Professional Documents
Culture Documents
Definitions
Cardiac Output: volume of blood ejected from each ventricle during 1 minute (HR x SV)
o Stroke Volume: Volume of blood ejected each heart beat
Preload: the load that stretches the cardiac muscle before contraction
o The volume of blood in the RV at the end of diastole constitutes its preload for the next
beat
Myocardial contractility: ability of the cardiac muscle, when given a load to shorten.
o Increases when stimulated by action of the sympathetic nervous system
o Decreases when blood flow/oxygen delivery to the myocardium is impaired
Afterload: degree of vascular resistance to ventricular contraction.
Pulse Pressure: difference in Systolic and diastolic (EX: 140/80. Pulse pressure = (140-80) = 60)
Valve Sounds
Aortic valve: Right 2nd intercostal space
Pulmonic Valve: Left 2nd/3rd interspace close to
sternum
Tricuspid Valve: Lower left sternal border
Mitral Valve: Cardiac Apex
PQRST
P: atrial depolarization
Q: Septal depolarization
R: ventricular depolarization
S: following R
T: ventricular repolarization // recovery
Jugular Venous Pressure
Reflects right arterial pressure (= central
venous pressure and right ventricular end diastolic
pressure)
Best estimate from the right internal jugular
vein
JVP is best assess from pulsations in the right
internal jugular vein, which is directly in line with
the superior vena cava and right atrium.
To estimate level of JVP – find the highest point
of oscillation in the internal jugular vein
Measured in vertical distance above sternal angle (Angle of Louis)
3 Peaks
o A: Atrial contraction
o C: Carotid transmission (closure of tricuspid valve)
o V: Venous filling
Carotid Pulse
Look at: carotid upstroke, amplitude and contour, presence/absence of thrill or bruit
Amplitude and contour: assessed by placing patient HOB 30 degrees, then place index and middle
finger or thumb on carotid in the lower third of neck
o Amplitude correlates with pulse pressure
o Contour named by speed of upstroke – normal is brisk (smooth, rapid, follows S1
immediately)
*Never palpate both sides of carotid at the same time [Symbol] decreases blood flow can result in
syncope
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Pulsus Alternans: rhythm of the pulse remains regular but force of arterial pressure alternates
between strong and weak ventricular contractions
o Almost always indicates severe left ventricular dysfunction
o Usually felt with palpating radial or femoral arteries
o Alternating loud and soft korotkoff sounds or a sudden doubling of the apparent heart rate
as the cuff pressure declines = Pulsus Alternans
Paradoxical Pulse: greater than normal drop in systolic BP during inspiration
o 10 – 12 mmHg = paradoxical pulse
Carotid Artery Thrills and Bruits
o Auscultate for bruit (murmur like sound) – place diaphragm at the upper portion of neck
just below angle of jaw
Brachial Artery: used for patient with carotid obstruction, kinking or thrills
o Pt’s arm should rest with elbow extended with palm up
o Use index and middle finger or thumb of opposite hand
The Heart
*For a cardiac exam, stand on the patients right side. Pt should be supine with HOB at 30 degrees.
*To Assess PMI, have patient lay on left side – brings ventricular apex closer to chest wall.
S1 & S2
S1 ---Systole --- S2 ------ Diastole ------ S1 --- Systole --- S2
Diastole last longer than systole
S1 is usually louder than S2 at the apex, S2 is usually louder than S1 at the base
S1 diminished in: first degree heart block
S2 diminished in: aortic stenosis
INSPECTION
PALPATATION
Heaves, Lifts, Thrills; S1, S2, S3 and S4
o Heaves and Lifts: Use palm or fingerpads against chest
Produced by enlarged right or left ventricle or atrium
o Thrills: press ball of hand (near wrist) on chest to check for buzzing caused by turbulent
flow. If present ausculate for murmur. If thrill present it is atleast a grade 4 murmur
o S1 & S2: Place right hand on chest with left middle and index finger to palpate carotid
upstroke
For S3 and S4 apply lighter pressue
Left Ventricular Area
o Apical Impuse/PMI
If unable to palpate supine, have patient lay in left lateral decubitus position
If still unable, have pt exhale fully and stop breathing
Location:
Vertical position: 5th or 4th intercostal space
Horizontal position: distance in cm from midclavicular line
Diameter
Supine patient – less than 2.5cm (may feel larger in L lat decubitus)
Amplitude
Normal = small, brisk and tapping
Young adults may have hyperkinetic impulse during excitement
Duration *Most useful for ID hypertrophy of left ventricle
CARDIOVASCULAR
Auscultate heart sounds as your palpate apical impulse. Estimate proportion
of systole occupied by the apical impulse.
o Palpable S3 and S4
Left lateral decubitus, palpate apical impulse with one finger as patient exhales and
briefly stops breathing
S3: brief early middiastolic impulse
S4: outward movement just before S1
Right Ventricular Area {Left sternal border 3rd, 4th, 5th interspaced
o Supine, head elevated to 30degrees. Pt exhale and briefly stop breathing & palpate for
systolic impulse of RV.
If impulse noted – ass location, amplitude and duration
o If increased AP diameter – have patient inhale and stop breathing – palpate for RV in
epigastric area with your hand flattened, press index finger under rib cage and up towards left
shoulder
Pulmonic Area {Left 2nd interspace}
o Overlies pulmonary artery
Aortic Area {Right 2nd interspace}
o Overlies aortic outflow tract
o Pulsations suggest: dilated or aneurysmal aorta
PRECUSSION
Palpation has replaced percussion for estimating heart size
AUSCULATION
6 Points of Auscultation
o RIGHT 2nd interspace – aortic
o LEFT 2nd interspace – pulmonic
o LEFT 4th and 5th interspace – tricuspid
o LEFT 5th midclavicular line – mitral (Apex)
Stethoscope
o Diaphragm – best for high pitched sounds of S1 and S2, the murmurs of aortic and mitral
regurgitation and pericardial friction rubs
o Bell – best for low pitched sounds of S3 and S4 and murmur of mitral stenosis
Use at apex then move medially along the lower sternal border
Apply LIGHT pressure; rest hand on chest to help maintain light pressure
Pattern of Auscultation
o Start with pt’s head and upper chest elevated 30 degrees – start at base or apex. Listen first
with diaphragm then bell.
Important Maneuvers
o Mitral stenosis: Pt in left lateral decubitus postion – brings left ventricle closer to chest
wall
Accentuates left sided S3 and S4
o Aortic regurgitation: Sit up, lean forward, exhale completely and stop breathing
Use diaphragm along left sternal border and apex
Could miss soft diastolic decrescendo murmur if not in this position.
ID Systole and Diastole
o As you auscultate chest, palpate right carotid artery in lower third of neck.
S1 falls just before the carotid upstroke and S2 follows carotid upstroke
Base: S2 louder than S1
Apex: S1 is louder than S2
o Systole: interval between S1 and S2
o Diastole: interval between S2 and S1
CARDIOVASCULAR
S1 ---Systole --- S2 ------ Diastole ------ S1 --- Systole --- S2
Heart sounds
o Split S2:
Listen in 2nd and 3rd interspace
Note: Width, Timing and intensity
Expiratory splitting = valvular abnormalities
o Extra Sounds in Systole
Ejection sounds or systolic clicks
Most common: systolic click of mitral valve prolapse
o Extra Sounds in Diastole
S3, S4, or opening snap
S3 and S4 in athletes is normal
Heart Murmurs
o Timing:
Systolic Murmur: falling between S1 and S2
Murmur that coincide with carotid upstroke = systolic murmur
Mid systolic: begin after S1 and stop before S2 – arise from aortic or
pulmonic valve [Aortic stenosis, hypertrophic cardiomyopathy, pulmonic
stenosis]
Pansystolic: Starts with S1 and Stops with S2 – occurs with regurgitant flow
across AV valves [mitral & tricuspid regurgitation, ventricular septal defect]
Late systolic: starts mid/late systole and persist up to S2. - mitral
valve prolapse
Diastolic murmur: falling between S2 and S1
Usually represent valvular heart disease
[[ Aortic regurgitation & Mitral stenosis]]
Early diastolic: starts after S2 fades until S1 – regurgitation across
aortic/pulmonic
Mid diastolic: start short time after S2 and fades – turbulant flow across AV
valve
Late diastolic: starts late in diastole up to S1
o Shape
Cresendo: grows louder {presystolic murmur of mitral stenosis}
Decresendo: grows softer {early diastolic murmur of aortic regurgitation}
Crescendo-Decrescendo: first rises then falls
Plateau: same internsity throughout
o Location of Maximum intensity
Where you hear it in the intercostal space and its proximity to sternum
EX: 2nd right interspace often originates in aortic valve
o Intensity
Grading
Grade 1 – very faint, heard only if “tuned in”
Grade 2 – quiet but heard immediately
Grade 3 – moderately loud
Grade 4 – Loud, palpable thrill
Grade 5 – Very loud, with thrill
Grade 6 – very loud with thrill (may be heard with stethoscope off chest)
o Pitch
Low, medium or high
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o Quality
EX: blowing, harsh, rumbling and musical
Right sided murmur = increase with inspiration
Left sided murmur = increased with expiration
EX: Medium pitched, grade 2/6, blowing decrescendo diastole murmur, best heard in 4th intercostal space
with radiation to the apex
Hypertrophic cardiomyopathy – supine patient to bear down. Place hand on mi abdomen and ask patient
to strain against it. Place stethoscope on patient's chest and listen at the left lower sternal border
**INCREASES during strain phase
Heart Failure & Pulmonary hypertension – inflate 15 mmHG higher than systolic. Have patient bear down
for 15 seconds then return to normal breathing. Keep inflated and listen for korotkoff sounds over
brachial artery.
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