Health Assessment - Cardiac

Front 1

Blood Flow:

Back 1

– SVC –
– RA –
– Tricuspid valve –
– RV –
– Pulmonic valve –
– Pulmonary artery –
– LA –
– Mitral valve –
– LV – Aortic valve –
– Aorta

Front 2

S1 =

Back 2

closing of the mitral/tricuspid valves

Front 3

S2 =

Back 3

closing of the aortic/pulmonic valves

Front 4

P wave =

Back 4

atrial depolarization

Front 5

P‐R interval

Back 5

filling of ventricles

Front 6

QRS =

Back 6

traveling of impulse thru Bundle of Hiss to R
& L Perkingie fibers

Front 7

HEALTH HISTORY CUES –Child
Cardiac (4)

Back 7

Work of breathing
– Pallor
– Limited activity
– Change in heart rate

Front 8

Cardiac Assessment
HEALTH HISTORY CUES‐Adult:
6

Back 8

SOB with or without exertion
– Chest pain
– Syncope
– Fatigue
– Palpitations
– Claudication
– Early satiety, abdominal fullness

Front 9

3 Non‐modifiable Cardiac Risk Factors:

Back 9

Non‐modifiable
– Age
– Gender
– Genetics

Front 10

Cardiac Risk Factors:
3 Modifiable

Back 10

– HTN
– HLD
– DM

Front 11

Cardiac Risk Factors:
• Lifestyle

Back 11

Smoking
– Sedentary lifestyle
– Obesity
Hostility prone behavior
(Type A)

Front 12

Cardiac Risk Factors:
Emerging Risk Factors 3

Back 12

- Chlamydia pneumonia
– Homocystinemia
– CRP

Front 13

Cardiac Assessment: History
Common Presenting Symptoms 3

Back 13

Fatigue/activity intolerance
• Most prevalent cardiac symptom
• Need to ask questions about change
• Objective assessment
– 6 minute walk
– GXT

Front 14

Chest Pain

Back 14

Symptom analysis: location, intensity, chronology,
aggravating/alleviating factors, associated
– Stable angina ‐ predictable pattern
– Rate pressure product (RPP)
• Educate pt. to know…..keep below the threshold where pt.
experiences physical symptoms

Front 15

Other causes for CP (3)

Back 15

– GERD
– Chest wall
– Pulmonary

Front 16

Canadian Cardiovascular Society Classification
for CP

Back 16

– Class 0: Asymptomatic
– Class 1: Angina with strenuous Exercise
– Class 2: Angina with moderate exertion
– Class 3: Angina with mild exertion
• Walking 1‐2 level blocks at normal pace
• Climbing 1 flight of stairs at normal pace
– Class 4: Angina at any level of physical exertion

Front 17

Cardiac Assessment: History
Shortness of Breath
5

Back 17

– Dyspnea on exertion (DOE)
– Orthopnea
– Paroxysmal Nocturnal Dyspnea (PND)
– Talk Test
– Use of NYHA Classification scale

Front 18

NY Heart Association Classification for SOB/used in Heart Failure

Back 18

I
No symptoms and no limitation in
ordinary physical activity, e.g. shortness
of breath when walking, climbing stairs
etc.
II
Mild symptoms (mild shortness of
breath and/or angina) and slight
limitation during ordinary activity
NY Heart Association Classification for SOB/used in Heart Failure
activity.
III
Marked limitation in activity due to
symptoms, even during less‐thanordinary
activity, e.g. walking short
distances (20–100 m).
Comfortable only at rest.
IV
Severe limitations. Experiences
symptoms even while at rest. Mostly
bedbound patients.

Front 19

CHADS model

Back 19

CHADS score helps to predict how high the
risk is of not using anticoagulation

assigns a score from 0 to 6,
based on the patient's age and other medical
conditions

Washington University
of Medicine in St. Louis model to determine if
anticoagulation therapy is needed based on
risk

Front 20

Treatment with Coumadin reduces the risk of
stroke in atrial fibrillation by

Back 20

about 2/3 (66%,)
and treatment with aspirin reduces the risk by
1/4 (25%)

Front 21

Developers of the CHADS model recommend
strongly considering therapy with Coumadin
for anybody whose CHADS score

Back 21

is 1 or higher

Front 22

Clubbing

Back 22

> 180
‐convex at base & touch
w/out space

Front 23

Janeway lesion seen in

Back 23

in acute bacterial
Endocardidtis..flat..painless

Front 24

Janeway lesion

Back 24

seen in acute bacterial
Endocardidtis
flat.
painless

Front 25

Osler’s nodes:

Back 25

painful erythematous nodules
Associated w/infective carditis

Front 26

Xanthomas..

Back 26

Common among older adults
and people with high blood lipids
Around the eye called xanthelasma

Front 27

Cardiac Assessment:
Inspection/Palpation

Thrill”: fine vibration

Back 27

indicates turbulence
in the blood flow

Front 28

Cardiac Assessment:
Inspection/Palpation

“Heave”:

Back 28

strong outward thrust – may indicate
ventricular hypertrophy

Front 29

Cardiac Assessment:
Inspection/Palpation

PMI :

Back 29

5th intercostal, MCL

Front 30

Location of Thrill
Over the base of the heart at the 2nd intercostal
space, just to the right of the sternum, during
systole

Back 30

Aortic stenosis

Front 31

Location of Thrill
At the apex during systole

Back 31

Mitral regurgitation

Front 32

Location of Thrill
To the left of the sternum at the 2nd intercostal

Back 32

Pulmonic stenosis

Front 33

Location of Thrill
To the left of the sternum at the 4th intercostal
space

Back 33

Small muscular
ventricular septal
defect (Roger's
disease)

Front 34

Infant Normal Heart Rate:

Back 34

100 ‐ 130 bpm

Front 35

Child Normal Heart Rate:

Back 35

80 ‐ 100 bpm

Front 36

Adult Normal Heart Rate:

Back 36

60 ‐ 100 bpm

Front 37

Cardiac Assessment: Grading pulses

Back 37

two scales
always stat x/3 or x/4

• 3+ scale
– 3/3 =bounding
– 2/3 =normal
– 1/3= weak

• 4+scale
– 4/4= bounding
– ¾ =normal
– 2/4 =weak
– 0/3 =absent – ¼ = thready/
intermittent
– 0/4 =absent

Front 38

Pulsus magnus –

Back 38

bounding

Front 39

Pulsus Parvus -

Back 39

weak
the pulse is weak/small (parvus), and late (tardus) relative to its usually expected character.

It is seen in aortic valve stenosis.[1]

With respect to aortic stenosis, "typical findings include a narrow pulse pressure, LVH, a harsh late-peaking systolic murmur heard best at the right second intercostal space with radiation to the carotid arteries,

Front 40

Pulsus Alterans –

Back 40

weak/strong alternating
Pulsus alternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis

Front 41

Pulsus paradox

Back 41

r/t BP
abnormally large decrease in systolic blood pressure and pulse
wave amplitude during inspiration
– normal fall in pressure is less than 10 mm Hg.
– excessive decline may be a sign of tamponade, adhesive
pericarditis, severe lung disease, advanced heart failure, or
other conditions.

Front 42

Allen Test

Back 42

If color does not return or returns after 7 seconds, then the
ulnar artery supply to the hand is not sufficient and the radial
artery therefore cannot be safely cannulated.

Front 43

5 Risk factors for AAA

Back 43

• >65
• Smoking
• Male gender
• 1st degree relative
• Auscultated bruit

Front 44

Pre‐hypertension

Back 44

120‐130/80‐89

Front 45

Stage 1 HTN

Back 45

140‐159/90‐99

Front 46

Stage 2 HTN

Back 46

160‐179/100‐109

Front 47

Clinical Interpretation of ABI

Back 47

Normal 1.0 or >
– At risk 0.9
– Borderline ischemia <6.0 to 0.8
– Severe ischemia <0.5

Front 48

Edema
– Rate the degree of edema

Back 48

O= no pitting
• +1 = 0‐1/4” pitting (mild)
• +2 = ¼ ‐ ½” pitting (moderate)
• +3 = ½ ‐ 1” pitting (severe)
• +4 = > 1” (severe

Front 49

Interpretation: Distance between JVP and Sternum Normal: 4 cm or
less (norm) if Increased >4 cm (Jugular Venous Distention)

Back 49

Right‐sided Heart Failure (most common)
• Increased right atrial pressure
– Constrictive Pericarditis
– Tricuspid stenosis
– Superior Vena Cava Obstruction
– Valsalva phenomenon (laughing, coughing)

Front 50

Provocative: Hepatojugular Reflux

Back 50

Apply firm pressure to midabdomen for 30 seconds
• Apply 20‐30 mmHg of pressure
– Positive test: >4 cm JVP rise for >10 seconds
• Suggests CHF (right or left sided failure)
• Falsely positive if Valsalva (abdominal guarding)

Front 51

S1 loudest at

Back 51

Associated w/closure of mitral & tricuspid valves
– Loudest at apex‐ mitral & tricuspid areas
– Upstroke of pulse , rise of QRS

Front 52

S2

Back 52

associated w/closure of aortic & pulmonic valves
– Loudest at base‐aortic & pulmonic areas

Front 53

Auscultation: Diaphragm
Cardiac Assessment: Auscultation

Back 53

Diaphragm – S1 & S2

Front 54

Auscultation: Bell

Back 54

S3, S4, murmurs

Front 55

Auscultation:Aortic :

Back 55

2nd ICS R, >S2,

Front 56

Auscultation:Pulmonic

Back 56

2nd ICS, L, >s2

Front 57

Auscultation: Erbs

Back 57

3rd ICS L, S1 = S2

Front 58

Auscultation: Tricuspid :

Back 58

5th ICS L, >S1

Front 59

Auscultation Mitral :

Back 59

5th ICS L, MCL, >S1

Front 60

Split sounds:
– Split S2‐ pulmonic area

Back 60

Respiratory effect
– Normal
– Related to respiration b/c of volume changes you hear both
valves splits into A2 and P2 respectively
• Paradoxical split
– Seen with LBBB
• Fixed
– Atrial ‐Septal Defect
– Right Heart Failure

Front 61

Third Heart Sound S3

Back 61

Ventricular gallop
– Heard at apex
– Occurs during early diastole
– Ken Tuc KY
– Pathological seen in CHF, sign of being “wet”
– Physiologic seen in increased flow states, under 30
– Blood splashes into stretched ventricle

Front 62

Fourth heart Sound S4

Back 62

Atrial gallop
– Occurs w/atrial contraction
– Ten Ne See
– Always pathological
– Found in a stiff heart
• Recent MI, HTN

Front 63

Auscultation : Murmurs

Back 63

Turbulent flow
– Timing
• Diastolic murmurs indicate heart disease
• Systolic murmurs can indicate heart disease or can be
normal
– Shape: intensity overtime‐ crescendo, decrescendo
– Location: site of max intensity
– Radiation: can you hear it elsewhere
– Pitch: high, medium, low

Front 64

Auscultation : Murmurs
Intensity: grade

Back 64

I = faint heard only if know 1/6
• II = quiet but heard immediately 2/6
• III = moderately loud 3/6
• IV = loud 4/6 w/palpable thrill
• V = very loud heard w/stethoscope partly off chest wall 5/6
• VI = heard w/stethoscope totally off the chest wall

Front 65

Auscultation : Murmurs
Aortic stenosis‐

Back 65

systolic in Aortic area

Front 66

Auscultation : Murmurs
Aortic Insufficiency

Back 66

diastolic in aortic area

Front 67

Auscultation : Murmurs
Aortic insufficiency – w/regurgitation‐

Back 67

systolic &
diastolic components

Front 68

Auscultation
Mitral Murmurs

Back 68

diastolic murmur at apex

Front 69

Mitral regurge‐
Auscultation

Back 69

systolic murmur at apex

Front 70

Mitral Valve Prolapse

Auscultation

Back 70

Midsystolic click
– Late murmur

Front 71

Pericardial friction rub caused by

Back 71

caused by movement of inflammatory adhesions
between visceral and parietal pericardial layers

Front 72

Pericardial friction rub sounds like pieces

Back 72

leather squeaking as they
are rubbed together

Front 73

Pericardial friction rub best heard with

Back 73

the patient leaning forward or on
hands and knees with breath held in expiration