Cardiac exam Flashcards
Which splitting heart sound is louder?
A2
why is A2 usually louder?
because of the high pressure of the aorta - heard throughout the precordium
Why is P2 usually soft?
it reflects the low pressure of the pulmonary artery
Where is the splitting of S2 heard the best ?
2nd and 3rd intercostal spaces close to the sternum
What are the 2 components of S1?
early mitral and late tricuspid
Where do you hear the mitral part of S1?
through precordium and loudest at the apex
Where do you hear the tricuspid part of S1?
lower left sternal border
What heart sound is louder with inspiration?
S2 - this is what potentially causes the splitting of the sounds into A2 and P2
What is a heart murmur distinguished by?
pitch and duration
what does a heart murmur usually diagnostic of?
turbulent blood flow usually indicating valvular heart disease
What is a stenotic valve?
an abnormally narrowed valvular orifice that obstructs blood blow as in aortic stenosis
What is a valve that fails to close fully create?
aortic regurgitation
order of cardiac exam?
inspect, palpate, auscultate
what are you inspecting on the skin for the cardiac exam?
malar flush (redness/flushness of skin due to mitral stenosis) , pallor, cyanosis, edema
what are you inspecting the cornea for?
Cornea arcus
What is cornea arcus?
gray- white discoloration around the cornea that is indicative of hyperlipidemia
what are you inspecting around the eyes for
xanthelasma - yellowish cholesterol deposits around the eye
why do you perform a fundoscopic exam for cardiovascular?
look for retinopathy and roth’s spots
What are roth’s spots ?
pale - centered hemorrhages that occur in bacterial endocarditis
what are you checking on inspection of nails?
clubbing, color, capillary refill, lesions
what is the examination of the jugular veins meauring?
indirect measure of volume status
What are you checking for while inspecting the carotids?
pulsations, amplitude,timing
What is CVP (central venous pressure)?
Pressure in the venae cavae (near the R atrium)
What can you observe to monitor a patient’s CVP?
the external jugulars
At what position can you visualize a healthy persons jugular pulsation?
semirecumbent at 7cm above the atrium
When could you notice a abnormally high CVP?
when a patient is sitting upright
what is a normal JVP?
6-8 cm/H20
What are the abnormalities of JVP?
jugular venous distention, flattened neck veins
What is jugular venous distention (JVD) caused by?
Right HF, Chronic L HF, Constrictive pericarditis, tricuspid stenosis, cardiac tamponade
if a patient presents with flattened jugular veins what would you be concerned by?
hypovolemia
What is the first step to a carotid exam ?
auscultate
What do you need to be aware of while palpating the carotids?
carotid sinuses
If a person is palpating the carotids and they palpate both at the same time is that okay?
no, do not palpate at the same time
Why do we check the carotid pulses?
this is a clue for vascular occlusion, indication of hemodynamics of L heart, indication of aortic valve disease, helps to evaluate severity of aortic stenosis
what is the best way to evaluate the severity of aortic stenosis?
evaluation of the carotids
What is the phenomenon “pulsus parvus et tardus” refer to?
Weak (parvus) and delayed (tardus) carotid upstroke
when should we feel the carotid pulse?
at S2
when is timing delayed and amplitude decreased?
aortic stenosis
What side of the heart does the CVP evaluate?
right side - because its chekcing the jugular
What side of the heart does the JVP evaluate?
right side
When would you feel pulsus parvus et tardus ?
with aortic stenosis
What causes a bruit?
it is a swishing sound caused by blood flow through a partially obstructed blood vessel or a localized increased rate of blood flow in an unobstructed vessel
What is a carotid bruit usually indicative of?
carotid artery disease - blood flowing through the stenotic vessel making a swishing sound
What is a good estimate of fluid volume in the body?
CVP / JVP
What is JVP?
estimate of CVP (central venous pressure)
When palpating the precordium what part of the hand do you use?
the palmar surface
What do you palpate with your palmar surface when palpating the precordium ?
Aortic, pulmonic, parasternal (accessory aortic), apical area (tricuspid and mitral)
What sounds are you looking for at the parasternal area?
heaves, thrills, lifts
where is the PMI usually located
the point of maximal impulse is usually located at the apex
What does the PMI (located at the apex) usually correlate with ?
LV
If you feel a thrill- what is this caused by?
turbulent blood flow that causes a vibiratory senstion
If you heard a heave / thrill where would this be located?
3rd and 4th parasternal space
if you heard a heave/thrill in an older adult thoughout systole, what would this be indicative of?
right ventricular hypertrophy or heart failure
when is hearing a heave/thrill normal?
in small children or thin adults
WHat is the most common cause of RV failure?
LV failure
What could chronic LV failure cause?
jugular distention
Where is a normal PMI heard?
4th and 5th intercostal space + midclavicualr line
How many intercostal spaces would a normal PMI be heard at ?
1 intercostal space
What is a normal amplitude of PMI?
brisk/ tapping
What position would you hear a normal PMI best at?
supine but also heard good at LL decubitus
Why would you hear an abnormal PMI location?
LV hypertrophy, pregnancy, thoracic abnormalities
Where do you hear the aortic area?
right upper sternal border - 2nd intercostal space
Where do you hear the pulmonic area?
2nd intercostal space at the Left sternal border
Where do you hear the accessory aortic area?
3rd and 4th left sternal border
Where do you hear the tricuspid area?
Left lower sternal border at the 4th and 5th intercostal space
Where do you hear the mitral area?
the apex!! the 5th intercostal space at the midclavicular line
What should the head of bed be angled at for supine auscultation?
30-45 deg
WHat heart sounds can you hear better at LL decubitus ?
S3, S4, mitral murmurs
What heart sounds can you hear best supine?
aortic murmurs, pericardial rubs
What part of the stethoscope do you use to hear high pitched heart sounds (S1,S2)?
diaphragm
What part of the stethoscope do you use to hear aortic regurgitation?
Diaphragm
What part of the stethoscope do you use to hear mitral regurgitation?
diaphragm
what part of the stethoscope do you use to hear the opening of mitral stenosis?
diaphragm
What part of the stethoscope do you use to hear a pericardial friction rub?
diaphragm
What part of the stethoscope do you use to hear mitral stenosis?
bell
what part of the stethoscope do you use to hear low pitched sounds (S3,S4) ?
bell
Where is S1 sound heard the best?
LLSB and Apex
Where is the S2 sound heard the best ?
base of the heart
When should you hear the splitting of S2?
inspiration
is a S4 sound normal?
no, usually pathologic
in S2 does the aortic valve or pulmonic valve close first?
the aortic valve - due to the higher pressure
What are the 2 abnormal splittign sounds of S2?
Fixed splitting, reversed (paradoxical splitting)
What causes fixed splitting?
no alteration between inspiration and expiration - due to RVF (right ventricle leads out to the pulmonic valve ) and septal defect
What is a reversed (paradoxical) splitting sound caused by?
splitting on expiration - caused by L BBB
What usually causes S3?
When blood rushes quickly into the ventricles
When is S3 usually heard in children and young adults?
early diastole
When is S3 usually pathalogic?
in older adults - usually due to blood rushing into an already filled ventricle due to a decrease in EF or result of CHF
What is referred to as a ventricular gallop?
pathologic S3 with tachycardia
When do you see S3?
in volume overload states
If a person has S3- what could you consider the ddx to be?
CHF, advanced MR or TR, VSD, Dilated cardiomyopathy
When is a ventricular gallop heard?
in volume overloaded states
When is a atrial gallop heard?
in pressure overloaded states
What causes an S4 sound?
when the atria contract- they are contracting against a stiffened ventricle which causes an increase in the force of contraction so it can overcome resistance.
When would you see a S4 sound?
in pressure overload states - hypertrophic cardiomyopathy, aortic stenosis, HTN
What sound can be a sign of systolic CHF?
S3
What sound could be a sign of diastolic CHF?
S4
