Cardiac Exam Flashcards
Cardiac symptoms
chest pain
* myocardial ischemia
Low cardiac output symptoms
* dyspnea
* HF symptoms
* syncope
Women’s S/S of Acute myocardial infarction
New or different Symptoms in weeks prior to event
* unusual fatigue (70%)
* Sleep disturbance (48%)
* SOB. (42%)
* Indigestion (39%)
* Anxiety (35)
Symptoms during ACS
* SOB (58%)
* Weakness (55%)
* Unusual fatigue (43%)
* Diaphoresis (39%)
* Dizziness (39%)
* Chest pain or pressure (30%)
* No chest discomfort during the event (43%)
ACS in the elderly
Unrecognized MI by age
* 18% in men 45-54
* 42% in men 75-84
* 60% in men over 85
Presentation >75 yrs
* Dyspnea
* neuro symtoms - syncope, weakness, acute confusion
* Chest pain or pressure < 50%
Weakness and fatiuge are most often reported
Point of maximal Impulse
Normal
* palpabel sensation of underlying left ventricle
* 5th ICS @MCL
* about the area of a nickle
* gentle tap by one finger, single impule
* about 1/3 of systole
Abnormal
* Displaced PMI - usually laterally toward axillary line: indicates increased LV volume
* Unusually forceful, sustained: pressure overload, HTN
Unable to palpate
* Left lateral decubitus position enhances
* may be due to : thick chestwall, obesity, COPD
Aortic heart sound
- 2nd intercostal space, right ternal boarder
(left side of heart) - Heard during S2
Pulmonic Area
- 2nd intercostal space left sternal boarder
- right side of heart
- heard during S2
Erbs Point
- 3rd intercostal space, left sternal boarder
- hear both S1 and S2
Tricuspid area
- 5th intercostal space, Left sternal border
- right A/V valve
- heard during s1
Mitral area
- 5th intercostal space, MCL
- Left AV valve
- heard during S1
S1
- begining of systole
- closure of the miral and tricuspid (AV) valves
- beast heard at the apex (bottom) with diaphram
- simultaneous with carotid upstroke (pulse)
S2
- Marks the end of systole
- closure of the aortic and pulmonic valves
- beast heard at the base (top) with diaphram
Physiologic S2
- widening of normal interval between aortic and pulmonic valve
- caused by a delay in pulmonic component
- heard best in pulmonic region (2nd ICS, left sternal border)
- Split INcreases with INspiration
- found in adults <30 yrs
Pathologic split S2
- fixed split - no change with inspiration
- paradoxical split - narrows with inspiration
- heard best at pulmonic region (2nd ICS, left sternal border)
- fixed split: often found in uncorrected septal defect
- Paradoxical: found in conditions that delay aortic clossure such as LBBB
- will resolve with treatment of underlying condition
S3
- marker of ventricular overload, and or systolic dysfunction
- heard in early diastole like its hooked on the end of S2 (lub dub-dub) (Kentucky)
- low pitched-best heard with bell
- for Dx of HF correlate with additional findings (dyspnea, tachycardia, crackles
- may not be heard in HF if pt is euvolemic and relatively symptom free
S4
- marker of poor diastolic function
- most often found in poorly controlled HTN (off meds for weeks) or recurrent myocardial ischemia
- heard late in diastole, hooked to the front of S1 (presystolic sound)
- Soft low pitch (higer than s3) best heard with bell
- dub-lub dub
Heart valve dysfunction
- failure to open - Stenosis
- Failure to close - Incompetent valves cause regurgitant murmurs
Systolic murmurs
- Can be pathologic or benign
- Mr. Pass MVP
Mitral Regurgitation, Physiologic (innocent, functional): holosystolic
Aortic Stenosis: cresendo-decresendo
SYSTOLIC
Mitral Valve Prolapse: mid systolic with mid systolic click
Diastolic Murmurs
- Always Pathologic
- Ms. Ard
Mitral Stenosis: late diastolic
Aortic Regurgitation: early diastolic
DIASTOLIC
Heart murmur grading
- very faint
- quiet but immediately heard
- moderately loud without thrill - about as loud as S1/S2
- Loud with thrill
- very loud with thrill
- audible without stethascope
Systolic murmur pysiologic vs pathologic
Likely benign if all are noted
* negative Hx
* lower grade <4
* no radiation beyond pericordium
* S1 and S2 intact
* no heave or thrill
* PMI WNL
* Softens or disappears with supine to stand position change
Pathologic - echo next step unitl proven otherwise if 1 or more of the following
* abnormal Hx
* higher grade 4 or more
* radiation beyond the pericordium to neck, axilla, other
* S1, S2 obliterated
* Thrill or heave
* PMI displaced
* Increases in intensity with supine to stand
Character of murmurs
Harsh
* Hears well with bell and diaphram
* aortic stenosis
Rumble
* Low, best with bell
* Mitral stenosis
Blowing
* high, best with diaphram
* aortic regurge
Musical
* Vibratory quality
* still murmur
Carotid bruit Vs Radiating murmur
Carotid Bruit
* softer
* often unilateral
* differnet sound than chest
* presence of high grade athlersclerotic disease
Radiating murmur
* Louder
* bilateral
* same sound and timing as found in chest
