(The impulse locates the left border of the heart and is normally found in the 5th interspace 7 cm to 9cm lateral to the midsternal line, just medial to the left midclavicular line)
seen in HTN and aortic stenosis
_________ is the period of ventricular relaxatin
mitral valve is closed: preventing blood from regurgitating back into the left atrium
mitral valve is open: allow blood to flow from the left atrium into the relaxed left ventricle
– distensibility of the aorta and the large arteries
– peripheral vascular resistance, particularly at the arteriolar level
– volume of blood in the arterial system
discomfort in the chest, shoulder, back, neck or arm in angina pectoris
or rarely: tooth or jaw pain
What are these clinical syndromes?
unstable angina, non-ST elevation myocardial infarction, and ST elevation infarction
and Rhythms, and Table 9-2, Selected
Irregular Rhythms, for selected heart
rates and rhythms (pp. 391-392).
obstructive lung disease
What is this sometimes mimicked by?
mimicked by: nocturnal asthma attacks
What are the possible causes?
cardiac (heart failure), nutritional (hypoalbuminemia) or positional
tight rings (on fingers)
cause: nephrotic syndrome: renal disease
enlarged waistline (clothes tighter around the middle)
cause: ascites and liver failure
Factor Modi#cation on pp. 358-360
for discussion of assessing patient
readiness to make health-promoting
behavior changes; see also Chapter
3, Interviewing and the Health
History (p. 72) for a discussion of
Examination: General Survey,
Vital Signs, and Pain, pp. 112-113,
for discussion of the bene#ts of
restricting dietary sodium
of Change Model and Assessing
Readiness, p. 138, and Chapter 8,
Thorax and Lungs, pp. 293-331, for
examples of how this model can be
applied to clinical counseling.
Chapter 8, Thorax and Lungs,
Nutrition, and Diet, Chapter 4,
Beginning the Physical Examination:
General Survey, Vital Signs,
and Pain, pp. 108-112.
Examination: General Survey,
Vital Signs, and Pain, especially
What does this reading correlate with?
Correlates best with the current standard, 24-hour blood pressure monitoring
What is the drawback?
venous pressure is increased (so elevating the pt’s head to 60 degrees or even 90 degrees may be required)
tricuspid stenosis, chronic pulmonary HTN, superior vena obstruction;
and pericardial disease such as tamponade and constrictive pericarditis
What happens to the veins on inspiration?
Does this indicate heart failure?
vein collapse on inspiration
does NOT indicate heart failure
increases risk of death from heart failure
~ tricuspid stenosis
first degree atrioventricular block, supraventricular tachycardia, junctional rhythms
~ pulmonary HTN, pulmonic stenosis
Selected Heart Rates and Rhythms,
p. 391, and Table 9-2, Selected
Irregular Rhythms, p. 392.
local factors: atherosclerotic narrowing or occlusion
Arterial Pulse and Pressure Waves,
Placing the patient in what position may accentuate this finding?
upright position may accentuate this #nding.
possible constrictive pericarditis,
but MOST commonly OBSTRUCTIVE AIRWAY DISEASE
What are other causes?
others: tortuous carotid artery with intraluminal turbulence, external carotid arterial disease, aortic stenosis, hypervascularity of hyperthyroidism, and external compression from thoracic outlet syndrome
What is the age when it reaches 8%?
75 years of age and older
In what disease does it vary from 30-90%?
The presence of a thrill changes ___________. (pg. 371)
in patients with _________?
wall or increased anteroposterior
____%-_____% of healthy adults in
the supine position and in ____ of
healthy adults in the left lateral
decubitus position, especially those
who are thin.
Abnormalities of the Ventricular
Impulses, p. 394.
may displace the apical impulse
enlargement is seen in what 3 diseases?
cardiomyopathy, and ischemic heart disease
from deformities of the ____________
midclavicular line makes cardiac
enlargement and a low left ventricular
ejection fraction_____ and ______
times more likely, respectively.
patient, it usually measures less than 2.5 cm, about the size of a quarter,
and occupies only one interspace. It may feel larger in the left lateral
In the left lateral decubitus position,
a di#use PMI with a diameter greater
than 3 cm indicates ____________.
feels brisk and tapping. Some young adults have an increased amplitude,
or _______, especially when excited or after exercise; its duration,
however, is normal.
reflect what 5 diseases?
pressure overload of the left ventricle (as in aortic stenosis),
volume overload of the left ventricle (as in mitral regurgitation).
What is it caused by?
If the impulse is displaced laterally, what should you consider?
from pressure overload (HTN)
And impulse just before the systolic apical beat itself indicates what heart sound?
systolic tap of low or slightly increased amplitude is sometimes felt in______ people, especially when stroke volume is increased by conditions such as anxiety.
with little or no change in duration
occurs in chronic volume overload
of the right ventricle, which can
occur in __________ (pg. 374)
and duration occurs with pressure
overload of the right ventricle,
as in what 2 diseases?
in the left parasternal area.
The impulse is felt easily, however,_______ where heart sounds are also more audible.
high in the epigastrium
A palpable S2 suggests increased pressure in the ________
pulmonary artery (pulmonary HTN)
A pulsation here suggests _______________.
dilated or aneurysmal aorta
A _________ may make the impulse undetectable
large pericardial effusion
What should you use (anatomical location/valve area) to describe where murmurs and sounds are best heard?
What part is better for picking up the relatively high-pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs?
What part of the stethoscope is more sensitive to low-pitched sounds of S3 and S4 and the murmur of mitral stenosis?
with the diaphragm, pressing it firmly against the chest.
then move medially along the lower sternal border. Resting the heel of your
hand on the chest like a fulcrum may help you to maintain light pressure
especially mitral stenosis
in expiration, this position accentuates what?
(You may easily miss the soft diastolic murmur of aortic regurgitation unless you listen at
PR intervals are shorter
aortic valve (early closure)
(neither is valvular in origin)
What else may diminish the intensity of murmurs?
What do these sxs suggest?
What should you assess next?
What do you check the apical impulse for?
How do you listen to aortic regurgitation?
Assess any delay in the carotid upstroke and the intensity of A2 for evidence of aortic stenosis.
Check the apical impulse
for left ventricular hypertrophy.
Listen for aortic regurgitation as the
patient leans forward and exhales
line in the 5th and 6th intercostal spaces. S1 and S2 are soft. S3 present at the
apex. High-pitched harsh 2/6 holosystolic murmur best heard at the apex, radiating to the axilla.” suggests what?