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LEIK Cardiovascular System Review graded A+
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LEIK Cardiovascular System Review graded A+
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LEIK Cardiovascular System ReviewAcute Myocardial Infarction (MI) - ANSMiddle-aged or older male complains of midsternal chest
pain that feels like heavy pressure on the chest. The pain is associated with numbness and/or
tingling in the left
jaw and the left arm. The patient is diaphoretic with cool, clammy skin. Women with MIs are
more likely to present with nonspecific symptoms such as dyspnea, fatigue, back pain, and
nausea.
Dissecting Abdominal Aortic Aneurysm (AAA) - ANSElderly white male complains of
pulsating-type sensation in abdomen and/or low back pain. With impending rupture, sudden
onset of severe chest and low back pain that
steadily becomes sharp and excruciating. Patients with hypertension (HTN) and smokers
are at higher risk.
Congestive Heart Failure (CHF) - ANSElderly patient complains of an acute (or gradual) onset
of dyspnea, fatigue, dry cough, and swollen feet and ankles. The patient has a sudden (or
gradual) increase in weight.
Lung exam will reveal crackles on both the lung bases (bibasilar crackles) along with an S3
heart sound. History of preexisting coronary artery disease (CAD), prior MI, or
previous episode of CHF is possible. Usually is taking diuretics, digoxin (Lanoxin), and
antihypertensive medications.
Bacterial Endocarditis - ANSPatient presents with fever, chills, and malaise that is associated
with a new murmur and the abrupt onset of CHF. Associated skin fi ndings are found mostly on
the fingers/
hands and toes/feet. These are subungual hemorrhages (splinter hemorrhages on the nailbed),
petechiae on the palate, painful violet-colored nodes on the fingers or feet
(Osler nodes), and tender red spots on the palms/soles (Janeway lesions).
Anatomy - ANSPosition of the Heart
Most of the left ventricular mass is located behind the right ventricle. The right ventricle sits
anteriorly toward the chest. It is the chamber of the heart that lies closest to the sternum.
A large part of the atria is located posteriorly facing the back. The lower border of the left
ventricle is where the apical impulse is generated.
■ Apical impulse: Located at the 5th intercostal space (ICS) by the midclavicular line on the left
side of the chest.
Displacement of the Point of Maximal Impulse (PMI) - ANS■ Severe left ventricular hypertrophy
(LVH) and cardiomyopathy: The PMI is displaced laterally on the chest, is larger (more than 3
cm) in size, and is more prominent.
,■ Pregnancy, third trimester: As the uterus grows larger, it pushes up against the diaphragm and
causes the heart to shift to the left of the chest anteriorly. The result is a displaced PMI that is
located slightly upward on the left side of the chest.
Deoxygenated Blood - ANS■ Enters the heart through the superior vena cava and inferior vena
cava.
■ Right atrium → tricuspid valve → right ventricle → pulmonic valve → pulmonary artery → the
lungs → alveoli (red blood cells [RBCs]) pick up oxygen and release carbon dioxide.
Oxygenated Blood - ANS■ Exits the lungs through the pulmonary veins and enters the heart.
■ Left atrium → mitral valve → left ventricle → aortic valve → aorta → general
circulation.
Systole and Diastole - ANSSystole Diastole
MOTIVATED APPLES
M (mitral valve)
T (tricuspid valve)
AV (atrioventricular valves)
A (aortic valve)
P (pulmonic valve)
S (semilunar valves)
S1 (Systole) - ANS■ The "lub" sound (of "lub-dub")
■ Closure of the mitral and tricuspid valves
■ Atrioventricular (AV) valves (three leaflets)
S2 (Diastole) - ANS■ The "dub" sound (of "lub-dub")
■ Closure of the aortic and pulmonic valves
■ Semilunar valves (two leaflets)
S3 Heart Sound - ANS■ Pathognomic for CHF (CHF or heart failure).
■ Occurs during early diastole (also called a "ventricular gallop" or an "S3 gallop").
■ Sounds like "Kentucky."
■ Always considered abnormal if it occurs after the age of 35.
This may be a normal variant in some children or young adults if there are no signs or
symptoms of heart or valvular disease.
*Heard with bell
,S4 Heart Sound - ANSCaused by increased resistance due to a stiff left ventricle; usually
indicates LVH; considered a normal finding in some elderly (slight thickening of left ventricle).
■ S4 occurs during late diastole (also called an "atrial gallop" or "atrial kick").
■ Sounds like "Tennessee."
■ Best heard at the apex or apical area (mitral area) using the bell of the stethoscope.
*Heard with bell
Summation Gallop - ANS■ All heart sounds are present (from S1 to S4) and sound like a
galloping horse.
■ A pathologic finding.
Stethoscope Skills - ANSBell of Stethoscope
■ Low tones such as the extra heart sounds (S3 or S4)
■ Mitral stenosis
Diaphragm of the Stethoscope
■ Mid- to high-pitched tones such as lung sounds
■ Mitral regurgitation
■ Aortic stenosis
Benign Split S2 - ANSBest heard over the PULMONIC area (or second ICS left side of
sternum); due to splitting of the aortic and pulmonic components; a normal finding if it
APPEARS during INSPIration
and DISappears at EXPIration.
Benign S4 in the Elderly - ANSSome healthy elderly patients have an S4 (late diastole) heart
sound; also known as the "atrial kick" (the atria have to squeeze harder to overcome resistance
of a stiff left
ventricle). If there are no signs or symptoms of heart/valvular disease, it is considered a normal
variant.
SOLVING QUESTIONS: HEART MURMURS - ANSTo solve a murmur question correctly, only
two pieces of information are needed.
■ Look for the timing of the murmur (systole or diastole).
■ Look for the location of the murmur (aortic or mitral area).
All the murmurs seen on the exams will fit into the following two mnemonics:
Mr. ASS (Mitral Regurgitation, Aortic Stenosis, Systolic)
Ms. ARD (Mitral Stenosis, Aortic Regurgitation, Diastolic)
MR (Mitral Regurgitation)
, *Listen w/ Diaphragm
SYStolic Murmur - ANSA PANsystolic (or HOLOsystolic) Starts at S1 continues to S2 murmur:
■ Heard best at the APEX of the heart or the apical area
■ Radiates to AXILLA.
■ LOUD BLOWING and high-pitched murmur (use the DIAPHRAGM of the stethoscope)
AS (Aortic Stenosis)
*Listen w/ Diaphragm
SYStolic Murmur - ANSA MIDsystolic ejection murmur:
■ Best heard at the SECOND ICS at the RIGHT side of the sternum
■ Radiates to the NECK
■ A HARSH and NOISY murmur (use diaphragm of stethoscope)
Patients with aortic stenosis should AVOID PHYSICAL OVEREXERTION! As there is
INCREASED risk of SUDDEN DEATH!
Monitored by serial cardiac sonograms with Doppler fl ow studies. Surgical valve replacement if
worsens.
*AVOID PHYSICAL OVEREXERTION!
MS (Mitral Stenosis)
DIAstolic Murmur - ANSA LOW-pitched DIAstolic RUMBLING murmur:
■ Heard best at the APEX of the heart or the APICAL area
■ Also called an "OPENING SNAP" (use BELL of the stethoscope)
*Diastolic murmurs are ALWAYS indicative of HEART DISEASE!
AR (Aortic Regurgitation)
DIAstolic Murmur - ANSA HIGH-pitched DIAstolic murmur:
■ Best heard at the second ICS at the RIGHT side of the sternum
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