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44 Cards in this Set
- Front
- Back
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Why 30 degrees?
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This is so that you will be able to identify JVD
hypovolemic patient may have to lie flat before you see the neck veins (measured JVP will be low) hypervolemic patients will have a high JVP In contrast, when jugular venous pressure is increases, an elevation up to 60 degrees or even 90 may be required. |
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Why inspect the corotid pulsations
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supplies brain, variable causes to abnormal
it provided valuable information about cardiac function and is especially useful when detecting stenosis or insufficiency of the aortic valve |
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Why inspect the neck veins?
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a- waves just precedes S1 and the corotid pulse
- prominent a-waves in increased resistance to right atrial contraction, as in tricuspid stenosis; also in first degree atrioventricular block, supraventricular tachycardia, junctional rhythms, pulmonary hypertension, and pulmonic stenosis - absent a waves in atrial fibrillation - the x descent can be seen in a systolic collapse - large v waves in tricuspid regurgitation, constrictie pericarditis |
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Why measure JVP?
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JVD causes elevated JVP
Heart failure - provides information regarding the patient's volume status and cardiac function - it reflects pressure in the right atrium |
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Why inspect and palpate cardiac points/PMI/precordium?
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looking for heaves, lifts, and thrills (formed by the turbulence of underlying murmurs)
use palpation of the carotid pulse or of the apical impulse to help determine whether the sound or murmur is systolic or diastolic |
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Why auscultate and why correlate?
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you auscultate to listen to murmurs
you correlate with the patient's blood pressure, arterial pulses, venous pulsations, jugular venous pressure and the patient history to confirm a diagnosis and make a hypothesis of the origin of the murmur |
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Why use the bell?
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more sensitive to low-pitched sounds of S3 and S4 and the murmur of mitral stenosis
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Why use the diaphragm?
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better for picking up the relatively high-pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs
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the heart as a pump: key points for examining the heart
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note the heart chambers and valves and the forward flow of blood from the right side of the heart through the pulmonary arteries and veins to the left side of heart
- combine this knowlege with careful examination and systematic clinical reasoning - this will lead you to correct identification of valvular and congestive heart disease |
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systole
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the ventricles contract
- the right ventricle pumps blood into the pulmonary arteries (pulmonic valve is open) - the left ventricle pumps blood into the aorta (aortic valve is open) |
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Diastole
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the ventricles relax and fill
- blood flows from the right atrium to the right ventricle (tricuspid valve is open) - blood flows from the left atrium to the left ventricle ( mitral valve is open) (all murmors will be systolic or diastolic murmurs) |
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The heart as a pump: important concepts
- preload - contractility - afterload - cardiac output - blood pressure |
preload => volume overload
contractility: ventricles contract during systole afterload => pressure overload cardiac output: stroke volume (blood going out) x HR Blood pressure: cadiac output x systemic vascular resistance Ejection fraction is measured on an ECHO (how much blood is put out percentage wise) |
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Blood pressure
Systolic vs. diastolic blood pressure |
Systolic: pressure generated by the left ventricle during systole, when the LV ejects blood into the aorta and the arterial tree
- pressure waves in the arteries creates a pulse Diastolic : pressure generated by blood remaining in the arterial tree during diastole, when the ventricles are relaxed |
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Jugular venous pressure (JVP) and pulsations
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jugular veins reflect right atrial pressure
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assessing the carotid
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never palpate the right and left carotid arteries simultaneously
the upstroke may be: - brisk - normal - delayed - suggests aortic stenosis - bounding - suggests aortic insufficiency (aortic regurgitation) Listen with the stethescope for any bruits (cause tubulent flow through blood vessel) from cardiac stenosis |
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palpating the chest wall
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using the finger pds, palpate for heaves or lifts from abnormal ventricular movements
using the ball of the hand papate for thrills, or turbulence transmitted to the chest wall surface by damaged heart valve |
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assessing the point of maximal impulse (PMI)
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- inspect the anterior chest for a visible PMI
- using your finger pads, palpate at the apex for the PMI The PMI may be: - tapping - normal - sustained - suggests LV hypertrophy from hypertension or aortic stenosis - diffuse - suggests a dilated ventricle from congestive heart failure or cardiomyopathy assess location, amplitude, duration, and diameter |
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Areas of the Cardiac Exam
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1) aortic
2) pulmonic 3) tricuspid 4) mitral |
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Listening to the heart - auscultation
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Listening for S1 and S2 using the diaphragm of the stethoscope
- then listen to the apex with the bell - the diaphragm is best for detecting high-pitched sounds like S1, S2, and also S4 and most murmurs - the bell is best for detecting low pitched sounds like S3 and the rumble of mitral stenosis |
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S1 and S2
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S1 = closing of the mitral valve
Systole => (blood flowing out the pulmonic and aortic valves) S2 = closing of the aortic valve Diastole => (blood flowing from the atria to the ventricles) mitral is louder than tricuspid aortic is louder than pulmonary (louder because of pressure gradients) S2 will have more splitting of the heart sounds than S1 |
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S2 splitting
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due to aortic and pulmonic valves not closing together
- heard best during deep inspiration pathologic split on expiration, normal to split on inspiration |
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describing heart murmurs: timing and duration
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- identify and describe any murmors
- timing: are the murmors systolic or diastolic? - tip: palpate the carotid upstroke (occurs in systole) as you listen - if the murmor coincides with the carotid uptake, it iis systolic Duration - early/mid/ or late systolic - early/mid/late sytolic |
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Describing heart murmurs: shape
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crescendo
decrescendo both (diamond-shaped) example: crescendo-decrescendo systolic murmur of aortic stenosis plateau machinery ex. holosystolic (from S1 to S2) murmur of mitral regurgitation |
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describing heart murmors: intensity
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grade the murmor on a scale of 1 to 6
grades 4 through 6 must have accompanying thrill at the same point if you can hear it, its probably a 3 at least |
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MR. AS/ MS. AR
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MR. AS lives ONLY in systole with TRaPS
MS. AR lives ONLY in diastoly with T.SiPR |
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Grading of Murmurs
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Grade 1: very faint, heart only after listener has "tuned in"; may not be heard in all positions
Grade 2: quiet, but heard immediately after placing the stethoscope on the chest Grade 3: moderately loud Grade 4: loud, with palpable thrill Grade 5: very loud, with thrill. May be heard when the stethoscope is partly off the chest Grade 6: very loud, with thrill. May be heart with stethoscope entirely off the chest |
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Describing heart murmurs: quality, pitch, and location
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- quality: apply terms like harsh (mitral regurg, musical, soft, blowing, or rumbling)
- pitch: apply terms like high, medium, or low-pitched - examples: Harsh 2/6 medium pitched holosystolic murmur best heard a tthe apex describes "mitral regurgitation" soft, blowing 3/6 decrescendo diastolic murmur best heard at the lower left sternal border describes "aortic regrugitation" |
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Mitral regurgitation murmur
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blowing holosystolic
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aortic stenosis murmur
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crescendo-decrescendo narrowed
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mitral stenosis
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crescendo
thickened, stiffened leaflets of mitral valve often from rheumatic fever diastolic |
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arotic regurgitation
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decrescendo
leaflests of aortiic valve fail to close completely blood regurgitates from the aorta to LV (leakage of aortic valve back into the left ventricle) |
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PDA (patent ductus arteriosus)
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fails to close
shortly after birth bounding pulse fast breathing poor feeding habits shortness of breath sweating while feeding tiring very easily poor growth very loud, called washing machine |
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coarctation of the aorta
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the pulse of the femoral area or feet will be weaker than the pulse in the arms or the carotid
- sometimes the femoral pulse may not be felt at all - the blood pressure in your legs is usually weaker than in the arms - harsh murmur may radiate to back |
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VSD (ventricular septum deviation)
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mimic mitral regurgiation
it is holosystolic |
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What is louder when you squat?
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increased intensity of aortic stenosis
increased left ventricular volume increased vascular tone |
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what is louder when you lean forward?
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accentuats or brings out aortic murmurs
you may easily miss the soft diastolic murmur of aortic regurgitation unless you listen at this position |
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what is louder when you lie on your left side?
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this position accentuates or brings out a left-sided S3 and S4 and mitral murmurs, especially mitral stenosis.
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what is louder when you stand or strain?
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increased sounds of mitral valve prolapse (click moved earlier in systole and murmur lengthens)
increased hypertrophic cardiomypathy |
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rubs
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friction rubs occur from an inflamed pericaridium
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opening snap
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very early diastolic sound
opening of a stenotic mitral valve |
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S3
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period of rapid ventricular filling as blood flows in early diastole
LA to LV children/young adults = rapid deceleration of the column of blood against the ventricular wall (water faucet sound) |
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S4
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atrial contraction
immediately preceeds S1 diastole described as gallop |
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atrial fib.
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irregularly irregular (no pattern)
atrial chamber of the heart bag of worms appearance multiple foci anticoagulate |
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pitting edema
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found in CHF patients
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