heart

liver-inferior vena cava- RA-tricuspid valve-RV-pulmonic valve- pulmonary artery- gives un-oxygenated blood to lungs- pulmonary vein- LA- mitral valve to LV- to rest of the body

ventricles relax and fill with blood 2/3 of cardiac cycle

heart's contraction, fills the pulmonary and systemic arteries. 1/3 of cardiac cycle

closure of the semilunar valves and signals the end of systole

first heart sound. closure of the AV valves and thus signals the beginning of systole

more to the right and less to the left. intrathoracic pressure is decreased on inspiration. pushes more blood into the vena cava, increasing venous return to right side of heart. more blood needed in lungs on inspiration, decreases amount returned to the left side of the heart

depolarization of the atria

beg of the P wave to the bed of the QRS complex

depolarization of the ventricles

repolarization of the ventricles

CO = SV x R (stroke volume x Rate)

the venous return that builds during diastole. the length to which the ventricular muscle is stretched at the end of diastole to just before the contraction

the opposing pressure the ventricle must generate to open the aortic valve against higher aortic pressure

within a hour after birth

• prolonged P-R interval
• prolonged Q-T interval
• increased incidence of bungle brach block

often pulmonary disorder but occurs with mitral stenosis

paraoxymal nocturnal dyspnea. person awakens after 2 hours of sleeping with the perception of needing fresh air. happens with heart failure

worse at evening time and better in morning after elevation of legs all night

need to sit up to breath, use many pillows when sleeping

happens with heart failure when people are ambulatory during the day. recumbency at night promotes fluid reabsorbtion and excretion

infants with heart prob have trouble eating they get tired quick and are exhausted after eating.

push on liver. heart failure jugular stays distended. with no heart failure will be distended for a few seconds and go back to normal

4th or 5th intercostal space, at or medial to the midclavicular line

due to increased ventricular volume or wall thickness, occurs with CAD, HTN, heart failure and cardiomyopathy

2nd right intercostal space

2nd left intercostal space

left lower sternal border

5th intercostal space at around midclavicular line

check apical pulse with radial pulse. occurs with atrial fibrilation, premature beats and heart failure

normal phenomenon that occurs toward the end of inspiration in some people. split S2 fixed (unaffected by respiration, always there. paradoxical split sounds fuse on inspiration and split on expiration

associated with mitral valve prolapse. most common extra sound

• grade i: barely audible, heard only in quiet room and then with difficulty
• grade ii: clearly audible, but faint
• grade iii: moderately loud, easy to hear
• grade iv: loud, associated with a thrill palpable on the chest wall
• grade v: very loud, heard with one cornerof the stethoscope lifted off the chest wall
• grade vi: loudest, still heard with entire steth raised off chest wall

• mitral stenosis: rumbling
• aortic stenosis: harsh

only heard when on left side (sometimes)

• cardiac enlargement: shifts to the left
• pnemothorax: shifts away from affected side
• diaphragmatic hernia: shifts usually to right because this hernia occurs more often on the left
• dextrocardia: a rare anomaly in which the heart is located on the right side of the chest.

failure of the shunt to close.

• tachy >200 per min in newborns and >150 in infants
• brady <90 in newborns and <60 in infants

atrial septal defect

murmor from breast vasculature (10%)

turbulence of blood flow in the jugular venous system. common in healthy children no pathological significance

• dilated pupils
• skin pale and grey maybe cynotic
• dyspnea
• orthopnea
• crackles, wheeze
• decreased BP
• nausea and vomiting
• ascites
• dependent pitting edema
• anxiety
• falling o2
• confusion
• jugular vein distention
• infarct
• fatigue
• tachycardia
• enlarged spleen and liver
• decreased urine output
• weak pulse, cool moist skin

• persistence of the channel joining left pulmonary artery to aorta. Normal in fetus spontaneously closes after birth.
• S: usually no symptoms in early childhood
• O: BP has wide pulse pressure and bounding peripheral pulses from rapid runoff of blood into low-resistance pulmonary bed during diastole. continuous murmor heard in systole and diastole called a machinery murmor

• abnormal opening in the atrial septum, resulting ususally in left-to-right shunt and causing lg increase in pulmonary blood flow
• S: defect tolerated well. symptoms in infant rare, children and young adults have mild fatigue and DOE
• O: sternal lift often present. S2 has fixed split, with P2 often louder than A2. Murmor caused by shunt itself not increased blood flow through pulmonic valve

• abnormal opening in septum between the ventricles, usually subaortic area. Size and position vary.
• S: small defects- asymptomatic. infants with lg defects have poor growth, slow weight gain, later look pale, thin, delicate. may have feeding problems, DOE, frequent resp infections, and when condition is severe heart failure
• O: loud, harsh holosytolic murmor, best heard at left lower sternal border, may be accompanied by a thrill. lg defects also have soft diastolic murmur at apex

• 1. right ventricular outflow stenois
• 2. VSD
• 3. right ventricular hypertrophy
• 4. overriding aorta
• all these cause shunting of a lot of venous blood flow directly into aorta away from pulmonary system, so blood never gets oxygenated

• S: severe cyanosis, not in first months of life, develops as infant grows and RV outflow stenosis gets worse. Cyanosis with crying and exertion at first, then at rest. uses squatting posture after starts walking. DOE common. development is slowed.
• O: Thrill palpable at left lower sternal border. S1 norm. S2 has A2 loud and P2 diminished or absent. Murmur is systolic, loud, crescendo-decrescendo

• S: Fatigue, DOE, palpitation, dizziness, fainting, anginal pain
• O: Pallor, slow diminished radical pulse, low BP, and auscultatory gap are common. Apical impulse sustained and displaced to the left. Thrill in systole over second and third right interspaces and right side of neck

• calcification of pulmonic valve restricts forward flow of blood.
• O: Thrill is systole at 2nd and 3rd interspace, ejection click often present after S1, diminished S2 and usually with wide split, S4 common with RV hypertrophy

• blood regurgitates back into LA during systole through incompetent mitral valve
• S: fatigue, palpitation, orthopnea, PND,
• O: Thrill in systole at apex. apical impulse displace down and to the left
• Murmur: pansystolic, often loud, blowing, best heard at apex, radiates well to left axilla

• backflow of blood through incompetent tricuspid valve into RA
• O: engorged pulsating neck veins, liver enlarged. lift at sternum if RV hypertrophy present, often thrill at left lower sternal border, increases with inspiration
• Murmur: Soft, blowing, pansystolic, best heard at left lower sternal border, increases with inspiration

• calcified mitral valve will not open properly, impedes forward flow of blood into LV during diastole. results in LA enlarged and LA pressure increased
• S: fatigue, palpitations, DOE, orthopnea, occasional PND or pulmonary edema
• O: diminished, often irregular arterial pulse, lift at apex, diastolic thrill common at apex
• Murmur: low-pitched diastolic rumble, best heard at apex, with person in left lateral position, does not radiate

• calcification of tricuspid valve impedes forward flow into RV during diastole
• O: Diminished arerial pulse, jugular venous pulse prominent
• Murmur: Diastolic rumble, best heard at left lower sternal border, louder in inspiration.

stream of blood regurg back thru incompetent aortic valve in LV during diastole. LV dialation and hypertrophy due to increased LV stroke volume. rapid ejection of large stroke volume into poorly filled aorta, then rapid runoff in diastole as part of blood pushed back into LV.

• backflow of blood through incompetent pulmonic valve, from pulmonary artery to RV.
• Murmur has same timing and characteristics as that of aortic regurgitation, and is hard to distinguish on physical exam

• S: Only minor symptoms from many years, then rapid deterioration: DOE, PND, angina, dizziness
• O: Bounding "water-hammer" pulse in carotid, brachial, and femoral arteries. BP has wide pulse pressure, pulsations in cervical and suprasternal area, apical impulse displaced to left and down, apical impulse feels brief.
• Murmur: starts allmost simultaneously with S2, soft high pitches, blowing diastolic, decrescendo, best heard at 3rd left interspace at base, as person sits up and leans forward, radiates down.