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365 Cards in this Set

  • Front
  • Back
What is Angina Pectoris traditionally described as?
Pressure or choking sensation substernally or into the neck; can radiate to jaw or down left arm
How does Angina Pectoris discomfort begin?
During strenous physical activity, easting, exposure to intense cold, windy weather, or exposure to emtional stress
Anginal Pain
Substernal; provoked by effort, emtion, eating; relieved by rest and/or niro; excessive sweating
Plerual Pain
Precpitated by beathing or coughing; sharp; present during respiration; absent when breath held
Esophageal Pain
Burning, substernal; sometimes to shoulder; nocturnal occurence, usually when lying flat. Relief with food, antacids, sometimes Nitro
From Peptic Ulcer
Almost always infradiaphragmatic and epigastric; nocturnal occurence and daytime attacks releived by food; UNRELATED TO ACTIVITY
Biliary Pain
Under R- scapula, prolonged in duration; after eating; will TRIGGER angina more than mimic it
Arthiritis/Bursitis
Lasts for hours; local tenderness and/or pain w/ movement
Cervical Pain
With injury; provoked by activity, persists after activity; painful on palpation and/or movement
Musculoskeletal Pain
Provoked by movement, twisting or costochondral bending; long lasting; often associated with FOCAL tenderness
Psychoneurotic Pain
With axiety; poorly described; located on intramammary region
Light Exercise Intensity
Walking 10-15 steps, preparing simple meal for 1, retrieving newspaper, pulling down bedspread, brushing teeth
Moderate Exercise Intensity
Making bed, dusting/sweeping, walking a level short block, office filing
Moderately Heavy Exercise
Climbing 1-2 flights of stiars, lifting full cartons, long walks, sexual intercourse
Heavy Exercse
Jogging, athletics, cleaning whole house in less than 1 day, raking large # of leaves, mowing lawn w/ hand mower, shoveling deep snow
Loss of consciousness w/ sudden turning of neck
Carotid sinus syndrome
Loss of consciousness w/ looking upward
Vertebral artery occlusion
Pack -Years
# of smoking years x # packs per day
How are women's chances of cardiac disease increased
Post-menopasual years & use of oral contraceptions
How does elevated homocysteine level cause cardiac disease?
It is an AA needed to make proteins (found in meat); leads to decreased B6, B12, and Folate --> increased atherosclerosis and formaiton of blood clots
What are some signs to look for in infants with cardiac problems?
- breathing changes: more heavy and rapid during feeding or defecation, -knee-chest position favored, -tiring easily during feeding
Signs to look for in children with cardiac problems?
-tiring during play, -long naps, -squatting > sitting when watching tv, -unexplained joint pain, -nosebleeds
Indications of heart disease during pregnancy
dyspnea, progressive orthopnea, PND, hemoptysis, syncope w/ exertion, chest pain due to effort or emtion
Effects of K+ excess
weakness, bradycardia, hypotension, confusion
Effects of K+ depletion
weakness, fatigue, muscle cramps, dysrhythmias
Digitalis toxicity
anorexia, nausea, vomitting, diarrhea, halo, yellow vision
Desired level of cholesterol
200mg/dL
Desired level of LDL cholesterol
100mg/dL
LDL goal with previous MI
70mg/dL
Area overlying the chest
Precordium
Heart position in tall slender person
Vertically and centrally
Heart position in short/stocky person
Horizontally and more the left
Dextrocardia
Heart positioned to the right, rotated or displaced or mirror image
Heart and stomach to right and liver to left
Situs Inversus
Outermost layer of heart, extends into great vessels
Epicardium
Muscle layer of the heart; pumping action
Myocardium
Innermost layer, lines valves and chambers
Endocardium
Primary muscle mass of the heart
Left and Right ventricles
Postion on RA
To the right of the RV; forms right border or heart
LA
Above the ventricles; forms posterior aspect of heart
How is the heart turned
Ventrally on its axis, putting R-sdie more forward
Size of adult heart
12X8X6cm
What is near the SVC
SA node
What is near the Coronary Sinus
AV node
What are some variations to how much blood returns to the RA
Exercise or fever
S1 heart sound
Closer of AV valces
S2 heart sound
Closer of the SL valves after pressure in the ventricles has fallen below the aorta and PA
When does the SL valves open
when the pressure in the LV overcomes the aorta pushing them open
S3 heart sound
filling of the ventricles - passievly
S4 heart sound
atira contraction for blood into venticles
Sequence of closer between A2 and P2
A2 then P2
Conduction sequence
SA (in RA) --> both atira --> AV (in atrial septum)
Start of ventricular contraction
Starts at apex and goes up to base
P wave
Spread of stimulus through atira
PR interval
Initial atria depol. to initial stimulation of venticles (0.12-0.20 sec)
QRS complex
spread of stimulus through ventricles (< 10 sec)
ST segment and T wave
return of stimulated ventricle to resting
U wave
Small deflection after T wave
QT interval
Ventricular depol --> repol
Normal heart rate what cycle is longer? shorter?
Diastole longer than systole
WHat happenes when heart rate increases
2 cycles approximate in time
In infants: SVC delivers what?
Oxygen POOR blood from body
In infants: IVC delivers what?
Oxygen RICH blood from umbelical vein
Foramel ovale
Opening for blood to go from RA --> LA (bypassing lungs)
Ductus Arteriosis
RA --> RV --> PA --> aorta
When does PDA close?
Within 24-48 hours after birth
When does FO close?
As pressure rises in left atrium
Position of heart in babies?
More horizontally -- thus apex is higher in 4th ICS
WHen does adult heart position reached?
7 years old
Maternal blood volume increases by how much in preganncy?
40-50%
When does BV reach its max in pregnancy
30th week
When does BV return to normal
3-4th week after delivery
CO increases by how much? Peaks when?
Increases by 30-40%; peaks at 25th -32nd week of gestation
Effects of HR at labor/ delivery
Increased; Bradycardia at delivery
BP in preganncy
always remains at prepregnancy level
SV peaks when? what happens at labor?
Peaks at 28th week; decreased at labor
What happens to heart in eldery?
SV decreases and CO during exercise declines by 30-40%, Endocardium thickens, Myocardium becomes less elastic
What 2 things further copromise heart in elderly?
FIbrosis and Sclerosis in SA node region (mitral and aortic)
What are EKG changes secondary to?
Cellular alteration to fibrosis in conduction system and neurogenic changes
Common abnormalities in elderly
AV block, BBB, ST-wave issues, PAC or PVC, LAH, LVH, A fib
What are the signs of heart failure systematically?
crackles in the lungs, engorgement of the liver and peripheral edema
What is the proper sequence when evaluating the heart?
inspection, palpation, percussion, and then asucultation
What is the difference in listening to the heart of a thin nonmuscular individual compared to a obese or muscular individual?
a thin individual will louder and closer sounds while an bese individual will have dimmer more distant sounds
Where is the apical impulse visible ?
midclaviclar line in te 6th left intercostal space
What can a readily visible and palpable impulse when a patient is supine be a sign on?
result of a heart problem
What should an examiner consider with a faint apical impulse especially in the lateral recumbent position?
intervening extracardiac problem like pleural or pericardial effusion
Why should you press lightly with palpation?
sensation decreases as you increase pressure
What are the characteristic of the apical impulse?
should be no more than 1 cm in radius and is normally gentle and brie not lasting as long as systole
what is the apical impulse considered if it is more vigorous than expected?
a heave or a lift
What type of apical impulse may indicated increased cardiac output or left ventricular hypertrophy?
more forceful, widely distributed, fills systole or is deisplacd laterally and downward
What does it mean when the apical impulse is shifted to the right without a loss or gain in thurst?
dextrocardia, diaphragmatic hernia, distended stomach or pulmonary abnormality
What is the point at wch the apical impulse is most readily seen or felt?
point of maximal impulse
What are the characteristics of a thrill?
fine, palpable, rushing vibration, a palpable murmur, often but not always over the base of the heart in the area of the right or left second intercostal space
What does a thrill indicate?
turbulencor a disruption of the expected blood flow related to some defect in the closure of one of the semiluanr valves
What is syncronous with te carotid artery in the cardac cycle?
S1
What is it called when a murmur is felt, and at what grade does this occur?
a thrill and occurs wen a murmur is grade IV level or more
What is the probable cause of a systole murmur in the suprasternal notch and or second and third right intercostal space?
aortic stenosis
What is the probable cause of a systole murmur in the suprasternal notch and or second and third left intercostal space?
pulmonic stenosis
What is the probable cause of a systole murmur in the fourth left intercostal space?
ventricular septal defect
What is the probable cause of a systole murmur in the apex?
mitral regurgitation
What is the probable cause of a systole murmur in the left lower sternal border?
tetralogy of fallot
What is the probable cause of a systole murmur in the left upper sterna border often with extensive radiation?
patent ductus arteriosus
What is the probable cause of a diastole murmur in the right sternal border?
aortic regurgitation or aneurysm of the ascending aorta
What is the probable cause of a diastole murmur in the apex?
mitral stenosis
With percussion how would you determine the left ventricular size?
location of the apical impulse
In what direction does the right ventricle enlarge?
anterior posterior diamter rather tan laterally diminishing the value of percussion of the white heart border
What is the change in percussion noted along the cardiac border?
change from resonant to dull
In consideration of blood flow wat area of the heart is best to hear the heart sound?
sound is transmitted in the direction of blood flow, so they are best heard in areas where the blood flows after is passes through a valve
What can elevate te diaphragm to cause a change in the site of the apex of the heart?
pregnancy, ascites, or oter intrabsominal conditions
Where do you listen to the aortic valve area?
second right intercostal speace at the right sternal border
Where do you listen to the pulmonic valve area?
second left intercostal space at the left sternal border
Where do you listen to the second pulmonic area?
second left intercostl space at the left sternal border
Where do you listen to the triscuspid area?
fourth left intercostal space along te lower left sternal border
Where do you listen to the mitral area?
at the apex of the heart at the fifth left intercostal space at the midclavicular line
If the cardiac rhythm is irregular what should you compare the beats of the heart to?
compare te beats per minute of the heart with the number of beats per minute at the radial pulse
What should you instruct the patient to do when determining the synchrony of the carotid pulse with S1?
instruct patient to breathe normally and then hold the breath in expiration
What marks the initiation of diastole?
S2
How do you listen for splitting?
instruct the patient to inhale deeply and listen for S2 to become two components during inspiration in the pulmonic auscultatory area
What is the best position to have a patient in to ear relatively high pitched murmurs?
sitting up leaning sligly forward in expiration using the diaphragm
What is the best position to have a patient in to hear low pitced filling sounds in diastole?
patient lateral recumbent using the bell
Why is it beneficial to inch the stethoscope from one site to another instead of jumping?
helps prevent missing important sounds, partilarly more widely transmitted abnormal sounds and allows tracking of a sound from its loudest pont to its farthest reach
What is S1 due to and where is it best heard?
closure of the AV valve and best heard toward the apex of the heart
What is S2 due to and where is it best heard?
closure of semilunar valve, nest eard in the aortic and pulmonic area, it is louder than S1 at the base of the heart and usually softer at the apex
What is splitting?
term used to define the failure of the mitral and tricsupid valves or te pulmonic anaortic valves to close simultaneously
During what phase of breathing is splitting heard better?
during inhalaton
Why is splitting of S2 an expected event?
because pressres are igher and depolarization occurs earlier on the left side of the heart, ejection times on te rigt are longer and the pulmonic valve closes a bit later than the aortic valve
What tends to mask the sound of the pulmonic valve closure (P2)?
aortic valve closure (A2)
When do ejection times tend to equalize?
when the breath is held in expiration
What conditions produce a louder S1 sound?
blood vocity in increased like in anemia, fever, hyperthyroidism, anxiety and exercise or the mitral valv is stenotic
When does the intensity of S1 vary?
complete heart block, gross disruption of rhythm like fibrillation
What decreases intensity of S1?
increased overlying ssue fat or fluid, systemic or pulmonary hypertension, brosis and calcification of a diseased mitral valve that can result from rheumatic heart disease
What increases the intensity of S2?
systemc ypertension, sypillis of te aortic valve, exercise or excitement accntuates S2, pulmonary hypertension, mitral stenosis, and congestie heart failure, the vales are disease but still fully mobile
What decress the intensity of S2?
a shockllike state, valves are immobile, thickened or calcified, aortic stenosi, pulmonic stenosis, overlying tissue, fat or fluid mutes S2
What are the two steps the ventricles fill during diastole?
an early, passive flow of blood from te atria is folled by a more vigorous atrial ejection early in diastole (S3) and the second phase (S4) bibration in the balves, papillae and entricular walls late in dastole
What can you make a patient do to make S3 and S4 easier to hear?
increasing venous return by asking the patient to raise a leg or by atrial pressure by asking the tient to grip your hand vigorously and repatedly
What conditions may cause S3 to be louder?
filling pressure is increased or ventricular compliance is reduced
What conditions may cause S4 to be more intense?
increased ersistance to filling because of loss of compliance of the ventricular walls in hypertensive disease and coronary artery disease or due to increased stroke volume of igh output states like profound anemia, pregnancy, and thyrotoxicity
What loud heart sound always suggests patology?
a loud S4
What different sounds may valvular stenosis produce?
opening snap (mitral valve), ejection clicks (semilunar valve), or mid to late nonejection systolic click (mitral prolapse)
What may cause wide splitting?
delayed activation of contraction or emptying of te rigt ventricule resulting in delay in pulmonic closure like in a right bundle branch block
What causes wide splitting of S2?
stenosis delays closure of pulmonic alve, pulmonary hypertension delays ventricular emptying or mitral regurgitation induces early closure of aortic valve
When does splitting become more narrow or is absent?
closure of aortic valve is delayed like in a left bundle branch block
When is splitting said to be fixed?
when it is unaffected by respiration
When do you have fixed splitting?
delyed closure of the pulmonic valve when output of the right ventricle is greater than that of the left such as occurs in large atrial septal defects, a ventricular septal defect with left to right shunting or right ventricular failure
When do you have paradoxic reversed splitting?
closure of the aortic valve is delayed such as left bundle branch block so that P2 occurs first followed by A2
What causes a pericardial friction rub?
inflammation of the pericardial sac causes a roughening of the parietal and visceral surfaces, it is heard more towards the apex of the heart
What changes should you listen to for a prosthetic mitral valve?
listen for a distinct click early in diastole, loudest at the apex and transmitted precordially
What changes should you listen to for a prosthetic aortic valve?
causes a sound early in systole
What causes murmurs?
caused by the disruption in the flow of blood into through or out of the heart
What leads to regurgitation?
when the valve leaflets are intended to fit snuggly togetherand tey lose competency the slak opening allow backward flow of blood
Besides murmurs that result from valvular defects what also can lead to a heart murmur?
high output demands that increase the speed of blood flow (thyrotoxicosis, anemia, and pregnancy), structual defects (allow blood flow through inappropriate pathways), diminished strength of myocardial contraction, altered blood flow in the major vessels near the heart, transmitted urmurs due to valvular rtic stenosis, ruptured chordae tendinae of the mitral valve or severe aortic regrgitation, viforous left ventricular ejection, obstructive disease in cervial arteries like atheroscleroti carotid arteris, fibromuscular hyperplasia, or arteritits
Where do you hear increased S3 and what is its description?
bell at apex in lateral recumbent is a early diastole low pitch sound
Where do you hear increased S4 and what is its description?
bell at apex patient supine or lateral recumbent, late siastole or early systole low pitch
Were do you hear gallops and what is its description?
bell at apex patient supine or lateral recumbent, presystole intense and easily heard
Where do you hear mitral valve opening snap and its description?
diaphragm medial to apex, may raidate to base, any position, early diastole breifly before S3; high pitch sharp snap or click not affected by respiration and easily confused with S2
Where do you hear ejection clicks?
use the diaphragm with the patient sitting
Where do you detect the aortic valve and what is its description?
at the apex at te base in te second rigt intercostal space, early systole, intense high pitch radiates and not affected by respirations
Where do you dected the pulmonary valve and what is its description?
early systole, less intesne than aortic click intensifies on expiration decreased on inspiration
Whare do you detect the pericardial friction rub and what is its description?
widely heard, clearest at apex, may occupy all of systole and diastole its intense, grating and machine like
What is the position, area to auscultate, endpiece used, pitch of sound, effects of respiration, external influences and causes of the first heart sound?
any position, at the apex use the diaphragm, a high pitch, soften on inspiration, increaed with excitement, exercise, amyl nitrate epinephrine and atropine due to closure of tricuspid and mitral valves
What is the position, area to auscultate, endpiece used, pitch of sound, effects of respiration, external influences and causes of the second heart sound?
sitting or supine, A2 at 2nd RICS, P2 at 2nd LICS, use diaphragm, high pitch, fusion of A2P2 on expiration and physioligc split on inspiration, increased wth thin chest walls and exercise, due to closure of semilunar valves
What is the position, area to auscultate, endpiece used, pitch of sound, effects of respiration, external influences and causes of the third heart sound?
supine or left lateral, at the apex, use bell low pitch, inreased on inspiration, increased with exercise, fast heart rate, elevation of legs and increased venous return due to rapid ventricular filling
What is the position, area to auscultate, endpiece used, pitch of sound,
effects of respiration, external influences and causes of the fourth heart sound?
supine or left semilateral, at the apex, use bell low pitch, inreased on inspiration, increased with exercise, fast heart rate, elevation of legs and increased venous return due to forcful atrial ejection into distended ventricle
What is the position, area to auscultate, endpiece used, pitch of sound,
effects of respiration, external influences and causes of the quadruple rhythm
supine or left lateral at the apex using the bell low pitch increased on inspiration, increased with arortic ejection, pulmonary ejection sound increased on inspiration, all heart sounds are heard separtely
What is the position, area to auscultate, endpiece used, pitch of sound, effects of respiration, external influences and causes of the summation gallop
supine or left latral at the apex, usng te bell low pitch increased on inspirattion, aortic ejection same as S1 and S2 pulmonry efection sound increased on expiration and S3 and S4 fuse with fast heart rates
What is the position, area to auscultate, endpiece used, pitch of sound,
effects of respiration, external influences and causes of the ejection sounds?
sitting of suprine, 2nd RICS, 2nd LICS, or apex, use diaphragm high pitch, inreased on expiration with pulmonary stenosis, aortic ejetion same as S1 and S2, pulmonary ejection increased on expiration dur to opening of deformed semilunar valves
What is the position, area to auscultate, endpiece used, pitch of sound, effects of respiration, external influences and causes of the systolic click?
sitting or supine, at the apex, using the diaphragm, its a high pitch, increased on inspiration, occurs laer in systole with increased venous return due to prolapse mitral valve leaflet
What is the position, area to auscultate, endpiece used, pitch of sound,
effects of respiration, external influences and causes of the opening snap?
any position, at the apex, using the diaphragm high pitch, uninfluenced by inspiration, may be confused wit S3 due to abrupt recoil of stenotic mitral or tricuspid valve
What is the description of a holosystolic (pansystolc) murmur?
begins wit S1 occupies all of systole and ends at S2
What is the description of a holodiastolic (pandiastolic) murmur?
begins with S2 occupies allf diastole and ends at S1
What is the description of a continous murmur?
starts in systole, contins wiout interruption through S2 into all or part of diastole does not necessarily perist throughout the entire cardiac cycle
What is a grade I murmur?
barely audible in a quiet room
What is a grade II murmur?
quiet but clearly audible
What is a grade III murmur?
moderately loud
What is a grade IV murmur?
loud, associated wit a thrill
What is a grade V murmur?
veru loud, thrill easily palpable
What is a grade VI murmur?
very loud, audible withstetoscope not in contact with chest, thrill palpable and visible
What causes a crescendo pattern in a heart murmur?
increasing intensity caused by increased blood velocity
What causes a decrescendo pattern in a heart murmur?
increasng intensity caused by decreased blood viscocity
What happens to venous return on the respiratory phase
venous return incerases on inspiration and decreases on expiration
What are the physical findings of mitral stenosis?
low frequency distolic rumble, more intesne in early and late diastole, that does not radiate, visible lift in rigt parasternal area of right ventricle hypertrophied and arterial pulse amplitude decreased
What is the description of mitral stenosis?
narrowed valve restricts forward flow, forcerful ejection intro ventricle
What causes mitral stenosis?
rheumatic fever or cardiac infection
What are the physical findings of aortic stenosis?
midsystolic ejection murmur, thats diamond shaped radiating along the left sternal border
What is the descripon of aortic stenosis?
calcification of the valve cusps restricts forward flow; forceful ejection from ventricles into systemic circulation
What causes aortic stenosis?
congenital bicuspid, valve, rheumatic heart disease and atherosclerosis, and may be the cause of sudden death
What is the physical findings of subaortic stenosis?
murmur fills systole, diamon shaped medium pitch, arterial puse is brisk double wave in carotid common and jugular venous pulse prominent
What is the description of a subaortic stenosis?
fibrous ring usually 1 to 4mm below aortic valve; most pronounced on ventricular septal side may become progressively severewith time
What are the findings with pulmonic stenosis?
systolic ejection murmur, diamond shaped, medium pitch, S1 normally has ejection click, prolonged splitting
What is the description of pulmonic stenosis?
valve restricts forward flow, forceful ejection from ventricles into pulmonary circulation
What is the cause of pulmonic stenosis?
almost always congenital
What are the findings with tricuspid stenosis?
diastolic rumble in diastole resembling mitral stenosis but louder on inspiration, arterial pulse amplitude decreased, jugular venous pulse prominent, slow fall of v wave
What is the description of tricuspid stenosis?
calciication of valve cusps restricts forward flow forceful ejection into ventricules usually seen with mitral stenosis
What causes tricuspid stenosis?
rheumatic heart disease, congenital defect, endocardial fibroelastosi, right atrial myxoma
What are the findings with mitral regurgitation?
holosystolic, plateau shaped high pitch harsh blowing murmur radiating from the apex to the base
What is the description of mitral regurgitation?
valve incompetence allows backflow frm ventricle to atrium
What causes mitral regurgitation?
rhematic fever, myocardial infarction, myxoma, rupture of chordae
What are the findings with mitral valve prolapse?
typically late systolic murmur preceded by midsytolic clicks
What is the description of mitral valve prolapse?
valve is incompetent early in systole but prolapses into atrium later in systole, may become progressively sever, resulting in a holosystolic murmur, often concurrent with pectus excavatum
What are findings with aortic regurgitation?
early diastolic murmur, high pitched rumblix murmur at theapex (Austin Flint)
What type of pulse is common with aortic regurgitation?
wider pulse pressure, hammer or bisferiens or corrigan pulse common in carotid, brcieal and femoral arteries?
What is the description of aortic regurgitation?
valve incompetence allows backflow from aorta to ventricle
What causes aortic regurgitation?
rheumatic heart disease, endocarditis, aortic disease, syphilis, ankylsing spodylities, dissection, cardiac trauma
What is the description of pulmonic regurgitation?
valve incompetence allows backflow from pulmonary artery to the ventricle
What cause pulmonic regurgitation?
secondary to pulmonary hypertension or bacterial endocardits
What is the findings of tricuspid regurgitation?
holosystolic murmur over gt ventricle blowing increased on inspiration , the jugular venous pulse has a large v wave
What is the description of tricuspid regurgitation?
valve incomplete allows bacflow from ventricle to atrium
What causes tricuspid regurgitation?
congenital defects, abcterial endocardities especially from IV drug abusers, pulmonary hypertension and cardiac trauma
What are still murmurs?
murmurs with no apparent cause
What is it believed still murmurs result from?
vigorous myocardial contraction, consequent stronger blood flow in ealy systole or midsystole and the rush of blood from the larger chamber of the heart into the smaller bore of a bood vessel
What are the characterstics of a still murmur?
usually grade I or II, usually midsystolic without radiation or medium pitch, blowing brieft and often accompanied by splitting of S2, often located in the second LICS near the left stenal border, tends to disappear when a patient sits or stands
What happens to a right-sided chamber murmur on inspriation/expiration?
I: Increases E: decreases
What makes a hypertrophic murmur increase?
Valsalva maneuver
What increases a murmur heard in cardiomyopathy?
Squatting => standing (rapidly for 30 s)
What decreaes a murmur heard in cardiomyopathy?
1) Standing to squatting (rapidly) 2) Passive leg elevation to 45 degrees, patient supine
What increases a mitral regurgitation murmur?
Handgrip
What increases a VSD murmur?
Transient arterial occlusion => BP cuff on both arms inflated, note intensity after 20s
What decreases a VSD murmur?
Inhalation of amyl nitrate
What distinguishes a murmur caused by Aortic Stenosis?
Nothing, this dx is made by exclusion
How do you interpret rhythm?
1) determine steadiness (regular) 2) irregular => is there a consistent pattern 3) patternless/unpredictible/irregular indicates disease or conduction impairment
A heart rate that is irregular but occurs in a repeated pattern indicates?
Sinus dysrhythmia => cyclic variation of heart rate by increasing on inspiration and decreasing on expiration
When should you examine a newborns heart rate?
First 24 hours, and again at about 2-3 days of age
What symptoms do infants with R sided CHF have?
Large, firm livers with the inferior edge as much as 5-6cm below the R costal margin. Usually precedes crackles.
A purple infant may have what?
Polycythemia
An ashen white infant may have what?
Shock
A centrally cyanosed infant may have what?
Congenital heart disease
Acrocyanosis (hands/feet blue) may indicate what?
Normal
Why does cyanosis occur in congenital heart disease?
Mixing of atrial/venous blood, prevention of expected oxygenation of blood
What does SEVERE cyanosis at birth indicate?
Transposition of the great vessels, tetralogy of Fallot, tricuspid atresia, severe septal defect, severe pulmonic stenosis
What does cyanosis indicate if it appears after the neonatal period?
pure pulmonic stenosis, Eisenmenger complex, tetralogy of Fallot, large septal defects
Where is the apical impulse felt in the newborn?
4-5 ICS, medial to MCL. Smaller baby/thinner chest = more obvious
Where is the apical impulse felt the first few hours of life?
Somewhat farther to the R, sometimes even substernal
What does a pneumothorax do to the apical impulse?
Shifts it away from area
What does a diaphragmatic hernia do to the apical impulse?
Shifts heart to R because it is found on L
What does dextrocardia do to the apical impulse?
Will see impulse on R, flip-flopped
What side of the heart is more vigorous in a newborn?
RV, Can even feel closure of pulmonic valve in 2nd ICS
What heart sound is louder in infants?
S2 higher in pitch and more discrete than S1
Diminished vigor of heart sounds in an infant indicates what?
heart failrue
Splitting of heart sounds in an infant indicates what?
normal, S2 splitting not at birth but after a few hours
What extra heart sounds are commonly heard in infants?
S3 and S4 => normal, but if loud suspect
When are murmurs relatively common in an infant?
From birth to about 48 hrs of age (disappear 2-3 days)
Why are murmurs heard in a newborn?
Transition from fetal to pulmonic circulation rather than congenital
What grade are newborn murmurs?
Grade I or II, systolic, no other symptoms/signs
What type of murmur may a significant congenital abnormality have?
Paradoxical = usually none
If hear failure in an infant is suspected what should be examined?
Liver = enlarges before moisture in lungs, left lobe larger than right
What should you do if you can't tell an infant's respirations from a murmur?
Pinch the nares, listen while feeding, time the sound to carotid pulsation
If you push up on the liver of an infant what type of murmur disappears?
Increases RA pressure => L-R shunt through septal opening/PDA will disappear
If you push up on the liver of an infant what type of murmur intensifies?
Increases RA pressure => R-L shunt intensifies
What is "machine-like" quality to murmur?
Extends beyond S2 and occupies diastole => PDA
What are diastolic murmurs associated with?
Early closing of ductus arteriosus, mild-brief pulmonary insufficiency
When is the infant heart rate greatest?
At birth/ shortly after => 200 bpm
A rate of 200 bpm in a newborn may indicate what?
Paroxysmal atrial tachycardia
What is the heart rate of an infant a few hours after birth?
120 bpm
If a child has a long-standing enlarged heart what happens?
Precordium bulges over it because it has more cartilage and can morph
Is sinus arrhythmia a concern in childhood?
Not really - heart rate varies in cyclic patterns (fast on inspiration, slow on expriation)
When are dysrhythmias a concern in kids?
When they are ectopic in origin (supraventricular, ventricular ectopic beats)
How many bpm increase with each degree of temperature elevation?
10-20 bpm
Newborn heart rate?
120-170
1 year heart rate?
80-160
3 year heart rate?
80-120
6 year heart rate?
75-115
10 year heart rate?
70-110
Most organic murmurs in kids are the result of?
congenital heart disease
Acquired murmurs in kids are the result of?
rheumatic fever
What is a Still murmur?
Occurs in healthy kids between 3-7 years => vigorous expulsion of blood from LV into aorta with activity => musical murmur!
Why are heart sounds so easily heard in ids?
Heart is close to thin chest wall
What happens to the heart rate in pregnancy?
Increases gradually 10-30% higher at term
What happens to the apical impulse in pregnancy?
Upward, more lateral by 1-1.5cm
What sounds are heard during pregnancy?
Splitting, S3 after 20 weeks, S4 is abnormal, systolic ejection murmurs over pulmonic area (90%) => intensifies during breathing but should not be > II
What suggests abnormalities in CV system during pregnancy?
Cyanosis, clubbing, JVD, Diastolic murmur
What happens to the heart rate in elderly people?
Slows down => vagal tone, or more rapid and irregular from low 40s to 100 bpm, ectopic beats common
What happens to the apical impulse in the elderly?
May be hard to find, because of increased AP diameter of chest.
Where is the heart in obese patients?
More transverse because the diaphragm is raised
What heart sound is common in elderly?
S4 => indicates decreased LV compliance
What causes physiologic murmurs in the elderly?
Aortic lengthening, tortuosity, sclerotic changes
Who is at risk for bacterial endocarditis?
Valve defects (congenital/acquired), IV drugs
What are the symptoms of BE?
Fever, fatigue, murmurs, sudden onset CHF, neurologic dysfunctions, Janeway lesions, Osler nodes
Where do Janeway lesions appear? Osler nodes?
Janeway = palms/soles; Osler = tips of fingers/toes
What is diastolic CHF a result of?
Advanced glycation cross-linking collagen and creating a stiff ventricle unable to dilate actively
Who does diastolic CHF occur in?
Older adults => tissue exposed to glucose; Diabetes
What are the symptoms of CHF?
Fatigue, orthopnea, SOB, edema, pulmonary edema
How do you differentiate systolic vs. diastolic CHF?
Systolic = narrow pulse pressure; Diastolic = wide pulse pressure
What finding is important for differenting L sided CHF?
JVD
What complications can pericarditis give?
Pericardial effusion leading to cardiac tamponade
What are the symptoms of pericarditis?
Sharp/stabbing chest pain, movement/inspiration aggrevates pain, pain most severe when SUPINE, relieved when LEANING FORWARD
How do you dx pericarditis?
Will hear a scratchy, grating, triphasic friction rub on auscultation, all through ventricular systole, early diastolic vent filling, and late diastolic atrial systole
Where do you hear a pericardial friction rub?
Left of sternum in 3 & 4 ICS
What are the common causes of cardiac tamponade?
Pericarditis, malignancy, aortic dissection, trauma
What is the major complication of cardiac tamponade?
Seriously constrains cardiac relaxation, impairing access of blood to the R heart
What are the signs/symptoms of cardiac tamponade?
anxiety, restlessness, chest pain, dyspnea, discomfort, syncope, light-headedness, pale/gray/blue skin, palpitations, tachypnea, edema of abdomen/arms/neck veins
How do you diagnose cardiac tamponade?
Beck's triad: JVD, hypotension, muffled heart sounds
What long term issues occur from tamponade?
pericardium scars/constricts, limits filling; muffles heart sounds; drops BP, weakens pulse and paradoxic pulse becomes exaggerated
What is cor pulmonale?
Enlargement of the RV secondary to pulmonary malfunction
What is the chronic common cause of cor pulmonale?
COPD
What is the acute common cause of cor pulmonale?
Massive pulmonary embolism, ARDS
What are the signs/symptoms of cor pulmonale ?
fatigue, tachypnea, exertional dyspnea, cough, hemoptysis, pulmonary disease, wheezes/crackles, increase in chest diameter, chest wall retractions, prominent A/V wave with distended neck veins, cyanosis, left parasternal systolic heave, loud S2 exaggerated in pulmonic region
What is the pathophysiology of an MI?
LV morst commonly affected, artherosclerosis and thrombosis are the common underlying causes
What are the symptoms/signs of an MI?
Deep substernal or isceral pain that radiates to jaw/neck/L arm. Mild discomfort
What objective findings accompany an MI?
Dysrhythmia, S4, distant heart sounds, soft/systolic/blowing/apical murmur, thready pulse, varied BP with hypertension in early phases
What causes myocarditis?
infectious agents, toxins, autoimmune diseases (amyloidosis)
What are the symptoms/signs of myocarditis?
Initially vague, but fatigue, dyspnea, fever, palpitations, cardiac enlargement, murmurs gallop rhythms, tachycardia, dysrhythmias, pulsus alterans
Where are conduction distrubances seen?
Proximal to bundle of His or diffusely throughout the conduction system
What causes conduction distrubances?
Ischemia, infiltrations, neoplasia, antidepressants, digitalis, quinidine, other meds
What are the symptoms/signs of conduction disturbances?
Transient weakness, syncope (acutely withotu warning, but sometimes in the form of a "gray-out" rather than a "black-out", strokelike episodes, rapid/irregular heartbeat, labile heart rates, rhythm disturbances
What are the causes of syncope?
Use CANADA: Cardiac (valve stenosis, Stokes-adams attacks, conduction issues), Arteriovenous (steal syndromes), Nervous (psychologic, autonomic, vagal, coughing), Anemia (altered blood, CO), Drugs Diabetes (alcohol, poisons), Altitude, Acute fevers
What is atrial flutter?
Atrial rate far in excess of ventricular rate; 4:1 conduction ratio (>200 bpm). Ventricular response to flutter is limited because of physiologic heart block. ECG looks saw-toothed. Heart sounds are not weak.
What is sinus bradycardia?
Slow rate below 50-60. Not suggestive of a clinical problem.
What is atrial fibrillation?
Dysrhythmic contraction of the atria causes spasms of muscle wall, no regularity in rhythm. Conduction system is in an ANARCHIC state => irregularly irregular
What is heart block?
Heart rate slower than expected
What characterizes a first degree AV block?
Prolonged PR interval
What is the rate of an incomplete heart block?
25-45 min at rest
What is the pathophysiology of a heart block?
Conduction from atria => ventricles partially or completely disrupted. Ventricle is left to beat on its own with block.
What is atrial tachycardia?
Rapid, regular heart rate (200bpm) withotu disruption of rhythm. May be heard only on occasion (in paroxysms)
What is the pathophysiology of atrial tachycardia?
Electrical stimulus originating in a focus in the atrium separate from the SA node. Conduction through ventricle is complete (no loss of sounds). Patient is usually a young adult.
How can you resolve atrial tachycardia?
Rate decreases with vagal stimulation, holding a deep breath, or gental massage of carotid sinus.
What is ventricular tachycardia?
Rapid, relatively regular heartbeat (often nearly 200/min) without loss in apparent strength
What is the pathophysiology of Vtach?
Electrical source of beat is an ectopic focus somewhere in the ventricles. Really bad sign of serious heart disease
What is ventricular fibrillation?
Complete loss of regular heart rhythm with expected conduction pattern absent if weakened and rapid. Ventricular contraction is irregular.
What is the pathophysiology of Vfib?
Ventricle has lost rhythm of expecte response, all evidence of vigorous contraction is gone. Calls for immediate action and may immediately precede sudden death.
What is sick sinus sydrome?
Arrhythmias caused by a malfunction of the sinus node
What causes sick sinus syndrome?
Secondary to hypertension, arteriosclerotic heart disease, or rheumatic heart, or idiopathically
What are the symptoms/signs of sick sinus syndrome?
Fainting, transient dizzy spells, light-headedness, seizures, palpitations, angina, dysrhythmias, CHF
What are the four defects included in tetralogy of fallot?
VSD, pulmonic stenosis, dextroposition of aorta, RV hypertrophy
What must be done in order for someone to survive TOF?
Surgical correction initiated after the first "spell"
What are the signs of TOF?
Dyspnea with feeding, poor growth, exercise intolerance. Paroxysmal dyspnea with loss of conciousness and central cyanosis (tetralogy spell)
What does the doctor see in TOF?
Parasternal heave, precordial prominence, systolic ejection murmur over 3 ICS (somtimes radiats to L side of neck), single S2 heard. Clubbing of fingers and toes in older kids
What percentage of VSDs close spontaneously within the first 2 years of life?
30-50%
What are the signs/symptoms of VSD?
Recurrent respiratory infections. Rapid breathing, poor growth, symptoms of CHF (in large defects). Small atrial pulse, JVP NOT affected.
What type of murmur is heard in VSD?
holosystolic murmur, loud, course, high-pitched, best heard along L sternal boarder in the 3-5 ICS. Smaller defect causes a louder murmur.
What do you feel with VSD?
Distinc lift along L sternal boarder and apical area. Smaller defects have more pronounced thrills than large ones.
What is the pathophysiology of PDA?
Blood flows through the ductus during systole and diastole, increasing pressure in the pulmonary circulation and consequently workload of the RV.
What are the signs/symptoms of PDA?
Asymptomatic when small, large one causes dyspnea on exertion. Dilated/pulsatile neck vessels, wide pulse pressure, LOUD murmur.
What is the PDA murmur like?
Harsh, loud, continuous murmur heard at the 1-3 ICS and lower sternal boarder with a machine-like quality. Mumur is unaltered by postural change, unlike mumur of venous hum.
What are the signs/symptoms of ASD?
Often asymptomatic. Heart failure rarely occurs in kids, often in adults. Ejection murmur, diastolic murmur, thrills, thrusts, S2 wide splitting.
What is the murmur like in ASD?
Diamond-shaped systolic ejection mumur (loud, high pitched, harsh) over pulmonic area. Brief rumbling diastolic murmur. They usually do not radiate beyond the precordium. Murmur is not impressive in fat kids.
What is palpated with a ASD?
Systolic thrill felt over ara of murmur, palpable parasternal thrust. Radiation to back in fat kids signals significance.
What is acute rheumatic fever (ARF)?
Systemic connective tissue disease occuring after streptococcal pharyngitis or skin infection.
What are the MAJOR manifestations of ARF?
Carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules
What are the MINOR manifestations of ARF?
Clinical, previous RF or Rheumatic heart disease, arthralgia, fever, labs, acute phase reactions (ESR, CRP, Leukocytosis), prolonged PR interval on ECG
What valves are affected in ARF?
Aortic & mitral => become stenotic and regurgitant
Who is affected by ARF?
Children between 5-15 years of age.
How can you prevent ARF?
Adequately treat streptococcal pharyngitis or skin infections
What is the supporting evidence for streptococcal infection?
Increased titer of antistreptolysin antibodies (streptolysin O), positive throat culture for GAS, recent scarlet fever. Presence of 2 MAJOR and 2 MINOR manifestations => HIGH probability if these 4 manifestations are preceeded by a GAS infection.
What are the signs/symptoms of ARF?
Fever, inflamed swollen joints, rash, aimless jerky movements, nodules under skin, chest pain, palpitations, fatigue, SOB, murmurs (mitral regurg/aortic insufficiency), cardiomegaly, friction rub of pericarditis, CHF
What is the rash called in ARF?
flat/slightly raised painless rash with pink margines with pale centers and a ragged edge (erythema marginatum)
What are the two types of chorea seen in ARF?
Sydenham chorea, or St. Vitus dance
How is ARF diagnosed?
Using the Jones Critera
What is Kawasaki disease?
Condition causing inflammation in walls of small and medium-sized arteries throughout the body, including coronaries.
What is Kawasaki disease also called?
Mucocutaneous lymph node syndrome = affects nodes, skin, mucous membranes
Who does Kawasaki disease effect?
80% => infants/children under 5 years.
What are the signs/symptoms of Kawasaki disease?
high fever (lasts longer than 5 days), conjunctivitis, crackled/red/inflamed lips, strawberry tongue, white coating on back of tongue, cervical lymphadenopathy, erythema of palms/soles, arthralgia, joint swelling symmetrically, irrritability, tachycardia
What are the diagnostic characteristics of Kawasaki disease?
Fever of 5 days duration with 4 out of 5 of the following: painless bulbar conjunctival injection w/ no exudate, changes in extremities (erythema, edema, desquamination), polymorphous erythematous rash of trunk/extremiteis (macular, morbilliform, target lesions), changes in lips/oral cavity (mucosal erythema, red/fissured/dry/swollen lips, strawberry tongue), cervical lymphadenopathy UNILATERAL (>1.5cm diameter)
What happens if patients with 5 day fever do NOT have 4 of the 5 diagnostic symptoms?
When they have CAD detected in echo/angiography.
What are the symptoms/signs of artherosclerotic heart disease?
Vascular wall thickening, narrowing of lumens. May be asymptomatic, but also have angina, SOB, palpitations, dysrhythmias, CHF
Who is at greater risk for artherosclerotic heart disease?
Family hx, early death, dyslipidemia
What are the symptoms/signs of mitral insufficiency/regurg?
Decompensated CHF, SOB, pulmonary edema, orthopnea, PND, decreased tolerance for exercise, sometimes asymptomatic, high-pitched PANSYSTOLIC murmur radiating to AXILLA, S3 heart sound.
What is the pathophysiology of angina?
when myocardial oxygen demand meets supply. Recurrent or acute.
What are the signs/symptoms of angina?
Substernal pain, intense pressure radiating to neck/jaws/arms on the L. SOB, fatigue, diaphoresis, faintness, syncope.
What is used to diagnose angina?
Tachycardia, tachypnea, HTN, diaphoresis, ischemia, crackles, reduced S1 intensity, S4 sounds.
What comorbidities may accompany angina?
COPD, xanthelasma, HTN, peripheral artery disease, abnormal pulsations on palpation over precordium, murmurs, arrhythias
What is senile cardiac amyloidosis?
Amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in heart
What is the pathophysiology of senile cardiac amyloidosis?
reduced heart contractility, causes heart failure
what are the signs/symptoms of senile cardiac amyloidosis?
Palpitations, lower extremity edema, fatibue, reduced activity tolerance, pleural effusion, arrythmia, lower extremity edema, dilated neck veins, hepatomegaly/ascites
What does the ECG look like on someone with senile cardiac amyloidosis?
Shows small, thickened LV. RV may also be thick.
What are the signs/symptoms of aortic sclerosis?
Asymptomatic. Can hear a MIDSYSTOLIC (ejection) murmur.