Cardiac Physical Exam Flashcards
Why is the eye exam important for a cardiac exam?
Because the eyes are the gateway to the kidneys
What 3 blood pressures must you take when doing a cardiac exam?
one in each arm and one in the leg (can be up to 10 mm Hg difference between arms).
Should the leg BP be higher or lower than the arm BP?
higher due to gravity (20-40 mm Hg higher). place 2 cm above the patellar tendon and auscultate the popliteal artery.
What could cause a lower BP in the leg?
coarctation (narrowing) of the aorta, which is a secondary cause of hypertension.
What are you looking for initially, when examining the patient lying at 30-45 degrees?
Internal jugular veins (can be hard in those who are obese) to assess for volume overload to the right side of the heart.
What should you use when you can’t find the internal jugular vein?
the external jugular vein (not as accurate though)
What do distended neck veins reflect, along with lower extremity edema?
Right sided heart failure. Symptoms include sweating (diaphoresis) and SOB (dyspnea).
How do you assess jugular venous pressure (JVP) (RA pressure)?
- Normal = 5 cm (above the sternal angle of Louis) meaning normal right atrial pressure. Look for the meniscus of the vein.
- Bottom of angle of mandible = 10 cm (wet).
- At the level of the earlobe= 12 cm (wet).
What is hepatojugular reflux?
maneuver to assess for right ventricular volume overload. You have the pt. bring their knees up and take a deep breath. You then place subxiphoid pressure on the patient for 10-60 seconds, and observe the neck veins fill from the bottom up, and stay up through inspiration and expiration. If it stays up, then this is a (+) hepatojugular reflex, consistent with right ventricular volume overload.
What is Kussmaul’s sign?
Distention of neck veins with inspiration. This is a sign of pericardial effusion, impending respiratory failure.
What is an A wave of the jugular venous pulse?
Atrial contraction. Gives you 10-15% of the normal cardiac output in healthy people. In those with heart failure or valvular problems, it can contribute to 30-40% of the total cardiac output!
They will help show you rhythm and volume status.
Must be in sinus rhythm to get an A wave.
What are the 3 types of A waves?
- A wave
- large A
- cannon A waves
With what heart sound are A waves associated?
S4 sounds. This helps you to form a differential diagnosis of what type of murmur you may have.
What are some issues that cause A waves?
Pulmonic Stenosis tricuspid stenosis hypertension IHSS (idiopathic hypertrophic subaortic stenosis) ischemic heart disease aortic stenosis aging *These will give you A waves where you need a stronger cardiac output to augment contraction.
What will you see with large A waves?
two atrial beats to one ventricular beat.
What are the two causes of large A waves?
- paroxysmal atrial tachycardia
2. atrial flutter
What causes cannon A waves?
large intermittent A waves caused by 3rd degree heart block (atria and ventricles are not firing at the same time)
What are c waves of the jugular venous pulse?
Isovolumetric contraction (occurs at the beginning of systole= R wave).
**When palpating the pulse while auscultating, if you feel the upstroke at the same time that you hear the first heart sound, are you in systole or diastole?
systole
What is a v wave of the jugular venous pulse?
atrial filling (occurs at the beginning of diastole) and if you hear a late sound here, this is associated with tricuspid regurgitation.
What is the x descent?
atrial relaXation and closing of tricuspid valve during ventricular contraction. Associated with acute pericardial effusion (tamponade)
What is the y descent?
right atrial emptYing and associated with slow pericardial effusion (SLE, chronic renal failure)
What type of neck bruit is associated with aortic regurgitation?
rapid upstroke, rapid decline, wide pulse pressure
What does the apex tell you?
axis/displacement, enlargement. PMI (point of maximal intensity) should be felt in 5th intercostal space.
What heart sound will you hear if the ventricle is big and the apex is displaced?
S3
Where is the S4 sound best heard?
Left lateral recumbent position
**What augments S3 and S4?
Hand grip
**What increases S1?
inspiration
**What is S3?
diastolic filling sound (listen on the LEFT LATERAL RECUMBENT POSITION) heard best with the bell because it is low pitched. Have patient grip hand.
**What is S2 sound?
closure of aortic and pulmonic valves (aortic comes slightly before pulmonic)
How do you augment right sided murmurs?
use maneuvers that increase volume (inspiration/leg raising/squatting)
What do right sided murmurs reflect?
tricuspid/pulmonic issues
With what is cardiac tamponade associated?
infarcts, trauma, and infectious processes
With what is chronic pericardial effusion associated?
lupus, chronic renal failure, metastatic disease