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266 Cards in this Set
- Front
- Back
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Where is the heart positioned
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Behind sternum and 3rd-6th costal cartilage
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What is the area of the chest overlying the heart called
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precordium
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What is the position of the heart in a thin tall person
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Hangs vertically and positioned centrally
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What is the position in a stocky short person
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Lies more to the left and horizontal
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What is dextrocardia
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Heart positioned as a mirror image
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What is situs inversus
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When the heart and stomach are to the right and the liver to the left.
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Describe the pericardium
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tough double-walled fibrous sac encasing the heart. Consists of Fibrous pericardium (parietal layer), serous pericardium (parietal), pericardial space (several mm of fluid bt layers for low friction movement), and serous pericardium (visceral layer).
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Describe the epicardium
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Thin outermost muscle layer. Covers surface of heart and extends onto great vessels
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Describe the myocardium
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Thick muscular middle layer responsible for pumping action
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Describe the endocardium
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Innermost layer lines chambers of the heart and covers heart valves and small muscles associated w/ opening and closing of valves
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What chamber is located on the anterior surface of the heart
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Right
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What is the position of the L ventricle
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Behind the right but extends anteriorly, forms left border of the heart
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Where do you feel the contraction of the L ventricle
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5th left ICS at MC line
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Where is the R atrium located
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above and slightly to right of the R ventricle, helps form right border of heart
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Where is the L atrium located
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Above the L ventricle, forms posterior aspect of heart
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What is the size of the average adult heart
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12cm long, 8cm wide, 6cm AP.
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Where is the tricuspid valve located?
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bt R atrium and ventricle
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Where is the bicuspid/mitral valve located?
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Bt L atrium and ventricle
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How many cusps do the semilunar valves have?
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3
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Name the semilunar valves
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Pulmonary and aortic.
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What are the 2 phases of the cardiac cycle
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systole and diastole
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What happens in systole
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Ventricles contract
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What happens in diastole
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Ventricles dilate (Requires energy) to draw blood in as the atria contract.
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What occurs as systole begins
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Ventricular contraction increases pressure in ventricles. Mitral/tricuspid valves close, causing the S1 "lubb" heart sound. Ventricular pressure rises until it exceeds that in the aorta and pulmonary artery, so the valves are forced open into the arteries.
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When happens once the ventricles empty
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Pressure in ventricles falls below that in the aorta/pulm artery, and valves close causing the S2 "dubb" heart sound. Once pressure in ventricles falls below atria, cuspid valves open to refill the ventricles.
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What makes up the S2 heart sound
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A2: produced by aortic valve closure; P2: produced by pum valve closure
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What makes up the S3 heart sound
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Ventricular filling
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What makes up the S4 heart sound
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Atria contracting to ensure ejection of any remaining blood (not always heard)
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What are some differences in the cardiac cycle between the two sides of the heart.
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More pressure in L side. Slightly earlier on the L. So aortic valve closes slightly before pulmonic, Splits the S2 into A2, P2.
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Describe the pathway of the electrical impulse for the heart
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Originates and paced by SA node in R atrium, travels thru both atria to the AV node in the atrial septum where it is delayed. Then passes into Bundle of His to Purkinje fibers of ventricles.
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What is the direction of ventricular contraction?
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Initiated at the apex and proceeds toward the base
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What does a ECG measure
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current from ions moving in and out of the myocardial cell membranes
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What does the ECG record?
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Depolarization (spread of stimulus through heart) and Repolarization (return of stimulated heart muscle to resting state) as waves
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What is the P wave
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Spread of stimulus thru atria (depolarization)
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PR interval
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Time from initial stimulation of atria to initial stim of ventricles (usually 0.12-0.2sec)
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QRS complex
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Spread of stimulus through ventricles (less than 0.1sec)
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ST segment and T wave
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Return of stimulated ventricular muscle to resting state (repolarization)
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U wave
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Small deflection sometimes seen just after T wave
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QT interval
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Time from onset of ventricular depolarization to repolarization. Varies w/ cardiac rate
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When the heart is beating ~68-72 bpm, what happens to systole/diastole?
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Systole shorter than diastole
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When the rate is 120bpm from stress, pathology, what happens to the 2 phases?
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Become about equal.
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Describe fetal circulation
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Umbilical vessel -> R atrium -> Foramen ovale OR R ATRIUM -> L atrium -> L ventricle -> system
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Where does blood go after it enters the fetal R ventricle
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Into pulmonary artery then through ductus arteriosus into aorta.
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Describe fetal ventricles
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Equal in weight and muscle mass bc both pump blood into systemic circulation
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What happens to the heart at birth
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Ductus arteriosus closes 24-48hrs. Foramen ovale closes as pressure rises in the L atrium.
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Describe the heart at 1yo
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Relative sizes of L and R ventricles approximates the adult ratio of 2:1
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Where does the heart lie in infants/kids?
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More horizontally in chest, so apex rides higher, sometimes into the 4th L ICS.
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When does the heart reach its adult position
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7yo
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How much more blood does a pregnant woman have?
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40-50% over prepregnancy level
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What causes this?
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An increas in plasma volume beginning in 1st trimester and reaching max after 30th week
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How much does blood volume increase if carrying twins?
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70%
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How does the heart respond to this?
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works harder via increased rate and stroke volume. L ventricle increases thickness and mass.
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When does the volume return to normal
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3-4weeks after delivery
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How much does cardiac output increase?
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30-40% over nonpregnant state, reaches highest level at 25-32wks gestation. Maintained until term.
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When does it return to normal
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2wks after delivery
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How does pregnancy affect heart position
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Uterus and diaghragm move upward, so shifted toward horizontal position, slight axis rotation.
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What happens to heart size in elderly
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May decrease unless there's enlargement due to Htn/heart disease. L vent thickens/valves fibrose and calcify.
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Other changes w/ age?
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Heart rate slows. Stroke volume decreases, cardiac output during exercise declines 30-40%.
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What happens to the endocardium
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Thickens
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What hapepns to myocardium
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Less elastic/more rigid so contractility is delayed.
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What happens to the heart's ability to respond to stress/increased O2 demand?
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Less efficient; tachycardia poorly tolerated, and return to normal heart rate takes longer.
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What else can decrease cardiac function
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Fibrosis/sclerosis of SA node/heart valves (esp mitral and aortic cusps), increased vagal tone, decreased baroreceptor sensitivity
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What ECG changes are seen
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Occur secondary to cellular alteration, fibrosis in conduction system, and neurogenic changes. Often see 1st degree atrioventricular block, BBB, ST-T wave abnormalities, premature systole, L ant hemiblock, L vent. Hypertrophy, a-Fibb!
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What is the sequence of the proper heart exam?
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Inspect, palpate, percuss chest, auscultate heart.
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Signs of Heart Failure?
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Crackles in lungs, engorged liver, peripheral edema
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Influencing factors of the cardiovascular exam
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Effect of a barrel chest or pectus deformity, Xanthelasma, Fundoscopic changes of Htn, Ascites or pitting edema, Abdominal aortic bruit
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What does a tangential light do?
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Allow shadows to accent the furface flicker of underlying cardiac movement.
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What side of the pt should the doc stand on?
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Right
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What is a difference in a thin nonmuscular chest?
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Sounds are louder, closer
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What is a difference in a muscular or obese chest?
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Sounds are dimmer, more distant
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Where do you visualize the apical impulse
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Midclavicular line, 5th ICS
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Why might you not see it
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Obese, large breasts, muscular. In some pts may be in 4th ICS.
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If you see the apical impulse in more than one ICS is this a sign of disease?
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Yes. Should not be seen in more than one space if the heart is healthy.
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If you can't see the apical impulse when pt lying down, what can you tell the pt to do?
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Sit up to bring heart closer to ant wall.
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What anatomical differences affect examination findings?
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Shape/thickness of chest, amnt of tissue, air, fluid through which the impulses are transmitted.
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What does a readily visible and palpable impulse when the pt is supine suggest
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An intensity that may be the result of a problem.
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What does the absence of an apical impulse in addition to faint hrt sounds (esp when pt is in L lat recumbent) suggest?
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Intervening extracardiac problem, such as pleural or pericardial fluid.
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What are some other places you can inspect to determine cardiac function?
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Skin for cyanosis or venous distention, nail bed for cyanosis and cap refill time
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When palpating, what part of your hand do you use
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proximal halves of the 4 fingers held gently together, OR the whole hand.
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Describe how you should touch the pt
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Touch lightly, let the cardiac movements rise to your hand (sensation decreases as you increase pressure)
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What is the precordium
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Chest wall over the heart
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What should you do when palpating for the apical impusle
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ID its location by the ICS, and the distance from the midsternal line. Determine width of the area in which it's felt. (USUALLY no more than 1cm)
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Describe what you should feel when palpating the apical impulse
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Usually no more than 1cm. Usually gentle and brief, not lasting as long as systole.
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How would you describe an apical impulse that is more vigorous than expected?
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Heave or Lift.
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Is it normal to not feel the apical impulse in an adult?
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Yes. Bc of thickness of chest wall.
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What does it mean if an apical impulse is more foreceful or widely distributed, fills systole, or is displaced laterally and down?
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Increased Cardiac output, or LVH.
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What can cause a lift along the L sternal border?
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RVH
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What could cause a loss of thrust along the L sternal border?
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Overlying fluid or air, or displacement beneath the sternum.
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What does displacement to the right w/out a loss or gain in thrust suggest?
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dextrocardia, diaphragmatic hernia, distended stomach, or pulm. Abnormality.
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What is the point where the apical impulse is most readily seen/felt?
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PMI
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What is a thrill?
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Fine palpable rushing vibration, a palpable murmur, often (but not always) over the base of the heart in the R or L 2nd ICS.
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What does a thrill indicate?
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turbulence or a disruption of expected blood flow related to defect in closure of one of the semilunar valves. (generally aortic or pulm stenosis), Pulm Htn, or Atrial Septal Defect
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Describe the timeing of the carotid pulse to the heart cycle
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Practically synchronous with the S1 sound
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Where is the carotid pulse located?
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Just medial to and below the angle of the jaw
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What is the purpose of percussion in the cardio exam?
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Has limited value in defining heart borders and determining its size
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Why does percussion have limited value
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Bc shape of chest is relatively rigid, and can make the more malleable heart conform.
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What's the best way to judge LV size?
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By location of the apical impulse
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Describe the RV's size
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tends to enlarge in anteroposterior diameter rather than laterally, thus diminishing the value of percussion of the R heart border
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What can distort percussion findings?
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Obesity, unusual muscular developent, pathological conditions (presence of air, fluid)
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What's the best way to define heart borders?
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CXR
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If no CXR is available in your run down bass ackwards hospital, how would you percuss to determine heart size?
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Tap at the ant axillary line, move medially along ICS toward sternal border. Change from resonant to dull = cardiac border. Note w/ a pen.
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Where will you hear loss of resonance on the L?
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Close to the PMI at the apex of the hrt. Measure this point from the midsternal line at each ICS and record the distance
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What can you determine about the R cardiac border?
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You don't note a change in resonance until the R sternal border is encountered, the heart border is only found if it extends BEYOND the sternal border.
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Describe the frequency of the heart sounds
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All low. So you must make sure room is quiet to hear them.
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What must you do for the pt before auscultating?
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Make sure they're warm and relaxed. Make sure steth is warm.
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What adventitious sounds can distort the heart sounds?
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Shivering/movement.
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Which direction is the heart sound transmitted?
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In the direction of blood flow
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What's the best place to heart specific heart sounds
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In areas where the blood flows after it passes thru a valve.
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What can cause the site of the heart apex to change?
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Elevation of the diaphragms from prego, ascites, or intra-abdominal conditions.
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Because of this, what's the best place to begin the heart exam?
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At the heart base.
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At the very least, what sites should you auscultate?
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The 5 cardiac areas; aortic valve (2nd ICS, R sternal border). Pulm Valve (2nd ICS, L stern border). 2nd Pulm area (3rd ICS, L stern border) Tricuspic (4th ICS, lower L stern border). Mitral (apical) (apex of the heart, L 5th ICS midclav line)
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What parts of the steth should you use and how?
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Start w/ diaphragm using firm pressure, then bell using light pressure
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What should you listen for at each site?
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Each component of the cardiac cycle.
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What should you assess at one ausc site?
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rate and rhythm where the tones are easily heard. Note that site.
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If you hear an irregular rhythm, what should you do?
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compare the beats/min over the heart w/ the beats/min at the radial pulse. Note any deficit.
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What should the pt do regarding breathing?
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Breath normally, then hold breath in expiration. Listen for S1 while palpating the carotid pulse.
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What does S1 mark?
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Beginning of systole. Coincides w/ rise (upswing) of carotid pulse. Vent pressure increasing, cuspids slammed shut.
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What should you be listening for during S1?
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Note the intensity, any variations, effect of respirations, and any splitting of S1. Listen for any extra sounds or murmurs.
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What does S2 mark?
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Initiation of diastole.
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What should you listen for during S2?
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Concentrate on diastole, which is longer than systole, for any extra sounds/murmurs.
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How do you check for a split S2?
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Have pt inhale deeply, listening closely for S2 to become 2 componenents during inspiration.
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Where can you best hear a split S2?
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Pulmonic auscultatory area.
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What is situs inversus and dextrocardia
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Heart rotated to R
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How would you auscultate this heart?
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The exam sites would be a mirror image of normal
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How do you characterize heart sounds?
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pitch, intensity, duration, timing in the cardiac cycle.
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What are the 4 basic heart sounds
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S1, S2, S3, S4
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Which are the most distinct
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S1 and S2, should be characterized seperately bc variations can offer clues to cardiac function
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What about S3 and S4?
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May or may not be present. Absence is not unusual. Presence doesn't necessarily mean pathological condition. Must be evaluated in relation to other sounds/events in the hrt cycle
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Describe S1
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Results from closure of AV valves, indicates beginning of systole, best heart toward apex where it is usually louder than S2
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Describe what S1 sounds like at the base
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Louder on L than R, but softer than S2 in both areas. Lower in pitch and a bit longer than S2, occurs immediately after diastole.
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What causes splitting of S1?
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If asynchrony between closure of mitral and tricuspid valves.
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Where is S1 splitting best heard?
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Tricuspid area
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What can cause other variations in S1?
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Competency of pulm and systemic circulations, structure of heart valves, their position when V contraction begins, and force of the contraction.
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What causes S2?
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closure of Semilunar valves. Indicates end of systole
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Where is S2 best heard?
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Aortic and pulmonic areas
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Describe how it differs from S1
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Higher pitch and shorter duration than S1. Louder than S1 at base of heart; usually softer than S1 at apex.
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What is splitting?
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Failure of mitral and tricuspid valves OR pulm and aortic valves to close simultaneously.
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Do you usually hear S1 splitting?
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No - sound of tricuspid closing is too faint to hear. Rarely may be audible in tricuspid area, esp on deep INSPIRATION
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What's S2 splitting?
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Closure of aortic valve (A2) which contributes most of the sound of S2 in the aortic/pulm areas, and tends to mask the sound of P2 pulm valve closure.
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What happens to S2 during INSPIRATION
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P2 occurs slightly later.
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Is it normal to hear S2 in kids?
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Yes. But not well heard in older adults; AP diamter of chest increases w/ age
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Is splitting of S2 normal?
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Yes. Bc pressures are higher and depol occurs earlier on the L side of the heart. Ejection times on the R are longer, and the pulm valve closes a bit later than the aortic valve.
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Describe P2 if auscultated outside the pulmonary area
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Most often unusually loud or delayed.
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When is splitting of S2 greatest?
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Peak of INSPIRATION
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What happens during expiration?
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Disparity in ejection times diminishes, and split may disappear.
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What happens when breath is held in expiration
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Ejection times tend to equalize, eliminating the split.
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When is the degree of S2 splitting most evident
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Inspiration
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Describe how Vents fill in diastole
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1) early passive flow from atria early in diastole, distending the Vent walls and casuing vibration causing S3. 2) Squeezing of atrial muscle.
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Describe S3
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Quiet, low pitched, often hard to hear
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Describe S4
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During atrial ejection, vibration in the valves, papillae, and vent walls. Occurs very late in diastole ("Presystole"), may be confused w/ a split S1.
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How can you make S3 and S4 easier to hear
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Have pt raise a leg to increase venous return, or ask pt to grip hand vigorously and repeatedly to increase arterial pressure.
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What does heart sound like when S3 is audible?
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a Gallop
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What else can make S3 louder?
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If filling pressure is increased or if Vent compliance is reduced.
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When can you best hear S3?
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When pt is in L Lat decubitus. S4 may also be louder here.
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Describe S4
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Presystolic gallop. Most commonly heard in old pts, but can be heard at any age w/ increased resistance to filling
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What conditions can cause S4 sound?
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Resistance to filling bc loss of Vent wall compliance (Htn, CAD); Increased stroke volume of high-output states (profound anemia, prego, thyrotoxicosis)
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What does the rhythm of the heart sound like when S3 is present
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ken-TUCK-y
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What does the rhythm of the heart sound like when S4 is present
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TEN-nes-see
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What does a loud S4 indicate
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Pathology! Do additional eval.
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Do valves normally make a sound?
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No; open noiselessly unless thickened, roughened, or otherwise altered by disease.
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What would you hear w/ valvular stenosis?
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Opening snap (mitral valve), ejection clicks (semilunars), or mid-to-late nonejection systolic clicks (mitral prolapse)
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How can you best hear the pulm ejection click?
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on Expiration. Seldom heard on inspiration.
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Describe aortic ejection clicks
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Less sharp, less involved w/ S1, and may be heard as distant as the ant axillary line.
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What do extra heart sounds accompany?
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Murmurs. Should always be considered indicative of a path. Process.
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What can easily be mistaken for cardiac-generated sounds?
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Pericardial friction rub.
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What causes the rub?
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inflamm of pericardial sac causing a roughening of the parietal and visceral surfaces, producing a rubbing sound.
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When will you hear the rub?
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Throughout both systole and diastole, and overlies the intracardiac sounds.
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How many components make up pericard friction rub?
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3, associated in sequence w/ the atrial component of systole, Vent systole, and Vent diastole.
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Where will you hear the rub?
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Heard widely, but more distinct toward apex.
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Describe the sound of a 3-component friction rub
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Grating sound that may be intense enough to obscure the heart sounds.
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What if there are only 1-2 components?
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Sound may not be intense or machine-like. May then be hard to distinguish from intracardiac murmur. SEE TABLE 14-3
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What does it mean if your pt has a distinct click early in diastole, loudest at apex and transmitted precordially?
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They have a Prosthetic mitral valve
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What does the intensity of this sound depend on?
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Type of material used for prosthesis; animal tissue = quietest, maybe even silent
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What sound does a pacemaker make?
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The sound of silence……….
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What's a hrt murmur?
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A relatively prolonged extra sound heard in systole or diastole; indicate a problem
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What causes them?
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Disruption in blood flow into, through, or out of the hrt
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What do the characteristics of the murmur depend on?
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Adequacy of valve function, size of the opening, rate of blood flow, vigor of myocard, thickness/consistency of overlying tissue thru which the murmur must be heard
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What's a common cause of murmur?
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Diseased valves. Either don't open or close well.
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What's stenosis?
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When leaflets are thickened and passage narrowed, forward blood flow is restricted.
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Whats regurg?
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When valve leaflets lose competancy and can't close all the way, allow backward flow of blood
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How can you describe the sound of a murmur?
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Harsh, blowing, seagull
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What's the most common source of significant murmurs?
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Anatomic disorders of hrt valves
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What do you do if you find a murmur
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Carefully assess and diagnose. Some are benign, others are pathological Must do additional testing to determine which.
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What are other causes of murmurs?
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High output demands that increase speed of blood flow (thyrotoxicosis, anemia, prego)
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causes of murmurs?
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Structural defects, either congenital or acquired, allowing blood to flow thru inappropriate pathway (such as the myocardial septum)
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causes of murmurs?
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Decreased heart contractile strength
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causes of murmurs?
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Altered blood flow in major vessels near the hrt
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causes of murmurs?
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Transmitted murmurs from valvular aortic stenosis, ruptured chordae tendineae of mitral valve, or severe aortic regurg
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causes of murmurs?
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Vigorous L Vent ejection (more common in kids)
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causes of murmurs?
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Obstructive disease in cervical arteries, like atherosclerotic carotid arteries, fibromuscular hyperplasia, or arteritis
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What should you do next if a heart rhythm is irregular?
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Determine if there's a consistent pattern.
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What's it mean if a heart rate is irregular but occurs in a repeated pattern?
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Sinus dysrhythmia, a cyclic variation in HR characterized by increasing rate on INSPIRATION, and decreasing rate on EXPIRATION.
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What's a patternless, unpredictable, irregular rhythm indicate?
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Hrt disease or conduction system impairment
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What happens to a newborns circulation?
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Changes from fetal to systemic and pulm circ.
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When should you examine the newborn heart?
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W/in first 24hrs of live and again at 2-3 days
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What else should you do to evaluate heart function?
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Examine skin, lungs, liver.
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What happens w/ infants w/ R sided CHF?
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Have large, firm livers w/ inf edge as much as 5-6cm below R costal margin. Unlike adults, this may precede pulmonary crackles.
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Describe the color of newborn skin and mucous membranes
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Pink.
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What's a purplish plethora indicate
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polycythemia
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Ashen white?
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shock
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Central cyanosis (of skin and mucous memb of face and upper body)
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Congenital hrt disease
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What should the doc note?
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Intensity of discoloration, and extend of change after vigorous exertion.
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What's Acrocyanosis
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cyanosis of hands and feet w/out central cyanosis.
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Is it serious?
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No. Usually diappears w/in a few days or hrs after birth
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What does cyanosis indicate
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Congenital hrt defect allowing mixture of art and venous blood OR prevent expected oxygenation of blood.
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What does severe cyanosis at birth or shortly thereafter indicate
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Transposition of great vessels, Tetralogy of Fallot, tricuspid atresia, severe septal defect, or severe pulm stenosis
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What does cyanosis that does NOT appear until after the neonatal period suggest?
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Pure pulm stenosis, Eisenmenger complex, tetralogy of Fallot, or large septal defect.
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Where's the apical impulse in newborns?
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Usually 4th-5th L ICS just medial to midclav line. May be somewhat farther to the R in first few hrs of live, maybe even substernal.
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What should you do w/ the hrt if baby is having trouble breathing
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Note position of heart.
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What's a pneumothorax do to the heart?
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Shifts the apical impulse away from the area of the pneumothorax.
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What's a diaphragmatic hernia do?
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Usually found on the L, which shifts the hrt R.
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What's dextrocardia do?
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Results in an apical impulse on the R.
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Describe the R vent in the newborn
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More vigorous than the L in a well, full-term newborn. If baby is thin, might even be able to feel cosure of pulm valve in 2nd L ICS.
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Describe S2 in infants
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Higher in pitch, more discrete than S1.
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Is diminished vigor significant in infant?
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YES. Ma be the only apparent chagne when an infant is already in heart failure.
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Is splitting common?
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Yes.
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Describe splitting of S2 in newborn
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Usually not split at birth but splits within a few hours.
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Are S3 and S4 commonly heard?
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Yes. Increased intensity of either sound is suspect though.
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Are murmurs common in newborns?
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Yes, until 48hrs. Most are benign, from transition from fetal to pulm circ. Usually graded I or II, systolic, and unaccompanied by other symptoms; disappear in 2-3 days
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Is a congenital abnormality always associated w/ a murmur?
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No
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What should you do if you can't tell a murmur vs respiration?
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Pinch the nares briefly, listen while baby is feeding, or time the sound w/ carotid pulsation.
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Why are heart sounds more hard to eval in infants?
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Their heart rate is rapid
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When is a murmur significant in an infant?
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If the murmur persists beyond day 2 or 3, is intense fills systole, occupies diastole to any extent, or radiates widely.
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What happens if you push up on the liver?
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Increases R atrial pressure, so murmur of a L to R shunt through the setpal opening or patent ductus will disappear briefly; whereas murmur of R to L shunt will intensify
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Describe how a murmur sounds that extends beyond S2 and occupies diastole
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Machine-like.
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What are they associated w/
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Patent ductus arteriosus.
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When should It disappear
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in first 2-3 days.
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Are diastolic murmurs significant?
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Almost always; but once in a while could be transient and related to an early closing of ductus arteriosus, or a mild brief pulm insufficiency.
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What can change an infants heart rate?
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Eating, sleeping, waking.
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When is the variation greatest?
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At birth or shortly after. Even more marked in premies.
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What does rate of 200bpm indicate?
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Not uncommon, but could indicate paroxysmal atrial tachycardia.
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What's the normal rate a few hrs after birth
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closer to 120. If it won't come down, indicates something may be wrong
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Describe precordium of child
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Tends to bulge over an enlarged heart if the enlargement is long-standing
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Describe the child's thoracic cage
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More cartilaginous and yielding than an adult; responds more to the thrust of cardiac enlargement.
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What's sinus arrhythmia?
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Physiological event in childhood. HR varies in a cyclic pattern, usually faster on INSPIRATION and slower on EXPIRATION.
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What is the usualy cauuse of dysrhythmias in kids
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ectopic (supraventricular and ventricular ectopic beats).
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Describe the heart rate of a child
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more variable than in adults; reacting w/ wider swings to stress of any sort (exercise, fever, tension).
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HR of newborn?
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120-170
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1 yo
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80-160
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3 yo
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80-120
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6 yo
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75-115
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10 yo
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70-110
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What's the cause of most organic murmurs in infants/kids?
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Congenital heart disease;
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Whats the most common cause of acquired murmurs?
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acute rheumatic fever
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What is a "Still murmur"
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Named after the doc who described it. Occur in active healthy kids bt 3-7yo. Caused by vigorous expulsion of blood from L vent into aorta, increases in intensity w/ activity. Diminishes when kid is quiet. Often described as "musical"
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What should you take note of in a kid w/ known heart disease?
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Weight gain or loss, developmental delay, cyanosis, clubbing of fingers/toes
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What does cyanosis indicate
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Major clue to congenital heart defects, impeding oxygenation of blood
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What happens to heart rate in prego?
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Gradually increases throughout preg until 10-30% higher at term.
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What's diff on EKG
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Nothing significant.
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What happens to heart position?
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Shifts depending on size/position of uterus.
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What happens to apical impulse
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Upward and more lateraal by 1-1.5 cm
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Are changes in auscultated heart sounds normal?
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Yes bc increased blood volume and extra effort of the heart.
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Is splitting more or less audible?
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More for S1 and S2
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When may S3 be readily heard
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20wks of gestation
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Is S4 heart sound normal?
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No.
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Are systolic ejection murmurs normal?
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May be herd over pulm area in 90% of prego women.
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How can you intensify the murmur?
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Intensified on INSPIRATION or EXPIRATION but should not be louder than grade II.
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What's cyanosis, clubbing, or persistent neck vein distention or development of diastolic murmur suggest?
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An abnormality…
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What must you do when working w/ older pts?
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Slow pace of exam when asking them to move positions to something uncomfortable/difficult. Some may not be able to lay flat or control their breathing.
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What happens to cardiac response with age?
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May be slowed or insufficient even to minimal increase in demand. Even an abrupt change in position may cause lightheadedness, or drop in arterial pressure after a moderate meal.
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What happens to heart rate w/ age
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May be slower bc increased vagal tone, or faster w/ wide range from low 40's to >100 bpm. Occasional ectopic beats common, may or may not be significant
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What happens to apical impulse
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May be harder to find bc increased AP diameter.
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What happens in obese old ppl?
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In obese old ppl, diaphragm is rasised and heart more transverse.
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What happens in old ppl who exercise regularly?
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May reverse or deter age-associated changes.
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Is S4 normal?
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It's more common in elderly, may indicate decreased L vent compliance.
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What do early, soft physiologic murmurs mean?
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Sometimes heard. Caused by aortic lengthening, tortuosity, and sclerotic changes.
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