Cardiovascular Assessment Flashcards
On which side of the patient should you stand ?
Patient’s Right side
What is the precordium?
Anterior chest wall over the heart
What should you be looking for in the neck as part of the cardio exam?
Jugular venous distention
Jugular venous pulsations
What sounds do you listen to with the diaphragm?
High pitched sounds
What sounds do you listen to with the bell?
Low pitched sounds
Which side of the stethoscope is best for hearing S1 and S2? Why?
Diaphragm. They are high pitched
Which side of the stethoscope is best for hearing S3 and S4? Why?
Bell. Because they are low pitched
Pressing hard on the stethoscope will make it function as the (bell/diaphragm)
Diaphragm
Using light pressure with your stethoscope will make it function like a (bell/diaphragm)
Bell
Where do you hear the aortic valve?
2nd intercostal space on Right sternal border
Where do you hear the pulmonic valve?
2nd intercostal space on left sternal border
Where do you hear the tricuspid valve
4th or 5th intercostal space on the left sternal border
Where do you hear the mitral valve/apex of heart?
5th intercostal space, mid-clavicular line
Where would you listen for the 2nd pulmonic area?
3rd intercostal space, left sternal border
What is a normal heart rate?
60-100
What is considered tachycardia?
Over 100 bpm
What is considered bradycardia?
Less than 60 bpm
Are irregular heart rhythms consistent?
No they may come and go, so you should be sure to listen for more than just a second
What heart sound denotes the beginning of diastole?
S2
What heart sound marks the beginning of systole?
S1
Which valves close during S1
AV valves
Which valves close during S2?
Pulmoniary and aortic valves
Where is the best place to hear S1?
At the apex
What are possible causes of an accentuated (louder) S1?
Diseased AV valve
More forceful closure of AV valve
(Ex: tachycardia, fever, HTN, exercise, anemia, hyperthyroidism, stenosis)
What are possible causes of a diminished (softer) S1?
Weak contraction of heart
Reduced sound transmission
(Ex: thick chest wall or emphysematous lungs)
Where is the best place to hear S2
at the BASE (top)
Which phase is longer: diastole or systole?
Diastole (ventricles must fill)
What is meant by the S2 split?
The pulmonary valve closes slight later on the right than on the left, so S2 may be two discernible sounds: A2 and P2.
What is a wide S2?
Increase in the usual splitting during inspiration, due to a delayed closure of the pulmonic valve
What is a fixed S2?
Splitting does not vary with respiration
What is paradoxical S2?
Splitting that is present during expiration and gone during inspiration
A2 follows P2 due to a left bundle branch block
What is the usual cause of a paradoxical split of S2?
Left bundle branch block ***
What causes S3?
Low pitched sound in early diastole by passive, rapid filling of the ventricles. Blood is filling a chamber that is already volume overloaded
Where is the best place to hear an S3?
At apex with Bell
Who may have non-pathological S3?
Children
Healthy young adults
Pregnant women
What is the gallop rhythm of S3?
S1 + S2 + S3
“Ken-tucky “
What is a ventricular gallop?
A pathological S3
What can cause a pathological S3?
Heart failure
Anemia
Volume overload of ventricle
Decreased myocardial contractility
If someone is over 40 and they have an S3 is that normal?
No
What causes S4?
Rush of blood causing vibration of valves and papillary muscles during the atrial kick?
Where is S4 best heard?
with bell at Apex
What is atrial gallop rhythm?
An S4…due to the atrial component
In whom is it normal to have an S4?
Trained athletes
Some older people without other heart problems
What can cause a pathological S4?
Reduced compliance of ventricle filling
What grade of murmur:
Barely audible in a quiet room
1
What grade of murmur:
Quiet, but clearly audible
2
What grade of murmur:
Moderately loud
3
What grade of murmur:
Loud associated with thrill
4
What grade murmur:
Very loud, heard with stethoscope partially off chest, obvious thrill
5
What grade murmur:
Very loud, heard with stethoscope entirely off chest, obvious thrilll
6
When are systolic murmurs heard?
Between S1 and S2
What is the sound pattern of a systolic ejection murmur?
Usually crescendo-decresecndo
What valves are involved in systolic ejection murmurs?
Semilunar valves
What causes pansystolic/holosystolic murmurs?
Regurgitation across AV valves
ventricular septal defect
What causes a late systolic murmur?
Mitral prolapse
What is the pressure differential for a systolic ejection murmur (aortic/pulmonic stenosis)?
High pressure to high pressure
Where is the best place to hear a systolic ejection murmur (aortic/pulmonic stenosis)?
At base (top) along left and right sternal borders
What are the characteristics of an innocent systolic ejection murmur?
Grade 1 or 2 Softer when sitting Short systolic duration Minimal radiation Musical
Who is it common to have an innocent systolic ejection murmur?
Children Young adults Pregnancy Anemia Fever Hyperthyroidism
What is the pressure differential in a pansystolic murmur (mitral/tricuspid regurgitation)?
High pressure to low pressure
No resistance to flow back up to the atria so the murmur goes the whole time (no crescendo)
Which way does the blood flow with a ventricular septal defect?
Left to Right causing a blowing murmur at Left lower sternal border
(High pressure to low pressure causing a pansystolic murmur)
What can cause an early diastolic murmur?
Aortic regurgitation
What kind of sound do you hear with an early diastolic/aortic regurgitation murmur?
Decrescendo
What causes a mid-diastolic murmur?
Mitral/tricuspid valve stenosis
What can cause a systolic-diastolic murmur?
Aortic stenosis with aortic regurgitation
Obstruction to outflow due to narrowed valve AND valve fails to completely close during diastole
What can cause a “continuous” murmur?
Patent ductus arteriosus
What can cause a “to-and fro” murmur?
Systolic-diastolic murmurs caused by severe aortic regurgitation and stenosis
What are some positions you can put your pt in to enhance murmurs?
Lean forward
Left lateral decubitus
What are some ways you can alter the hemodynamics in order to hear murmurs better?
Squatting
Valsalva
Isometric exercise
Why does squatting/valsalva/isometric exercise change the way murmurs are heard?
Alters preload or afterload
What effect does the standing/strain phase of valsalva have on the heart?
Causes decreased left ventricular volume due to decreased venous return
-decreases vascular tone, so decreased BP and decreased peripheral vascular resistance
What effect will the standing/straining phase of valsalva have on murmurs?
Most murmurs decrease in intensity EXCEPT for hypertrophic cardiomyopathy (HCM)
What kind of murmur:
“Opening snap then diastolic rumble”
Mitral stenosis
What is a common cause of mitral valve regurgitation?
Rheumatic heart disease
What effect will the squatting/release phase of valsalva have on the heart?
Increased LV volume due to increased venous return
Increases vascular tone, increases BP, and increases peripheral vascular resistance
What effect will the squatting/release phase of valsalva have on murmurs?
Aortic stenosis increases
Hypertrophic cardiomyopathy decreases
What can cause an aortic or pulmonic ejection click?
You hear the valve forcefully opening due to:
Valve disease
Dilated aorta/pulmonary artery
Pulmonary hypertension
What is an aortic or pulmonic ejection click and when would you hear it?
A HIGH-pitched sound caused by the aortic or pulmonary valves forcefully opening. Heard after S1
What side of scope do you use to hear aortic or pulmonic ejection click?
Diaphragm
What causes a systolic click/mitral valve prolapse?
Ballooning of mitral leaflets into the L atrium during systole
What may also go along with a systolic click/mitral valve prolapse?
Mitral regurgitation
Is systolic click/mitral valve prolapse common?
Yes over 5% of people have it and it’s usually benign
What causes venous hum?
Turbulent blood flow through jugular veins
What causes pericardial friction rub?
Inflammation of pericardial sac
What does a pericardial friction rub sound like?
It has 3 components (triphasic) and it is scratchy and squeaky
What does jugular venous pressure indicate?
Pressure in the R atrium
Why do we care about jugular venous pressure?
It is used in the evaluation of heart failure
What directions do venous pulses move?
INWARD
Which side of the neck should you use to look at jugular venous pressures?
Right internal jugular vein
Are internal jugular pulasations easily palpable?
No they are rarely palpable
What does the pulsation of the internal jugular vein look like?
Two elevations, and a CHARACTERISTIC inward deflection
As the patient becomes more upright, what usually happens to the height of internal jugular pulsations?
Drops
What effect does inspiration have on the height of internal jugular pulsations?
Falls
Can you eliminate internal jugular vein pulsations by lightly pressing on the vein just above the clavicle?
Yes
How do you measure the jugular vein pulsations?
- 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
Why do you add 5cm to the JVP measurement?
Because the sternal angle is 5cm above the middle of the Right Atrium
What is an abnormal JVP measurement?
> 8cm
What can cause an elevated JVP?
Anything that causes hypervolemia
Heart failure
Pulmonary HTN
Increased venous vascular tone
Pericardial tamponade
What can cause decreased JVP measurement?
Anything that can cause hypovolemia:
Blood loss
Decreased venous vascular tone
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?
Raise the head of the bed
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?
Lower the head of the bed
What does the hepatojugular reflux test test for?
Fluid overload/Right sided heart failure
What is considered a positive hepatojugular reflux test?
> 3cm increase in JVP or it remains elevated after letting go?
How do you do the hepatojugular reflux test?
- 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
What is a “thrill”?
Buzzing or vibratory sensation
Caused by vigorous blood flow through any narrowed opening.
What should you do if you feel a thrill while palpating?
Auscultation the area for murmur
What is a lift/heave?
Vigorous cardiac impulse that can be seen/felt through the chest wall
What should you palpate for at the apex of the heart?
Apical impulse- the point of maximal impulse
If you suspect an enlarged heart, but can’t palpate the point of maximal impulse, what else can you do to estimate cardiac size?
Percussion
limited value
WWhat sounds can best be heard by listening at the apex with the patient in Left lateral decubitus position?
Low pitched filling sounds:
Gallops (S3 S4)
Murmurs: mitral stenosis
What are abnormal findings when inspecting the extremities?
Hair loss
Tropic skin changes
Ulcers
Gangrene
Hypertrophic nails
Edema
What is the range of grades for peripheral pulses?
0-3
What grade of pulse:
Brisk, expected (normal)
2+
What is pulse pressure?
Systolis minus diastolic
How do you palpate carotid arteries?
One at a time
Just inside medial border of SCM
What is a normal carotid upstroke?
Brisk, smooth, rapid
Immediately follows S1
What is a bruit?
A murmur-like sound arising from turbulent arterial blood flow
What side of scope do you use to hear bruits?
Diaphragm
What is the Allen test used for?
Evaluate the potency of ulnar artery prior to puncture of radial artery for arterial blood gas evaluation
What is a normal Allen test?
Palm flushes within 3-5 sec
Where do you palpate for the abdominal aorta?
Above umblicus,
Slightly left of midline
What is an abnormal size of the abdominal aorta?
> 3cm**
Where do you palpate for the dorsalis pedis pulse?
Dortmund of foot, just lateral to extensor tendon of big toe
Where do you palpate for the posterior tibial pulse?
Behind medial mallelous of ankle
If a pt has swelling or edema in extremities, what should you do?
Palpate for pitting edema
Where should you palpate for pitting edema?
Over dorsum of each foot
Behind each medial malleolus
Over the shins
What is a positive Homan sign?
Pain in calf when provider dorsifexes patient’s foot
