Approach to Cardiac Exam Flashcards
What is included in a normal heart exam?
History Physical ECG Xray Lab tests
What are some non-specific items you should ask in heart exam history?
fatigue, dyspnea, chest pain, palpation, syncope
What does a complete cardiac DDX need to consider?
Underlying etiology
Anatomic abnormalities
Physiologic disturbance
Why is family history important in a heart exam?
familial clustering is common in pts with certain heart diseases (hypertrophic cardiomyopathy, prolonged QT syndrome, Marfan’s syndrome)
What is the order of physical assessment of cardiac function?
inspection palpation percussion auscultation positioning of pt
Normal chest shape
AP diameter should be 1/2 of transverse diameter of thorax
Pectus carinatum
pigeon chest
central protrusion
Pectus excavatum
funnel chest
central depression
What should you inspect for on a PE?
precordium (trauma?)
scars, pacemaker, skeletal abnormalities
apex of heart (in 5th intercostal space)
What is the purpose of percussion in PE?
estimate cardiac size by starting far left and move medially to find cardiac dullness
if can’t feel apex of heart
What is the purpose of auscultation in PE?
S1 (mitral & tricuspid closure)
S2 (aortic & pulmonic closure)
What is the purpose of palpation in PE?
palpate for thrills which indicate blood flow causing murmurs
Why do you palpate for jugular venous pulse?
because jugular veins reflect the activity of the right side of the heart
Which jugular vein should you measure?
internal jugular vein
What does an elevated JVP indicate?
elevated RV diastolic pressure
What may a giant A wave indicate?
obstruction btwn RA & RV
increased pressure in RV
pulmonary hypertension
recurrent pulmonary emboli
AV dissociation
What does the C wave indicate?
backward push by closure of TV during isovolumetric systole & by impact of carotid artery adjacent to JV
What does an “X” wave indicate?
passive atrial filling & atrial relaxation (blood flows into RA from vena cava & triscupid valve is closed)
When do you see a steep X descent?
cardiac tamponade & constrictive pericarditis
When do you see a prominent V wave?
in TR & pulmonary hypertension
What does a slow Y descent suggest?
obstruction to RV filling
When do you see increased JVP?
SVC obstruction severe heart failure constrictive pericarditis cardiac tamponade RV infarction restrictive cardiomyopathy
Which heart sounds are abnormal?
S3 & S4
S3 heart sound
due to high pressures & abrupt deceleration of inflow across mitral valve @ end of rapid filling phase
(normal in children)
Ken-Tuck-Y
S4 heart sound
atrial gallop from forceful contraction of atria against stiffened ventricle (low compliant)
diastolic sound (Ten-Nes-See)
Where do you listen for mitral valve?
apex of heart
5th left ICS at mid clavicular line
Where do you listen for tricuspid valve?
4th left ICS @ LSB
Where do you listen for aortic v?
2nd ICS to R of sternum
Where do you listen for pul v?
2nd ICS L of sternum
Murmur grading system
1-barely audible 2-soft, but easily heard 3-loud w/o thrill 4-loud w/ thrill 5-loud w/ minimal contact of stethoscope 6-loud, can be heard w/o stethoscope
Normal right atrial pressure
0-8 mmHg
Normal right ventricle pressure
25 mmHg
Normal pulmonary artery pressure
30/12
Normal systolic vascular resistance
900-1500 dynes/second/cm
Normal vascular resistance
155-255 dynes/second/cm
Normal pulmonary wedge pressure
8-15 mmHG
normal CO
3.5-7 liters/min
Normal cardiac index
2.5-4 L/m
What is the most important part of a CV assessment?
taking a good patient history
What should you first inspect about your pt w/ CV cc?
need to make sure the pt is stable
What would distended neck veins suggest?
filling up with pressure & area of concern that needs to be addressed
What is Levine sign?
pt is holding chest & abdomen
sign of heart attack or unstable discomfort in chest
What anatomic abnormalities can contribute to pt complain?
which chamber involved
which valve affected
is pericardium involved
has there been an MI
What heart disease is genetically acquired?
hypertrophic cardiomyopathy
assoc w/ increase in septal hypertrophy compared to rest of ventricle
outlet obstruction
What is Marfan’s syndrome?
Connective tissue disorder
pts prone to aortic aneurysms & sudden death
What is prolonged QT syndrome?
prolonged QT interval & more prone to arrythmias
Acromegaly
prone to cardiac issues b/c have bi-ventricular dysfunction
Cushing’s disease
prone to hypertension & cardiac disease b/c elevated cortisol
Down’s syndrome
pre-disposition to congential heart disease
What does clubbing of nails suggest?
interstitial lung disease & congenital heart disease
What do hemorrhages under nails suggest?
new pulmonary emboli or endocarditis
How are temperature and HR related?
for every 1 degree above normal, increase HR by 10 bpm
Barrel chest
AP diameter is equal to transverse diameter of chest
COPD
Inspection landmarks
Suprasternal notch
Sternal angle
Midclavicular line
Ant axillary line
What is the normal PMI (point of maximal impulse)
4th-5th intercostal space @ mid-clavicular line
How do you determine central venous pressure?
measure distance of IJV from sternal notch & add 5cm (which is distance of RV from sternal notch)
gives you jugular venous pressure
What does the A wave indicate?
R atrial contraction (tricuspid valve is open)
coincides w/ S1
Why is the S2 sound split during inspiration?
because as you inhale, increase venous return to heart
takes time for venous return to get up into vessel
What may bilateral edema indicate?
heart, lung, kidney disease
What is a vscan?
ultrasound to monitor valve function
