1- the right ventricle occupies most of the

2-This chamber and the pulmonary artery form a wedgelike structure behind and to the left of the 

1. anterior cardiac surface. 

2-sternum, 

-tapered inferior tip of the left ventricle

- it produces the apical impulse=point of maximal impulse, or PMI. 

-found in the 5th interspace 7 cm to 9 cm lateral to the midsternal line

-In supine patients the normal diameter of the PMI may be as large as?

-left ventricular hypertrophy (LVH), or enlargement has a PMI diameter 

1-as a quarter, approximately 1 to 2.5 cm

2-  greater than 2.5 cm is evidence of 

(in some patients the most prominent precordial impulse (PMI) may not be at the apex of the left ventricle)

-in chronic obstructive pulmonary disease (COPD), the most prominent palpable impulse or PMI may be in the ____________ or __________ as a result of?

1-Systole is the period of 

2-pressure in the left ventricle rises from less than

1-ventricular contraction

2- 5 mm Hg in its resting state to a normal peak of 120 mm Hg

1- Diastole is the period of  

2-Ventricular pressure falls further to 

1-ventricular relaxation.

2-below 5 mm Hg, and blood flows from atrium to ventricle. Late in diastole, ventricular pressure rises slightly during inflow of blood from atrial contraction.

1- during systole what valves are open and closed  

2-during diastole what valves are open and closed  

1-the aortic and pulmonic valves are open and The mitral valve and tricuspidare closed, preventing blood from regurgitating back into the left atrium.

2- the aortic and pulmonic valves are closed, preventing regurgitation of blood from the aorta back into the left ventricle. The mitral and tricuspid valves are open, 

Closure of the mitral valve, During systole,

During systole, the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial pressure, shutting the mitral valve. 

the opening of the aortic valve.

-after S1

Aortic valve closure

As the left ventricle ejects most of its blood, ventricular pressure begins to fall. When left ventricular pressure drops below aortic pressure, the aortic valve shuts.

opening snap (OS) if valve leaflet motion is restricted, as in mitral stenosis.

-right after S2

(After the mitral valve opens, there is a period of rapid ventricular filling as blood flows early in diastole from left atrium to left ventricle.)

In children and young adults, what sound may arise from rapid slapping of the column of blood against the ventricular wall.

a third heart sound, S₃,

 In older adults, an S₃, sometimes termed “an S₃ gallop,” usually indicates a pathologic change in ventricular compliance.

Finally, although not often heard in normal adults, a fourth heart sound, S₄, marks ?

-when is it heard

-whats the pathology

-atrial contraction.

-It immediately precedes S₁ of the next beat

-also reflects a pathologic change in ventricular compliance.

1-Of the two components of the S₂, which is louder and softer

2-where are A2 and P2 heard

3- where do you search for splitting of the S₂.

1)-A₂ is normally louder, reflecting the high pressure in the aorta. 

-P₂, is relatively soft, reflecting the lower pressure in the pulmonary artery. 

2)- A₂ is heard throughout the precordium.

-P_{2 is heard best in its own area—the (LSB) 2nd and 3rd left interspaces close to the sternum. It is here that you should search for splitting of the S2.}

3)-LSB

1- Physiological Splitting

2- Pathological Splitting

1- S2 splits on inspiration, and A2 and P2 fuse on expiration

2- S2 splitting occurs on inspiration and expiration

Splitting of S1

1-S₁ also has two components (what order do they occur)

2-which is louder and softer

3-where do you listen for each sound

4- where do you listen for the split of S1

 produced by blood leaking backward when a valve fails to fully close, as in aortic regurgitation or insufficiency.

Angle of Louis

(Sternal Angle)

Cardiac Base

2

1)-2nd ICS, RSB

2)-2nd ICS, LSB

Listen to what anatomy here?

1)- 2nd intercostal space right sternal border(2nd, ICS, RSB)

2)- 2nd intercostal space left sternal border(2nd, ICS, LSB)

1)-(2nd, ICS, RSB)- sounds from the aortic valve

2)- (2nd, ICS, LSB)- sounds from the pulmonic valve

listen to what anatomy?

3rd intercostal space left sternal border (3rd ICS LSB)

also called?

(3rd ICS LSB)- aortic sounds transmission

-also called Erbs point

listen to what anatomy?

4th intercostal space left sternal border (4th ICS LSB)

(5th ICS MCL)- Mitral sounds, Cardiac Apex, PMI, Ventricular Impulses

Murmur

ASS

Aortic stenosis systolic

what does the letter represent

P

QRS

Q

R

S

T

-The small P wave of atrial depolarization

-The larger QRS complex of ventricular depolarization (S1)

-Q wave- a downward deflection from septal depolarization

-the R wave- an upward deflection from ventricular depolarization

-the S wave- a downward deflection following an R wave

 T wave of ventricular repolarization (S2)

Cardiac output-the volume of blood ejected from each ventricle during 1 minute, is the product of heart rate and stroke volume.

refers to the load that stretches the cardiac muscle before contraction. The volume of blood in the right ventricle at the end of diastole,

-Right ventricular preload is increased by increasing venous return to the right heart.

-Physiologic causes include inspiration and the increased volume of blood flow from exercising muscles.

-The increased blood volume in a dilated right ventricle of congestive heart failure also increases preload.

-Causes of decreased right ventricular preload include exhalation, decreased left ventricular output, and pooling of blood in the capillary bed or the venous system.

-refers to the ability of the cardiac muscle, when given a load, to shorten.

-Contractility increases when stimulated by action of the sympathetic nervous system and decreases when blood flow or oxygen delivery to the myocardium is impaired

-refers to the degree of vascular resistance to ventricular contraction.

-Sources of resistance to left ventricular contraction include the tone in the walls of the aorta, the large arteries, and the peripheral vascular tree (primarily the small arteries and arterioles), as well as the volume of blood already in the aorta.

1-preload-volume overload

2-afterload-pressure overload

3-alterations in ventricular impulses, detectable by palpation, and in normal heart sounds. Pathologic heart sounds and murmurs may also develop.

(*Changes in any of these four factors alter systolic pressure, diastolic pressure)

When measuring JUGULAR VENOUS PRESSURE (JVP)

1. what is normal and abnormal hight

2. what positions do u measure in

1-JVP measured at more than 4 cm above the sternal angle, or more than 9 cm above the right atrium, is considered elevated or abnormal

2-30 degrees 60 and 90

which is common in children, may still be heard through young adulthood

A second, more important example is the cervical systolic murmur or bruit, which may be innocent in children but suspicious for arterial obstruction in adults

-an unpleasant awareness of the heartbeat

-irregular heart beats

Symptoms or signs of irregular heart action warrant an ECG. Only atrial fibrillation, which is “irregularly irregular,” can be reliably identified at the bedside

-dyspnea that occurs when the patient is lying down and improves when the patient sits up.

(Classically, it is quantified according to the number of pillows the patient uses for sleeping, or by the fact that the patient needs to sleep sitting up)

JVP test

1-When inspecting a hypovolemic patient

2-in volume-overloaded or hypervolemic patients

1- may have to lie flat before you see the neck veins.

2- raise the head of the bed an elevation up to 60° or even 90° may be required. (In all these positions, the sternal angle usually remains about 5 cm above the right atrium)

•  Raise the head slightly on a pillow to relax the sternomastoid muscles.
• Raise the head of the bed or examining table to about 30°. Turn the patient's head slightly away from the side you are inspecting.
• Use tangential lighting and find the internal jugular venous pulsations.
• If necessary, raise or lower the head of the bed until you can see the oscillation point or meniscus of the internal jugular venous pulsations in the lower half of the neck.
• Focus on the right internal jugular vein. Look for pulsations in the suprasternal notch, between the attachments of the SCM on the sternum and clavicle, or just posterior to the SCM.
• Identify the highest point of pulsation in the right internal jugular vein. Extend a long rectangular object or card horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right angle. Measure the vertical distance in centimeters above the sternal angle where the horizontal object crosses the ruler. This distance, measured in centimeters above the sternal angle or the right atrium, is the JVP.

Internal Jugular Pulsations

VS

Carotid Pulsations

In patients with obstructive lung disease,

(This finding does not indicate congestive heart failure)

Pressure on the carotid sinus may cause a

where is the carotid sinus located?

reflex drop in pulse rate or blood pressure

Avoid pressing on the carotid sinus, which lies at the level of the top of the thyroid cartilage.

1- Small, thready, or weak pulse seen in 

2- bounding pulse seen in 

1-cardiogenic shock

2- aortic insufficiency

aortic stenosis

The normal upstroke is brisk. It is smooth, rapid, and follows S₁ almost immediately. The summit is smooth, rounded, and roughly midsystolic. The downstroke is less abrupt than the upstroke.

1- (beat-to-beat variation)

2- (respiratory variation)

carotid bruit

Listen to the carotids at the neck w/ the bell, low pitch sounds

-with pt in Left lateral decubitus position

1- Palpate and listen to

2- what pathology is heard here

1-Palpate the apical impulse and Listen at the apex with the bell of the stethoscope.

2-Low-pitched extra sounds such as an S₃, opening snap, diastolic rumble of mitral stenosis

Sitting, leaning forward, after full exhalation

where do you listen?

What pathology?

Listen along the left sternal border and at the apex with the diaphragm.

Soft decrescendo diastolic murmur of aortic regurgitation

1-the apex

2-the base

 both the carotid upstroke and the apical impulse occur in?

systole, right after S₁,

sounds or murmurs coinciding with them are systolic; sounds or murmurs occurring after the carotid upstroke or apical impulse are diastolic.

1- S₁ is decreased in 

2- S₂ is decreased in

1- first-degree heart block

2- aortic stenosis.

1-a heart situated on the right side (rare)

2-The apical impulse will then be found on the right.

3-heart, liver and stomach all are on opposite sides from normal

1-left ventricular hypertrophy from pressure

overload (as in hypertension).

2-volume overload.

1- S₃

_2-S₄.

1-systemic hypertension.

2-suggests a dilated or aneurysmal aorta.

1-hypokinetic apical impulse that is displaced far to the left.

Pt. on left side into the left lateral decubitus position

Ask the patient to sit up, lean forward, exhale completely, and stop breathing

1-valvular heart disease.

2-valvular disease but often occur when the heart valves are normal.

A crescendo murmur grows louder

eg?

the presystolic murmur of mitral stenosis in normal sinus rhythm

A crescendo-decrescendo murmur first rises in intensity, then falls.

eg

A plateau murmur has the same intensity throughout.

eg?

a pulsus alternans

The upright position may accentuate the alternation

Small, Weak Pulses

-whats it feel like

-causes

-the peak is brief.

Causes include (1) increased stroke volume, decreased peripheral resistance, or both, as in fever, anemia, hyperthyroidism, aortic regurgitation, arteriovenous fistulas, and patent ductus arteriosus; (2) increased stroke volume because of slow heart rates, as in bradycardia and complete heart block; and (3) decreased compliance (increased stiffness) of the aortic walls, as in aging or atherosclerosis.

-A bisferiens pulse is an increased arterial pulse with a double systolic peak.

-Causes include pure aortic regurgitation, combined aortic stenosis and regurgitation, and, though less commonly palpable, hypertrophic cardiomyopathy.

-The pulse alternates in amplitude from beat to beat even though the rhythm is basically regular

 -Pulsus alternans indicates left ventricular failure and is usually accompanied by a left-sided S₃.

 -A bigeminal pulse is caused by a normal beat alternating with a premature contraction.

-The stroke volume of the premature beat is diminished in relation to that of the normal beats, and the pulse varies in amplitude accordingly.

-A paradoxical pulse may be detected by a palpable decrease in the pulse's amplitude on quiet inspiration. If the sign is less pronounced, a blood pressure cuff is needed. Systolic pressure decreases by more than 10 mm Hg during inspiration.

-A paradoxical pulse is found in pericardial tamponade, constrictive pericarditis (though less commonly), and obstructive lung disease.

Left Ventricular Impulse

Hyperkinetic

Examples of Causes

 Diameter

Amplitude

Duration

Location

Examples of Causes-Anxiety, hyperthyroidism, severe anemia

Location-Normal (5th ICS MCL)

Diameter- about 2cm

Amplitude-More forceful tapping

Duration-2/3 systole

Left Ventricular Impulse

Pressure Overload

Examples of Causes

 Diameter

Amplitude

Duration

 Location

Examples of Causes-Aortic stenosis, hypertension

Location-Normal (5th ICS MCL)

Diameter- >2cm

Amplitude-More forceful tapping

Duration-Sustained (up to S₂)

Left Ventricular Impulse

Examples of Causes

 Diameter

Amplitude

Duration

 Location

Examples of Causes- Aortic or mitral regurgitation

Location-Displaced to the left and possibly downward

Diameter- >2cm

Amplitude-Diffuse

Duration-slightly Sustained

Right  Ventricular Impulse

Hyperkinetic

Examples of Causes

Diameter

Amplitude

Duration

Location

Examples of Causes-Anxiety, hyperthyroidism, severe anemia

Location-3rd, 4th, or 5th left interspaces

Diameter- not useful

Amplitude-More forceful

Duration-normal

Right  Ventricular Impulse

Pressure Overload

Examples of Causes

Diameter

Amplitude

Duration

Location

Examples of Causes-Pulmonic stenosis, pulmonary hypertension

Location-3rd, 4th, or 5th left interspaces also subxiphoid

Diameter- not useful

Amplitude-More forceful

Duration-sustained

Right  Ventricular Impulse

Volume Overload

Examples of Causes

Diameter

Amplitude

Duration

Location

Examples of Causes-Atrial septal defect

Location-Left sternal border,

Diameter- not useful

Amplitude-More forceful