Cardiovascular Flashcards
JVP
INTERNAL jugular that runs from sternoclavicular angle to angle of jaw
Underneath SCM
Chosen as most directly above RA and no valve, providing most ‘accurate’ estimation of RA pressures
Abdominojugular reflex
- press firmly middle abdomen with palm for 10s, JVP >4cm = positive
- indicate right) ventricular failure or elevated left) atrial pressure
- does not need to be on liver
A wave - atrial contraction Tricuspid closure X descent V wave - atrial filling Y descent
Dominant a wave - tricuspid stenosis, pulmonary HTN
Cannon a wave - complete heart block, VT
Large v wave - tricuspid regurg
Absent a wave - AF
Kussmaul (increase w/ inspiration) - constrictive pericarditis
Murmurs
Start in Apex/mitral region
TIME TO PULSE
SYSTOLIC
- Pan (regurg) - MR, TR, VSD
- PS
- Ejection - AS, HOCM
DIASTOLIC
- MS, TS
- AR, PR
Distinguishing L to R
- Inspiration accentuates R sided (as increases venous return)
- Expiration accentuates L sided (increases pulmonary return)
- Standing reduces venous return
- Squatting increases venous return
Distinguishing HOCM
- Valsalva (reduces preload, accentuating SAM and RVOT obstruction)
- Standing
Peripheral
Clubbing
Signs of CTD/Rheum
Peripheral stigmata of IE: splinter haemorrhages, osler nodes, janeway lesions
Palmar creases
Pulse - rate, rhythm, character
Radio-radio delay
BP - if high consider both arms, consider radio-femoral delay
General inspection
Syndromic - Marfans, Turners, Down, William, Noonan
Scars - PCI, CABG, PPM, Loop
Body habitus
Oxygen, Telem, Holter
Face & Neck
Eyes: Arcus corneus, xanthelesma, anaemia
Consider fundoscopy
Mouth: Marfan palate, dentitian
Flush
JVP - waveform, character, height (measure with tape from SC angle)
Carotid pulse
- Feel both sides
- Character and rhythm
Chest
Apex beat - 1cm medial from MCL, 5th ICS
- Go laterally to try feel
- Consider dextrocardia
Heaves (palm)
Thrills
Palpable P2 - 2nd ICS, L sternal border
Auscultate - start apex region (use both sides)
- Two heart sounds (S1, S2 (A2, P2))
- Murmurs
- Character
- ?Prosthetic valves, any clicks
L lateral
- Apex beat
- Listen
Sit up
- Back - percuss, listen
- Auscultate - inspire and expire
Abdo
Legs
JVP: dominant a wave
tricuspid stenosis (and slow y descent)
pulmonary stenosis
pulmonary HTN
JVP: cannon a wave
complete heart block
JVP: dominant v wave
tricuspid regurgitation
JVP: x descent
absent = AF
increase
- acute cardiac tamponade
- constrictive pericarditis
JVP: y descent
sharp:
- severe TR
- constrictive pericarditis
slow
- tricuspid stenosis
- atrial myxoma
Apex beat types
Normal:
Left) 5th intercostal space, 1xm medial to mid-clavicular line
Pressure loaded = heaving, hperdynamic, systolic overload
- forceful + sustained impulse
- aortic stenosis, HTN
Volume loaded
- displaced, diffuse, non-sustained
- advanced mitral regurgitation, dilated cardiomyopathy
Dyskinetic
- uncoordinated apex over larger area than normal
- left) ventricular dysfunction
Double impulse apex beat = 2 separate impulse
- HOCM
Tapping apex beat
- apex beat felt when S1 palpable
- mitral stenosis, rarely tricuspid stenosis
S1/ S2 splitting
Best pulmonary region = L) 2nd intercostal
S1 (mitral + tricuspid) - usually no split
- split = cardiac conduction abnormality - most commonly complete heart block
S2 (aortic then pulmonary)
Increase normal split = wider inspiration = delayed Right) ventricular emptying
- eg RBBB, pulmonary stenosis, mitral regurgitation
Louder expiration = delayed Left)
Fixed = no resp variation
- ASD
Reversed splitting = P2 then A2
- delayed left) ventricular
- eg LBBB, aortic stenosis, coarctation,
S3
mid-diastolic ‘KENTUCKY’
reduced ventricular compliance
increase atrial/ ventricular end diastolic pressure
Left) S3 - loudest apex, expiration
- can be physiological eg pregnancy
- otherwise L) ventricular failure, AR, MR
Right) S3 - loudest left) sternal/ inspiration
- R) heart failure, constrictive pericarditis
S4
late diastolic, ‘tennessee’
