes

increased HR and SV

LV increases wall thickness and mass

horizontal position

pulse faster

apical impulse shifts up and lateral 1-1.5cm

What two medications should you ask patients if they are on

beta-blockers

ACE inhibitors

Cyanotic spells (TET spells) in infants

cyanosis after crying or feeding in tetralogy of fallot

Indications of heart disease during pregnancy

progressive/severe dyspnea

progressive orthopnea

paroxysmal nocturnal dyspnea

hemoptysis

syncope w/exertion

chest pain related to effort or emotion

Examination of the heart order

inspect, palpate, percuss, auscultate

How should the patient be positioned to listen to the apical impulse

supine

Point of maximal impulse (PMI)

point at which apical impulse is most readily seen or felt

midclavicular 5th intercostal space

Heave/lift

PMI is more vigorous than expected

Thrill (palpable murmur)

fine, palpable, rushing vibration

Left ventricular size is better judges by _______ rather than percussion

the location of the apical impulse

Right ventricle tends to enlarge in the _______ rather than laterally

anteroposterior (A-P)

What is more useful than percussion in defining the heart borders

chest radiographs

Mnemonic for the five auscultatory areas

All Palmer People Try Mangoes

Auscultation - Aortic valve area

2nd right intercostal space, right sternal border

Auscultation - Pulmonic valve area

2nd left intercostal space, left sternal border

Auscultation - 2nd pulmonic area (Erb’s point)

3rd left intercostal space, left sternal border

Auscultation - Tricuspid area

4th left intercostal space, lower left sternal border

Auscultation - Mitral/Apical area

5th left intercostal space at midclavicular line

Intensity of heart sounds via auscultation - Aortic, Pulmonic, 2nd Pulmonic valve areas

pitch S1 < S2

loudness S1 < S2

duration S1 > S2

Where is the loudest A2 sound heard

aortic valve area (2nd right intercostal space, right sternal border)

Where is the loudest P2 sound heard

2nd pulmonic area (3rd left intercostal space, left sternal border)

Intensity of heart sounds via auscultation - mitral valve area

pitch S1 > S2

loudness S1 > S2

duration S1 > S2

Intensity of heart sounds via auscultation - tricuspid valve area

pitch S1 = S2

loudness S1 > S2

duration S1 > S2

Which side of the heart are the sounds louder in auscultation? Why?

left b/c pressure is higher

A split of S1 (Lu Lub Dub) is typically heard the best over what area

tricuspid (4th left intercostal space, lower left sternal border)

The apex of the heart is over what two areas

tricuspid and mitral

The base of the heart is over what two areas

aortic and pulmonic

S2 sound is louder at the ____ of the heart

base (aortic and pulmonic)

Physiologic splitting of S2 (Lub Du Dub) can be heard when

during inspiration

S3 sound is heard after S2 and is known as a

ventricular gallop

S4 sound is hear before S1 and is known as a

atrial gallop

What is a summation gallop

S3 and S4 heard right next to each other after S2 at apex

Paradoxical splitting

goes away when inhale

Murmur intensity grading

1 - barely audible in a quiet room

2 - quiet but clearly audible

3 - moderately loud

4 - loud, associated with a thrill

5 - very loud, thrill easily palpable

6 - very loud, audible w/stethoscope not touching, visible thrill

Diastolic murmurs

ARMS PRTS

Mitral stenosis can be heard where

bell

apex

left lateral decubitus position

Mitral stenosis findings

low frequency diastolic rumble

thrill at apex

lift in right parasternal area

Mitral stenosis causes

rheumatic fever or cardiac infection

Aortic stenosis can be heard where

aortic area (2nd right intercostal border)

Aortic stenosis findings

mid-systolic

medium pitch + crescendo/decrescendo

thrill at apex

radiates along left sternal border

Aortic stenosis causes

congenital bicuspid valve

rheumatic heart disease

atherosclerosis

Subaortic stenosis can be heard where

apex - left sternal border

Subaortic stenosis findings

murmur fills systole

medium pitch + coarse

thrill at apex and right sternal border

jugular venous pulse prominent

Subaortic stenosis cause

congenital heart disease

What murmur could be confused with a ventricular septal defect

pulmonic stenosis

Pulmonic stenosis can be hear where

pulmonic area

radiating left into neck

Pulmonic stenosis findings

thrill in 2nd + 3rd left intercostal spaces

systolic murmur

medium pitch

Pulmonic stenosis cause

congenital

Tricuspid stenosis can be heard where

Bell

over tricuspid area

Tricuspid stenosis findings

rumble accentuated early and late in diastole

resemble mitral stenosis but louder on inspiration

arterial pulse amplitude decreased

jugular venous pulse prominent

Tricuspid stenosis causes

rheumatic heart disease

congenital defect

endocardial fibroelastosis

right atrial myxoma

Mitral regurgitation can be heard where

apex

transmitted to left axilla

Mitral regurgitation findings

holosystolic

high pitch + harsh blowing quality

thrill at apex during systole

Mitral regurgitation causes

rheumatic fever

MI

myxoma

rupture of chordae

Mitral valve prolapse can be heard where

apex - lower left sternal border

easily missed in supine

Mitral valve prolapse findings

late systolic preceded by mid-systolic clicks

highly variable in intensity and timing

Mitral valve prolapse causes

pectus excavatum

Aortic regurgitation can be heard where

diaphragm (stethoscope)

Austin-flint murmur (bell of stethoscope)

pt sitting leaning forward

ejection click in 2nd intercostal space

Aortic regurgitation findings

high pitch blowing

Austin-flint - low-pitch rumbling at apex

wide pulse pressure (water hammer/corrigan pulse)

Aortic regurgitation causes

rheumatic heart disease

endocarditis

aorta diseases (Marfan)

syphilis

ankylosing spondylitis

dissection

Pulmonic regurgitation causes

secondary to pulmonary HTN

secondary to bacterial endocarditis

Tricuspid regurgitation can be heard where

lower left sternum

occasional radiating to the left

Tricuspid regurgitation findings

holosystolic murmur over right ventricle

blowing

increased on inspiration

jugular venous pulse has large V waves

Tricuspid regurgitation causes

congenital defects

bacterial endocarditis

pulmonary HTN

What two types of murmurs occur during the whole systole (holosystolic)

mitral regurgitation

tricuspid regurgitation

Irregular heart rhythm but occurring in a repeated pattern may indicate

sinus dysrhythmia (cyclic variation of HR)

Patternless, unpredictable, irregular heart rhythm may indicate

heart disease or conduction system impairment

What disease accounts for most acquired murmurs in children

Kawasaki disease

What type of murmur may be heard over the pulmonic area in 90% of pregnant women

systolic ejection murmurs (SEMs)

S4 heart sound is more commonly heard in what population

older adults

Bacterial endocarditis

bacterial infection of endothelial layer of heart and valves

• acute - fever + fatigue

  • chronic - fatigue + murmur

Congestive heart failure - Left sided

heart fails to propel blood forward resulting in congestion in pulmonary circulation

crackles on pulmonary examination

Congestive heart failure - pulse pressure characteristics

systolic CHF = narrow pulse pressure

diastolic CHF = wide pulse pressure

Congestive heart failure - Right sided

heart fails to propel blood forward resulting in congestion in systemic circulation

peripheral edema (pitting in LE)

ascites

Pericarditis (inflammation of pericardium)

sharp and stabbing chest pain

pain worse w/coughing, swallowing, supine, deep breathing

friction rub on auscultation

Cardiac tamponade (excessive accumulation of effused fluids or blood btw pericardium)

chest pain + difficulty breathing

pale, grey, blue skin

palpitations and rapid breathing

Beck triad

Beck triad

jugular venous distension

hypotension

muffled heart sounds