heart/neck vessels & peripheral vascular/lymphatics

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  • Slide 1
  • Heart/Neck Vessels & Peripheral Vascular/Lymphatics
  • Slide 2
  • Anatomy Review 4 chambers Right/left atrium Right/left ventricle 4 valves Tricuspid Mitral Pulmonic Aortic
  • Slide 3
  • Anatomy and Physiology Cardiac output (L/min) determined by: Heart rate (beats/min) Stroke volume (L/beat) CO = SV x HR MeasureTypical value Normal range end-diastolic volumeend-diastolic volume (EDV) 120 ml [1] [1] 65 - 240 ml [1] [1] end-systolic volumeend-systolic volume (ESV) 50 ml [1] [1] 16 - 143 ml [1] [1] stroke volume stroke volume (SV) 70 ml55 - 100 ml ejection fraction (E f ) 58%55 to 70% [2] [2] heart rate heart rate (HR) 70 bpmbpm 60 to 100 bpm [3] [3] cardiac outputcardiac output (CO) 4.9 L/minuteL/minute 4.0 - 8.0 L/min
  • Slide 4
  • Health History Chest pain Do you have any chest pain or discomfort? OLDCART Do you do you use any recreational drugs? Do you have any increased life stress/anxiety? Dyspnea Do you have any labored or difficulty breathing (dyspnea)? OLDCART Related to exercise (exertional dyspnea)? Quantify: Have far can you walk before getting short of breath? Related to position/lying supine (orthopnea)? How many pillows do you sleep on at night?
  • Slide 5
  • Health History Palpitations Ever have palpitations/or unpleasant awareness of heartbeat? (fluttering/ pounding) Dizziness or Syncope Have you felt dizzy or ever lost consciousness/passed out (syncope)? Fatigue Do you seem to tire easily? Cyanosis or pallor Ever noted your facial skin turn blue or ashen gray?
  • Slide 6
  • Health History Cough Any pink or blood tinged frothy sputum? Edema Do you have any swelling in your feet or legs? Nocturia Do you awaken at night with an urgent need to urinate?
  • Slide 7
  • Health History Past Cardiac History CHF, angina, MI, murmurs, rheumatic fever, congenital heart disease Assess for risk factors of coronary artery disease Hypertension, hyperlipidemia, diabetes, physical inactivity, obesity, smoking, stress, increasing age. family history of CAD (especially in 1 st degree relatives F
  • Hepatojugular Reflux Very sensitive in detecting right-sided heart failure Elevate to 30 degrees Press firmly in right upper quadrant Observe neck for elevation in JVP Rise of >1cm is abnormal http://www.youtube.com/watch?v=X9fKPIe6nDQ
  • Slide 15
  • Inspection & Palpation Inspect & palpate precordium for: Lifts/Heaves Thrills Use ball of your hand firmly on the chest Apical impulse http://www.youtube.com/watch?v=FkM6m uqmve0&feature=relatedhttp://www.youtube.com/watch?v=FkM6m uqmve0&feature=related Apical impulse @ 5 th intercostal space midclavicular line. No lifts, heaves, or thrills noted. Note location of heart may also be determined by percussing for borders of dullness
  • Slide 16
  • Apical Impulse AKA: Point of maximal impulse (PMI) Apical impulse specifically for apex beat. Localize apical impulse using one finger. Ask to exhale and hold breath may help find. May need to roll midway to left. Note: location, size (1cm x 2cm), amplitude (short gentle tap), duration (short, occupies only first half of systole Not palpable in obese, thick chest wall Increased size or location with volume overload, hypertrophy (HTN, CAD, CHF, cardiomyopathy) Increased amplitude & duration with high cardiac output states (anxiety, fever, hyperthyroidism, anemia
  • Slide 17
  • Auscultation Wth the diaphragm auscultate @ the apex of the heart for: Rate Normal Adult Rate: 60-100 beats/min Bradycardiaheart rate less than 60 Tachycardiaheart rate greater than 100. Rhythm Regular vs. irregular Sinus arrythmia (rhythm varies with breathing) Regularly irregular, irregularly irregular If pulse irregular assess for pulse deficit Auscultate the apical beat while simultaneously palpating the radial pulse. Every beat hear should perfuse to periphery Apical pulse 80bpm and regular. No pulse deficit noted.
  • Slide 18
  • Auscultation Proceed over precordium with bell Best for low pitch Auscultate over: Aortic area Pulmonic area Erbs point Tricuspid area Mitral area Epigastric For: Gallops (best with bell) Murmurs (depends) Rubs
  • Slide 19
  • Normal Heart Sounds S1 Lubb Sound of mitral & tricuspid valve closing simultaneously Start of systole Heard loudest at apex of heart Approx 5 th intercostal space, midclavicular line on left S2 http://www.youtube.com/watch?v=2aO0HKIP3vI http://www.youtube.com/watch?v=2aO0HKIP3vI Dubb Sound of simultaneous closing of pulmonic and aortic valves End of systole Heard loudest at base of heart Best over 2 nd intercostal space on right
  • Slide 20
  • Gallops: S3 & S4 Heart Sound Associated Heart Process Normal Characteristics Pathological Characteristics Cadence Word Clue S3 Heard @ apex or LL sternal border with bell Early diastolic Occurs after S2 Heard more often in children and young adults Waxes and Wanes May disappear when pt sits up Higher pitch Louder More constant sound Associated with volume overload and left ventricular systolic dysfunction Ken-tu-cky. SLOSH-ing- in S4 Heard @ apex with bell Late diastolic (atrial filling) Occurs before S1 No typical characteristics Seen in uncontrolled hypertension Ten-nes-see a-STIFF-wall
  • Slide 21
  • Murmurs Swishing or blowing noises that occurs with turbulent blood flow in heart or great vessels. Categorized as: Innocent Always systolic & without evidence of physiological/structural abnormalities Functional Associated with physiological alterations such as high cardiac output states i.e. exercise, anemia, hyperthyroidism or increased blood volume associated with pregnancy Pathologic Caused by structural abnormalities in valves or chambers Stenosis, regurgitation, patent ductus arteriosis
  • Slide 22
  • Structural Abnormalities in Valves and Chambers
  • Slide 23
  • Murmur Characteristics Timing Systolic: Heard during systole (between S1 and S2) If possible note: early, late or mid systolic) Diastolic: Heard during diastole (between S2 and S1) If possible note: early, late or mid diastolic Continuous: Heard in both systole and diastole http://www.youtube.com/watch?v=XvtBpnV_lOE
  • Slide 24
  • Valvular Disease & Murmur Locations ValveSystolic MurmurDiastolic Murmur AorticAortic stenosisAortic regurgitation PulmonicPulmonic stenosisPulmonic regurgitation MitralMitral regurgitationMitral stenosis TricuspidTricuspid regurgitationTricuspid stenosis http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html
  • Slide 25
  • Murmur Characteristics Quality (Shape/Pattern & Sound) Shape/Pattern Crescendo/Decrescendo AKA- Diamond shaped murmur; ejection type murmur Primary causes: Stenotic valves Holosystolic AKA- Pansystolic Decrescendo Primary causes: Aortic and pulmonic regurgitation, Mitral and tricuspid stenosis http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html
  • Slide 26
  • Murmur Characteristics Quality Sound Musical, blowing, harsh, or rumbling Pitch High, medium, or low; Loud or soft Location Area of maximal intensity Radiation May be heard in another place on precordium or neck, back or axilla
  • Slide 27
  • Murmur Characteristics Intensity (loudness) 1 - Very faint, heard only after listener has tuned in; may not be heard in all positions 2 - Quiet, but heard immediately after placing the stethoscope on the chest 3 - Moderately loud 4 Loud, with palpable thrill 5 - Very loud, with thrill. May be heard when stethoscope is partly off the chest 6 Very loud, with thrill. May be heard with stethoscope just removed from and not touching the skin.
  • Slide 28
  • Murmur Characteristic Example Aortic Stenosis Timing: Midsystolic Pitch: Loud Quality: Harsh Location: Loudest @ 2 nd right interspace Radiation: Widely to side of neck, down left sternal border, or apex http://www.merckmanuals.com/professional/resources/multimedia/name/audio.html
  • Slide 29
  • Auscultation Pericardial friction rub Membranous sac surrounding heart becomes inflamed Differentiate pericardial from pleural friction rub by having patient hold breath http://www.merckmanuals.com/professional/resources/multi media/name/audio.html
  • Slide 30
  • Physical Exam Findings for CHF Right-Sided Failure Distended neck veins Dependent edema Ascites Hepatomegaly Nocturia Left-Sided Failure Pulmonary Edema Coughing Hemoptysis Orthopnea Dyspnea/Tachypnea Crackles in lungs Cyanotic nail beds, ashen color Cold, moist extremities Restlessness/anxiety S3 gallop rhythm Tachycardia http://www.youtube.com/watch?v=QODCQ HwSfOU&feature=related
  • Slide 31
  • Peripheral Vascular & Lymphatics http://images.google.com
  • Slide 32
  • Peripheral Vascular System Arteries Supply oxygenated blood to the body from the heart Veins Return unoxygenated blood to the heart Contain one-way valves that keep the blood from flowing backwards Muscles help squeeze the blood in the veins to the heart
  • Slide 33
  • Health History Common or concerning symptoms Pain in the arms or legs Intermittent claudication: leg or arm pain that is exercise induced Cold, numbness, pallor in the legs; hair loss Color change in fingertips or toes in cold weather Swelling in calves, legs or feet Swelling with redness or tenderness High risk: Tobacco use, diabetes, HTN, Hyperlipidemia, CV disease Severit

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