Advanced Cardiac Exam

Question 1

Risk assessment for CAD

Answer 1

History:

• FHx
• Smoking
• Diet
• Physical Activity
• Lipids (cholesterol especially)
• Diabetes

Exam:

• Blood pressure
• Peripheral artery disease

Question 1

Jugular venous pulse diagram

Answer 1

Question 2

Pulsus paradoxus

Answer 2

Question 3

Important setup for getting a proper blood pressure

Answer 3

Be sure to check in left arm with mechanical cuff after patient has been sitting and resting for > 5 min, back and feet supported and arm supported at/near heart level.

Question 4

While talking to a patient, always take a mental note of ____.

Answer 4

While talking to a patient, always take a mental note of conversational dyspnea.

Question 5

Areas that may have significantly impaired perfusion or blood flow in heart failure

Answer 5

• Base of lung (crackles of PE)
• Lower extremity edema
• Calf and forearm temperature
• Capillary refill time
• Dependent rubor

Question 6

Dependent rubor

Answer 6

Fiery to dusky-red coloration visible when the leg is in a “dependent position,” but not when it’s elevated above the heart. Caused by peripheral arterial disease.

To test for dependent rubor, position the patient supine and elevate the legs 60 degrees for 1 minute; then examine sole color.

The longer dependent rubor takes to reappear, the worse the PAD

Question 7

Allen’s Test

Answer 7

Test for collateral circulation within the hand

1. Place thumbs over the radial and ulnar arteries in the wrist
2. Have the patient pump their hand until it is white
3. Release one thumb
4. Watch for capillary refill (normal is 3-5 seconds)
5. Repeat steps 1-4 for the other artery

Question 8

Consolidation vs Effusion

Answer 8

Question 9

You have a patient with severe emphysema in clinic and are trying to listen to their heart, but are having trouble hearing due to their hyperinflated lungs. What can you ask them to do to help you hear?

Answer 9

Lean left or lean forward

This will bring the apex of the heart closer to the chest wall, with less intervening lung space.

Question 10

Precordium lift or heaves

Answer 10

Forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. These will be associated with a palpable thrill.

Question 11

The JVP is essential for distinguishing ___ from ___ in patients with dyspnea, ascites, or edema.

Answer 11

The JVP is essential for distinguishing cardiopulmonary disease from liver or kidney disease in patients with dyspnea, ascites, or edema.

Question 12

Lewis method of CVP estimation

Answer 12

45 degree angle

Tell the patient to exhale (increases the sensitivity and minimizes error)

of cm the CVP is above the sternal angle + 5 cm

Anything <8 cm H₂O is normal.

Question 13

Percussion of the heart

Answer 13

Percussion of the heart detecting a cardiothoracic ratio > 0.5 is highly sensitive (~97%), but not as specific (~61%) to cardiomegaly as one would hope.

Question 14

Carotid pulse analysis

Answer 14

• Palpation:
  
  • 2+
  • 1+
  • Doppler
• Auscultation:
  
  • Bruit or no?

Question 15

For a thorough cardiac exam, you should palpatae . . .

Answer 15

. . . everywhere you auscultate. At least if you hear a murmur, see if there is a palpable thrill there.

Also along the LSB for the right ventricle heave

Question 16

What is this called?

Answer 16

Pectus excavatum

Question 17

The bell is really mostly to hear. . .

Answer 17

S3 and S4, usually at LLSB

Question 18

Order of operations for careful auscultation of the heart (at each location)

Answer 18

Question 19

S2 louder than S1 at apex is concerning for __.

Answer 19

S2 louder than S1 at apex is concerning for pulmonary HTN.

Question 20

Inspiration increases preload in . . .

Answer 20

. . . mostly the RV

Question 21

Paradoxical splitting

Answer 21

Splitting heard at base with diaphragm upon expiration

Happens if aortic valve closes late at baseline. May indicate aortic stenosis or left bundle branch block.

Question 22

If you hear extra sounds at the apex, they are likely to be ___.

If you hear them at the upper sternal borders, they are likely to be ___.

Answer 22

If you hear extra sounds at the apex, they are likely to be gallops.

If you hear them at the upper sternal borders, they are likely to be S2 split.

Question 23

Grade 4 of above systolic murmurs are. . .

Answer 23

. . . associated with a palpable thrill

Question 24

Maneuvers to exaggerate murmurs

Answer 24

Question 25

Locations to auscultate for heart murmurs

Answer 25

Question 26

Shape of JVP

Answer 26

Question 27

If you are having trouble telling systole and disatole apart, what can you use as a guide?

Answer 27

The pulse! Pulse will happen during systole

Question 28

Physiologic splitting

Answer 28

Question 29

Paradoxical splitting

Answer 29

Question 30

Wide splitting

Answer 30

Question 31

Fixed splitting

Answer 31

Question 32

Where do you listen for splitting?

Answer 32

The base (the great vessel areas)

Question 33

Describing a heart murmur

Answer 33

• Intensity
• Timing
• Shape
• Location
• Radiation
• (Maneuvers)

Question 34

Mitral prolapse and HCM maneuvers

Answer 34

Question 35

Murmur summary table

(AS, AR, MS, MR, MVP, TR, HCM)

Answer 35

Question 36

If you can’t tell whether what you’re looking at is the carotid or the jugular, how can you check?

Answer 36

Change the angle of the patient.

The jugular’s height will change with angle. The carotid’s will not.

Question 37

Hepatojugular reflux

Answer 37

Distension of the neck veins precipitated by the maneuver of firm pressure over the liver. It is seen in tricuspid regurgitation, heart failure due to other non-valvular causes, and other conditions including constrictive pericarditis, cardia tamponade, and inferior vena cava obstruction