Cardiac Exam Flashcards
History
Fatigue, dyspnea, chest pain, palpation said, syncope
Family History
Familial clustering is common in patients with certain heart diseases
i.e: hypertrophic cardiomyopathy, Marfan’s syndrome, prolonged QT syndrome
Physical
Inspection
Palpation
Percussion
Auscultation
Quiet room
Gown patient
Sitting, supine, left lateral decubitus, leaning forward, standing
Inspect
Face - acromegaly, cushnoid, Down's syndrome, hyperthyroid, myxedema Jaundice - yellow Cyanosis - blue Pallor - pale, anemia, shock Nails - clubbing, hemorrhages Body habitus - tall, short Hydration - blood pressure ,weight Temperature: 1 degree fever above normal => increase HR by 10 beats
Precordium
Scars, pacemaker, skeletal abnormalities
PMI
Precordial Palpation
Point of maximum intensity
Note location, amplitude, duration, direction
Apicial impulse, visible at midclavicular line in. 5th ICS
1-2.5 cm diameter
Vigorous, heave, lift
Systolic outward thrust
Heart Sounds
Aortic valve - 2nd ICS to the R of sternum
Pulmonic valve - 2nd ICS to the L of the sternum
Tricuspid valve - 4th ICS to the L of the sternum
Mitral valve - apex of heart, 5th ICS left midclavicular line
S1
MV closure 1st component
TV closure 2nd component
Beginning of systole
Loudest at apex
S2
Aortic valve closure 1st component
Pulmonic valve closure 2nd component
Loudest at the base
End of systole
Heart Sounds Inspiration vs Expiration
Expiration - single sound
Inspiration - splitting of S2, because of increased venous return during inspiration and more time for right ventricle to deliver blood to the lung
Murmurs Grading System
1 = barely audible, faint 2 = soft, but easily heard, quiet 3 = loud, without a thrill 4 = loud with a thrill 5 = loud with minimal contact between stethoscope and chest - thrill 6 = loud, can be heard without a stethoscope - thrill
Midsystolic Murmur
Begins after S1
Stops before S2
Brief gaps are audible between the murmur and the heart sounds
Pansystolic (Holosystolic) Murmur
Starts with S1
Stops at S2
No gap between murmur and heart sound
Late Systolic Murmur
Starts in mid or late systole
Persists up to S2
Early Diastolic Murmur
Starts immediately after S2
No discernible gap
Fades into silence before next S1
Middiastolic Murmur
Starts a short time after S2
May fade away or merge into a later diastolic murmur
Preload
Stretching of myocytes prior to contraction
After load
Load on heart during ejection of blood from ventricle
Contractility
Capacity to produce active force at a specific preload
Rate
Heart rate number of cardiac cycles per minute
Stroke Volume (SV)
Blood ejected from ventricle per beat
EDV - ESV
End Diastolic Volume (EDV)
Volume of blood in ventricle at end of diastole
Preload
End Systolic Volume (ESV)
Volume of blood remaining in ventricle at end of systole
Cardiac Output (CO)
Volume of blood per minute pumped by the heart
SV x HR
Ejection Fraction (EF)
Measures contractility
SV/EDV
Kussmauls Sign
Venous column (JVP) rises during inspiration rather than falls
Seen in R heart failure, constrictive pericarditis, or RV infarction
Barrel Chest
Think COPD
Increased A-P diameter
Pectus Carinatum
Pigeon chest
Central protrusion
Pectus Excavatum
Funnel chest
Central depression
Jugular Venous Pulse (JVP)
Jugular veins reflect the activity of the right side of the heart
Level of JVP visibility gives an indication of the right atrial pressure
Internal jugular is better than external jugular
Place patient in supine position to allow veins to engorge, then raise 30-45 degrees
Normal JVP = 0-9
Most common cause of elevated JVP = elevated RV diastolic pressure
A Wave
Right atrial contraction
Tricuspid valve opens
Coincides with S1
Precedes carotid pulsation
Giant wave:
- obstruction between RA and RV (tricuspid stenosis, right atrial myxoma)
- increased pressure in RV (pulmonary stenosis)
- pulmonary hypertension
- recurrent pulmonary emboli
- A-V dissociation (complete heart block, VT) RA contracts against the closed TV
C Wave
Backward push by closure of TV during isovolumetic systole and by impact of carotid artery adjacent to the JV
X Wave - X Slope
Passive atrial filling and atrial relaxation
Blood flows into RA from cava and closure of TV
Steep X decent in cardiac tamponade and constrictive pericarditis
V Wave
Atrial filling
Increased volume and pressure in RA when TV closed
Prominent V wave in tricuspid regurgitation and pulmonary hypertension
Y Slope or Y Descent
Open TV and rapid RV filling in RV diastole
Deep Y descent in severe Tricuspid regurgitation
A slow Y descent suggests obstruction to RV filling (tricuspid stenosis, RA myxoma)
Increased JVP
SVC obstruction Sever heart failure Constrictive pericarditis Cardiac tamponade RV infarction Restrictive cardiomyopathy
Five Finger Method
History Physical ECG X-Ray Lab Tests
Hepatojugular Reflex (HJR)
Liver engorged
Poorly compliant RV, RV failure
Constrictive pericarditis
Obstructive RV filling by tricuspid stenosis or RA tumor
Systole
Ventricular contraction
Ejection
Diastole
Ventricular relaxation
Filling
S3
High pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase
Physiologic in children/young adults
Pathological >40 yo
Ken-Tuck-Y
S4
Atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle
Can be normal in trained athletes
Ten-Nes-See
Grading Peripheral Pulses
0 = absent 1 = barely palpable 2 = average intensity 3 = strong 4 = bounding
R/R/A = rate/rhythm/amplitude
Edema
Dorsum of foot
Behind medial malleolus
Anterior tibia (shin)
0 = absent 1+ = barely detectable, nonpitting (2mm) 2+ = slight indentation (4mm) 10-15 sec 3+ = deeper indentation (6mm) >1 min 4+ = very marked indentation (8mm) 2-5 min
