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Physical Diagnosis Exam 2 (Lauren) > Cardiovascular Assessment > Flashcards

Cardiovascular Assessment Flashcards

1
Q

On which side of the patient should you stand ?

A

Patient’s Right side

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2
Q

What is the precordium?

A

Anterior chest wall over the heart

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3
Q

What should you be looking for in the neck as part of the cardio exam?

A

Jugular venous distention

Jugular venous pulsations

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4
Q

What sounds do you listen to with the diaphragm?

A

High pitched sounds

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5
Q

What sounds do you listen to with the bell?

A

Low pitched sounds

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6
Q

Which side of the stethoscope is best for hearing S1 and S2? Why?

A

Diaphragm. They are high pitched

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7
Q

Which side of the stethoscope is best for hearing S3 and S4? Why?

A

Bell. Because they are low pitched

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8
Q

Pressing hard on the stethoscope will make it function as the (bell/diaphragm)

A

Diaphragm

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9
Q

Using light pressure with your stethoscope will make it function like a (bell/diaphragm)

A

Bell

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10
Q

Where do you hear the aortic valve?

A

2nd intercostal space on Right sternal border

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11
Q

Where do you hear the pulmonic valve?

A

2nd intercostal space on left sternal border

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12
Q

Where do you hear the tricuspid valve

A

4th or 5th intercostal space on the left sternal border

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13
Q

Where do you hear the mitral valve/apex of heart?

A

5th intercostal space, mid-clavicular line

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14
Q

Where would you listen for the 2nd pulmonic area?

A

3rd intercostal space, left sternal border

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15
Q

What is a normal heart rate?

A

60-100

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16
Q

What is considered tachycardia?

A

Over 100 bpm

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17
Q

What is considered bradycardia?

A

Less than 60 bpm

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18
Q

Are irregular heart rhythms consistent?

A

No they may come and go, so you should be sure to listen for more than just a second

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19
Q

What heart sound denotes the beginning of diastole?

A

S2

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20
Q

What heart sound marks the beginning of systole?

A

S1

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21
Q

Which valves close during S1

A

AV valves

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22
Q

Which valves close during S2?

A

Pulmoniary and aortic valves

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23
Q

Where is the best place to hear S1?

A

At the apex

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24
Q

What are possible causes of an accentuated (louder) S1?

A

Diseased AV valve

More forceful closure of AV valve

(Ex: tachycardia, fever, HTN, exercise, anemia, hyperthyroidism, stenosis)

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25
Q

What are possible causes of a diminished (softer) S1?

A

Weak contraction of heart

Reduced sound transmission

(Ex: thick chest wall or emphysematous lungs)

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26
Q

Where is the best place to hear S2

A

at the BASE (top)

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27
Q

Which phase is longer: diastole or systole?

A

Diastole (ventricles must fill)

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28
Q

What is meant by the S2 split?

A

The pulmonary valve closes slight later on the right than on the left, so S2 may be two discernible sounds: A2 and P2.

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29
Q

What is a wide S2?

A

Increase in the usual splitting during inspiration, due to a delayed closure of the pulmonic valve

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30
Q

What is a fixed S2?

A

Splitting does not vary with respiration

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31
Q

What is paradoxical S2?

A

Splitting that is present during expiration and gone during inspiration

A2 follows P2 due to a left bundle branch block

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32
Q

What is the usual cause of a paradoxical split of S2?

A

Left bundle branch block ***

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33
Q

What causes S3?

A

Low pitched sound in early diastole by passive, rapid filling of the ventricles. Blood is filling a chamber that is already volume overloaded

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34
Q

Where is the best place to hear an S3?

A

At apex with Bell

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35
Q

Who may have non-pathological S3?

A

Children

Healthy young adults

Pregnant women

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36
Q

What is the gallop rhythm of S3?

A

S1 + S2 + S3

“Ken-tucky “

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37
Q

What is a ventricular gallop?

A

A pathological S3

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38
Q

What can cause a pathological S3?

A

Heart failure

Anemia

Volume overload of ventricle

Decreased myocardial contractility

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39
Q

If someone is over 40 and they have an S3 is that normal?

A

No

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40
Q

What causes S4?

A

Rush of blood causing vibration of valves and papillary muscles during the atrial kick?

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41
Q

Where is S4 best heard?

A

with bell at Apex

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42
Q

What is atrial gallop rhythm?

A

An S4…due to the atrial component

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43
Q

In whom is it normal to have an S4?

A

Trained athletes

Some older people without other heart problems

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44
Q

What can cause a pathological S4?

A

Reduced compliance of ventricle filling

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45
Q

What grade of murmur:

Barely audible in a quiet room

A

1

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46
Q

What grade of murmur:

Quiet, but clearly audible

A

2

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47
Q

What grade of murmur:

Moderately loud

A

3

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48
Q

What grade of murmur:

Loud associated with thrill

A

4

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49
Q

What grade murmur:

Very loud, heard with stethoscope partially off chest, obvious thrill

A

5

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50
Q

What grade murmur:

Very loud, heard with stethoscope entirely off chest, obvious thrilll

A

6

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51
Q

When are systolic murmurs heard?

A

Between S1 and S2

52
Q

What is the sound pattern of a systolic ejection murmur?

A

Usually crescendo-decresecndo

53
Q

What valves are involved in systolic ejection murmurs?

A

Semilunar valves

54
Q

What causes pansystolic/holosystolic murmurs?

A

Regurgitation across AV valves

ventricular septal defect

55
Q

What causes a late systolic murmur?

A

Mitral prolapse

56
Q

What is the pressure differential for a systolic ejection murmur (aortic/pulmonic stenosis)?

A

High pressure to high pressure

57
Q

Where is the best place to hear a systolic ejection murmur (aortic/pulmonic stenosis)?

A

At base (top) along left and right sternal borders

58
Q

What are the characteristics of an innocent systolic ejection murmur?

A 
Grade 1 or 2
Softer when sitting
Short systolic duration
Minimal radiation
Musical
59
Q

Who is it common to have an innocent systolic ejection murmur?

A 
Children
Young adults 
Pregnancy
Anemia
Fever
Hyperthyroidism
60
Q

What is the pressure differential in a pansystolic murmur (mitral/tricuspid regurgitation)?

A

High pressure to low pressure

No resistance to flow back up to the atria so the murmur goes the whole time (no crescendo)

61
Q

Which way does the blood flow with a ventricular septal defect?

A

Left to Right causing a blowing murmur at Left lower sternal border

(High pressure to low pressure causing a pansystolic murmur)

62
Q

What can cause an early diastolic murmur?

A

Aortic regurgitation

63
Q

What kind of sound do you hear with an early diastolic/aortic regurgitation murmur?

A

Decrescendo

64
Q

What causes a mid-diastolic murmur?

A

Mitral/tricuspid valve stenosis

65
Q

What can cause a systolic-diastolic murmur?

A

Aortic stenosis with aortic regurgitation

Obstruction to outflow due to narrowed valve AND valve fails to completely close during diastole

66
Q

What can cause a “continuous” murmur?

A

Patent ductus arteriosus

67
Q

What can cause a “to-and fro” murmur?

A

Systolic-diastolic murmurs caused by severe aortic regurgitation and stenosis

68
Q

What are some positions you can put your pt in to enhance murmurs?

A

Lean forward

Left lateral decubitus

69
Q

What are some ways you can alter the hemodynamics in order to hear murmurs better?

A

Squatting

Valsalva

Isometric exercise

70
Q

Why does squatting/valsalva/isometric exercise change the way murmurs are heard?

A

Alters preload or afterload

71
Q

What effect does the standing/strain phase of valsalva have on the heart?

A

Causes decreased left ventricular volume due to decreased venous return

-decreases vascular tone, so decreased BP and decreased peripheral vascular resistance

72
Q

What effect will the standing/straining phase of valsalva have on murmurs?

A

Most murmurs decrease in intensity EXCEPT for hypertrophic cardiomyopathy (HCM)

73
Q

What kind of murmur:

“Opening snap then diastolic rumble”

A

Mitral stenosis

74
Q

What is a common cause of mitral valve regurgitation?

A

Rheumatic heart disease

75
Q

What effect will the squatting/release phase of valsalva have on the heart?

A

Increased LV volume due to increased venous return

Increases vascular tone, increases BP, and increases peripheral vascular resistance

76
Q

What effect will the squatting/release phase of valsalva have on murmurs?

A

Aortic stenosis increases

Hypertrophic cardiomyopathy decreases

77
Q

What can cause an aortic or pulmonic ejection click?

A

You hear the valve forcefully opening due to:

Valve disease

Dilated aorta/pulmonary artery

Pulmonary hypertension

78
Q

What is an aortic or pulmonic ejection click and when would you hear it?

A

A HIGH-pitched sound caused by the aortic or pulmonary valves forcefully opening. Heard after S1

79
Q

What side of scope do you use to hear aortic or pulmonic ejection click?

A

Diaphragm

80
Q

What causes a systolic click/mitral valve prolapse?

A

Ballooning of mitral leaflets into the L atrium during systole

81
Q

What may also go along with a systolic click/mitral valve prolapse?

A

Mitral regurgitation

82
Q

Is systolic click/mitral valve prolapse common?

A

Yes over 5% of people have it and it’s usually benign

83
Q

What causes venous hum?

A

Turbulent blood flow through jugular veins

84
Q

What causes pericardial friction rub?

A

Inflammation of pericardial sac

85
Q

What does a pericardial friction rub sound like?

A

It has 3 components (triphasic) and it is scratchy and squeaky

86
Q

What does jugular venous pressure indicate?

A

Pressure in the R atrium

87
Q

Why do we care about jugular venous pressure?

A

It is used in the evaluation of heart failure

88
Q

What directions do venous pulses move?

A

INWARD

89
Q

Which side of the neck should you use to look at jugular venous pressures?

A

Right internal jugular vein

90
Q

Are internal jugular pulasations easily palpable?

A

No they are rarely palpable

91
Q

What does the pulsation of the internal jugular vein look like?

A

Two elevations, and a CHARACTERISTIC inward deflection

92
Q

As the patient becomes more upright, what usually happens to the height of internal jugular pulsations?

A

Drops

93
Q

What effect does inspiration have on the height of internal jugular pulsations?

A

Falls

94
Q

Can you eliminate internal jugular vein pulsations by lightly pressing on the vein just above the clavicle?

A

Yes

95
Q

How do you measure the jugular vein pulsations?

A
  • exam table at 30*
  • pts head turned to left
  • find highest point of oscillation
  • measure vertical distance above sternal angle
  • ADD 5 cm****

Sum=JVP

96
Q

Why do you add 5cm to the JVP measurement?

A

Because the sternal angle is 5cm above the middle of the Right Atrium

97
Q

What is an abnormal JVP measurement?

A

> 8cm

98
Q

What can cause an elevated JVP?

A

Anything that causes hypervolemia

Heart failure

Pulmonary HTN

Increased venous vascular tone

Pericardial tamponade

99
Q

What can cause decreased JVP measurement?

A

Anything that can cause hypovolemia:

Blood loss

Decreased venous vascular tone

100
Q

You normally start the JVP measurement with the head of the bed at 30 degrees, but what should you do if you suspect your pt is fluid overloaded?

A

Raise the head of the bed

101
Q

You normally start the JVP measurement with the head of the bed at 30 degrees. What should you do if you suspect your pt if hypovolemic?

A

Lower the head of the bed

102
Q

What does the hepatojugular reflux test test for?

A

Fluid overload/Right sided heart failure

103
Q

What is considered a positive hepatojugular reflux test?

A

> 3cm increase in JVP or it remains elevated after letting go?

104
Q

How do you do the hepatojugular reflux test?

A
  • Pt is supine and head of bed is at 30*
  • apply firm pressure over the liver for 10sec
  • observe neck for an increase in JVP followed by a decrease as the hand is released
105
Q

What is a “thrill”?

A

Buzzing or vibratory sensation

Caused by vigorous blood flow through any narrowed opening.

106
Q

What should you do if you feel a thrill while palpating?

A

Auscultation the area for murmur

107
Q

What is a lift/heave?

A

Vigorous cardiac impulse that can be seen/felt through the chest wall

108
Q

What should you palpate for at the apex of the heart?

A

Apical impulse- the point of maximal impulse

109
Q

If you suspect an enlarged heart, but can’t palpate the point of maximal impulse, what else can you do to estimate cardiac size?

A

Percussion

limited value

110
Q

WWhat sounds can best be heard by listening at the apex with the patient in Left lateral decubitus position?

A

Low pitched filling sounds:

Gallops (S3 S4)

Murmurs: mitral stenosis

111
Q

What are abnormal findings when inspecting the extremities?

A

Hair loss

Tropic skin changes

Ulcers

Gangrene

Hypertrophic nails

Edema

112
Q

What is the range of grades for peripheral pulses?

A

0-3

113
Q

What grade of pulse:

Brisk, expected (normal)

A

2+

114
Q

What is pulse pressure?

A

Systolis minus diastolic

115
Q

How do you palpate carotid arteries?

A

One at a time

Just inside medial border of SCM

116
Q

What is a normal carotid upstroke?

A

Brisk, smooth, rapid

Immediately follows S1

117
Q

What is a bruit?

A

A murmur-like sound arising from turbulent arterial blood flow

118
Q

What side of scope do you use to hear bruits?

A

Diaphragm

119
Q

What is the Allen test used for?

A

Evaluate the potency of ulnar artery prior to puncture of radial artery for arterial blood gas evaluation

120
Q

What is a normal Allen test?

A

Palm flushes within 3-5 sec

121
Q

Where do you palpate for the abdominal aorta?

A

Above umblicus,

Slightly left of midline

122
Q

What is an abnormal size of the abdominal aorta?

A

> 3cm**

123
Q

Where do you palpate for the dorsalis pedis pulse?

A

Dortmund of foot, just lateral to extensor tendon of big toe

124
Q

Where do you palpate for the posterior tibial pulse?

A

Behind medial mallelous of ankle

125
Q

If a pt has swelling or edema in extremities, what should you do?

A

Palpate for pitting edema

126
Q

Where should you palpate for pitting edema?

A

Over dorsum of each foot

Behind each medial malleolus

Over the shins

127
Q

What is a positive Homan sign?

A

Pain in calf when provider dorsifexes patient’s foot

Physical Diagnosis Exam 2 (Lauren) (3 decks)

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