Approach to Cardiac Exam

Question 1

Sequence of Assessment for Cardiac Function

Answer 1

Inspect
Palpate
Percussion
Auscultation

Question 2

Five Finger Method for Normal heart

Answer 2

History
Physical
ECG
X-Ray
Lab tests

Question 3

Inspection Chest Shape

Answer 3

• Barrel Chested: inreased AP diameter
• Pectus Carinatum (Pigeon chest): central protrusion
• Pectus Excavatum (funnel chest): central depression

Question 4

Apex of Heart Location

Answer 4

5th ICS left, 1 cm Medial to MCL

Question 5

Percussion and palpation

Answer 5

start far left and move medially

-Palpate for thrill and PMI (4th-5th ICS at mid clavicular line)

Question 6

Auscultation

Answer 6

S1: mitral and tricuspid closure, start of ventricular systole
S2: Aortic and pulm closures, end of systole

Question 7

Physical

Answer 7

• JVP
• reflect activity of heart
• IJ better than EJ
• pt supine to allow veins to engorge and raise to 30-45 degree
• elevated JVP elevated RV diastolic pressure

Question 8

A Wave

Answer 8

R atrial contraction

• S1
• Big with
  1. obstruction bw RA and RV
  2. Increased pressure in RV
  3. Pulm hypertension
  4. recurrent pulmonary emboli

Question 9

C wave

Answer 9

Backward push by closure of tricuspid valve during isovolumetric systole

Question 10

X Wave

Answer 10

passive atrial filling and relaxation
-blood flows into RA from cava and closure of TV
Steep X: cardiac tamponade and constrictive pericarditis

Question 11

V Wave

Answer 11

• Atrial filling
• increasing vol and pressure in RA when TV closed
• Big in tricuspid regurgitation and pulm hypertension

Question 12

Y Slope

Answer 12

• open TV and rapid RV filling in RV diastole
• Deep: severe tricuspid regurg
• Slow: obstruction to RV filling

Question 13

Causes of Increased JVP

Answer 13

SVC obstruction
severe heart failure
constrictive pericarditis, cardiac tamponade, RV infarction
restrictive cardiomyopathy

Question 14

Causes of positive HJR

Answer 14

poorly compliant RV
RV failure
Constructive pericarditis
Obstructive RV filling

Question 15

Heart Sounds

Answer 15

Normal
S1: TV (2nd) & MV (1st) close–>loudest at apex
S2: AV (1st) & PV (2nd) close–>loudest at base
Abnormal
S3:high pressures and deceleration of inflow across MV at end of filling
S4: forceful atria contraction against stiffened ventricle

Question 16

Normal Inspiration and Expiration of S1 and S2

Answer 16

S2 split during inspiration

-increased venous return during inspiration and more time for RV to deliver blood to lung (delayed P2)

Question 17

Heart Sounds

Answer 17

Mitral: apex 5th left ICS at mid clavicular line
Tricuspid: 4th left ICS at LSB
Aortic V: 2nd ICS to R of sternum
Pulm V: 2nd ICS L of sternum

Question 18

Murmur Grading System

Answer 18

1: Barely Audible
2: Soft but easily heard
3: Loud, without thrill
4. Loud with minimal contact between stethoscope and chest-thrill
5: Loud, can be heard without stethoscope -thrill

Question 19

Carotid A

Answer 19

-auscultate with bell

Question 20

Edema rating

Answer 20

0 Absent
1+ barely detectable (2mm)
2+ slight indent (4 mm)
3+ deeper indent (6 mm)
4+ very marked indent (8mm)