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237 Cards in this Set

  • Front
  • Back
What is the relationship with the chest surface anatomy and the positioning of the heart?
The heart is positioned behind the sternum and the contiguous parts of the third to the sixth costal cartilages.
What is the area of the heart that is known as the base?
The broader upper portion
What is the area of the heart that is known as the apex?
The narrower lower tip of the heart
What is the likely positioning of the heart in a tall slender person?
The heart tends to hang vertically and to be positioned centrally
What is the difference between dextrocardia and situs inversus?
In situs inversus, the heart and stomach are placed to the right and the liver to the left.
In dextrocardia, the heart is positioned to the right
What is the likely positioning of the heart in a short stocky person?
The heart tends to hang more to the left and more horizontally
What is the primary function of the atria?
They act primarily as reservoirs for blood returning tothe heart from the veins throughout the body.
What forms the anterior surface of the heart?
It is formed by the right ventricle
Where is the apical impulse felt?
Usually in the 5th left intercostal space at the midclavicular line
What valves are known are the atrioventricular valves?
mitral and tricuspid
What causes the opening of the AV valves?
the atria contracting
What causes the closing of the AV valves?
The contraction of the ventricles
The relaxation of the ventricles cause the ____ of the semilunar valves
closure
What produces the first heart sound?
As systole begins, ventricular contraction raises the pressure in the ventricles and forces the mitral and tricuspid valves closed. The valve closure makes the S1 sound
Lubb is the ____ heart sound.
first
Dubb is the _____heart sound
second
When the aortic and pulmonic valves close, the ventricular pressure is ___ than the aorta and pulmonary artery.
less
What is responsible for S3?
Ventricular filling during diastole
What is responsible for S4?
Atrial contraction
What happens first atrial refilling or ventricular contraction
They happen at the same time
When ventricular pressure is ____ atrial pressure, the mitral and tricuspid valves open.
below
Is it normal to have a split S2?
Yes, this represents the two components of the second heart sound.
A2 is the closure of the aortic valve
P2 is the closure of the pulmonic valve
What heart sound does the jugular a wave correspond to?
S4 --> atrial systole
Isometric relaxation of the ventricle corresponds to the Aortic valve ____ and the AV valve _____
closing
opening
The jugular wave c corresponds to what part of the ventricular ejection phase?
rapid ejection phase
Isometric contraction of the ventricle corresponds to the Aortic valve _____ and the AV valve _____
opening
closing
When is the U wave sometimes seen?
just after the T wave
What causes normal variation in the QT interval?
The cardiac rate
How long does the PR interval usually last?
0.12 to 0.20 seconds
When do we expect the diastole to equal systole in length?
When the heart rate is about 120
When the heart is beating at a rate of 68 to 72 beats per minute, ventricular systole is ________ than diastole.
shorter
What represents ventricular depolarization on the EKG?
QRS complex
What represent ventricular repolarization on the EKG?
ST segment and T wave
What represents the time from initial stimulation of the atria to initial stimulation of the ventricles on the EKG?
PR interval
How long does a normal QRS typically last?
less than .10 seconds
What is responsible for pumping blood into the systemic circulation of the fetus?
Both the right and left ventricle
How does the right ventricle bypass the lungs to get blood to the systemic circulation in the fetus?
The RV pumps blood through the PDA rather than through the lungs
How long does it take for the patent ductus arteriosus to normally close?
Within 24 to 48 hours
When should we expect to see the relative sizes of the left and the right ventricle approach that of an adult?
by age 1
What is the normal ratio of the left and right ventricle in an adult?
2:1
How would we locate the apex of the heart in a child using the surface anatomy?
4th intercostal space
What is the position of the heart in a child?
It is usually more horizontal in a child
When should we expect to see the positioning of the heart to approximate an adult?
By the age of 7 years
What is mainly responsible for the increase in the 40% to 50% increase in blood volume in pregnant female?
Increase in plasma volume
At what time frame during pregnancy is it ever normal for the blood pressure to be elevated ?
Never
What do you expect to return back to the prepregnancy level fastest the Blood volume or the cardiac output?
The cardiac output returns back to normal about 2 weeks after delievery
When you examine your pregnant patient, you start to search for the PMI. Where would you expect the PMI to be ?
You expect the heart to be shifted in a horizontal position so the PMI would be higher than normal
When does the cardiac output reach the highest level in a pregnant female?
about 25 to 32 weeks
What age- related cardiovascular changes make an elderly person susceptible to orthostatic hypotension.
Increased vagal tone and decreased baroreceptor sensitivity
In an elderly person, you expect excercise tolerance to _____, due to ___ cardiac output, ____ stroke volume, _____Heart rate
Decrease
Decreased
Decreased
Decreased
In an elderly person, what is a common ECG change Left Anterior Hemiblock or Left posterior hemiblock?
Left anterior hemiblock
What peaks first in a pregnant woman the heart rate or the cardiac output?
The Heart rate and the stroke volume peak at 28th week
The cardiac output and the blood volume peak at 20th week
What is the precordial catch?
It is a sudden, sharp relatively brief pain that does not radiate, occurs most often at rest and is unrelated to exertion
It may not have a discoverable cause
What are the different types of chest pain that is relieved by eating?
Esophageal
from a peptic ulcer
What are the different types of chest pain that could be caused by eating?
Anginal
Biliary
What types of chest pain are precipitated by emotion?
Anginal
Psychoneurotic
What GI source of chest pain could also trigger angina?
Biliary
Which GI source of chest pain could also be relieved by nitroglycerin?
Esophageal
Anginal
What type of chest pain can awaken the patient from sleep?
Either GI or angina pectoris
______ is associated with pain often early morning
_______is associated with pain worse in the evening after a day of physical effort.
Angina Pectoris
Musculoskeletal
What is the correct order of examining the heart?
Inspection
Palpation,
Percussion
Auscultation
Where should we look for inspection of the Apical impulse?
the apical impulse should be visible at about the MCL in the 5th left ICS
What should be a differential diagnosis, when the apical impulse is only visible when the patient is sitting up.
This is a normal variant
This maneuver brings the heart closer to the anterior wall.
What are the different causes of a downward and laterally displaced PMI?
Increased cardiac output
Left ventricular hypertrophy
What is a possible cause of a lift along the left sternal border?
Right ventricular hypertrophy
What is usually the radius of the PMI?
1 cm
You feel a palpable rushing vibration over the apex in diastole. How would you predict the valvular lesion?
A thrill likely caused by mitral stenosis
What are the possibilities of a diastolic thrill along the right sternal border?
Aortic regurgitation
Aneurysm of ascending aorta
How would you grade a murmur that has presented itself early in the examination as a palpable thrill?
Likely at or greater than grade IV level murmur
The carotid pulse is synchronous to _____.
S1
What is the likely cause of a thrill along the left lower sternal border?
Tetralogy of Fallot
When percussing the heart, you should start at the _____ line, move medially along the intercostal spaces toward the ________.
anterior axillary
sternal border
When percussing, what percussion note change should alert you to the cardiac border?
The change from a resonant to a dull note
Why is the percussion of the right ventricle of limited value?
The right ventricle tends to enlarge in the AP diameter rather than laterally
S1 marks the beginning of _____
systole
S1 coincides with the ____of the carotid pulse
rise (upswing)
What is the best position to hear high- pitched murmurs?
With the patient sitting up and leaning slightly forward.
What is the phase of respiration that augments a high pitched murmur?
In expiration
What is the best position to the low- pitched sounds?
In the left lateral recumbent position
S2 marks the initiation of ______
diastole
Which is lasts longer systole or diastole in a normal heart rate?
Diastole
When should we expect for the systole to equal diastole?
when the heart rate is rapid
During which phase of respiration augments the splitting of S2?
Inspiration
Under what valvular condition would produce a loud S1
The mitral valve stenosis
A grade IV systolic murmur with a thrill in the left lower sternal border would likely be ______ but a grade IV systolic murmur with a thrill in the left upper sternal border would likely be ________
Tetralogy of Fallot
Patent ductus arteriosus
What is splitting?
The failure of the mitral and tricuspid valves to close simultaneously or the failure of pulmonic and aortic valves to close simultaneously.
What mauevers can augment the splitting of S1?
Although the splitting of S1 is not usually heard because the sound of the tricuspid valve closing is too faint too hear. Rarely, however, it may be audible in the tricuspid area, particularly in deep inspiration
Pulmonary hypertension would lead to a _____ S1
Softer
Systemic hypertension would lead to a _____ S1
softer
Emphysema would cause a ______S1
softer
Mitral valve stenosis would cause a _______ S1
louder
Where would you auscultate to hear the Loudest S1?
Apex
When systole begins with the mitral valve open, this would produce a _____ S1
loud
The split S2 decreases with ______ and increases with ______.
exhalation
inhalation
What area do you auscultate to hear the duration of S1 <S2
Nowhere;
In all positions S1 lasts longer than S2
Where would you auscultate to hear the loudest A2
Aortic area
Where would you auscultate to hear the loudest P2
the second pulmonic area
Where is S1 best heard?
Toward the apex in the mitral and tricuspid area
What produces the S1 sounds?
It results from the closure of the AV valves
What produces the S2 sounds
It results from the closure of the semilunar valves
Which heart sound indicates the end of systole?
S2
Which heart sound indicates the start of systole?
S1
S2 is ____ than S1 at the base of the heart but _____ than S1 at the apex
louder
softer
Which is heard better at the base S3 or S4?
Neither, both are heard at the apex
In pulmonary hypertension S1 is ____ and S2 is ______.
decreased
increased
What conditions would increase P2?
Pulmonary hypertension
mitral stenosis
CHF
With mitral valve stenosis S1 is ____ and S2 is _____
loud
loud
What is fixed splitting?
When the splitting is unaffected by respirations
Why should we expect splitting?
The ejection times are longer on the right so the pulmonic valve closes later.
Depolarization occurs earlier on the left side
What conditions would produce fixed splitting?
Large ASD
VSD with left to right shunting
RVH
Fixed splitting occurs when the RV output is ___ than the left
greater
Left bundle branch block creates _____ splitting of S2 and right bundle branch block creates _______ splitting of S2.
paradoxical
wide
What would be the changes to S2 would you expect with mitral regurgitation
wide splitting
What valvular stenosis produces wide splitting?
pulmonary
The emptying of which ventricle is responsible for wide splitting?
right ventricle
What causes the S3 sound?
The early passive flow of blood into the ventricle early in diastole. This distends the ventricular walls and causes vibration
The ___ phase of ventricular filling causes S3 and the _____ phase of ventricular filling causes S4
early
late
What causes the S4 sound?
Atrial ejection of blood into the ventricles causing vibration in the valves, papillae, and ventricular walls
What is the best patient positioning to hear a S3
Left lateral recumbent position
What hormonal imbalance can produce a S4?
Elevated thyroid hormone in thyrotoxicosis
Which heart sound is produced by poor ventricular compliance, S3 or S4?
both
When examining a patient, S1 and S2 sound like ten-nes-see, how should you document this murmur?
and a present S4
Which is known as the presystolic gallop rhythm S3 or S4?
S4
Which is known as the protodiastolic gallop rhythm S3 or S4?
S3
What maneuvers will accentuate S3 and S4?
Asking the patient to raise a leg - increasing venous return
Asking the patient to grip your hand vigorously and repeatedly- increasing arterial pressure
Which valves typically produce ejection clicks?
Stenosis of semilunar valves
During what phase of respiration is a pulmonary ejection click murmur heard?
Expiration
Which phase of the cardiac cycle do you typically hear a pericardial friction rub?
during both systole and diastole
Where is a pericardial friction rub heard best?
at the apex
A prosthetic mitral valve has a murmur early in _____ and a prosthetic aortic valve has a murmur early in ______
diastole
systole
What are the three components of the pericardial friction rub?
It may have three components associated with Atrial component of systole, ventricular systole, and ventricular diastole
Which drugs are known to increase S1
Amyl nitrate
epinephrine
Atropine
What are some causes for an opening snap?
It is caused by the abrupt recoil of a stenotic mitral or tricuspid valve
What is a quadruple rhythm?
S1, S2, S3, S4 are all heard separately.
What typically accompanies a tricuspid stenosis?
It is usually seen with mitral stenosis?
What murmur typically has a late systolic murmur that crescendos if mild and is an early systolic murmur that decrescendos if severe
Mitral regurgitation
What is typically a holosystolic, plateau shaped intensity, blowing murmur that radiates to the left axilla.
Mitral regurgitation
What does it mean to have a diamond shaped murmur?
crescendo-decrescendo murmur
Can you name some systolic diamond shaped murmurs?
Aortic stenosis
Subaortic stenosis
Pulmonic stenosis
Can you name some diastolic diamond shaped murmurs?
Aortic regurgitation
Pulmonic regurgitation
What is an Austin- Flint murmur?
A low-pitched rumbling murmur heard at the apex that is associated with Aortic regurgitation.
Tricuspid Stenosis is associated with a large ____ wave but Tricuspid Regurgitation is associated with a large _____ wave.
a
v
Which murmur is associated with a double wave in the carotid?
Subaortic Stenosis
Which murmur is associated with decreased arterial pulse amplitude, mitral stenosis or tricuspid stenosis?
Both
Which murmur is associated with decreased arterial pulse amplitude, Mitral stenosis or subaortic stenosis?
mitral stenosis
Subaortic stenosis has a brisk arterial pulse
Which murmur is typically a late systolic murmur preceded by a midsystolic click?
Mitral Valve Prolapse
Why does mitral valve prolapse typically present with a late systolic murmur preceded by a midsystolic click?
This is because the valve is competent early in systole but prolapses into the atrium later in systole.
What chest wall deformity is commonly associated with mitral valve prolapse?
Pectus Excavatum
What murmurs can result as secondary to pulmonary hypertension?
Pulmonic regurgitation
Tricuspid regurgitation
Which murmur can result in a widened pulse pressure?
Aortic regurgitation
Can you name the different holosystolic murmurs?
Mitral regurgitation
Tricuspid regurgitation
What murmur can result in a palpable pulmonary artery impulse over the second left ICS?
In the setting of pulmonary hypertension, tricuspid regurgitation
You palpate a Corrigan pulse over both the femoral and the carotid arteries, what murmur should you expect?
Aortic Regurgitation
What visible precordium signs, indicate RVH?
Visible right parasternal lift
How do you assess for aortic regurgitation?
Listen with the diaphragm, have the patient sit and lean forward
What disease does a Still murmur indicate?
none
an innocent murmur
What is the cause of a Still murmur?
It is the result of vigorous myocardial contraction, the resulting stronger blood flow in early systole or midsystole, and the rush of blood from the larger chamber of the heart into the smaller bore of a blood vessel
You are conducting a high school sports physical and you hear a grade II midsystolic murmur with a split S2 that disappears when the patient sits up. What do you suspect?
An innocent (Still) murmur
What maneuver would differentiate between pulmonic stenosis and VSD
Using transient arterial occlusion; placing blood pressure cuffs on bilateral upper arms and simultaneously inflating to 20 to 40 mmHg above the patient's Blood pressure
What is the difference between a grade 5 and a grade 6 murmur?
Grade 6 has a palpable and visible thrill and can be heard with the stethoscope not in contact with the chest.
Grade 5 is very loud and the thrill is easily palpable
What is the difference between an early diastolic and a mid-diastolic murmur
An early diastolic murmur can be heard with S2 and a mid-diastolic murmur can be heard at a clear interval after S2
A plateau murmur has _____ intensity and a crescendo murmur has ______intensity.
constant
increasing
What is the difference between a grade III and a grade IV murmur?
grade III is moderately loud but a grade IV is loud and is associated with a thrill
Right sided murmurs ____ with expiration and ____ with inspiration.
decrease
Increase
To increase the intensity of a systolic murmur caused by cardiomyopathy, what maneuver should be performed?
going from the squatting to standing position rapidly for 30 seconds
What is sinus dysrhythmia?
A cyclic variation of the heart rate characterized by an increasing rate on inspiration and decreasing rate on expiration
Examine the heart of a newborn once at _____ and again at ______.
within the first 24 hours
2-3 days later
Which other organ systems need to be considered when examining the heart of a new born
skin
lungs
liver
What is more commonly the presenting physical finding in a newborn with right-sided congestive heart failure?
large firm livers
A newborn with purplish skin should immediately suggest _______ to you.
polycythemia
A mother of a newborn calls your office with complaints that her child's fingers and toes are bluish. How should you counsel her?
Reassure, it usually disappears within a few days or even a few hours after birth
A mother of a newborn calls your office with complaints that her child's face is bluish. How should you counsel her?
Have her go to the ER, this can suggest CHF
Where should you feel the Apical impulse of a newborn?
It is felt at the fourth and fifth left intercostal space just medial to the midclavicular line
Where should you expect the apical impulse to be in a left sided pneumothorax ?
It would be deviated away, in the right ward direction
What clinical condition should you expect if you are able to palpate the closure of the pulmonary valve in the second left intercostal space in a newborn?
None
The right ventricle is relatively more vigorous than the left
When you reexamine a newborn for the second time, two days later, you notice a new split S2. What should be concerned about?
Nothing
Splitting of the heart sounds is common. S2 is usually heard with a split at birth, then often splits within a few hours
Why are murmurs common in newborns?
Most murmurs are innocent and are the result of the transition from fetal to pulmonic circulation.
What are some common characteristics of innocent newborn murmurs?
Systolic, Grade I to II, unaccompanied by other signs and symptoms
What maneuvers can help you distinguish a right to left shunt from a left to right shunt in a newborn?
Push up on the liver to increase the right atrial pressure.
This should intensify a right to left shunt but it should cause the left to right shunt or PDA to disappear
What are some characteristics of a murmur in a newborn that should cause concern?
1. If heard continuously after a few days of life
2. Has a diastolic component
3. has a radiations
4. Fills Systole
5. Is intense
What is a characteristics of a patent ductus arteriosus murmur?
continuous, machinery- like
What has more diagnostic significance in a newborn, diastolic or systolic murmurs?
Diastolic murmurs are always significant
What should be the differential diagnosis in a baby with a diastolic murmur?
Early closing ductus arteriosus or
pulmonary insufficiency
What concerns should you have in an infant whose heart rate drops from 180 to 120 when sleeping?
none
Infant's heart rates are more variable than that of older children.
The variation is greatest at or shortly after birth
What are the expected changes in a child with longstanding cardiomegaly?
A bulging precordium, because a child's thoracic cage tends to be more cartilaginous and yeilding than that of an adult
What is the the expected rate of a 6 year old?
75 to 115
What are the common ages for Still murmurs?
age 3 to 7
A still murmur should ____ with activity and ______ with when the child is quiet.
increase
decrease
The heart rate gradually ______ with pregnancy.
increases
What is the expected increase in the heart rate of a pregnant patient?
10 to 30% increase
What are the expected changes to the apical impulse in a pregnant female?
The apical impulse should move upward and lateral by 1 to 1.5 cm
You auscultate a S4 in a pregnant female, how should you reassure the patient?
You need to schedule an echo, this is an abnormal finding
You auscultate a S3 in a pregnant female, how should you reassure the patient?
This is common due to the increased blood volume and extra effort of the heart
You auscultate an grade II systolic ejection murmur over the left second ICS that intensifies with inspiration in a pregnant female. How should you reassure the patient?
This is normal and occurs in 90% of pregnant females
You auscultate an grade II systolic ejection murmur over the left second ICS that intensifies with expiration in a pregnant female. How should you reassure the patient?
This is normal and occurs in 90% of pregnant females
Where should we find Janeway lesions?
They are small erythematous or hemorrhagic macules that appear on the palms and soles
What effects should the age- related aortic lenghtening and sclerosis produce?
An early soft physiologic murmur
Where should we palpate Osler nodes
In a patient with bacterial endocarditis, these appear on the tips of the fingers and toes
What is the expected heart rate in a newborn?
120 -170 beats per minute
What extra heart sound is commonly present in an MI?
S4
What position is known to worsen the pain in a patient with pericarditis?
supine
Why are diabetic adults likely to get diastolic CHF?
Diastolic CHF is a result of advanced glycation cross- linking collagen and creating a stiff ventricle that is unable to dilate actively.
What is the most helpful finding in diagnosing left-sided CHF?
JVD
What type of CHF would have a wide pulse pressure?
systolic
What type of CHF would have a narrow pulse pressure?
diastolic
What is Beck's triad associated with?
cardiac tamponade
What is Beck's triad?
JVD
Hypotension
muffled heart sounds
Name some acute causes of Cor pulmonale.
Acute respiratory distress syndrome
Massive pulmonary embolism
What is the Cor pulmonale?
The enlargement of the right ventricle secondary to pulmonary malfunction
What are the four abnormalities in the Tetralogy of Fallot
Overriding aortic valve
VSD
Stenotic pulmonary valve
RVH
Describe a tet spell
Paroxysmal dyspnea with loss of consciousness and central cyanosis
Describe the murmur associated with Tetralogy of Fallot.
Systolic ejection murmur over the 3rd intercostal space, sometimes radiating to the left side of the neck
A single S2 is heard
What is the percentage of VSDs that will close on their own within two years?
30 -50 % of small defects will close spontaneously during the first 2 years of life
A small child is examined in your office, and you hear a loud holosystolic murmur along the left sternal border in the 3rd to 5th ICS but there is no JVD and no precordial thrill. What is your diagnosis?
A large VSD.
The arterial pulse is small and jugular venous pulse is unaffected
A smaller defect causes a louder murmur and a more easily felt thrill
Describe eythema marginatum
It is a flat or slightly raised rash with pink margins with pale centers and a ragged edge
What is the typical murmurs of acute rheumatic fever?
Mitral Regurgitation
Aortic Insufficiency
Which is more likely to cause CHF in a child, a large ASD or a large VSD
A large VSD, heart failure rarely occurs in children with ASD
What maneuvers can differentiate a murmur caused by patent ductus arteriosus and murmur of venous hum?
A murmur caused by PDA is unaltered by a postural change unlike venous hum
You hear a continuous machinery like murmur at the first to third ICSs and the lower sternal border in a newborn. What should you suspect?
Patent ductus arteriosus
In a child with PDA, what would you predict as the pulse pressure?
Widened
In cardiac tamponade, which side of the heart has restriction in filling? The left or the right?
The right
You hear a loud diamond shaped systolic ejection murmur that is heard over the pulmonic area in a 3 year old. What would you expect would happen to the S2?
It would be widely split. This is a murmur of atrial septal defect.
What is a common spot for radiation in a significant loud diamond shaped systolic ejection murmur that is heard over the pulmonic area?
This is a murmur caused by ASD, it can radiate to the back
What is the normal sequlea for a valve that is affected by ARF?
It becomes regurgitant and stenotic
What valves are most commonly affected in ARF?
Aortic and mitral
Describe the Jones Criteria for diagnosing ARF.
the presence of two major or one major and two minor manifestations suggest a high probability of ARF, if supported by evidence of a preceding group A streptococcal infection
Name all of the minor criteria for the diagnosis of ARF
Previous RF or rheumatic heart disease
Fever
Arthralgia
Elevated ESR
leukocytosis
C-reactive protein
prolonged PR interval on EKG
You see a patient in the office with arthralgias, fever, with a prolonged PR interval on EKG. You perform a rapid strept test that is positive. Can you diagnose the patient with ARF?
NO
you need one major and two minor manifestations or one major and two minor manifestations
What type of arteries are the target in Kawasaki disease?
small and medium -sized arteries
How would you expect the appearance of the left ventricle to appear in a patient with known senile cardiac amyloidosis on echo?
Small, thickened
You see a three year old child with a history of fever for 6 days, painless pink eye, a polymorphous rash on the trunk and both legs. You suspect Kawasaki disease but what tools would you need to confirm the diagnosis.
You need to detect coronary artery disease by two dimensional echo or coronary angiography
Name the five findings that are common in Kawasaki.
Painless bulbar conjunctiva injection without exudate
Changes in extremities including erythema, edema, and desquamation
Polymorphous eyythematous rash of the trunk and extremities
Changes in the lips and oral cavity including diffuse oral or pharyhgeal erythma; red strawberry tongue
Cervical lymphadenopathy usually unilateral
What are the typical findings on the tongue for Kawasaki disease?
Strawberry tongue, white coating on the tongue, prominent papillae on the back of the tongue
What age group is typically affected by Kawasaki disease?
80% of the time it affects infants and children under 5 years of age
What murmur can be confused with carotid bruits?
Aortic Stenosis
It can radiate along the left sternal border and to carotid with palpable thrill
When palpating the apex, you feel a palpable thrill in diastole. What murmurs would you suspect?
Mitral stenosis
Subaortic stenosis
When palpating the apex, you feel a palpable thrill in systole. What murmurs would you suspect?
Mitral regurgitation