Cardiac Flashcards
Inspects the chest looking for scars, pacemaker, forceful PMI, chest deformity. Comments on findings.
Inspect the chest by asking the patient to untie gown and lower gown to above breast line. “We would normally have the patient lower the gown below the nipple but for the patient’s comfort only to the breast will suffice.” (also look at the back) for scars or visible pulsations (remember to look underneath arms for thoracotomy scars and for small scars from minimally invasive surgery).
“First, I’ll be inspecting your chest. Can I please adjust your drape and gown? Ok I’m going to lower your drape to the pubic symphysis. (looking at the patient’s chest) I don’t see any visible scars from any past surgeries, any bruises due to trauma, or any pacemakers. I’m noting that there is a symmetrical rise and fall of the chest (bend down to look for this), and no signs of deformities such as pectus excavatum (concave chest) and pectus carinatum (overgrowth of sternum). I also don’t see any forceful point of maximal impulse.”
-Scars ⟶ pacemaker, surgery
-Pectus excavatum: concave sternum -Pectus carinatum: overgrowth of sternum 4
Explain how you would palpate the 4 cardiac areas for pulsations and thrills. Describe locations. Describe findings of the apical impulse (location, diameter, timing, forceful). Explain the significance of a thrill.
“Now I’m going to palpate for thrill which is a buzzing/vibrating sensation. I’m going to locate the sternal angle and I’m going to the right 2nd ICS at the parasternal border in the aortic area. Next, the L 2nd ICS in the pulmonic area. Then the 4th ICS on the L parasternal border for the tricuspid area. Lastly, the 5th ICS at the mid clavicular line for the mitral area. Upon palpation of the cardiac areas of the heart, I did not feel any thrills which would be caused by turbulent flow.”
Palpate the 4 cardiac areas for pulsations and thrills. Describe locations. Describe findings of the apical impulse (location, diameter, timing, forceful). Explain the significance of a thrill.
Thrills-Press the ball of your hand (the padded are of your palm near the wrist) firmly on the chest to check for a buzzing or vibratory sensation-vascular turbulence from heart murmurs-if present auscultate for murmurs.
Thrills are more easily palpated in the patient position that accentuates the murmur, such as the leaning forward to enhance detection of aortic insufficiency.
Run your palm through the 4 areas of heart auscultation to feel for thrills- Aortic (right 2nd intercostal space), Pulmonic (left 2nd intercostal space), Tricuspid (Left 4th intercostal space), and Mitral (Left 5th intercostal space along Midclavicular line)
Palpate for apical impulse and describe finding: (Point of Maximal Impulse)
Feel for the point of maximal impulse (PMI), note its diameter, and localize it.
The apical impulse represents the brief early pulsation of the left ventricle as it moves anteriorly during contraction and contacts the chest wall.
(Palm of your hand and point out with finger) “To check for PMI, I’m going to palpate the apical impulse. Is it okay if I place my hand on you? Ok, I’m going to locate the PMI which is normally on the Left 5th intercostal space along the midclavicular line (so locate sternal angle, 5th intercostal space, then midclavicular line on the left; medial to the midclavicular line). I don’t feel it so can you roll to your left in the lateral decubitus position (where the left ventricle comes close to the chest wall). I’m going to locate it and I’m noting that it is in the correct location at the 5th ICS along the midclavicular line and is about the proper size which is 1-2.5cm.) (explain findings-if displaced lower into the 6th ICS it is due to LVH, or if displaced lower into the 6th ICS it is due to cardiomegaly, if diffused > 2.5 cm due to LV dilation).”
● Located in left 5th intercostal space along the midclavicular line → normal
● Displaced laterally→ LV hypertrophy → HTN, AS (aortic stenosis), AR (aortic regurgitation)
● Diffuse (>2cm) → LV dilation → CHF
● In dextrocardia, a rare congenital transposition of the heart, the heart is situated in the right chest cavity
and generates a right-sided apical impulse. Use percussion to help locate the heart border, the liver, and stomach. In full situs inversus, the heart, trilobed lung, stomach, and spleen are on the right, and liver and gallbladder are on the left.
Palpates for and discuss the significance of a parasternal heave.
“Next, I’m going to check for any signs for any parasternal heaves by placing the ulnar side of my hand on the L parasternal border at about 3-5th ICS and feeling for palpable pulsations of the chest wall. I do not note any parasternal heaves which would be indicative of (explain findings).”
Feel for a heave using the length of your fingers along the left sternal border; check 1 side
● Heave → RV hypertrophy → pulmonary HTN, pulmonary embolism
Auscultates for heart sounds and murmurs at the 4 areas and indicates which sound is heard best in each area.
“First, I’m going to locate the carotid pulse so that I can time the S1 and S2 sounds while auscultating. To begin auscultation. I’m going to locate the sternal angle (angle of Louis) which is at the level of the 2nd rib and then go to the right (2nd rib then 2nd ICS at the parasternal border) to listen to the aortic valve. Then to the left 2nd ICS to listen to the pulmonic. Down to the (left lower sternal boarder) left 4th ICS to listen to the tricuspid. Can you inhale please (listen for S2 split)?”
If female: “Can you lift your breast up for me? Lastly, to the left 5th ICS at the midclavicular line to listen to the mitral area).
“I’m noting that I heard the first and second heart sounds which signifies closure of the heart valves. I did hear S1 coincide with the carotid upstroke and it was louder in the tricuspid and mitral areas. S2 was louder in the aortic and pulmonic areas.”
“I did not hear any murmurs or additional S3 or S4 sounds. An S3 or S4 sound would be heard best in the mitral area. Also, S3 can be physiological in pregnant women, children or athletes, and can be pathological for example in CHF or MR with a noncompliant/compliant ventricle. The S4 sound is always pathological.”
“The heart becomes less compliant with age thus S4 is mostly seen in old people.”
Palpate the right carotid artery while listening to heart sounds to correctly identify S1 and S2 (S1…carotid upstroke…S2)
Aortic Area: S2 louder than S1
Pulmonic Area: S1, S2 w/split
Tricuspid Area: S1 louder than S2
Mitral Area: S1 Louder than S2, S3 May be heard after S2
Physiological S3 heard in children, pregnant women, and athletes
Pathological S3 in CHF or MR
Explain how you would identify where a split S2 is heard most loudly and describe the hemodynamics of a physiological split.
Also, in the pulmonic area, If I had to ask my patient to inspire, I would be able to hear a physiological S2 split. This is because when you inspire, the intra thoracic pressure decreases further causing a delay in the blood returning to the right side of the heart, causing the pulmonic valve to close later.”
“S2 consists of an aortic (A2) and a pulmonic (P2) component. A2 precedes P2.”
Identify where a split S2 is heard most loudly and describe the hemodynamics of a physiological split.
● S2 is heard loudest in the pulmonic area.
● Normally, we don’t hear the S2 split because the closing of the valves is <30ms apart and the human ear
cannot decipher sounds <30ms apart. When we cause this delay of the pulmonic valve closing by inspiration, the sound becomes 45-80ms apart and we can decipher those sounds.
List which murmurs radiate to which areas, demonstrate positioning techniques to augment the aortic and mitral valve murmurs and list the murmurs that are augmented by inspiration and expiration
“Next, I’m going to be listening for any radiating murmurs. I will be using the bell of my stethoscope so I can pick up the lower frequency sounds and murmurs. I’ll be checking the left axilla for any radiating MR murmur and the right carotid for radiation as in an AS murmur. I did not hear any radiating murmurs.”
“Next, can you roll to your left side to the left later decubitus position. This will bring the LV close to the chest wall and accentuate any murmur (e.g. opening snap of MS).”
“I’m going to locate the 5th IC midclavicular line and listen for any murmurs. I did not hear any mitral valve murmurs.”
“Can you sit up for me please and lean forward. I’m going to switch back to my diaphragm of my stethoscope to listen down the left parasternal border for any murmurs. Can you inhale and exhale and hold it for me? I did not hear any aortic murmurs (e.g. AR).”
● Aortic stenosis radiates to the right carotid region (Auscultate the carotid region)
● Mitral regurgitation radiates to the axilla. (Auscultate the left axilla) Accentuated by inspiration.
