Cardiac OSCE Flashcards
What is the pulse grading scale?
0 Absent, Not Palpable 1 Diminished, barely palpable 2 Expected 3 Full, increased 4 Bounding
what does a normal carotid feel like?
● Normal carotid: Feels like sharp knock; abnormal is a weak nudge then slight pulsation or push
What is a water-hammer pulse?
● Water-hammer pulse: Due to large stroke volume and backflow of blood from the aorta into LV; indicative of aortic regurgitation.
o Palpate radial pulse while the patient lies on the exam table, applying pressure until pulse is obscured. Raise arm straight over patient’s head, perpendicular to the table, and palpate pulse for a sudden rise and collapse of radial pulse that feels “jumpy”
What is a pulsus alternans?
● Pulsus alternans: Alternating strong and weak pulses palpable at radial or femoral arteries
what is a paradoxical pulse?
● Paradoxical pulse: can be used to assess pericarditis or tamponade when there is varied pulse strength and amplitude as patient breathes
what is Kussmaul’s sign?
● Kussmaul’s sign: Normal JVP shows decline in inspiration but the a wave amplitude increases. If there is an increase in JVP, or even no change in JVP on inspiration, this is a positive Kussmaul’s and may indicate impaired venous return to the right heart.
In the left lateral decubitus position, a diffuse PMI with a diameter >___cm signals left ventricular enlargement; a diameter of >__cm makes left ventricular overload almost 5 times more likely.
In the left lateral decubitus position, a diffuse PMI with a diameter >3cm signals left ventricular enlargement; a diameter of >4cm makes left ventricular overload almost 5 times more likely.
A hyperkinetic high-amplitude impulse may occur in what conditions?
A hyperkinetic high-amplitude impulse may occur in hyperthyroidism, severe anemia, pressure overload of the left ventricle from hypertension or aortic stenosis, or volume overload of the left ventricle from aortic regurgitation.
What is the murmur grading scale?
1/6 Very faint; not heard in all positions No
2/6 Soft, but heard immediately after placing stethoscope on chest No
3/6 Moderately loud No
4/6 Loud, with palpable thrill Yes
5/6 Very loud, with thrill. May be heard with stethoscope partly off chest Yes
6/6 Very loud, with thrill. May be heard with stethoscope entirely off chest Yes
What are the four Common SYSTOLIC Murmurs?
Common SYSTOLIC Murmurs:
● Aortic Stenosis
● Mitral Regurgitation
● Pulmonary Stenosis
● Tricuspid Insufficiency
What are the four Common DIASTOLIC Murmurs?
Common DIASTOLIC Murmurs:
● Aortic Regurgitation
● Mitral Stenosis
● Pulmonary Insufficiency
● Tricuspid Stenosis
aortic stenosis
● Aortic Stenosis
○ Harsh quality
○ RIGHT 2nd ICS/3rd ICS
○ Radiates to suprasternal notch and carotids
○ Delayed pulses (pulsus tardus et parvus)
mitral regurgitation
● Mitral Regurgitation
○ Blowing quality, holosystolic
○ Prominent at apex, radiates to LEFT axilla
○ Loudness correlates with degree of valve insufficiency
pulmonary stenosis
● Pulmonary Stenosis ○ Harsh, loud, ejection click ○ LEFT 2nd ICS/3rd ICS ○ Radiates to the LEFT shoulder ○ Increases with inspiration
tricuspid insufficiency
● Tricuspid Insufficiency
○ Blowing quality, increases with inspiration
○ Holosystolic
○ Lower LEFT sternal border
aortic regurg
● Aortic Regurgitation
○ Blowing, decrescendo murmur
○ LEFT 2nd ICS to the 4th ICS
○ Auscultate with diaphragm
mitral stenosis
● Mitral Stenosis
○ Rumbling, low pitched
○ Best heard at apex
○ Auscultate with bell
pulmonary insufficiency
● Pulmonary Insufficiency
○ Blowing quality
tricuspid stenosis
● Tricuspid Stenosis
○ Increases in intensity with inspiration
○ Decreases in intensity with expiration and valsalva
what is the purpose of having a patient lay left lateral decubitus?
Left lateral decubitus
● Patient on left side with left arm above head
● Palpate PMI and auscultate for systolic murmurs
● Increases chance of hearing mitral stenosis and extra heart sounds
what is the purpose of having a patient sit and lean forward?
Sitting and leaning forward
● Increases chance of hearing aortic regurgitation
what is the purpose of having a patient strain/do valsava?
Straining/Valsalva
● Increases chance of hearing mitral regurgitation
Valsalva maneuvers ______ murmur duration in MVP
Valsalva maneuvers ______ murmur intensity for HCM
● Valsalva: used to differentiate between aortic and mitral prolapse or hypertrophic cardiomyopathy
o Valsalva maneuvers increase murmur duration in MVP
o Valsalva maneuvers increase murmur intensity for HCM
How to differentiate between aortic stenosis and mitral valve prolapse or hypertrophic cardiomyopathy?
● Sitting and Squatting: Used to differentiate between aortic stenosis and mitral valve prolapse or hypertrophic cardiomyopathy
o Have patient stand then squat.
▪ Squatting increases venous return, peripheral vascular resistance, stroke volume, and blood pressure, while standing has opposing effects.
o Auscultate during the squatting and standing phases.
▪ During the squatting, a MV prolapse and HCM will give delay in click and decrease in murmur intensity.
when is the abdominal jugular reflex positive?
o Test is positive when there is a sustained increase in JVP by > 4 cm within 3-5 sec after pressure removed.
An elevated JVP in highly correlated with what?
An elevated JVP is highly correlated with both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis.
What does JVP look like in patients with obstructive lung disease?
In patients with obstructive lung disease, JVP can appear elevated on expiration, but the veins collapse on inspiration. This finding does not indicate heart failure.
