Basic anatomy of the Head, Neck, EENT This is self explanatory and listed in the next bullet Assessment

nt of the Head, Neck, EENT Head Skull: Cranial bones frontal: anterior parietal: superior lateral occipital: posterior temporal: inferior lateral Sutures: immovable joints (Born w/them soft & take 18 months to close) coronal: from ear to ear; between frontal and parietal bones sagittal: anterior to posterior between parietal bones lambdoid: crosswise between parietal bones and occipital bone Facial bones: articulate at sutures nasal bone zygomatic bone (cheek bone) maxilla (upper jaw) mandible (lower jaw) temporomandibular joint: allows mandible to move up/down and side-to-side Cervical vertebrae C1 (atlas) C2 (axis) C3-6 C7 Has long spinous process that can be felt when neck is flexed and is used as a landmark Neck Delimited (defined) Above Base of skull Inferior border of mandible Below Manubrium sterni Clavicle First rib Firth thoracic vertebra FIRTH???? Neck muscles Sternomastoid Run from sternum & clavicle to mastoid process head rotation and head flexion Trapezius

 Run from occipital bone and vertebrae to scapula and clavicle move shoulder and extend & turn head Neck triangles Anterior Lymph Nodes In acute infection lymph nodes are usually bilateral enlarged warm mobile tender firm Cancer lymph nodes are usually unilateral hard nontender and fixed Trachea Head turned down. To the side. Swallow. Tracheal shifts Thyroid gland Posterior approach Anterior approach Auscultate

Abnormal Findings Abnormalities in Head Size and Contour Hydrocephalus Build up of cerebral fluid causes pressure on brain and head to bulge cranial plates separate Pagets disease of bone (osteitis deformans) Density of the bone causing bowing of the long bones which in turn cause headaches, vision problems, pressure on cranial nerve fnct & hearing pbls. Bowing of forehead causes pressure Acromegaly Progressive disease due to excessive secretion of growth hormones. Causes the skull to enlarge & thicken Over production of Pituitary Growth Hormone Elongating of facial bones Torticollis (wryneck) Head tilt to one side causes limited ROM or from sternomastoid muscle injury during birth or a congenital defect. Thyroidmultiple nodules Ususaully just an infection Thyroidsingle nodule More seriously related to cancer in young men Pilar cyst (wen) Parotid gland enlargement (salivary gland) They will think they have the mumps Blockage of duct will cause swelling Atopic (allergic) facies

Child will look physically exhausted dark circles below eyes mouth breathers that causes abnormal teeth due to so much more oxygen Chronic allergies (atropic dermatitis) has distinguishing facial features. Face appears exhausted, blueish below eyes, sluggish venous return, double or single crease in eyelid, open mouth breathing. Allergic salute and crease After rubbing nose up so much it causes crease across the nose Transverse line on the nose assoc w/ chronic use of hand pushing nose up & back. Microcephalic Head size below normal for age Macrocephalic Head size enlarged or rapidly increasing in size (hydrocephalus) Abnormal Facial Appearances With Chronic Illnesses Parkinsons syndrome Neurotransmitter deficit. Usually expressionless mask-like w/elevated eyebrows, staring gaze, oily skin & drooling with a possible shuffle. Cushings syndrome Graves disease Manifested by goiter (enlarged thyroid) or exophthalmos (buldging eyeballs). Hyperthyroidism Creates bulging of the eyes Myxedema (hypothyroidism) Deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema Patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows Bells palsy Cranial nerve #7 due to a lower motor neuron lesion Affects are almost always unilateral having a rapid onset. Cause usually thru HSV. Brain attack or cerebrovascular accident Cranial nerve #7 upper motor neuron Assemitrical may be able to raise eyebrow but droopy mouth Cachectic appearance Wasting syndrome hollow cheeks sunken eyes defeated facial expression Caused by cancer and dehydration Scleroderma HARD SKIN connective tissue disease characterized by shrinking degenerative changes in skin, blood vessels and skeletal muscle. Skin appears heard, shiny, thin pursed lips w/radial furrowing. Which of the following is the most appropriate health history question? Any unusually frequent or unusually severe headaches?

 Eyes

Have you had headaches recently? Have you ever had a headache? When did your headaches start? Structure and Function Subjective DataHealth History Questions Objective DataPhysical Exam Abnormal Findings Structure and Function External anatomy Palpebral fissure Ellipical open space in between your eyelids Limbus Border between sclera and cornea External anatomy Tarsal plates Upper eye Give liddage shape Lower eye Mybomien glands Secrete lubricating oil keeps tears in eyes to lubricare Meibomian glands Modified sebacceous glands that secrete an oily lubricating material onto the lids Stops tears from overflowing and helps to form an airtight seal when the eyelids are closed Conatined by the tarsal plates Conjunctiva Transparent protective covering over the exposed part of the eye Thin mucus membrane folded like an envelop between the eyelids and eyeball Exposed portion of eye Normally clear Lacrimal apparatus Provides constant irrigation to keep the conjunctiva and cornea moist and lubricated Lacrimal gland, puncta, nasolacrimal sac, nasolacrimal duct, inferior meatus Extraocular muscles (move eyes to your point of interest) Superior rectus Inferior rectus Lateral rectus Medial rectus Superior oblique Inferior oblique Internal anatomy Outer layersclera

Appears white Continuous with the cornea Middle layerchoroid (responsible for bending light) Ciliary body and iris Color of yey Pupil Round and regular Its size is determined by a balance between the para/sympathetic chains of the autonomic nervous system Controlls light entering eye Lens Biconvex disc located just posterior to the pupil Serves as a refracting medium keeping a viewed object in continual focus on the retina Anterior chamber Posterior to the cornea and in front of the iris and lens Contains aqueous humor that is produced continually by the ciliary body Fluid serves to deliver nutrients to the surrounding tissues to drain metabolic wastes Contains aqueous humor Inner layerretina Optic disc Fibers of retina converge to form optic nerve Retinal vessels Vessels of the retina which normally include a paired artery and extend to each quadrant, growing progressively smaller in caliber as they reach the periphery Arteries, veins.. Etc... Macula A slightly darker pigmented region surrounding the fovea centralis Receives and transduces light from the center of the visual field. Area of sharpest vision Visual pathways and visual fields Refraction of light rays Crossing of fibers at optic nerve Visual reflexes Pupillary light reflexes Normal constriction of the pupils when bright light shines on the retina

Afferent link is CN II, (optic nerve), and the efferent path is CN III, (oculomotor nerve) In order to test this reflex, darken the room, ask the person to gaze into the distance, and advance a light from the side and note response A constriction of the same-sided pupil is a direct light reflex, and a simultaneous constriction of the other pupil is a consensual light reflex

Fixation Reflex direction of the eye toward an object attracting a person's attention The image is fixed in the center of the visual field, the fovea centralis Consists of very rapid ocular movements to put the target back on the fovea centralis Accommodation Adaptation of the eye for near vision by increasing the curvature of the lens through movement of the ciliary muscles Test this reflex by asking the person to focus on a distant object, which dilates the pupils, then have them shift gaze to a close object Normal response Papillary constriction and convergence of the axes of the eyes Developmental care Infants and children Aging adult Pinguicia pg.307 Located on the sclera that are yellowish, elevated nodules and are caused by prolonged exposure to sun, wind & dust Cataracts Opacity of the lens of the eye that develops slowly w/ aging & gradually obstructs vision Glaucoma Increaase of interocular pressure Macular degeneration Breakdown of macular cells (sharpest vision) Arcus Senilis Gray-white arc or circle around the limbu Due to the deposition of lipid material in the aging adult Lipids accumulate cornea may look thickened and raised (gray shadowing around the eye)

 Has no effect on vision Lens loses elasticity-become hard & glasslike Presbyopia Condition found in aging adults where the pupil size decreases, the lens loses its elasticity and becomes hard and glasslike Decreases the lens' ability to change shape in order to accommodate for near vision (cant see near) Average age of onset is 40 Cross-cultural care Racial variations Open angle glaucoma most likely in African Americans 6 times more Objective Data Physical Exam Preparation Position Sitting eye level... Equipment Snellen eye chart Handheld visual screener Opaque card or occluder Penlight Applicator stick Ophthalmoscope Central visual acuity (cranial nerve #2) Snellen eye chart Most commonly used and accurate measure of visual accuity Contains lines of letters in decreasing size Have patient stand 20' away Top number indicates the distance the person is standing from the chart, while the denominator gives the distance at which a normal eye could have read that particular line The higher the bottom number the worse the vision Near vision Hold paper 14 inches from face 14/14. Higher bottom number worse vision Visual fields Confrontation test Gross measure of peripheral vision Extraocular muscle functionInspect Corneal light reflex (Hirschberg test) Tests how your eyes fuse

Is the gaze steady and fixed should be able to hold pen up and see reflection of the pen in the same spot in both eyes

Cover test If eye is covered and then as soon as you uncover you see it jump that means that it want hold gaze Diagnostic positions test Check six positions of gaze Myopia Difficulty with distant vision External ocular structuresInspect General Eyebrows Eyelids and lashes Eyeballs Conjunctiva and sclera Eversion of the upper lid Lacrimal apparatus Anterior eyeball structures Inspect Cornea and lens Look for scratches Iris and pupil Size and shape Should be equal Pupillary light reflex May be slower as long as they have it... Accommodation Abnormalities in the Eyelids Periorbital edema Swelling of the eyes Puffy EyesLocal infection can be caused by allergies, crying, CHF renal failure, hypothyroidism (myxedema) CHF Exophthalmos (protruding eyes) Marty Feldman had this problem also known as Lid Lag This is where the upper lid rests above limbus & white sclera is visible Associated w/thyrotoxicosis Enophthalmos (sunken eyes) Eyeballs recessed caused by loss of fat in the orbits & occurs w/dehydration and chronic wasting illness. Ptosis (drooping upper lid) Occurs w/neuromuscular weakness, oculomotor cranial nerve 3 damaged or sympathetic nerve damage. Gives person a sleepy appearance & poss impaired vision. Upward palpebral slant Ectropion

Lower lid is loose and rolls out Trauma and aging Entropion Lower lid rolls in Caused by spasm and scar tissue Lesions on the Eyelids Blepharitis Inflammation of the glands & eyelash follicles along the margin of the eyelids Chalazion Infection or retention cyst of a meibomian gland, showing as a beady nodule on the eyelid Hordeolum (stye) red, painful pustule that is a localized infection of hair follicle at eyelid margin Dacryocystitis (inflammation of the lacrimal sac) Dacryoadenitis (inflammation of the lacrimal gland) Basal cell carcinoma Abnormalities in the Pupil Unequal pupil sizeanisocoria 5% of the population Monocular blindness Constricted and fixed pupilsmiosis Occurs with glaucoma medication eye drops Dilated and fixed pupilsmydriasis Caused by trauma Argyll Robertson pupil Pupil does not react to light; does constrict w/ accommodation Tonic pupil (Adies pupil) Cranial nerve III damage Oculomotor nerve (superior, inferior and medial rectus and the inferior oblique muscles Horners syndrome Vascular Disorders of the External Eye Conjunctivitis Pink Eye Subconjunctival hemorrhage Iritis (circumcorneal redness) Acute glaucoma Increased intraocular pressure Opacities in the Lens Cataracts are due to clumping of proteins Central gray opacitynuclear cataract Star-shaped opacitycortical cataract Abnormalities in the Retinal Vessels and Background Arteriovenous crossing (nicking) Narrowed (attenuated) arteries Vessel nicking Diabetic retinopathy

 Deteriation of vascular of eyes Microaneurysms Abnormal finding of round red dots on the ocular fundus that are localized dilations of small vessels Intraretinal hemorrhages Exudates Which question is most likely to elicit information about a medical emergency? Do spots move in front of your eyes? Do your eyes feel tired? Do your eyes seem watery? Do you have night blindness? Ears Structure and Function Subjective DataHealth History Questions Objective DataPhysical Exam Abnormal Findings External ear External auditory canal Opening of the ear 2.5-3 cm long and terminates at the ear drum Lined with glands that secrete cerumen Tympanic membrane Separation of the external and middle ear Tilted obliquely to the ear canal, facing downward and somewhat forward Translucent with a pearly gray color and a prominent cone of light in the anteroinferior quadrant Middle ear Malleus One of the bones from the middle ear, which pulls the tympanic membrane tightly over Incus Stapes "stirrup" inner of the 3 ossicles of the middle ear Eustachian tube Connects the middle ear with the nasopharynx and allows the passage of air Inner ear Vestibule and semicircular canals Cochlea Inner ear structure containing the central hearing apparatus Hearing Levels of auditory system Peripheral Brainstem

 Cerebral cortex Pathways of hearing Air conduction Air conduction is the most efficient way of hearing Bone conduction Alternate route of hearing Bones of the skull vibrate Hearing loss Conductive Mechanical blocking Air still there Involves a mechanical dysfunction of the external or middle ear Able to hear IF sound amplitude is to reach nerve elements Sensorineural (perceptive) Type of loss that signifies pathology of the inner ear, cranial nerve VIII, or the auditory areas of the cerebral cortex May be caused by gradual nerve degeneration that occurs with aging, or ototoxic drugs, which affect the hair of the cochlea Equilibrium Vertigo Wrong information is sent by the labyrinth which creates a staggering gait and a strong, spinning, whirling sensation External EarInspect and palpate Size and shape Skin condition Tenderness External auditory meatus Otoscopic examination Position of head and ear Method of holding and inserting otoscope External canal Color Swelling Lesions Discharge Tympanic membrane (should appear pearly gray in color) Color and characteristics Position Integrity of membrane Abnormal Findings Abnormalities of the External Ear Frostbite Otitis externa (swimmers ear) Brachial remnant and ear deformity

 Cerebrospinal fluid otorrhea Abnormalities in the Ear Canal Excessive cerumen Otitis externa Inflammation of the outer ear and ear canal Osteoma Foreign body Exostosis Furuncle Polyp Smooth, pale gray nodules in the nasal cavity due to chronic allergic rhinitis Nose Structure and Function External nose Nasal cavity Septum Turbinates What do they do? NoseInspect and palpate External nose Nasal cavity Holding the otoscope Nasal septum Turbinates Paranasal sinuses You can palpate most of the sinuses Frontal Maxillary Ethmoid Sphenoid Sinus AreasPalpate Frontal and maxillary sinuses Transillumination Shining penlight under brow. If the sinus is open it will glow pink Abnormalities of the Nose Acute rhinitis Nasal obstruction caused by swollen mucosa where turbinates are drk red & swollen. 1st sign is clear, watery discharge, rhinorrhea, which later b/c purulent. Allergic rhinitis (Seasonal Allergies) Rhinorrhea, itchin of nose & eyes, lacrimation, nasal congestion and sneezing. Turbinates swell filling the air space and appear pale w/a smooth glistening surface. Sinusitis

Upper respiratory infection that causes facial pain. S&S: red swollen nasal mucosa; swollen turbinates, purulent discharge. Also may have fever,chills, malaise. Poss a dull throbbing pain in cheeks and teeth. Nasal polyps Carcinoma Choanal atresia Epistaxis Foreign body Perforated septum Furuncle

Mouth Hard and soft palates Uvula Tongue Salivary glands Parotid Submandibular Sublingual Teeth MouthInspect Lips Teeth and gums Tongue Buccal mucosa Palate and uvula Abnormalities of the Lips Cleft lip Herpes simplex I Angular cheilitis (stomatitis, perleche) Carcinoma Retention cyst (mucocele) Abnormalities of the Teeth and Gums Baby bottle tooth decay Occurs in infants/toddlers who take bottle of milk, juice to bed. Liquid pools around the upper front teeth, where bacteria act on the carbonation forming metabolic acids which breakdown tooth enamel & destroys proteins. Malocclusion Mouth breathing Dental caries Epulis Gingival hyperplasia Gingivitis Abnormalities of the Buccal Mucosa Aphthous ulcers Kopliks spots Leukoplakia Monilial infection

 Thrush Abnormalities of the Tongue Ankyloglossia Fissured or scrotal tongue Deep furrows in tongue in small irregular rows. 5% of pop. & in Down Syndrome. Increases w/age and occurs with dehydration. Geographic tongue (migratory glossitis) Smooth, glossy tongue (atrophic glossitis) Occurs w/Vitamin B12, folic acid or iron deficiency Tongue is slick & shiny, mucosa thins looks red w/dec pallor Black hairy tongue Occurs w/excessive or long term use of antibiotics due to the inhabition of normal bacteria & allow proliferation of fungus Enlarged tongue (macroglossia) Occurs in Down Syndrome, cretinism, myxedema, acromegaly Impairs speech but is not painful. Carcinoma Cancer.. Candidiasis or Monilial Infection THRUSH White, cheesy curdlike patches on the buccal mucosa & tongue. An opportunistic infection that occurs w/use of antibiotics, corticosteroids Ex. Advair. And immunosuppressed person. Abnormalities of the Oropharynx Cleft palate Bifid uvula Oral Kaposis sarcoma Bruiselike, dark red or violet on hard palate but also may be on soft palate. Oral lesions may develop prior which may develop w/AIDS. Acute tonsillitis and pharyngitis Bright red throat; swollen tonsils; white or yellow exudates on tonsils & pharanyx; swollen uvula & enlarged tender anterior cervical and tonsillar nodes. Painful swallowing and is accompanied w/fever >101F Throat Oropharynx Tonsils Nasopharynx ThroatInspect Tonsils grading Use of tongue blade Posterior pharyngeal wall Subjective DataHealth History Questions Nose

Discharge Frequent colds Sinus pain Trauma Epistaxis Nose bleeds Allergies Altered smell Mouth and throat Sores or lesions Sore throat Bleeding gums Toothache Hoarseness Dysphagia Difficulty swallowing Altered taste Smoking, alcohol consumption Self-care behaviors Effects of age in reference to Head, Neck, EENT This section seems like it is missing a lot of information... Diminished smell and taste Atrophic tissues Dental changes Senile Tremors Usually appear in the aging adult, benign & including head nodding and tongue protrusion. Which question would be least appropriate for the aging adult? Do you have difficulty driving? Do you use eyedrops for glaucoma? Do your eyes seem excessively moist? Have activities such as reading decreased? Parotid glands Salivary glands in the cheeks over the mandible, anterior to and below the ear Largest of the salivary glands but are not normally palpable Enlarged with mumps and AIDS Submandibular glands Salivary glands beneath the mandible at the angle of the jaw Headaches Cluster Headaches Always one-sided. Often behind or around the eye, temple, forehead, cheek Continuous, burning, piercing, excruciating Can occur multiple time a day, severe stabbing pain Timing 1-2 per day, ea. lasting between 30 minutes and 2 hrs. These headaches occur for 1 to 2 months; then remission for months or years Aggrevating triggers

Alcohol, stress, wind or heat exposure Relieving factor Need to move, pace the floor Associated symptoms Nasal congestion or runny nose, watery or reddened eye, eyelid drooping, miosis, feelings of agitation Migraine Headaches Commonly one-sided but may occur on both sides. Pain is often behind the eyes, the temples, or forehead Throbbing, pulsating pain Rapid onset, peaks 1-2 hrs, lasts 4hr-72hr, sometimes longer Moderate to severe pain Timing About 2 per month; lasts for 1-3 days Aggrevating triggers Hormonal flucuations (premenstral) ; Foods (alcohol, caffeine, MSG, nitrates, chocolate, cheese) --changes in sleep patterns, sensory stimuli (flashing lights or perfumes)--changes in weather--physical activity. Associated Symptoms Often preceeded by aura; nausea; photophobia; abdominal pain; tingling in arm or leg; vetigo; family history; Relieving factors Lie down; darken room; sleep; NASID; narcotics if severe Tension Headaches Usually bilateral; across the frontal, temporal and/or occipital region of head Forehead, sides and back of head Bandlike tightness, viselike; Non-throbbing Gradual onset, last 30 minutes to days Diffuse dull, aching pain; Mild to moderate Timing Situational, in response to overwork, posture Aggravating triggers Stress, anxiety, depression, poor posture Associated symptoms Fatigue, anxiety, stress. Sensation of tightening around the head, of being gripped like a vice. Sometime photophobia or phonophobia Relieving factors Rest, massaging muscles in area, NSAID Meningitis Meningitis is inflammation of the arachnoid and pia mater of the brain and spinal cord Meningitis is caused by bacterial and viral organisms, although fungal and protozoal meningitis also occurs Cerebrospinal fluid is analyzed to determine the diagnosis and the type of meningitis Nuchal rigidity & fever CVA. Cardiovascular Angle? Or Cerebrovascular Accident

 Cardiovascular Angle Angle formed by the 12th rib & the vertebral column on the posterior thorax, overlying the kidney Cerebrovascular Accident An upper motor neuron lesion caused by an obstruction of cerebral vessel (artherosclerosis) or a rupture in a cerebral vessel Damage due to CVS result of paralysis in 1 of the 4 quadrants of the face. Ischemic stroke or brain attack, is a sudden loss of brain function resulting from Cerebral Vascular Accident (Ischemic Stroke) a disruption of the blood supply to a part of the brain Tracheal shift Tracheal shift towards lung problem In diseased states where the pressure within the pleural cavity decreases on one side, the upper mediastinum (including the trachea) shifts towards the affected side. Atelectasis Also known as a collapsed lung, atelectasis refers to the diminished lung volume either as a result of a blockage (obstructive) or inability to inflate sufficiently Pleural fibrosis Thickening of the pleura usually as a result of prolonged inflammation Calcification may occur Pneumonectomy Partial or complete surgical removal of the lung often conducted in order to treat lung cancer Lung agenesis/aplasia Congenital abnormality where there is an absence of a lung and/or its bronchus Tracheal shift away from the lung problem In diseased states where the pressure within the pleural cavity increases on one side, the mediastinum (including the trachea) shifts away from the affected side. Pneumothoras Partial or complete collapse of the lung due to air entering the pleural space and compressing the lung thereby preventing it from expanding upon inspiration. Tracheal deviation more prominent in a tension pneumothorax. Pleural effusion Accumulation of fluid in the pleural space, which is the the area between the lung and chest wall. Significant clinical features like a tracheal deviation will only be present in the case of a massive pleural effusion. Tumors Any large mass of the bronchi, lung or pleural cavity including a benign or malignant tumor, may result in tracheal deviation.

 Tracheal Deviation Common signs and symptoms associated with most of the causes of tracheal deviation include: Difficulty breathing (dyspnea) Cough Abnormal breathing sounds Intraocular pressure (IOP) is the fluid pressure inside the eye. IOP is an important aspect in the evaluation of patients at risk from glaucoma Pupillary constriction Accommodation An adaptation of the eye for near vision by increasing the curvature of the lens through movement of the ciliary muscles. test this reflex by asking the person to focus on a distant object, which dilates the pupils, then have them shift gaze to a close object. A normal response is papillary constriction and convergence of the axes of the eyes. Macula A slightly darker pigmented region surrounding the fovea centralis Receives and transduces light from the center of the visual field Heart and Neck Vessels Structure and Function Subjective DataHealth History Questions Objective DataThe Physical Exam Abnormal Findings Structure and Function Position and surface landmarks Precordium Mediastinum Apex and base of heart Right and left cardiac borders Great vessels Heart wall Pericardium Myocardium Endocardium Precordium, Apex, and Base Area over heart on top of chest to the left of body Down by 5th intercostal spase THE HEART WALL The heart wall has several layers: Pericardium: A tough fibrous, double walled sac that surrounds and protects the heart It has two layers that contain a few milliliters of serous pericardial fluid The pericardial fluid ensures smooth, friction-free movement of the heart muscle It is adherent to the great vessels, esophagus, sternum, and pleurae & is anchored to the diaphragm The Myocardium:

Is the muscular wall of the heart; performs the pumping action The Endocardium: Is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves

Chambers Atriaright and left Ventriclesright and left Valves Atrioventricular (between atrium and ventrical) Tricuspid Mitral Semilunar (between aortic and pulmonary valve) Pulmonic Aortic Circlitory loop Pulmonic system Right ventricle to lungs Systemic System Left ventricle to rest of body Direction of blood flow

1. Liver inferior vena cava 2. right atrium RA tricuspid valve 3. Right ventricle pulmonic valve 4. pulmonary artery 5. lungs (oxygenates the blood) Pulmonary veins 6. Left atrium LA mitral valve 7. Left ventricle LV Aortic valve 8. Aorta 9. The body

1. head and upper extremities superior vena cava 2. Right Atrium

THE CARDIAC CYCLE (lub dub creates electrical impulse) (P is atrial contracting qrs is ventrical contracting etc.) (AV valves cause S1) DIASTOLE (Resting Phase) Filling of the ventricles occurs when the heart is relaxed (Both happen at the same time) The atrioventricular valves (tricuspid & mitral valves) which separate the ventricles and atria are open The pressure in the atria is higher than that of the ventricles, so blood pours rapidly into the ventricles Toward the end of diastole, the atria contract and push the last amount of blood into the ventricles

 This is called the Atrial Kick Diastole takes up 2/3 of the cardiac cycle SYSTOLE: As the pressure builds in the ventricles and exceeds that of the atria, the AV valves shut The closing of the AV valves contributes to the first heart sound S1 The AV valves close to prevent regurgitation of blood back up into the atria during contraction For a brief moment all 4 valves are closed The ventricular walls contract This contraction against a closed system works to build pressure inside the ventricles to a high level When the pressure in the ventricle finally exceeds that of the aorta, the aortic valve opens and the blood is ejected rapidly The action of the pulmonic valve is nearly synchronous to the aortic valve and allows blood to flow out of the right ventricle and in to the lungs After the ventricles contents are ejected, its pressure falls When the pressure falls below that of the aorta, some blood flows backward toward the ventricle, causing the aortic valve to shut This closure of the semilunar valves (the aortic & pulmonic valves) causes the second heart sound, S2 and signals the end of systole Now all four valves are shut and the ventricles relax Meanwhile, the atria have been filling with blood delivered from the lungs Atrial pressure is now higher than that of the relaxed ventricles and the mitral valve drifts open again, as will the tricuspid valve

Systole takes up 1/3 of the cardiac cycle

REMEMBER The events of diastole and systole happen on both the right and left side of the heart The pressures in the right side of the heart are much lower than that of the left side because less energy is needed to pump blood to the lungs than is required to pump blood to the entire body The events on the right side of the heart occur slightly later than in the left side of the heart due to the route of myocardial depolarization In the 1st heart sound, the mitral valve closes just before the tricuspid, and in the 2nd heart sound, aortic closure occurs just slightly before the pulmonic closure, however they are usually heard as fused components S1 is loudest at the apex S1 coincides with the carotid pulse S2 means systole is over Extra heart sounds Third heart sound (S3) (Normally disappears when the patient sits up) Ventricular filling sound before the atrial kick that fills the rest of the ventricle Congenital Heart Failure The blood backs up because it doesn't fully exit the right ventricle Pericardial friction rub Fourth heart sound Murmurs Characteristics of sound Frequency (pitch) Intensity (loudness) Duration Timing Conduction Pumping ability Cardiac output Preload Afterload THIRD HEART SOUND Normally diastole is a silent event The S3 is a ventricular filling sound and occurs in early diastole during the rapid filling phase It occurs in some conditions, such as decrease compliance of the ventricles in heart failure, (when the AV valves open and the blood first pours into the ventricles) It may be normal in children and young adults and may persist after the age of 40, especially in women The normal S3 usually disappears when the person sits up Number one sign of someone going into CHS is S3 FOURTH HEART SOUND The S4 is a ventricular filling sound

This sound occurs at the end of diastole (presystole) when the ventricle is resistant to filling The atria contract and push blood into a noncompliant ventricle The S4 occurs just before S1 It occurs with aortic stenosis and cardiomyopathy MURMURS Blood circulating through normal cardiac chambers and valves usually make no noise Some conditions create turbulent blood flow and collision currents These result in a murmur, a gentle, blowing, swooshing sound that can be heard on the chest wall CHARACTERISTICS OF SOUND FREQUENCY (pitch): S3 and S4 are low pitched, where as a pericardial friction rub is high pitched Intensity (loudness): As in mitral regurgitation Duration: Very short for heart sounds Timing: Note systole or diastole S1 is at the beginning of systole S2 is at the end of systole S3 is at early diastole S4 is at end diastole THE ECG WAVES The ECG waves are arbitrarily labeled PQRST and stand for the following: P wave Depolarization of the Atria PR interval From the beginning of the P wave to the beginning of the QRS complex (the time necessary for atrial depolarization plus time for the impulse to travel to through the AV node to the ventricle) QRS complex Depolarization of the ventricles T wave Repolarization of the ventricles S4>S1>S2>S3 PUMPING ABILITY Cardiac Output: Equals the volume of blood in each systole Preload: The venous return that builds during diastole It is the length to which the ventricular muscle is stretched at the end of diastole just before contraction The greater the stretch, the stronger the hearts contraction (important in exercise) and thus an increase of blood ejected/increased stroke volume

 Afterload: Is the opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure Structure and Function (cont.) Neck vessels Carotid artery Jugular veins Internal External Venous pulse and pressure Subjective Data Health History Questions Chest pain Dyspnea Orthopnea Cough Fatigue Cyanosis or pallor Edema Nocturia Cardiac history Family cardiac history Personal habits (cardiac risk factors) Objective DataThe Physical Exam Preparation Position and draping Room preparation Order of examination Equipment needed Marking pen Small centimeter ruler Stethoscope with diaphragm and bell endpieces Alcohol swab Carotid arteries Palpate Auscultate for bruit Means.. Jugular veins Inspect the jugular venous pulse 30 - 45 degree angle If you can see it when they sit up. Its jugular vein distention Estimate the jugular venous pressure Palpate for hepatojugular reflux Precordium Inspect the anterior chest Lifts of heaves Palpate the apical impulse Point of maximal impulse Should occupy 1 intercostal space 4th or 5th space mid clavicular line

Palpate across the precordium For vibrations Like humming. Is a thrill Signifies blood flow usually accompanied by murmurs... Percuss to outline the cardiac borders Identify auscultatory areas Note the rate and rhythm Sinus arrhythmia Pulse deficit Identify S1 and S2 S1 is louder than S2 at the apex S1 coincides with carotid artery pulse S1 coincides with R wave on electrocardiogram Listen to S1 and S2 separately S2 is louder at the base Listen for extra heart sounds Listen for murmurs Characteristics of normal heart sounds First heart sound Second heart sound Splitting of second heart sound Extra heart sounds Midsystolic click Third heart sound Fourth heart sound Murmurs Timing Loudness Pitch Pattern Abnormal Findings - Systolic Extra Sounds (Just know that: WE GRADE MURMERS) Ejection click Occurs in early systole at the start of ejection b/c it results from opening of the semilunar (SL) valve Aortic ejection click is heard @ the 2nd RT interspace & apex Pulmonic ejection click is heard in the 2nd LT interspace & often grows softer w/inspiration Aortic prosthetic valve sounds Present click when carbonite valve placed due to the mechanical opening This sound is less intense w/a pig valve Midsystolic click Assoc w/ Mitral valve prolapsed where the leeflets close but they balloon back back into the left atrium Click comes form the ballooning which causes tensing of the valve leeflets & the chordae tendineae creates click (Think of a guitarthe chordae tendineae are being pulled tight, strumming the stringsCLICK, CLICK, CLICK)

 Abnormal Findings Diastolic Extra Sounds Opening snap- heard during early diastole. Normally opening of the AV valves is silent. In the presence of stenosis, increasingly higher atrial pressure is required to open valve. The deformed valve opens with a noise: the opening snap. Sharp and high pitched, with a snapping quality. Sounds after S2 and is best heard at 3rd or 4th left interspace at the sternal border, less well at apex. Sign of mitral stenosis. Mitral prosthetic valve sound- An iatrogenic sound, the opening of a ball-and-cage mitral prosthesis gives an early diastolic sound: an opening click just after S2. It is loud and heard over the whole precordium, loudest at the apex and left lower sternal border. Third heart sound- ventricular filling sound heard in early diastole during the rapid filling phase. A dull soft sound and low pitched. Best heard at apex or left lower sternal border. Heard frequently in children and young adults and more in women. Normal S3 usually disappears when person sits up. The S3 indicates decreased compliance of the ventricles, as in heart failure. S3 may be earliest sign of heart failure. The pathologic S3 (ventricular gallop or S3 gallop) persists when sitting up. S3 also occurs with conditions of volume overload such as mitral regurgitation and aortic or tricuspid regurgitation. S3 is also found in high cardiac output states in the absence of heart disease, such as hyperthyroidism, anemia, and pregnancy. Fourth heart sound- S4 is a ventricular filling sound. Occurs when atria contract late in systole. Heard immediately before S1, soft sound of very low pitch. A physiologic S4 may occur in adults older than 40 or 50 years with no evidence of cardiovascular disease, especially after exercise. A pathologic S4 (atrial gallop or S4 gallop) occurs with decreased compliance of the ventricle and with systolic overload, including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. Summation sound S1 through S4 all at the same time When both pathologic S3 and S4 are present, hear a quadruple rhythm. Sound super imposed in mid diastole and hear one loud, prolonged, summated sound, often louder than S1 or S2. Often seen in cases of cardiac stress, one response is tachycardia. Pericardial Effusion Causes pressure on the heart need to drain it

 An abnormal amount of fluid b/t the heart & the pericardium (sac surrounding the heart) Caused by: inflammation of the pericardium (pericarditis), viral infections, MIs, cancer or TB There may or not be symptoms associeated w/ but may have pain made worse by deep breathing & mad worse by sitting up & leaning forward Abnormal Pulsations on the Precordium Thrill at the base Palpable vibration that signifies turbulent blood flow & accompanies loud murmur BUT in absence of, doesnt mean murmurs are to be ruled out In second and third RIGHT interspaces- aortic stenosis and systemic hypertension In second and third LEFT interspaces- pulmonic stenosis and pulmonic hypertension Lift (heave) at the sternal border Sustained forceful thrusting of the ventricle during systole. Occurs w/ventricular hypertrophy as a result of workload. RT heave is seen at the sterna border, LT heave seen at the apex. Volume overload at the apex Over to the left more Seen in mitral & aortic regurgitation and RT & LT shunt Where the enlargement displaces the apical impulse laterally. Pressure overload at the apex Seen in aortic stenosis or systemic hypertension Increased in force & duration but not displaced to the LT Abnormal Findings - Congenital Heart Defects Patent ductus arteriosus Atrial septal defect Ventricular septal defect Tetralogy of Fallot Coarctation of the aorta Abnormal Findings - Murmurs Caused by Valvular Defects Murmur is a backward or forward flow through a valve A gentle, blowing, swooshing sound that can be heard on the chest wall Blood circulating through normal cardiac chambers and valves usually make no noise. Some conditions create turbulent blood flow and collision currents Midsystolic ejection murmurs Due to forward flow through semilunar valves Aortic stenosis Restricts forward flow of blood during systole thus causing a back up of blood into the left ventricle which causes LV hypERtrophy S1 normal, S2 split, S4 present Will have fatigue, palpitations, dizziness, fainting & angina pain Pulmonic stenosis

Restricts forward flow of blood out the pulmonary artery to the lungs Thrill in systole, ejection clicking present after S1, dimished S2 & wide spread S4 common w/RV hypertrophy Pansystolic regurgitant murmurs Backward flow of blood from areas of pressure to one of pressure. Mitral regurgitation Incompetent MV, blood flows back into LA during systole In diastole, blood passes back into LV again along w/new flow; results in LV dilation & hypertrophy S&S inc: Fatigue, papitition, orthopnea, PND Tricuspid regurgitation Incompetent TV, blood flows back into RA during systole Diastolic rumbles of atrioventricular valves Filling murmurs at low pressure Mitral stenosis Calcification of mitral valve will not open properly, impedes forward flow of blood into LV during diastole Results in LA enlargements & LA pressure Tricuspid stenosis Calcification of tricuspid valve, impedes forward flow into RV during diastole. Early diastolic murmurs Due to SL valve incompetence Aortic regurgitation Occurs during diastole, due to an incompetent aortic valve which blood fills the LV; dilation and hypertrophy occurs. Pulmonary edema Pulmonic regurgitation Backflow of blood through incompetent pulmonic valve, from pulmonary artery to RV Occurs during diastole, which blood fills the RV Mitral reguritation Mitral valve dosent close tight enough. Blood goes back into the left atrium Tricuspid Regurgitation Look above Aoritic regurgition Pulmonary edema HEART FAILURE Decreased cardiac output occurs when the heart fails as a pump, and the circulation becomes backed up and congested Signs and Symptoms of heart failure come from two basic mechanisms:

The hearts inability to pump enough blood to meet the metabolic demands of the body The kidneys compensatory mechanisms of abnormal retention of sodium and water to compensate for the decreased cardiac output This increases blood volume and venous return, which causes further congestion Onset of heart failure may be: Acute (S3) Following a myocardial infarction when direct damage to the hearts contracting ability has occurred Chronic In hypertension, when the ventricles must pump against chronically increased pressure Which patient is at highest risk for orthostatic hypotension? A 50-year-old man with pneumonia A 4-year-old patient with cystic fibrosis A 20-year-old woman who smokes and takes oral contraceptives An 86-year-old woman with mild ankle edema Peripheral Vascular System and Lymphatic System Structure and Function Subjective DataHealth History Questions Objective DataThe Physical Exam Abnormal Findings Arteries Temporal artery Carotid artery Arteries in the arm Brachial Ulnar Radial Arteries in the leg Femoral Popliteal Dorsalis pedis Posterior tibial 5 ps of ischema Pain Pulse Pallor Paristesia Paralysis Veins Jugular veins (Chapter 19) Veins in the arm Veins in the leg Deep veins Femoral Popliteal Superficial veins

Great saphenous Small saphenous Perforators (connecting veins) How do you get blood flow or something. Pump Valves close so blood dosent go back down Breath in and out Lymphatics Retrieves excess fluid form your tissue not returned from your veins to your heart Right lymphatic duct Thoracic duct Functions of the lymphatic system Absorbs lipids from GI tract Filter fluid Pathogens exposed to lymphocytes Inflammation causes swelling Lymph nodes Related organs to lymphatic system Spleen Tonsils Superficial lymph nodes palpable Cervical nodes Axillary nodes Epitrochlear nodes Inguinal nodes With acute infection nodes will be Large, warm, bilaterall Subjective DataHealth History Questions Leg pain or cramps Say how far can you walk before you have the pain Caused by intermitten clottercation Skin changes on arm or legs Swelling Lymph node enlargement Medications Can cause vasodilation Objective DataThe Physical Exam Preparation Equipment needed (occasionally) Paper tape measure Tourniquet or blood pressure cuff Stethoscope Doppler ultrasonic stethoscope ArmsInspect and palpate Skin Profile sign Capillary refill Symmetry Radial pulse

Ulnar pulse Brachial pulse Epitrochlear lymph node Checking for circulation Draw ABGs Arterial blood gasses Pull the blood out of the radial artery BEFORE YOU DO IT. You need to know if the artery is blocked or not Modified allens test Put finger on radial and ulnar artery and have them pump their hand Let go of alnar arterie and see if you have return of blood flow to hand. Blood should return 2 seconds LegsInspect and palpate Skin and hair Symmetry Temperature Calf muscle Calfs not symmetric warm caused by DVT Inguinal lymph nodes Femoral pulse Popliteal pulse Posterior tibial pulse Dorsalis pedis pulse Pretibial edema Leg veins Assess while patient stands Manual compression test Pitting Edema Press down and check for pitting Checks for edema 1+ 2mm indentation 2+ = 4 3+=6. 4+=8mm Manual Compression Test Hold upper and lower. Let go of upper feel wave = bad valve... Additional techniques Color changes Let blood drain for 30 seconds then sit them up and dangle their feet the blood should return in 10 - 15 seconds or less Doppler ultrasonic stethoscope Ankle-brachial index (ABI) Abnormal Findings - Variations in Arterial Pulse Weak, thready pulse 1+ Full, bounding pulse 3+ Water-Hammer (Corrigans) pulse 3+ (collapses suddenly) Pulsus bigeminus Pulsus alternans Pulsus paradoxus Pulsus bisferiens Abnormal Findings - Peripheral Vascular Disease

Arms Raynauds syndrome Tri color of hands More systeptibal to frost bite Lymphedema Cant get rid of all of that lymph drainage Legs Arteriosclerosisischemic ulcer Venous (stasis) ulcer Problem with venous return usually dark brown ankle Superficial varicose veins Valves are incompitant blood pools Deep vein thrombophlebitis The relevant variable when discussing claudication with a patient is Related foods Distance Blood glucose Emotional state 4 major drugs to give to someone in an ischemic state MONA not in that order Morphine Oxygen Nitrogen Asprin Give Oxygen first Then Nitrogen Then Morphine (helps with pain but also clears the lung). Then aspirin Someone having chest pain walking in the hallway Stop sit them down dont walk them back into the room If they say I just dont feel right. Something is going to go bad. Fast. Cardiac chest pain First sign of heart attack Electrical conduction of the heart SA node to the AV node to the Bundle of Thist to the Pikingiee fibers S3 Physiologic in a pregnant woman When she sits up it goes away Cardinal sign for someone in CHF Pathological S3 is a ventricular filling sound. Occurs early in diastole during rapid filling phase Heard after S2 w/a low pitch like distant thunder sound S4 S4 is a ventricular filling sound Occurs when aorta contracts early in diastole Heard immediately before S1 w/ a very soft, very low pitch (hard to hear) CHF Do you have ventricular overload? Yes

cardiac output The heart fails as a pump & the circulation b/c backed up and congested S&S The hearts inability to pump enough blood to meet the metabolic demands of the body The kidneys compensatory mechanisms of abnormal retention of sodium & water to compensate for the decreased cardiac output This increases blood volume & venous return, which causes further congestion Understand a murmur is backward or forward flow Murmurs are valvular sounds Bruit are vascular sounds Thrills mean you have a murmur Vericose veins Nodds disease? Mechanism for veins Cass pump, valve, Arteries Muscular walled vessles Veins Thinner and have valves Pericardial friction rub More clear when they sit up and lean forward Inflammation of the pericardium. High pitch & scratchy sound sand paper Commonly heard during 1st wk after a MI S1 is louder at the apex S2 is louder at the base When someone is having chest pain you use MONA. Without oxygen the tissue dies. Time = tissue. Tissue without oxygen becomes eschemia then enfark Mitral opens before the tricuspid usually dont hear it