Anatomy Review - myDSN

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					Heart/Neck Vessels &
Peripheral Vascular/Lymphatics
Anatomy Review
n   4 chambers
    – Right/left
    – Right/left
n   4 valves
    –   Tricuspid
    –   Mitral
    –   Pulmonic
    –   Aortic
Anatomy and Physiology
                                         Typical        Normal
n Cardiac output         Measure
                                         value          range
(L/min) determined by:   end-diastolic
                                       120 ml[1]        65 - 240 ml[1]
   – Heart rate          volume (EDV)

                                      50 ml[1]          16 - 143 ml[1]
   – Stroke volume       volume (ESV)
     (L/beat)            stroke volume
                                       70 ml            55 - 100 ml
      • CO = SV x HR     (SV)
                                         58%            55 to 70%[2]
                         fraction (Ef)
                         heart rate                     60 to 100
                                         70 bpm
                         (HR)                           bpm[3]
                         cardiac                        4.0 - 8.0
                                         4.9 L/minute
                         output (CO)                    L/min
    Health History
n   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?
n   Dyspnea
    – Do you have any labored or difficulty breathing
       • 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?
Health History
n   Palpitations
    – Ever have palpitations/or unpleasant awareness of
      heartbeat? (“fluttering/ pounding”)
n   Dizziness or Syncope
    – Have you felt dizzy or ever lost
      consciousness/passed out (syncope)?
n   Fatigue
    – Do you seem to tire easily?
n   Cyanosis or pallor
    – Ever noted your facial skin turn blue or ashen
Health History
n   Cough
    – Any pink or blood tinged frothy sputum?
n   Edema
    – Do you have any swelling in your feet or legs?
n   Nocturia
    – Do you awaken at night with an urgent need to
Health History
n   Past Cardiac History
    – CHF, angina, MI, murmurs, rheumatic fever,
      congenital heart disease
n   Assess for risk factors of coronary artery
    – Hypertension, hyperlipidemia, diabetes, physical
      inactivity, obesity, smoking, stress, increasing age.
      family history of CAD (especially in 1st degree
      relatives F<65, M<55)
    – Additional for women: Menopause or use of oral
What the History Can Tell You
n   Angina (pain resulting from ischemia)
    – Onset: Abrupt, often precipitated by event such as
      emotion, exertion, cold or eating.
    – Location: Substernal or retrosternal pain.
    – Duration: Usually lasts a few minutes and then
    – Characteristic: Described as squeezing or heavy
    – Radiation: May radiate to the neck, jaw, or arms
    – Relieving Factors/Treatments Tried: Often relieved with
      sublingual nitroglycerin
What the History Can Tell You
n Myocardial      Infarction
  – Onset: Abrupt, often unrelated to precipitating event.
  – Location: Substernal or over precordium.
  – Duration: Prolonged
  – Characteristic: Severe, described as viselike or
  – Associated Symptoms: dyspnea, dizziness, nausea,
    diaphoresis, palpitations, anxiety (sense of doom)
  – Radiation: May radiate to neck, jaw, arms or hands.
  – Treatments Tried: Sublingual nitroglycerin without
What the History Can Tell You
n Congestive     Heart Failure
  – Right-sided
    • Dependent Edema
    • Nocturia
  – Left-sided
    •   Coughing/Hemoptysis (pink frothy)
    •   Orthopnea
    •   Dyspnea with exertion
    •   Cyanosis or ashen color
    •   Cold, moist extremities
    •   Oliguria
    •   Restlessness/anxiety
Carotid Artery
n   Inspect for pulsation
    – Absent pulse wave with arterial occlusion
    or stenosis
n   Palpate lightly & one at a time for:
    – Contour
        • Smooth with rapid upstroke
    – Amplitude
        •   4+ Bounding
        •   3+ Full
        •   2+ Normal
        •   1+ Weak
        •   0 Absent
        •   Diminished or unequal with atherosclerosis or other arterial disease
n   Auscultate
    – Over angle of jaw, mid-cervical, & base of neck with bell
    – For presence of bruit
        • Blowing, swishing sound indicating turbulence
        Carotid arteries 2+ bilaterally without bruits.
    Jugular Venous Pressure
n   Assessment of jugular veins gives
    estimation of heart function
    – Ie. CHF
n   Internal Jugular Vein
    – Position patient supine at
      45 degrees without a pillow
    – Use Angle of Louis to read
      CVP at highest level of pulsation
        • Normal-Pulsation <2.5cm
        • Abnormal- Pulsation >2.5cm
            – Indicates increased CVP associated with heart
n   If you cannot find internal jugular veins,
    use the external and note point where
    look collapsed
Jugular Venous Pressure
n   External jugular
    veins are lateral to
    muscle above the
n   Assess if:
    – Visible (distended)
      @ 45 °

    External jugular veins
      flat @ 45 °
Hepatojugular Reflux

n Very sensitive in detecting right-sided
  heart failure
n Elevate to 30 degrees
n Press firmly in right upper quadrant
n Observe neck for elevation in JVP
  – Rise of >1cm is abnormal
Inspection & Palpation
n   Inspect & palpate
    precordium for:
    – Lifts/Heaves
    – Thrills
         • Use ball of your hand
           firmly on the chest
    – Apical impulse
Apical impulse @ 5th intercostal
   space midclavicular line. No lifts,
   heaves, or thrills noted.

         n   Note location of heart
             may also be determined
             by percussing for borders
             of dullness
Apical Impulse
n   AKA: Point of maximal impulse (PMI)
n   Apical impulse specifically for apex beat.
n   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
     – Not palpable in obese, thick chest wall
n   Increased size or location with volume overload,
    hypertrophy (HTN, CAD, CHF, cardiomyopathy)
n   Increased amplitude & duration with high cardiac output
    states (anxiety, fever, hyperthyroidism, anemia
n   Wth the diaphragm auscultate
    @ the apex of the heart for:
    – Rate
       • Normal Adult Rate: 60-100 beats/min
       • Bradycardia–heart rate less than 60
       • Tachycardia–heart 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
n   Proceed over
    precordium with bell
    – Best for low pitch
n   Auscultate over:
    –   Aortic area
    –   Pulmonic area
    –   Erb’s point
    –   Tricuspid area
    –   Mitral area
    –   Epigastric
n   For:
    – Gallops (best with bell)
    – Murmurs (depends)
    – Rubs
Normal Heart Sounds
n   S1
    – “Lubb”
    – Sound of mitral & tricuspid
      valve closing simultaneously
         • Start of systole
    – Heard loudest at apex of heart
         • Approx 5th intercostal space, midclavicular line on left
n   S2                 

    – “Dubb”
    – Sound of simultaneous closing of pulmonic and
      aortic valves
         • End of systole
    – Heard loudest at base of heart
         • Best over 2nd intercostal space on right
     Gallops: S3 & S4
Heart       Associated         Normal            Pathological      Cadence
Sound       Heart Process      Characteristics   Characteristics   Word Clue
S3          Early diastolic Heard more often     Higher pitch      “Ken-tu-cky.”
                            in children and
Heard       Occurs after S2 young adults         Louder            ““SLOSH-ing-
@ apex                                                             in”
or LL                          Waxes and         More constant
sternal                        Wanes             sound
with bell                      May disappear     Associated with
                               when pt sits up   volume overload
                                                 and left
S4          Late diastolic     No typical        Seen in           “Ten-nes-see”
            (atrial filling)   characteristics   uncontrolled
Heard                                            hypertension      “a-STIFF-wall”
@ apex Occurs before
with bell S1
 – Swishing or blowing noises that occurs with
   turbulent blood flow in heart or great
 – 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
   • Pathologic
      – Caused by structural abnormalities in valves or
          » Stenosis, regurgitation, patent ductus arteriosis
Structural Abnormalities in
Valves and Chambers
Murmur Characteristics
n 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
              Valvular Disease &
              Murmur Locations
Valve                   Systolic Murmur                     Diastolic Murmur

Aortic                  Aortic stenosis                     Aortic regurgitation

Pulmonic                Pulmonic stenosis                   Pulmonic regurgitation

Mitral                  Mitral regurgitation                Mitral stenosis

Tricuspid               Tricuspid regurgitation             Tricuspid stenosis

Murmur Characteristics
n Quality       (Shape/Pattern & Sound)
  – Shape/Pattern
       • Crescendo/Decrescendo
            – AKA- Diamond shaped murmur; ejection type
            – Primary causes: Stenotic valves
       • Holosystolic
            – AKA- Pansystolic
       • Decrescendo
            – Primary causes: Aortic and pulmonic regurgitation,
              Mitral and tricuspid stenosis
Murmur Characteristics
n Quality
  – Sound
     • Musical, blowing, harsh, or rumbling
n Pitch
  – High, medium, or low; Loud or soft
n Location
  – Area of maximal intensity
n Radiation
  – May be heard in another place on
    precordium or neck, back or axilla
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.
Murmur Characteristic Example
n Aortic      Stenosis
  – Timing: Midsystolic
  – Pitch: Loud
  – Quality: Harsh
  – Location: Loudest @ 2nd right interspace
  – Radiation: Widely to side of neck, down left
    sternal border, or apex
n   Pericardial friction
    – Membranous sac
      surrounding heart
      becomes inflamed
    – Differentiate
      pericardial from
      pleural friction rub
      by having patient
      hold breath

   Physical Exam Findings for CHF
Right-Sided Failure                     Left-Sided Failure
 n Distended neck veins                 n Pulmonary Edema
 n Dependent edema                          – Coughing
 n Ascites                                  – Hemoptysis
                                            – Orthopnea
 n Hepatomegaly
                                            – Dyspnea/Tachypnea
 n Nocturia
                                            – Crackles in lungs
                                            – Cyanotic nail beds, ashen
 HwSfOU&feature=related                     – Cold, moist extremities
                                            – Restlessness/anxiety
                                        n   S3 gallop rhythm
                                        n   Tachycardia
Peripheral Vascular
& Lymphatics

Peripheral Vascular System
                n   Arteries
                    – Supply oxygenated
                      blood to the body
                      from the heart
                n   Veins
                    – Return
                      unoxygenated blood
                      to the heart
                    – Contain one-way
                      valves that keep the
                      blood from flowing
                    – Muscles help
                      squeeze the blood in
                      the veins to the heart
Health History
n   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
    – Severity of peripheral vascular disease closely
      parallels the risk for heart attack, stoke, and death
      from vascular causes
n   Inspect upper and lower extremities for:
     – Color
     – Symmetry
     – Lesions
     – Clubbing
     – Edema
     – Capillary refill
n   Pitting Edema- Apply pressure with finger for 5
    – 1+: Slight pitting, 1cm or less, disappears rapidly
    – 2+: Deeper pitting, 1.5cm, disappears 10-15 sec.
    – 3+: Deep pitting, 2cm, disappears more than 1 minute
    – 4+: Very deep pitting, 2.5cm, disappears 2-5 minutes
    No pitting edema noted
n   Inspect lower extremities for
    – Hair distribution
    – Varicosities
    – Muscle atrophy
n Palpate   upper and lower extremities for:
  – Temperature
  – Texture
  – Capillary refill
  – Lymph nodes
     • Epitrochlear, Inguinal
Lymph Nodes
n   Epitrochlear
    – In antecubital fossa
      and drains:
       • Hand
       • Lower hand
n   Inguinal
    – In groin and drains
      most of the lymph
       • Lower extremities
       • External genitalia
       • Anterior abdominal wall
n Peripheral        Pulses
   – Brachial, radial, femoral, popliteal, posterior
     tibial, dorsalis pedis
       • Assess for symmetry in limbs
       • Force
          –   4+ Bounding
          –   3+ Full, increased
          –   2+ Normal
          –   1+ Weak
          –   0 Absent

   pulse is difficult to palpate use a
n If
  Doppler (ultrasound stethoscope) to
  amplify sound of pulse wave
Peripheral Pulses- Brachial

n   Located medial to
    biceps tendon
n   Grade force
Peripheral Pulses-Radial

n   Note:
    – Rate
    – Rhythm
    – Force
Peripheral Pulses-Ulnar
n   Modified Allen Test
    – Evaluate adequacy of collateral circulation prior to cannulating
      radial artery
    – Firmly occlude both ulnar and radial arteries
    – Release pressure on ulnar artery
    – Normal- return of color in 2-5 seconds
Peripheral Pulses-Femoral
                   n   Located just
                       below inguinal
                       ligament halfway
                       between the
                       pubis and
                       anterior superior
                       iliac spine.
                   n   Grade force
                   n   If weak
                       auscultate for
 Peripheral Pulses-Popliteal
n Located
  just lateral
  to medial
n Grade
Peripheral Pulses-Posterior Tibial

n   Located behind the groove
    between the malleolus and
    Achilles tendon
n   Grade force bilaterally
Peripheral Pulses-Dorsalis Pedis
n   Located just lateral to &
    parallel with the extensor
    tendon of the big toe.
n   Force should be
Assess for Deep Vein Thrombosis
n   Assess for:
    – Erythema
    – Calf Edema
    – Increased warmth
    No calf erythema, edema,

    No longer widely practiced
    – Tenderness with
    – Homan’s sign
    No calf erythema, edema,
             or warmth.
Venous vs. Arterial Insufficiency
Assessment Criterion   Venous                 Arterial
Color                  Normal or cyanotic     Pale; worsened by
                                              elevation; dusky red
                                              when extremity is
Temperature            Normal                 Cool (blood flow
                                              blocked to extremity)
Pulse                  Normal                 Decreased or absent
Edema                  Often marked           Absent or mild
Skin Changes           Brown pigment around   Thin, shiny skin;
                       ankles                 decreased hair growth;
                                              thickened nails.
Is that all? J

    MIDTERM   40 points all multiple choice

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