Heart Sounds and Cardiac Output

Week 5 Topics

• Subject matter is Health Assessment Exam 2 Study Guide topics and facts

Heart Sounds

• S1 marks the start of systole, loudest at the apex, results from the closure of the tricuspid and mitral valves
• S2 signifies the end of systole, loudest at the base, results from the closure of the pulmonic and aortic valves
• S3 occurs after S2, referred to as Kentucky or Lub-dub-dub, associated with CHF and MI
• S4 occurs during atrial contraction, best heard in the mitral and tricuspid areas, Kentucky or Lub-dub-dub, may be due to poorly compliant ventricles, associated with CHF and MI
• Murmurs are due to turbulent blood flow
• Stenosis is an abnormally narrowed valve, treated with cholesterol level management
• Regurgitation is blood going backwards
• Bruits are turbulent flow outside the heart in arteries
• Murmurs are graded from 1 to 6 based on intensity
  • Assess location, radiation from PMI, pattern, timing, pitch, quality, intensity

Cardiac Output (CO)

• Is the amount of blood pumped by the heart each minute
• Normal range is 4-8 L/min
• 3 elements include: preload, contractility, afterload
• Normal HR is 60-100 bpm
• Stroke volume = amount of blood ejected from the ventricle with each heartbeat
  • Normal SV is 60-130 mL/beat
• Cardiac output will be equal to Heart Rate x Stroke Volume

Chest Pain

• Acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, mediastinitis, and esophageal rupture MUST be ruled out
• Evaluation includes:
  • Assessing vital signs and overall patient well-being
  • Determining onset, duration, character, location, severity, associated symptoms, and treatment
  • Reviewing medications, especially prophylactic penicillin
  • Diagnostics: ECG, CXR, blood work, CTA, Stress ECHO

Abdominal Aortic Aneurysm

• Screen males over 65, especially smokers
• Usually asymptomatic until rupture

Palpitations

• Palpitations is the awareness of heartbeat
• Considerations include anxiety and hyperthyroidism
• Diagnosis by ECG, TSH, and cardiac monitor
• Ask about speed, regularity, if they are intermittent or constant

Shortness of Breath (SOB)

• Dyspnea is inappropriate for the situation
• Orthopnea occurs when supine and improves when sitting, ask about the number of pillows used
• Paroxysmal nocturnal dyspnea involves sudden awakening from sleep

Edema

• Edema is excessive fluid in the extracellular interstitial space
• It can be local or systemic
• Questions to ask:
  • Location
  • Duration: constant, intermittent
  • Does it improve with rest/elevation?
  • Is there pitting?

Fatigue

• Fatigue is the inability to do regular ADLs
• Associated cardiac symptoms may be, chest pain, SOB, edema, cough, palpitations
• Medications like beta-blockers can cause fatigue

Syncope

• Syncope is the Loss of consciousness
• Associated with palpitations, dysrhythmias, unusual exertion, sudden turning of neck (carotid sinus effect), looking upward (vertebral artery occlusion), change in posture, orthostasis

Cardiac Assessment - Past Medical History (PMI)

• Inquire about cardiac surgery/hospitalization
• Inquire about rhythm disorder
• Inquire about acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism, chronic illness

Family History

• Inquire about long QT syndrome, diabetes, heart diseases, dyslipidemia, hypertension, congenital heart defects, and family members with cardiac risk factors

Personal/Social History

• Employment, physical demands, environmental hazards
• Tobacco use, nutritional status, use of alcohol/drugs

Inspection

• Inspect the precordium for apical impulse, pulsations, heaves or lifts
  • The apical impulse should be visible at about the midclavicular line in the 5th left intercostal space should not be seen in > single space if the heart is healthy

Palpation

• Precordial palpation sequence: apex, up the left sternal border, base, down the right sternal border, into the epigastrium, or axillae
• Palpate the precordium to detect apical impulses, thrills, heaves, or lifts
• If apical impulse is more vigorous than expected, label it as a heave or lift
• Point of maximal impulse (PMI): point at which the apical impulse is most readily seen or felt
• Thrill is a fine, palpable, rushing vibration, a palpable murmur
• Carotid artery palpation

Auscultation

• Assess rate and rhythm, frequency, intensity, duration, pathology
• Areas for Listening to the Heart:
  • Aortic: right 2nd intercostal space
  • Pulmonic: left 2nd intercostal space
  • Erb's Point: left 3rd intercostal space
  • Tricuspid: lower left sternal border 4th intercostal space
  • Mitral: left 5th intercostal space, medial to midclavicular line

JNC 8 Recommendations

• Recommendations include, screening and controlling HTN
• General nonblack population:
  • Thiazides, CCB, ACEI, ARB (first line)
• General black population:
  • Thiazides, CCB (first line)
• CKD:
  • Treatment should include ACEi or ARB
  • Up-titrate or add therapy after 1 month if BP goal not achieved
  • DO NOT use ACEi and ARB together
  • If >3 drugs needed, refer to hypertension specialist

Lipid Levels

• Total Cholesterol
  • Desirable: <200
  • Borderline: 200 – 239
  • High: >240
• LDL Cholesterol:
  • Desirable: <100
  • Borderline high: 130 - 159
  • High: 160-189
  • Very High: >190
• HDL Cholesterol:
  • High (good): >60
  • Low (bad): <40

Peripheral Vascular

Arterial Insufficiency vs Venous Insufficiency

• Arterial Insufficiency/PAD:
  • Narrowing of the arteries, commonly pelvis and legs
  • Clinical symptoms: cramping, pain, tired legs or hip muscles that worsens with activity and subsides with rest
  • Cool, pale extremity, decreases pulses, sharp pains, intermittent claudication, dry ulcer formation with necrotic tissue
  • Different from acute peripheral arterial occlusion
• Venous Insufficiency/PVD:
  • Inadequate return of venous blood from the legs to the heart
  • Clinical symptoms: tired, heavy, achy, cramping in the legs; pain worsens when standing and improved with leg elevation and activity
  • Warm, flushed, edematous, aching pain, weeping venous ulcers

Peripheral Vascular Assessment - History of Present Illness (HPI)

• Leg pain or cramps: onset, duration, character, continuous burning, skin changes, limping, waking at night with leg pain
• Swollen ankles: onset, duration, related circumstances, associated symptoms, medication

Past Medical History (PMH)

• Cardiac surgery or hospitalization
• Acute rheumatic fever, unexplained fever, swollen joints, vasculitis, chronic illness

Family History

• HTN, dyslipidemia, diabetes, heart disease, thrombosis, PVD, AAA, ages at time of illness and death

Personal and Social History

• Employment, tobacco use, nutritional status (diet, weight, exercise), alcohol/drug use

Peripheral Arteries

• Palpation: carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
• Palpate for: rate/rhythm, pulse contour (waveform), amplitude (force), symmetry, obstructions, variations

Amplitude: scale of 0 – 4

• 4: bounding aneurysmal

• 3: full, increased

• 2: expected

• 1: diminished, barely palpable

• 0: absent, not palpable

• Auscultate arteries for bruits: temporal, carotid, subclavian, abdominal aorta, renal, iliac, femoral

Assessment for PAD

• Four P’s of Occlusion:
  • Pain
  • Pallor
  • Pulselessness
  • Paresthesia
• Pain that results from muscle ischemia is called claudication
  • Dull ache, muscle fatigue/cramps, appears during exercise, relieved with rest
• Note the following after determining pain characteristics:
  • Pulses, bruits, loss of body warmth, pallor/cyanosis, collapsed superficial veins, atrophied skin and loss of hair

Allen’s Test

• Compress both ulnar and radial arteries with closed fist, open fist and release one artery to confirm blood flow in alterative artery

Peripheral Veins

• Jugular Venous Pressure: jugular pulse visualized, cannot palpate
• Assessing JVD/JVP:
  • HOB 45 degrees, pillow, slightly turned left
  • Use tangential lighting, look for RIJ oscillations between sternal/clavicular head of SCM muscle
  • Measure height above the angle of Louis in cm: Add approximately central venous pressure (right atrium).
    • More than 8 – 9 is abnormal
  • Assess veins for obstruction and insufficiency:
    • Pain with swelling and tenderness over muscles, engorgement of superficial veins, erythema and/or cyanosis
    • Thrombosis
    • Edema: grading 1 – 4
    • Varicose veins

Week 6 - Differential Diagnosis: Chest Pain

• Subject matter this week, and some of the following, is Chest Pain differential diagnoses

Pericarditis

• Location: substernal; may radiate to neck/left arm
• Characteristics: sharp or friction rub
• Aggravating factors: deep breathing and or supine position
• Symptoms are relieved by sitting up, or leaning forward, and or with anti-inflammatories

Dissecting Aortic Aneurysm

• Location: retrosternal/ upper abdominal, epigastric, radiate to back, neck, and or shoulders
• Characteristics: excruciating and tearing
• Aggravating factors: none
• Alleviating factors: analgesics

Pulmonary Embolism

• Location: over lung area
• Characteristics: stabbing along with stabbing, dyspnea, tachycardia, hemoptysis, hypotension /cyanosis
• Aggravating factors: inspiration
• Alleviating factors: analgesics

Pneumothorax

• Location: lateral thorax
• Characteristics: severe pain and SOB and tachycardia as well as decreased breath sounds and deviated trachea

Pneumonia or Pleuritis

• Symptoms: SOB, cough, fever, rales
• Location: unilateral, often localized

Peptic Ulcer

• Location: in the epigastric region
• Characteristics: burning sensation after eating, hematemesis, tarry stools

Cholecystitis

• S/s include a large and fatty meal (TRIGGER MEAL)

Chest wall syndrome

• Costochondritis: can occur, located anywhere in the chest
  • Sharp characteristics: continuous or gradual, can be tender to the touch, and take weeks to heal
  • Aggravating Factors: movement and palpitation
  • Treatment: time, analgesics and if needed, heat for application

Anxiety

• Symptoms: breathing as well as stabbing pain
• Location anywhere in :chest
• Aggravating Factors: include increased respiratory rate as well as stress & anxiety
• Treated with therapy: relaxation and or reduced resp rate

Herpes Zoster

• Physical findings- vesicular rash
• Quality Sharp or burning
• Aggravating Factors: Increased respiration

Heart Murmurs

• There are varying Grades I – VI
• One can have regurgitation: (valve doesn’t close properly results to backward flow of blood)
• Prolapse: when a valve slips out of place, or flaps that don’t close properly is present
• Stenosis: when there is valve opening narrows (restricts blood flow)

Week 8 - Primary Symptoms

• Dyspnea is present with difficult or labored breathing as well as SOB.
• Palpitations the sensation the heart is skipping beats or rapid, irregular heart rate or a “flip-flopping” feeling in the chest

Mitral Valve Prolapse

• One will show a mid systolic click in addition to a late systolic murmur

ECG

Pulmonary Stenosis

Lipid Disorders

Pulmonary and Circulatory Issues

General Recommendations

• One should retain a food /symptom diary if they have abdominal complaints

Lipid Panels and Findings

Liver Related Issues

• AST/ALT : if these are elevated – consider liver Injury

Thyroid:

Glucose: if high – diabetes

Urinalysis

Blood Work

Testing in general:

Week 9 Pelvic Exam

• Start off asking the menstral and health history, immunizatons and previous exams

Anus/ Pelvic Exam

• Internal & External
• Anus region and Sphincter
• Rectal wall
• Prostate via anterior rectal wall
• Increase the PSA by decreasing the % of free PSA

Testing In Exam Room

• One should test both prostate as well as stool for occult blood