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118 Cards in this Set
- Front
- Back
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In a tall, slender person, the heart tends to hang more
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Vertically and positioned centrally
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In a more stocky and short person the heart thends to lie more
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To the left and positioned horizontally
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The heart may be positioned to the right, either rotated or displaced (mirror image of what is expected)
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Dextrocardia
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When the heart and stomach are placed to the right and the liver to the left this habitus is termed
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situs inversus
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Thin outermost muscle layer of the heart that extends onto the great vessels
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Epicardium
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Primary muscle mass of the heart consists of the
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Right and left ventricles
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Most of the anterior surface of the heart is formed by the
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Right ventricle
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Poster to the right ventricle but extends around to the anterior is the
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Left Ventricle
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Apical impulses caused by the ventricular contraction and thrust are felt here
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5th left intercostal space at the midclavicular line
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Coronary arteries and veins are found below this layer
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Serous pericardium (visceral layer epicardium)
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The most posterior aspect of the heart is formed by the
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Left atrium
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Dimensions of the heart
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12 cm long; 8 cm wide at the widest point; 6 cm AP diameter
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The only intracardiac pathways of a normal heart
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Atrioventricular and semilunar valves
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AV valves
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Tricuspid and mitral valve
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Semilunar vavles
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Pulmonic and aortic
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Contraction of the ventricles open these valves
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Semilunar valves
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Ventricle contraction shuts these vavles
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AV valves
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Phase of cardiac cycle when ventricles contract
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Systole
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Energy-requiring phase of cardiac cycle when ventricles dilate
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Diastole
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First heart sound (S1; "lubb") is caused by
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AV vavle closure
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Usual sound of valves opening
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None
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Closure of these valves causes the second heart sound (S2, "dubb")
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Semilunar vavles
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Components of the S2
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A2 (aortic valve) and P2 (pulmonic valve)
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S3 is a heart sound caused by
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Filling of the ventricles
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S4 is a heart sound caused by
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Ejection of blood from the contraction of the atria
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Heart sound heard during isometric contraction
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S1
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Heart sound heard during isometric relaxation
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S2
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Cardiac phase of rapid ejection and reduced ejection phase
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Systole
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P wave represents
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Atrial depolarization
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Normal PR interval
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0.12 - 0.20 secs
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PR interval represents
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Time from stimulation of the atria to stimulation of the ventricles
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QRS complex represents
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Ventricular depolarization
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Normal interval of QRS complex
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< 0.10 secs
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T wave represents
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Ventricular repolarization
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Closure of the ductus arteriosus usually occur within (hrs)
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24-48 hrs
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Relative size of the adult ventricular sizes
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Left is twice as big as right ventricle
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Age when ventricular size approximate to that of an adult's?
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1 year
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Usually adult heart position is rached by this age
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7 years
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Blood volume increase during pregnancy
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40-50%
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Time when blood volume returns to normal postpardum (wks)
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3-4 weeks
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During pregnancy, cardiac output increases by
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30-40%
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After delivery, cardiac output returns to normal after (wks)
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2 weeks
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Cardiac output reaches highest level by (wks)
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25 to 32 weeks of gestation
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Vavles most affected by fibrosis and sclerosis in older adults
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Mitral vavle and aortic cusps
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Common EKG changes in older patients
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1st degree AV block, bundle branch blocks, ST-T wave abnormalities, premature systole (atrial and ventricular), left anterior hemiblock, left ventrcular hypertophy and atrial fibrilation
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A sudden, sharp, relatively brief non-radiating pain, occurs most often at rest and is unrelated to exertion and mya not have a discoverable cause
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Precordial catch
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Possible causes of chest pain
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Cardiac
Aortic Pleuropericardial Pain GI disease Pulmonary disease Musculoskeletal Psychoneurotic (illicit drug use) |
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Exercise intensity of getn' it on
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Moderately Heavy (climbing 1-2 flights of stairs, lifting full cartons, long walks)
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Risk factors for cardiac disability that would increase chances by app. 8x > if none is present
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Hyperlipidemia
Smoking DM |
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Upon palpation of your patient's PMI, you feel an apical impulse that is more forceful and widely distributed, last throughout systole or is laterally and downwardly displaced which may indicate...
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Left ventricular hypertrophy
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You feel lift along the left sternal border which may be caused by...
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Right ventricular hypertrophy
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An apical impulse displaced to the right without a loss or gain in thrust suggests...
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dextrocardia, diaphragmatic hernia, distned stomach or a pulmonary abnormality
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A fine palpable, rushing vibration or palpable murmur
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Thrill
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Most likely place to feel a thrill on the chest of your patient
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Over the base of the hear in the area of the right or left second intercostal space
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A thrill might indicate these problems
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Defect in the closure of one of the semilunar valves, pulmonary hypertension or atrial septal defect
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Location of the carotid pulse in relation to the jaw
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Medial and inferior to the angle of the jaw
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Grade level of a thrill
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Grade IV of more
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Thrills that are found at these sitse during systole may indicate these probable causes:
- Suprasternal notch and/or 2nd & 3rd right rib space - Suprasternal notch and/or 2nd & 3rd left rib space -4th left intercostal space -Apex -Left lower sternal border -Left upper sternal border often with extensive radiation |
- Suprasternal notch and/or 2nd & 3rd right rib space = Aortic stenosis
- Suprasternal notch and/or 2nd & 3rd left rib space = Pulmonic stenosis -4th left intercostal space = Ventricular Septal Defect -Apex = Mitral Regurge -Left lower sternal border = Tetralogy of Fallot -Left upper sternal border often with extensive radiation = Patent ductus arteriosus |
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Thrills that are found at these sitse during diastole may indicate these probable causes:
- Right sternal border - Apex |
- Right sternal border = Aortic Regurgitation or Aneurysm of ascending aorta
- Apex = Mitral stenosis |
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Amount of pressure when using the diaphragm of your stethoscope, and bell?
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Firm pressure with diaphragm
Light pressure with the bell |
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5 traditionally designated asucultatory areas (whatcha listening to?):
- 2nd right rib space at the sternal border - 2nd left rib space at the sternal border - 3rd left rib space at sternal border - 4th left rib space along sternal border - 5th left rib space at the MCL |
- 2nd right rib space at the sternal border = Aortic valve area
- 2nd left rib space at the sternal border = Pulmonic valve area - 3rd left rib space at sternal border = Second pulmonic valve area - 4th left rib space along sternal border = Tricuspid area - 5th left rib space at the MCL = Mitral area |
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Heart sound that usually splits during inspiration
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S2
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S2 marks the initiation of this cardiac event
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Diastole
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S2 spliet is best heard in this auscultatory area
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Pulmonic area
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S1 is best heard at this location of the heart
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The apex
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S1 is the result from closure of these valves and indicates this cardiac event
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AV valves close during systole
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S2 is heard best over this area of the heart
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The base
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S3 is best evaluated at this location of the heart (Ventricular gallop)
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Apex
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S4 is best evaluated at this location of the heart (Atrial gallop)
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Apex
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Auscultatory area best for S1 split
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Tricuspid
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Events that might produce louder S1
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- Increased in blood velocity (anemia, fever, hyperthyroidism, anxiety, exercise)
- Mitral stenosis |
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Events that might produce softer S1
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- Complete heart block
- fibrillation - increased overlying tissue, fat, or fluid - Pulmonary hypertension - Fibrosis or calcification of mitral valve preventing it from closing as forcibly |
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Events that might produce louder S2
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- Systemic hypertension, syphilis of aortic valve, exitement, exercise
- Pulmonary hypertension, mitral stenosis, CHF |
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Events that might produce softer S2
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- Arterial hypotension
- Aortic stenosis - Pulmonic stenosis - Overlying tissue, fat or fluid |
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Why does physiological splitting of S2 occur?
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- Pressures are higher and depolarization occurs earlier on the left side of the heart
- Ejection times on the right are longer and the pulmonic valve closes later than the aortic vavle |
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RBBB splits S1 or S2?
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Both
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When splitting is unaffected by respiration
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Fixed Splitting - Occurs with delatyed closure of the pulmonic vavle when output of the right ventricle is greater than that of the left
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Splitting that occurs when closure of the aortic vavle is delyed so that the P2 occurs first followed by A2
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Paradoxic (Reversed) Splitting - The interval between P2 and A1 is heard during expiration and disappears during inspiration
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Reasons why S3 would be louder
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-Increased ventricular filling
-Decreased compliance -S3 is best hear when patient is in the left lateral recumbent |
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Words that most resemble rhythms in which S3 or S4 is heard
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ken-TUCK-y = S3
TEN-nes-see = S4 |
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Ejection clicks are made by
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Semilunar Valves
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Mid-to-late nonejection systolic clicks are made by
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Mitral valve
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The pulmoniary ejection click is best heard on ____ and is seldom heard on ____
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Expiration, Inspiration
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Pericardial friction rub may be heard widely but is more distinct toward the
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Apex
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Origin of murmur:
Inspiration increases murmur Expiration decreases murmur |
Right-sided chambers
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Origin of murmur:
Vasalva and squatting to standing (rapidly for 30 secs) increases murmur Standing to squatting rapidly and passive leg elevation to 45 degs (supine) decreases murmur |
Hypertrophic cardiomyopathy
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Origin of murmur:
Handgrip increases murmur |
Mitral Regurgitation
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Origin of murmur:
Transient arterial occulsion (brachial artery) increases murmur Inhalation of amyl nitrate decreases murmur |
Ventricular septal defect
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Describe maneuvers that can distinguish aortic stenosis
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No maneuver distinguishes this murmur; the diagnosis can be made by exclusion
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Age and expected heart rates:
Newborn, 1 year, 3 years, 6 years and 10 years |
Newborn
1 year: 120-170 bpm 3 years: 80-160 bpm 6 years: 75-115 bpm 10 years: 70-110 bpm |
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This accounts for most acquired murmurs in children
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Rheumatic Fever
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This murmur occurs in active healthy children between the ages of 3 to 7 yrs; often described as musical
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A Still murmur
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Systolic ejection murmurs may be heard over the pulmonic area in 90% of pregnant women, Murmur should not be louder than grade ___?
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Grade II (Quiet but clearly audible)
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How is mitral stenosis detected?
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Heard with bell at the apex, with patient in left lateral decubitus position
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Where can you best hear aortic stenosis? (you hear a crescendo-decrescendo sound) along the left sternal border and to carotid with palpable thrill)
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Heard over aortic area; ejection sound at second right intercostal border; the more severe the stenosis, the later the peak of the murmur in systole
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Where would you detect a subaortic stenosis?
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Heard at apex and along left sternal border
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Where is pumonic stenosis heard?
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Over pulmonic area; it radiates to left and into neck; thrill in 2nd and 3rd left rib space
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Triscuspid is best heard over this area
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Heard with bell over tricuspid area
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Mitral regurgitation is best heard here
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Heard best at apex; loudes there, transmitted into left axilla
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Where can you detect a mitral valve prolapse and describe the sound?
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Heard at apex and left lower sternal border when patient is upright; late systolic murmur preceded by midsystolic clicks
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How would you listen for an aortic regrugitation murmur?
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Heard with diaphragm, patient sitting and leaning forward; ejection click heard in 2nd intercostal space; Austin-flint murmur heard with bell
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Low-pitched, rumbling murmur at apex common in aortic regurgitation
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Austin-Flint murmur
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How would you listen for a tricspid regurge murmur?
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Heard at left lower sternum, occasionally radiating a few centimeters to left
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Physical finding:
Displacement of the apical impulse can be well lateral to MCL and downward; PMI is >2 cm |
Left Ventricular Hypertrophy
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Physical finding:
Lifts along the left sternal border in the 3rd and 4th rib spaces; occasional systolic retraction at the apex |
Right Ventricular hypertrophy
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Findings:
Triphasic friction rub (ventricular systole, early diastolic ventricular filling and late diastolic atrial systole); 90% of patients with this disease present with these findings |
Pericarditis
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Presentation:
Edema, ascites, dyspnea; Heart sounds are muffled, bp drops and pulse weakened and rapid and paradoxic pulse becomses exaggerated |
Cardiac Tamponade
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Common causes of tamponade
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Pericarditis, aortic dissection and trauma
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Enlargement of the right ventricle secondary to pulmonary malfunction
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Cor Pulmonale
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Desirable level of total cholesterol
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200 mg/dL
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Desirable level of LDL
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100 mg/dL
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Cardiac defects of the tetrology of Fallot
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Ventricular Septal Defect
Pulmonary Stenosis Dextroposistion of the aorta (overriding aorta) Right Ventricular Hypertrophy |
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Clinical presentation of tetrology of Fallot
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Paroxysmal dyspnea with loss of consciousness
Central cyanosis Parasternal heave and precordial prominence Single S2 is heard Systolic ejection murmur is heard over the 3rd rib space |
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Holosystolic Murmur
Murmur is loud, coarse, high-pitched and best heard along the left sternal border in the 3rd-5th rib spaces |
Ventricular Septal Defect
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Neck vessels dilated and pulsate and the pulse pressure is wide
A harsh, loud, continuous murmur is often heard at the 1st-3rd rib spaces and the lower sternal border Murmur is machine-like quality and usually does not change with posture |
Patent Ductus Arteriosis
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Causes a systolic ejection murmur that is diamond shaped, often loud, high pitch and harsh
Best heard over the pulmonic area S2 split may be fairly wide |
Atrial Septal defect
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Major Manifestations of rheumatic fever according to Jones Criteria
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Carditis
Polyarthritis Chorea Erythema marginatum Subcutaneous nodule |
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Usually silent and painless until it produces sudden heart failure, strok or dysrhythmias
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Mitral insufficiency
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