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193 Cards in this Set
- Front
- Back
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Dimensions of the heart
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12 cm long
8 cm wide at its widest point 6 cm in its anteriorposterior diameter |
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S3 heart sound
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ventricular filling
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S4 heart sound
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atrial contraction
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normal length of PR interval
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0.12 to 0.2 sec
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normal width of QRS wave
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should be less than 0.12
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U wave
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small deflection sometimes seen just after the T wave
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QT interval
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the beginning of the Q wave to the end of the T wave
time elapsed from the onset of ventricular depolarizations until the completion of ventricular repolarization interval varies with the cardiac rate |
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How do ventricular systole and diastole compare when the heart is beating at a rate of 68-72 beats/minute?
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ventricular systole is shorter than diastole
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How do ventricular systole and diastole compare when the heart is beating at a rate of 120 beats/minute?
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ventricular diastole shortens and becomes about as short as systole
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What is the size and position of the heart in small children? At what age is the adult heart position reached?
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heart lies more horizontally in infants and young children
apex of the heart rides higher, sometimes well into the 4th left ICS adult heart position is reached by age 7 years |
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By how much does maternal blood volume increase during pregnancy?
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40-50%
70% with twin pregnancy **returns to normal within 3-4 weeks after delivery |
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How much does the cardiac output increase during pregnancy?
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30-40%
reaches its highest level by about 25-32 weeks of gestation **returns to normal about 2 weeks after delivery |
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How is the heart position changed during pregnancy?
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diaphragm moves up, shifting the heart toward a horizontal position and there is a slight axis rotation
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What cardiac changes are seen with old age?
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heart may decrease in size unless there is hypertension enlargement
L ventricular wall thickens valves tend to fibrose and calcify heart rate slows SV decreases CO declines by 30-40% endocardium thickens and myocardium becomes less elastic and more rigid response to stress and increased oxygen demand is less efficient fibrosis and sclerosis in the region of the SA node and in the heart valves (mitral and aortic cusps) by increased vagal tone and decreased baroreceptor sensitivity |
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Common EKG changes in older patients
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first degree AV block
BBB ST-T wave abnormalities premature systole (atrial or ventricular) left anterior hemiblock left ventricular hypertrophy atrial fibrillation |
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How is Heart Rate changed during pregnancy?
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1st trimester = increased
2nd trimester = peaks at 28 weeks 3rd trimester = slightly decreased labor and delivery = increased; bradycardia at delivery postpartum = returns to normal within 2-6 weeks |
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How is Blood Pressure changed during pregnancy?
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1st trimester = prepregnancy level
2nd trimester = slightly decreased 3rd trimester = prepregnancy level labor and delivery = prepregnancy level postpartum = prepregnancy level |
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How is blood volume changed during pregnancy?
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1st trimester = increased
2nd trimester = peaks at 20 weeks 3rd trimester = gradually decreased labor and delivery = rises sharply postpartum = returns to normal within 2-6 weeks |
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How is stroke volume changed during pregnancy?
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1st trimester = increased
2nd trimester = peaks at 28 weeks 3rd trimester = gradually decreased labor and delivery = decreased postpartum = returns to normal within 2-6 weeks |
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How does Cardiac Output change during pregnancy?
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1st trimester = increased
2nd trimester = peaks at 20 weeks 3rd trimester = slightly decreased labor and delivery = increased postpartum = returns to normal within 2-6 weeks |
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How does systemic vascular resistance change during pregnancy?
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1st trimester = decreased
2nd trimester = decreased 3rd trimester = decreased labor and delivery = sharply decreases at delivery postpartum = returns to normal within 2-6 weeks |
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How is angina pectoris described?
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pressure or choking sensation substernally or to the neck
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Precordial catch
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a sudden, sharp, relatively brief pain that does not radiate, occurs most often at rest and is unrelated to exertion and may not have a discoverable cause
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Characteristics of anginal pain
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substernal
provoked by effort, emotion, eating relieved by rest and/or nitroglycerin often accompanied by diaphoresis, occasionally nausea |
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Characteristics of pleural pain
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precipitated by breathing or coughing
usually described as sharp present during respiration absent when breath is held |
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Characteristics of esophageal pain
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burning, substernal, occasional radiation to shoulder
nocturnal occurrence, usually when lying flat relief with food, antacids or sometimes nitroglycerin |
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Characteristics of pain from peptic ulcer
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almost always infradiaphragmatic and epigastric
nocturnal occurrence and daytime attacks relieved by food unrelated to activity |
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Characteristics of biliary pain
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usually under right scapula, prolonged in duration
often occurring after eating will trigger angina more often than mimic it |
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Characteristics of arthritic/bursitis pain
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usually lasts for hours
local tenderness and/or pain with movement |
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Characteristics of cervical pain
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associated with injury
provoked by activity, persists after activity painful on palpitation and/or movement |
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Characteristics of Musculoskeletal chest pain
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Intensified or provoked by movement, particularly twisting or costochondral bending
long lasting often associated with focal tenderness |
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Characteristics of psychoneurotic pain
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associated with/after anxiety
poorly described located in intramammary region |
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Angina Pectoris pain description (OLDCARTS)
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history = presence of cardiac risk
Onset = specifically noted time of onset Related factors = physical effort or emotion Duration = disappears if stimulating cause can be terminated Limitations = commonly forces patients to stop effort Sleep = patient may awake from sleep Relieving factors = at times with nitroglycerin Time of day = often worse in early morning or after washing or eating Weather factors = greater likelihood in cold weather |
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Musculoskeletal pain description (OLDCARTS)
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history = trauma
Onset = vague onset Related factors = physical effort Duration = continues after cessation of effort Limitations = pts can often continue activity Sleep = delays falling asleep Relieving factors = at times with heat, NSAID, or rest Time of day = worse in evening after a day of physical effort Weather factors = greater likelihood in cold, damp weather |
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GI pain description (OLDCARTS)
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history = presence of indigestion
Onset = vague onset Related factors = food consumption or psychosocial stress Duration = may go on for several hour; unrelated to effort Limitations = pt can often continue activity Sleep = pt may away from sleep, particularly during early morning Relieving factors = antacids Time of day = no particular relationship to time of day; related to food, tension Weather factors = anytime |
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carotid sinus effect
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syncope on sudden turning of neck
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vertebral artery occlusion
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causes syncope when you look upward
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St. Vitus dance
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Syndenham chorea
a disease characterized by rapid, uncoordinated jerking movements, primarily affecting the face, feet and hands caused by childhood infection with group A strep and is very common in pts with acute rheumatic fever |
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erythema marginatum
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The presence of pink rings on the trunk and in inner surface of the limbs which come and go for as long as several months
associated with ARF |
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signs of digitalis toxicity
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anorexia
nausea vomiting diarrhea headache confusion dysrhythmias yellow vision with halo |
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signs of potassium excess
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weakness
bradycardia hypotension confusion |
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signs of potassium depletion
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weakness
fatigue muscle cramps dysrhythmias |
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signs of heart failure on physical examination
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crackles in the lungs
engorgement of the liver peripheral edema |
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probable cause of a thrill during systole in the suprasternal notch and/or 2nd or 3rd RIGHT ICS
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aortic stenosis right ICS
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probable cause of a thrill during systole in the suprasternal notch and/or 2nd or 3rd LEFT ICS
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pulmonic stenosis ICSpaces
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probable cause of a thrill during systole in the 4th LEFT ICS
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VSD
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probable cause of a thrill during systole at the apex
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mitral regurgitation
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probable cause of a thrill during systole at the left lower sternal border
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Tetralogy of Fallot
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probable cause of a thrill during systole at the left upper sternal border, often with extensive radiation
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Patent ductus arteriosus
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probable cause of a thrill during diastole at the right sternal border
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aortic regurgitation
aneurysm of ascending aorta |
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probable cause of a thrill during diastole at the apex
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mitral stenosis
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Where is an S2 split most commonly heard?
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in the pulmonic auscultatory area
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Where is S1 best heard?
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toward the apex (usually louder than S2 at this point)
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Where is an S1 split usually heard?
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tricuspid area if asynchrony is found
**not usually heard |
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When is A2 the loudest?
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aortic area, then pulmonic area
decreased in second pulmonic area |
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When in P2 the loudest?
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second pulmonic area, then pulmonic area
decreased in aortic area |
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When is S1 lounder than normal?
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blood velocity is increased (anemia, fever, hyperthyroidism, exercise)
mitral valve stenosis |
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When is the intensity of S1 decreased?
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increased overlying tissue, fat or fluid
systemic or pulmonary hypertension fibrosis and calcification of a diseased mitral valve |
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Where is S2 lounder than S1 normally?
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at the base of the heart
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ventricular gallop
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S3
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atrial gallop
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S4
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When is the S2 the split the greatest?
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at the peak of inspiration
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In which position is S3 most easily heard?
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left lateral recumbent
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rhythm of heart sound when S3 is heard
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Ken-TUCK-y
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rhythm of heart sound when S4 is heard
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TEN-nes-see
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When does the intensity of S2 increase?
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systemic hypertension
syphilis of the aortic valve exercise or excitement pulmonary hypertension mitral stenosis CHF when the valves are diseased but fully mobile |
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When does the intensity of S2 decrease?
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shock like state with arterial hypotension
valves are immobile, thickened or calcified |
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Which disease affects A2?
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aortic stenosis
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Which disease affects P2?
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pulmonic stenosis
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What mutes S2?
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overlying tissue, fat or fluid
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opening snap
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valvular stenosis in mitral valve
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ejection clicks
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valvular stenosis in semilunar valves
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mid to late nonejection systolic clicks
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mitral prolapse
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When is the pulmonary ejection click best heard?
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on expiration and is seldom heard on inspiration
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When during the cardiac cycle does S1 occur?
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immediately after diastole
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When during the cardiac cycle does S2 occur?
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at the end of systole
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What are the three possible components of pericardial friction rub?
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atrial component of systole
ventricular systole ventricular diastole |
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Where on the heart is the pericardial friction rub usually heard?
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usually heard widely but is more distinct toward the apex
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What heart sound makes a machine-like sound?
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pericardial friction rub
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What does a prosthetic mitral valve sound like and where can you hear it?
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distinct click early in diastole
loudest at the apex and transmitted precordially |
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What does a prosthetic aortic valve sound like?
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distinct click in early systole
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What is the difference in sound production between different prosthetic devices?
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animal valves are the quietest
pacemakers do not cause a sound |
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What is a heart murmur?
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A relatively prolonged extra sound heard during systole or diastole
Caused by disruption of flow through, into or out of the heart |
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Which heart sounds can be heard with the bell?
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S3, S4, quadruple rhythm, and summation gallop (triple gallop)
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When during the cardiac cycle does S1 occur?
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immediately after diastole
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When during the cardiac cycle does S2 occur?
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at the end of systole
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What are the three possible components of pericardial friction rub?
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atrial component of systole
ventricular systole ventricular diastole |
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Where on the heart is the pericardial friction rub usually heard?
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usually heard widely but is more distinct toward the apex
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What heart sound makes a machine-like sound?
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pericardial friction rub
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What does a prosthetic mitral valve sound like and where can you hear it?
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distinct click early in diastole
loudest at the apex and transmitted precordially |
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What does a prosthetic aortic valve sound like?
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distinct click in early systole
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What is the difference in sound production between different prosthetic devices?
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animal valves are the quietest
pacemakers do not cause a sound |
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What is a heart murmur?
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A relatively prolonged extra sound heard during systole or diastole
Caused by disruption of flow through, into or out of the heart |
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Which heart sounds can be heard with the bell?
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S3, S4, quadruple rhythm, and summation gallop (triple gallop)
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When during the cardiac cycle does S1 occur?
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immediately after diastole
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When during the cardiac cycle does S2 occur?
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at the end of systole
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What are the three possible components of pericardial friction rub?
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atrial component of systole
ventricular systole ventricular diastole |
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Where on the heart is the pericardial friction rub usually heard?
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usually heard widely but is more distinct toward the apex
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What heart sound makes a machine-like sound?
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pericardial friction rub
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What does a prosthetic mitral valve sound like and where can you hear it?
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distinct click early in diastole
loudest at the apex and transmitted precordially |
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What does a prosthetic aortic valve sound like?
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distinct click in early systole
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What is the difference in sound production between different prosthetic devices?
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animal valves are the quietest
pacemakers do not cause a sound |
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What is a heart murmur?
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A relatively prolonged extra sound heard during systole or diastole
Caused by disruption of flow through, into or out of the heart |
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Which heart sounds can be heard with the bell?
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S3, S4, quadruple rhythm, and summation gallop (triple gallop)
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When during the cardiac cycle does S1 occur?
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immediately after diastole
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When during the cardiac cycle does S2 occur?
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at the end of systole
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What are the three possible components of pericardial friction rub?
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atrial component of systole
ventricular systole ventricular diastole |
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Where on the heart is the pericardial friction rub usually heard?
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usually heard widely but is more distinct toward the apex
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What heart sound makes a machine-like sound?
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pericardial friction rub
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What does a prosthetic mitral valve sound like and where can you hear it?
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distinct click early in diastole
loudest at the apex and transmitted precordially |
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What does a prosthetic aortic valve sound like?
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distinct click in early systole
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What is the difference in sound production between different prosthetic devices?
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animal valves are the quietest
pacemakers do not cause a sound |
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What is a heart murmur?
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A relatively prolonged extra sound heard during systole or diastole
Caused by disruption of flow through, into or out of the heart |
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Which heart sounds can be heard with the bell?
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S3, S4, quadruple rhythm, and summation gallop (triple gallop)
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Which heart sounds can be heard with the diaphragm?
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S1, S2, ejection sounds, systolic clicks and opening snaps
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Which heart sounds are best heard at the apex (normal and abnormal sounds)?
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S1, S3, S4, quadruple rhythm, summation gallop, ejection sounds, systolic click, opening snap
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Which heart sounds are increased on inspiration?
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Physiologic split of S2, S3, S4, quadruple rhythm, summation gallop, systolic click
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Which heart sound is not affected by respiration?
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opening snap
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Which heart sound is softer on inspiration?
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S1
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Which heart sound is increased with expiration during pulmonary stenosis?
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ejection sounds
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Which heart sounds are high-pitched?
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S1, S2, ejection sound, systolic click and opening snap
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Which heart sounds are low-pitched?
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S3, S4, summation gallop and quadruple rhythm
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What causes a quadruple rhythm heart sound?
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S1, S2, S3, and S4 all heard separately
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What causes a summation gallop?
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S3 and S4 fuse with fast heart rates
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What causes an ejection sound?
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opening of deformed semilunar valves
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What causes a systolic click?
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Prolapse of mitral valve leaflet
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What causes an opening snap?
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abrupt recoil of stenotic mitral or tricuspid valve
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Which heart sounds are best heard in the 2nd RICS and 2nd LICS?
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2nd RICS = A2 and ejection sounds
2nd LICS = P2 and ejection sounds **ejections sounds can also be heard at the apex |
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Which heart sounds can be heard in any position?
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S1 and opening snaps
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Low pitched sounds are best heard with which part of the stethoscope?
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the bell
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High pitched sounds are best heard with which part of the stethoscope?
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the diaphragm
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How and where is mitral stenosis detected?
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heard with bell
at apex patient in left lateral decubitus position |
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What are the findings on examination of mitral stenosis?
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low-frequency diastolic rumble
more intense in early and late diastole does not radiate palpable thrill at apex in late diastole is common S1 increased and often palpable at left sternal border S2 split often with accented P2 opening snap follow P2 closely visible lift in right parasternal area if right ventricle is hypertrophied Arterial pulse amplitude is decreased |
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Description and cause of mitral stenosis
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narrowed valve restricts forward flow into left ventricle
often occurs with mitral regurg Causes by rheumatic fever or cardiac infection |
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Detection and location of aortic stenosis
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heard over aortic area
ejection sound at 2nd RICS (at border) |
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Findings on examination of aortic stenosis
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midsystolic (ejection) murmur
medium pitched coarse diamond shaped = crescendo-decrescendo sound radiates along left sternal border (sometimes to apex) and to carotid with palpable thrill S1 often heard best at apex, disappearing when stenosis is severe followed by ejection click S2 soft or absent and may not be split S4 palpable ejection sound muted in calcified valves the more sever the stenosis, the later the peak of the murmur in systole apical thrust shifts down and left and is prolonged if left ventricular hypertrophy is also present |
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Description and cause of aortic stenosis
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calcification of valve cusps restricts forward flow
forceful ejection from ventricule into systemic circulation Caused by congenital bicuspid valve, rheumatic heart disease or atherosclerosis May be the cause of sudden death, particularly in children and adolescents, either at rest or during exercise risk apparently related to degree of stenosis |
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Detection and location of subaortic stenosis
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heard at apex and along left sternal border
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Findings on examination of subaortic stenosis
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murmur fills sytole
diamond shaped medium pitched coarse thrill palpable during systole at apex and right sternal border multiple waves in apical impulses S2 usually split S3 and S4 often present Arterial pulse is brisk with double wave in carotid jugular venous pulse is prominent |
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Description and cause of subaortic stenosis
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Fibrous ring is produced = usually 1-4 mm below aortic valve
most pronounced on ventricular septal side may become progressively sever with time difficult to distinguish from aortic stenosis on clinical grounds alone |
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Detection and location of pulmonic stenosis
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heard over pulmonic area
radiating to left and into neck thrill in 2nd and 3rd ICS |
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Findings on examination of pulmonic stenosis
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systolic (ejection) murmur
diamond shaped medium pitch coarse usually with thrill S1 often followed quickly by ejection click S2 often diminished and usually widely split P2 soft or absent S4 common in right ventricular hypertrophy murmur may be prolonged and confused with that of a ventricular septal defect |
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Description and cause of pulmonic stenosis
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valve restricts forward flow
forceful ejection from ventricle into pulmonary circulation Cause is almost always congenital |
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Detection and location of tricuspid stenosis
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heard with bell
over tricuspid area |
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Findings on Examination of tricuspid stenosis
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diastolic rumble accentuated early and late in diastole
resembling mitral stenosis but louder on inspiration diastolic thrill palpable over right ventricle S2 may be split during inspiration arterial pulse amplitude decreased jugular venous pulse prominent, especially a wave slow fall of v wave |
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Description and cause of tricupsid stenosis
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calcification of valve cusps restricts forward flow into the right ventricle
usually seen with mitral stenosis = rarely occurs alone Causes: - rheumatic heart disease - congenital defect - endocardial fibroelastosis - right atrial myxoma |
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Detection and location of mitral regurgitation
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heard best at the apex and loudest there
transmitted into left axilla |
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Findings on examination of mitral regurg
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holosystolic
plateau-shaped intensity high pitch harsh blowing quality often quite loud and may obliterate S2 radiates from apex to base or to left axilla thrill may be palpable at apex during systole S1 intensity diminished S2 more intensity with P2 often accented S3 often present S3-S4 gallop common in late disease If mild, late systolic murmur crescendos If severe, early systolic intensity decrescendos apical thrust more to left and down in ventricular hypertrophy |
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Description and cause of mitral regurg
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valve incompetence allows backflow from ventricle to atrium
Causes: - rheumatic fever - MI - myxoma - rupture of chordae |
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Detection and location of mitral valve prolapse
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heard at apex and left lower sternal border
easily missed in supine position also listen with patient upright |
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findings on examination of mitral valve prolapse
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typically late systolic murmur preceded by midsystolic clicks
both murmur and clicks are highly variable in intensity and timing |
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Description and cause of mitral valve prolapse
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Valve is competent early in systole but prolapsees into atrium later in systole
may become progressively severe, resulting in holosystolic murmur often concurrent with pectus exavatum |
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detection and location of aortic regurg
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heard with diaphragm
patient sitting and leaning forward Austin-Flint murmur hear with bell ejection click heard in 2nd ICS |
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Findings on examination of aortic regurg
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early diastolic
high pitch blowing often with diamond-shaped midsystolic murmur duration varies with blood pressure low-pitched rumbling murmur at apex = Austin-Flint early ejection click sometimes present S1 soft S2 split may have tambour-like quality M1 and A2 often intensified S3-S4 gallop common In left ventricular hypertrophy, prominent prolonged apical impulse down to left pulse pressure wide water hammer or bisferiens or Corrigan pulse common in carotid, brachial and femoral arteries |
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pulmonic regurg findings on examination
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difficult to distinguish from aortic regurg on physical exam
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description and cause of aortic regurg
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valve incompetence allows backflow from aorta to ventricle
Causes: - rheumatic heart disease - endocarditis - aortic diseases (Marfans, medial necrosis) - syphilis - ankylosing spondylitis - dissection - cardiac trauma |
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description and cause of pulmonic regurg
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valve incompetence allows backflow from pulmonary artery to ventricle
Secondary to pulmonary hypertension or bacterial endocarditis |
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detection and location of tricuspid regurg
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heart at left lower sternum
occasionally radiating a few centimeters to the left |
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findings on examination of tricuspid regurg
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holosystolic murmur over right ventricle
blowing increased on inspiration S3 and thrill over tricuspid area common in pulmonary hypertension, pulmonary artery impulse palpable over 2nd ICS and P2 is accented in right ventricular hypertrophy, visible lift to right of sternum jugular venous pulse has large v waves |
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Description and cause of tricuspid regurg
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valve incompetence allows backflow from ventricle to atrium
Causes: - congenital defects - bacterial endocarditis (especially IV drug users) - pulmonary hypertension - cardiac trauma |
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Still murmurs
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innocent murmurs that are the result of vigorous myocardial contraction and stronger blood flow
seen in children, adolescents and especially in young athletes usually grade I or II midsystolic without radiation medium pitched blowing and brief often accompanied with S2 split often located in the 2nd ICS near the left sternal border |
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Which maneuver will increase intensity of a systolic murmur in the right-sided chambers?
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inspiration
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Which maneuver will decrease intensity of a systolic murmur in the right-sided chambers?
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expiration
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Which maneuver will increase intensity of a systolic murmur in a hypertrophic heart?
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valsalva
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Which maneuver will increase intensity of a systolic murmur in the mitral regurg?
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handgrip
**plus transient arterial occlusion and inhalation of amyl nitrate will distinguish mitral regurg and ventral septal defect from other causes of systolic murmur |
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Which maneuver will increase intensity of a systolic murmur in cardiomyopathy?
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squatting to standing (rapidly lfor 30 sec)
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Which maneuver will decrease intensity of a systolic murmur in cardiomyopathy?
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standing to squatting (rapidly)
passive leg elevation to 45 degrees with pt supine |
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Which maneuver will increase intensity of a systolic murmur in the ventral septal defect?
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transient arterial occlusion (sphygmomanometer placed on each of patient's upper arms and simultaneously inflated to 20-40 mm Hg above pt's previously recorded BP; intensity noted for 20 sec)
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Which maneuver will decrease intensity of a systolic murmur in the ventral septal defect?
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inhalation of amyl nitrate (three rapid breaths from a broken ampule) = not routinely recommended
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Which maneuver will increase/decrease intensity of a systolic murmur in aortic stenosis?
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no maneuver distinguishes this murmur
diagnosis made by exclusion |
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What extra-cardiac symptom are seen in infants with right-sided CHF?
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large, firm livers with the inferior edge as much as 5-6 cm below the right costal margin
precedes pulmonary crackles |
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What is a purplish plethora associated with in infants?
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polycythemia
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What is an ashen white color associated with in infants?
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shock
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What is central cyanosis associated with in infants?
|
congenital heart disease
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Acrocyanosis
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cyanosis of the hands and feet without central cyanosis
of little concern with infants usually disappears within a few days or hours after birth |
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Severe stenosis right after birth suggests which diseases?
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transposition of the great vessels
tetralogy of Fallot tricuspid atresia severe septal defect severe pulmonic stenosis |
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Cyanosis that does not appear until after the neonatal period suggests which disease?
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pulmonic stenosis
Eisenmenger complex tetralogy of Fallot large septal defect |
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What does a pneumothorax do to the apical impulse in infants?
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shift it away from the area of the pneumothorax
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What does a diaphragmatic hernia do to the apical impulse in infants?
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shifts the heart to the side opposite the hernia (they are more common on the left so heart shifts to right)
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How is S2 different in infants?
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higher pitched and more discrete than S1
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Are S3 and S4 commonly heard in children?
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Yes but intensity in these sounds are suspect
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Are murmurs commonly heard in newborns?
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Yes
grade I or II systolic unaccompanied by other signs or symptoms usually disappear within 2-3 days after birth |
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How do you tell the difference between the murmur of a left-to-right shunt and a murmur of a right-to-left shunt?
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if you push up on the liver (increasing right atrial pressure), a left-to-right shunt murmur will disappear and a right-to-left murmur will intensify
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What does a patent ductus arteriosus sound like?
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machine-like quality
extends beyond S2 occupies diastole should disappear in the first 2-3 days of life |
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What is the normal heart rate for infants and newborns?
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may be up to 200 beats/min but after a few hours of life, should be around 120
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How does heart rate change in children during inspiration and expiration?
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HR is faster on inspiration and slower on expiration
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What is the normal heart rate for a 1 year old?
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80-160
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What is the normal heart rate for a 3 year old?
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80-120
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What is the normal heart rate for a 6 year old?
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75-115
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What is the normal heart rate for a 10 year old?
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70-110
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What changes in auscultated heart sounds are found during pregnancy?
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S1 and S2 splitting
S3 may be readily heard after 20 weeks gestation **S4 is abnormal systolic ejection murmurs are heard over the pulmonic area in 90% of pregnant women **murmurs should not be louder than grade II |
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Does heart rate increase or decrease in old age?
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may decrease due to increased vagal tone or it may be more rapid
normal range = 40-100 |
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Is S4 common in older adults?
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yes = indicates decreased left ventricular compliance
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