Cardiac Exam Flashcards by Mary Kaar

History

Fatigue, dyspnea, chest pain, palpation said, syncope

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Family History

Familial clustering is common in patients with certain heart diseases
i.e: hypertrophic cardiomyopathy, Marfan’s syndrome, prolonged QT syndrome

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Physical

Inspection
Palpation
Percussion
Auscultation

Quiet room
Gown patient
Sitting, supine, left lateral decubitus, leaning forward, standing

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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

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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

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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

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MV closure 1st component
TV closure 2nd component
Beginning of systole
Loudest at apex

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Aortic valve closure 1st component
Pulmonic valve closure 2nd component
Loudest at the base
End of systole

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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

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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

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Midsystolic Murmur

Begins after S1
Stops before S2
Brief gaps are audible between the murmur and the heart sounds

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Pansystolic (Holosystolic) Murmur

Starts with S1
Stops at S2
No gap between murmur and heart sound

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Late Systolic Murmur

Starts in mid or late systole

Persists up to S2

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Early Diastolic Murmur

Starts immediately after S2
No discernible gap
Fades into silence before next S1

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Middiastolic Murmur

Starts a short time after S2

May fade away or merge into a later diastolic murmur

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Preload

Stretching of myocytes prior to contraction

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After load

Load on heart during ejection of blood from ventricle

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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

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

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 ```