Cardio Exam Flashcards
Examining the Heart & Blood Vessels
Anatomy of the Heart & Great Vessels The heart as a pump (Blood Pressure) Vital Signs: Blood Pressure & Heart Rate Jugular venous pressure (JVP) and pulsations Carotid pulse Chest wall and apical impulse/PMI Auscultation: S1 and S2; S3 and S4
Circulation of the Heart
Superior & Inferior Vena Cavas Right Atrium & Right Ventricle Pulmonary Arteries Pulmonary Vein Left Atrium & Left Ventricle Aorta & Aortic Arch
HPI for Chest Pain
Location Duration Recurrent episodes How often/ever before Does any thing make it better? Does any thing make it worse? Description of pain Does the pain occur at rest? With exertion? After eating? When you move? While sleeping? With stress? During sexual intercourse? SOB Palpitations Nausea or vomiting Cough Fever Hemoptysis Leg/Calf pain or swelling Dizziness
Dyspnea for Chest Pain that you want to know
DOE—dyspnea on exertion PND– paroxysmal nocturnal dyspnea Orthopnea Leg swelling Activity at the time of SOB
Fatigue and Cough for Chest Pain
Fatigue
Inability to keep up with peers
Associated symptoms– weakness in arm/leg
Medications
Cough
Onset/duration
Character
Hemoptysis
Syncope for Chest Pain
Associated symptoms– SOB, LOC What were you doing just prior to event Incontinence Black tarry stools Warning of fainting
Palpitations for Cardio
Description– skipping beats, fast, pain Quality Duration Associated symptoms—chest pain etc Caffeine use-red bulls, coffee h/o thyroid disease Tobacco/Alcohol/Drugs
LE Edema for Cardio
One leg or both legs Calf pain Gradual or sudden onset Decrease after a nights sleep Reduced by elevation h/o kidney, heart, or liver disease Leg ulcers Contraceptive use in women
Common symptoms of cardiovascular disorders in Older Adults
Confusion/syncope Palpitations Cough/wheezes Hemoptysis SOB Chest pain/tightness Incontinence/impotence/heat intolerance Fatigue Leg edema
PMH for Cardio
Cardiac surgery/hospitalizations Rhythm disorder Acute rheumatic fever Unexplained fever Swollen joints Inflammatory rheumatism St. Vitus dance Chronic Illnesses Hyperlipidemia DM HTN
Family History for Cardio
Diabetes Heart disease Hyperlipidemia HTN Congenital heart defects, VSD Sudden death Family members with cardiac risk factors
Personal/ Social History for Cardio
Employment Tobacco use Use of alcohol/drugs Nutritional status Personality assessment Relaxation
The Heart as a Pump
Systole
* occurs when the ventricles contract
* right ventricle pumps blood into the
pulmonary arteries (pulmonic valve is
open)
* left ventricle pumps blood into the aorta
(aortic valve is open)
Diastole
* occurs when the ventricles relax
* blood flows from the right atrium into the
right ventricle (tricuspid valve is open)
* blood flows from the left atrium into the
left ventricle (mitral valve is open)
Stroke Volume and CO
Cardiac Output = stroke volume x heart rate
Stroke Volume: volume of blood pumped from one ventricle of the heart with each beat
Contractility
ability of the ventricles to contract during systole
Preload
end diastolic volume at the beginning of systole directly related to the stretch (Starling’s Law)
Afterload
the amount of resistance that the left side of the heart has to overcome to eject blood (Squeeze)
Blood Pressure Equation
cardiac output x systemic vascular resistance= BP
Vital Signs for Cardio
Temperature:
* Fever may increase heart rate & respirations
* Hypothermia may decrease heart rate & respirations
Pulse:
* Normal for Adults: 60 – 100 BPM
* Tachycardia: > 100 BPM
* Bradycardia: < 60 BPM
* In children there is a range based on age
Respirations:
* Normal for Adults: 12 – 20 per minute
* Tachypnea: > 20 per minute
* Agonal: irregular & may be slow or fast
Blood Pressure:
* Systolic 100 – 140
* Diastolic 60 – 80
* Variations can occur based on size
Blood Pressure Measurements (4)
Direct Measurement: insertion of intra-arterial catheter (arterial line/A-line)
Indirect Measurement: BP cuff & stethoscope
Size of the cuff: too small/artificially elevated BP
Measurement by palpation: hold the arm at the level of the heart & palpate the brachial or radial artery, only identifies systolic BP
Different types of Blood Pressures
Orthostatic Hypotension: lie the patient flat for 5 minutes & take a BP, then sit them up & repeat the BP. If there is a drop of >20 mmHg & the patient is dizzy or has a syncopal event then they are positive. Should also be repeated in the standing position if no symptoms occur.
Supravalvular Aortic Stenosis: difference in blood pressures of >20 mmHg between the arms
Coarctation of the Aorta: if BP is elevated in both arms take the BP in the legs & if lower may be an indication
Pulsus Paradoxus: deflate the cuff until pulses are heard in expiration only then until heard during inspiration. If the difference is >10 mmHg consider cardiac tamponade, pericardial effusion, constrictive pericarditis, asthma & emphysema
Palpating the Pulse (rhythm and rate)
Palpate the radial artery on the volar surface radial aspect of the wrist with the 2nd, 3rd, & 4th fingers for rate, rhythm, contour, & amplitude of the pulse
Rate: count for 30 seconds & multiply by 2. Most accurate for regular rhythms.
Rhythm: regular, regularly irregular, or irregularly irregular (Afib) there may be a pulse deficit.
General, Skin and Nail Inspection for Cardio
General Appearance: Is the patient in acute distress, labored breathing, accessory muscle use etc…
Skin: temperature, central or peripheral cyanosis, pallor, xanthomata present (hypercholesterol), erythema marginatum (acute rheumatic fever)
Nails: splinter hemorrhages (non-specific finding in infective endocarditis)
Eye and Face Inspection for Cardio
Facies: wide set eyes, strabismus, low set ears, upturned nose, & hypoplasia of the mandible (supravalvular aortic stenosis), moon facies & wide set eyes (pulmonic stenosis), expressionless facies & puffy eyelids (hypothyroid/cardiomyopathy)
Eyes: xanthelasma (hypercholesterol), arcus senilus (hypercholesterol in <40 y/o), opacities in the cornea (sarcoidosis responsible for cor pulmonale or myocardial involvement), displacement of the lens ( Marfan’s Syndrome/aortic regurgitation), conjunctival hemorrhages (infective endocarditis), sausage link like vessels (hypertension)
Neck, Mouth, Chest, Extremities Inspection for Cardio
Neck: webbing (Turners Syndrome/Coarctation of the aorta & Noonan’s syndrome/pulmonic stenosis)
Mouth: highly arched palate (congenital heart problems/MVP), palate petechiae (infective endocarditis)
Chest: Pectus excavatum & caranutum (Marfan’s syndrome/MVP), visible movements of the chest
Extremities: Extra phalanx, finger or toe (ASD), long slender fingers (Marfan’s syndrome/aortic regurgitation)
Steps for Examining the Jugular Venous Pulse (JVP)
Elevate the head of the bed to 30-45 degrees
Turn the patient’s head gently to the left
Standing on the right side of the patient identify the topmost point of the venous pulsation using either the internal jugular vein (preferred) or external jugular vein
Place a centimeter ruler upright at the sterno-manubrial angle
Place a card or a tongue blade horizontally from the top of the JVP to the ruler making a right angle (90 degrees)
Measure the distance above the sternal angle in centimeters at 45 degrees the upper limit of normal is 4-5 cm at 30 degrees the upper limit of normal is 6 cm
JVP
Jugular vein reflects the right atrial pressure
JVP waves and descents
a wave (atria contract)
Reflects slight rise in atrial pressure that accompanies atrial contraction
Occurs before S1& the carotid pulse
x descent (atria relax) Atrial relaxation & ventricles contract
v wave (venous filling) Atria begin to fill
y descent (atria empties) Blood flows into right ventricle
Hepatojugular Reflex
Occurs because of the inability of the right side of the heart to accommodate increased venous return
Assesses right ventricular function
Performed with the patient lying flat in the bed, with their mouth open, & breathing normally
Observe the jugular height, press firmly under the right costal margin for 10-15 seconds
The jugular veins will remain distended during the entire period of compression in right ventricular failure or elevated pulmonary artery wedge pressure
The normal response is for the jugular veins to show a transient increase during the first few cardiac cycles followed by a fall to baseline levels during the latter part of compression
Auscultate 5 positions
- Aortic – right 2nd ICS sternal border
- Pulmonic – left 2nd ICS sternal border
- Erb’s Point – left 3rd ICS sternal border
- Tricuspid – left 4th ICS sternal border
- Mitral – left 5th ICS mid-clavicular line
Palpate 4 main cardiac areas
Aortic – right 2nd ICS sternal border
Pulmonic – left 2nd ICS sternal border
Tricuspid – left 4th ICS sternal border
Mitral – left 5th ICS mid-clavicular line
Describing a Murmur (7)
Timing: systolic or diastolic
If the murmur coincides with the carotid upstroke it is systolic
Location: in which of the 5 areas is the murmur best heard
Radiation: does the murmur radiate to the neck, back, or axilla
Duration: how long does it occur for
Mid/pan/or late systolic
Early/mid/or late diastolic
Intensity: graded I-VI based on increased sound ( grades 4-6 must have a thrill with them)
Pitch: high, medium, or low
Quality: harsh, musical, soft, blowing, or rumbling
Relationship to Respiration
Relationship to Position
Aortic Stenosis (Murmur)
Best heard in the aortic area mid to mid-late systolic Radiates to the neck Crescendo/decrescendo shape Medium pitch Harsh Decreased A2 Ejection click S4 Narrow pulse pressure Slow rising & delayed pulse
Mitral Regurgitation (murmur)
Best heard in the apex in early systole Radiates to the axilla Holosystolic/machinery type murmur High pitched Blowing type murmur PMI is laterally displaced & diffuse Decreased S1 S3
Pulmonic Stenosis (murmur)
Best heard in pulmonic area mid to mid-late systole Radiates to the neck Crescendo/decrescendo diamond shaped Medium pitched Harsh Similar to aortic stenosis
Tricuspid Regurgitation (murmur)
Best heard in tricuspid area in early systole Radiates to right of the sternum Holosystolic High pitched Blowing
Ventral Septal Defect (VSD)
Best heard in tricuspid area in early systole with muscular or non-restrictive pulmonary HTN & holosystolic with left to right shunt Radiates to right of sternum Holosystolic High pitch Harsh
Venous Hum (murmur)
Heard best above the clavicle Radiates to the right side of the neck Continuous High pitch Roaring/humming
Innocent Murmur
Widespread Minimal radiation Diamond shaped Medium pitch Twanging/vibratory
Mitral Stenosis- Diastolic murmur
Heard best at the apex in mid diastolic No radiation Decrescendo Low pitch Rumbling Increased S1 Opening snap RV rock (RV impulse at left lower sternal border) Presystolic accentuation
Aortic Regurgitation- Diastolic Murmur
Best heard in aortic area in early diastole
No radiation
Decrescendo
High pitch
Blowing
S3
Laterally displaced PMI
Wide pulse pressure (Resting > 100 mmHg when normal isusually 30-40 mmHg)
Bounding pulses
Austin Flint Murmur – apical diastolic murmur in association with AR mimicking MS
Systolic ejection murmur
Patent Ductus Arteriosus (PDA)– Continuous Murmur
Abnormal communication between the aorta & pulmonary artery
Occurs during the end of systole into diastole
Blowing
High pitched
Heard best at left upper sternal border near the left 2nd intercostal space
Most pronounced at S2
