Cardiac Exam Flashcards
What are the steps of the basic physical exam for the CV system?
- Auscultate along the LLSB with the diaphragm of the stethoscope at the end of exhalation with the patient sitting and leaning forward (for aortic regurgitation)
- Inspect precordium and palpate for location and size of apical impulse and form heaves and thrills with patient in supine position.
- Auscultate precorium in axilla, at apex, at lower left sternal border, at pulmonic area, and at aortic area with the diaphragm of the stethoscope with that patient in supine position
- Auscultate at the apex with the bell of the stethoscope
- Measure the CVP
- Palpate carotids separately
- Auscultate over the carotid arteries
- Auscultate apex in LLD (Left Lateral Decubitus position for S3 and S4) with the bell
What are the ROS of the CV system?
History of high blood pressure; heart disease; heart murmur; palpitations; chest pain or pressure; shortness of breath on exertion or while lying down; ankle swelling; pain in legs with walking (how far); sensitivity or color change in fingers or toes with cold temperatures; varicose veins or history of phlebitis; history of electrocardiogram; chest X-ray, or other diagnostic tests
What does a delayed or diminished carotid upstroke indicate?
Aortic Stenosis
Where is the Internal Jugular Vein found on PE?
In between the two SCM heads
Has a double pulse
Explain normal JVP.
What does a normal JVP (5 to 8 cm total) rule out?
The sternal angle is 5 cm above the right atrium.
JVP < 8 cm rules out Right Chronic Heart Failure
What does a JVP > 8 cm indicate?
Right ventricular infarct Pericardial effusion Tamponade Massive pulmonary emboli Left heart failure Superior venous caval obstruction
What is the location and size of the PMI in a healthy heart?
5th intercostal space with a 2 cm impulse
If the PMI is
• Laterally displaced ==>
• If larger than 2 cm ==>
• If impulse sustained ==>
- Laterally displaced ==> L eccentric hypertrophy
- If larger than 2 cm ==> L concentric hypertrophy
- If impulse sustained ==> L concentric hypertrophy
What do these thrills suggest?
Aortic
Pulmonic
Tricuspid
o Aortic area ==> aortic stenosis
o Pulmonic area ==> Pulmonary hypertension
o Tricuspid ==> R ventricular hypertrophy
What are the locations for auscultating Mitral Aortic Pulmonic Tricuspid
o Mitral: MCL 5th intercostal S1
o Aortic: Right Sternal Border 2nd intercostal S2
o Pulmonic: Left Sternal Border 2nd intecostal S2 with inhaled splitting
o Tricuspid: Left Sternal Border 4th or 5th intercostal S1
Regarding the carotid upstroke, when does S1 occur?
Just before the carotid upstroke
What do the following S2 splitting suggest…
Variable splitting during inhalation?
Wide splitting?
Paradoxical splitting A2 occurs after P2?
Fixed splitting?
Respiratory variation ==> P2 occurs later during inspiration Wide splitting (P2 occurs later) ==> Right Bundle Branch Block Paradoxical splitting (A2 occurs after P2) ==> Left Bundle Branch Block Fixed splitting ==> atrial septal defect
What does an S3 gallop indicate after the age of 40?
L ventricular heart failure and/or ventricular volume loads
Mitral Regurgitation
Aortic Insufficiency
Ventricular Septal Defect
What does S4 indicate?
Where is it located?
o Decreased Ventricular compliance ==> Left Vent hypertrophy, Myocardial ischemia, infarction
o At apex or medial to apex
What does a mid systolic click indicate?
Where is it located?
o Mitral valve prolapse (mitral valve folds into the atrium)
o High pitched sound at apex and lower sternal border with diaphragm
What is an opening snap and where is it heard?
What does an opening snap indicate?
Early diastolic sound heard between apex and LLSB
Mitral stenosis
What do the following mumurs sound like? Aortic Stenosis? Mitral Regurgitation? Aortic Regurgitation? Mitral Stenosis?
o Aortic stenosis ==> diamond shaped intensity between S1 and S2, medium pitch harsh sound, radiates to neck, Decreased A2, ejection click, S4, delayed carotid upstroke, narrow pulse pressure
o Mitral Regurgitation ==> “Holosystolic” rectangle shaped intensity between S1 and S2, high pitch musical or blowing sound, radiates to axilla, decreased S1, S3 laterally displaced diffuse PMI
o Aortic regurgitation ==> decrescendo after S2
o Mitral stenosis ==> S2 then opening snap with trumpet-shaped intensity that ends at S1
Where do Aortic and Pulmonic murmurs radiate to?
Where do Mitral and Tricuspid mumurs radiate to?
- Listen for Aortic and Pulmonic in subclavian or carotid
* Listen for Mitral and Tricuspid in axilla
What are the qualities of Acute Aortic Insufficiency?
- Murmur is short, decrescendo, blowing
- S1 and S2 are both soft
- S3 and S4 are commonly heard as before, with the patient supine or in the left lateral decubitus position, listening over the apex with the bell
- Listen over the left sternal border in the 3rd and 4th interspaces (tricuspid). Ask the patient to sit up, lean forward, exhale, and not take another breath. In this way, the murmur is easier to hear since you won’t be confused by the patient’s breath sounds
What are the qualities of Chronic Aortic Insufficiency?
- S3 is common
- Aortic ejection sound may be present
- between S2 and S1 Murmur is high pitched, blowing, and decrescendo along the left sternal border. It is heard best with the patient sitting up and leaning forward at end expiration (same as acute AI)
- Severity of the murmur correlates with the DURATION of the murmur
- Austin Flint murmur is common, which is a low-pitched diastolic rumble secondary to the regurgitant jet of blood across the aortic valve, causing early mitral valve closure
What are physical exam findings in Aortic Insufficiency aka Regurgitation?
Water hammer pulse Increased pulse pressure Pistol shot femoral pulse Quincke’s pulse DeMuesset’s sign
What is Water Hammer Pulse?
What are the exam moves to detect it?
A PE sign of Aortic Regurgitation
Bounding pulse that collapses
Blood travels back into the left ventricle and there is a sudden collapse of radial pulse
Pt is supine, radial pulse is felt with arm by side. Finger pressure is increased till the pulse ceases.
Pt then holds shoulder and arm at right angle, and the radial pulse is felt again.
What is Increased Pulse Pressure?
Difference btw systolic pressure and the diastolic pressure. Normal is defined as 50-60.
> 80 mmHg ==> Aortic Regurgitation/insufficiency
What is Pistol Shot Femoral Pulse?
a short, loud, snapping sound with each pulse when auscultating the femoral, brachial, or radial artery
A sign of Aortic Insufficiency
