Cardiovascular Exam Flashcards
What are the AV valves?
Tricuspid
Mitral
What are the semilunar valves?
Aortic
Pulmonic
What are the locations of sounds on PR to help identify valve or chamber origin?
Which is louder, semilunar or AV valves?
Semilunar
What is heard well in the 2nd right interspace?
aortic area
What is heard well in the 2nd left interspace?
pulmonic area
What area is well heard from the lower left sternal border?
The tricuspid area
What is the area best heard from the apex?
Mitral Area
Diastole =
relaxation of ventricles (filling) first, then final 1/3 is atrial contraction
Lub is ___. Whis is the closure of what valves?
S1
Left side - mitral valve
Right side - tricuspid valve
Compare the mitral and tricuspid closure sounds
oMitral
§Louder
§Location: apex2.Right side
oTricuspid
§Softer
§Location: LLSB
S2 is ____. Is due to closure of what valves?
Dub
Aortic (A2)
Pulmonic (P2)
May hear splitting with which sound?
typically S2 (may occasionally hear with S1 per lecture slides)
Compare S2 aortic and pulmonic valve sounds
1.Left side
oAortic (A2)
§Louder
§Heard best R 2nd ICS
2.Right side
oPulmonic (P2)
§Softer
§Heard best L 2nd ICS
In what populations might you hear an S3?
Child/young adult
Who might you hear an “S3 gallop”?
Older adult
S3 comes directly after….
S2
S4 comes directly before…
S1
S4, (atrial gallop) marks ____ and is…
Atrial contraction
Always pathological
What is the duration of murmurs?
Longer duration that heart sounds
What are the two types of valvular pathology we covered?
Stenotic
Regurgitant/insufficiency
Describe stenotic murmur
what is an example?
- Narrowing of valvular orifice
- Example: aortic stenosis
Describe regurgitant/insufficiency murmurs
What is an example?
- Fails to close fully allows blood to leak back
- Example: aortic regurgitation
How should we describe murmurs?
(7 things)
- •Timing: Systolic/diastolic
- •Shape: Crescendo, decrescendo, etc.
- •Location: Heard best where?
- •Radiation: hear murmur other places (carotids, axilla, etc)
- •Intensity: Grade-6 point scale
- •Pitch: High, medium or low
- •Quality: Blowing, harsh, rumbling, musical, etc.
Describe murmur grading
- 1: very faint, heard only after listener “tuned-in”
- 2: quiet but immediately heard with stethoscope on chest
- 3: moderately loud
- 4: loud with palpable thrill
- 5: very loud with thrill may be heard with stethoscope partially off chest
- 6: very loud with thrill, may be heard with stethoscope entirely off chest
What is a grade 4 murmur?
•4: loud with palpable thrill
Grade 5 murmur?
•5: very loud with thrill may be heard with stethoscope partially off chest
Grade 3 murmur?
•3: moderately loud
Grade 1 murmur?
•1: very faint, heard only after listener “tuned-in”
Grade 2 murmur?
•2: quiet but immediately heard with stethoscope on chest
Grade 6 murmur?
•6: very loud with thrill, may be heard with stethoscope entirely off chest
What is a palpable thrill?
Murmur that can be palpated
What is the sequence of exam we should proceed through?
- •Inspection
- •Palpation
- •Auscultation
What should we look for on inspection?
oChest shape
oObserve for chest wall motion (heaves or lifts)
oObserve skin color, nails, face, mouth, and extremities
What kind of chest wall motions should we inspect for? What are they typically caused by?
Heaves/lifts-forceful cardiac contraction causing movement of ribs/sternum
oOften caused by enlarged ventricles/atrium
In palpation…
oFor most of cardiac exam patient spine with head of table at…
30 degrees and patient on the right
What are items to palpate for?
(4)
- oAnterior chest wall (heaves/lifts/thrills)oApical impulse/PMI
- oMay move to left lateral decubitus position to bring apex closer to chest wall
- oCarotid pulse
- oJugular venous pressure/pulsations
What position increases your likliehood of feeling PMI?
Lateral Recumbant position
Jugular is the most direct route to examine the…
right atrium
How do you palpate heaves/lift?
§Palpate chest wall using hand/finger pads
§Feel movement of heart/ribs into fingers/hand
How do you palpate thrills?
§Thrills-vibratory sensation on skin from turbulent flow through abnormal valve (loud murmur)
§Use thenar/hypothenar to assess
§Palpate areas where valves are located
–Aortic, pulmonic, tricuspid, mitral
Apical pulse/PMI is located at?
5th ICS, midclavicular line
What is the amplitude of the PMI? What is the duration?
oAmplitude is small, brisk & tapping
oDuration through 1st 2/3 of systole; not continue into second heart sound (S2)
Palpation-apical impulse/PMI is typically felt with…
fingers of hand while
head of table at 30 degrees
•Left lateral decubitus position is useful because it… and should be used when PMI is…
- Brings apex closer to chest wall
- Utilize if not detected supine
What does the carotid pulse give information on?
•Gives useful information of cardiac function especially detecting aortic valve stenosis/insufficiency.
How should one assess the carotid pulse?
Press index & middle finger on right carotid artery in lower third of neck, press posteriorly & feel for pulsations
What characteristics of the carotid pulse should we be evaluating?
•Amplitude
•Correlates with pulse pressure
–Variation occurs from beat to beat or with respiration
•Contour/speed
–Upstroke-brisk, smooth, rapid, and follows S1 immediately
–Summit-smooth, rounded and mid-systolic
–Downstroke-less abrupt than upstroke
How do you palpate for S1/S2, and the carotid?
When do S1 and 2 occur relative to the carotid upstroke?
•Palpate for S1/S2
•Right hand on chest wall (3rd/4th/5th ICS) and
•Use firm pressure for S1/S2
•
•Palpate carotid
–Left index & middle fingers on right carotid artery•S1 occurs just before carotid upstroke
•S2 occurs just after carotid upstroke
Jugular venous pressure provides clinical index of? and reflects?
What clues can it provide?
•Provides clinical index of right heart pressures and cardiac function•Reflects right atrial pressure
•Give clues to:
–Volume status
–R & L ventricular fxn
–Patency of right heart valves
–Pressures in pericardium
–Arrhythmias
Which jugular vein is best used to estimate JVP?
•Best estimated from right internal jugular vein
○More direct anatomical
channel to right atrium
How do you measure JVP? (6 steps)
- Turn head away from side of inspection.
- oRaise or lower head of table until you can see highest point of venous pulsations in lower half of neck
- •Find highest point of oscillation•Extend object horizontally from this point and a ruler vertically from sternal angle making a right angle.
- •Measure the vertical distance in cm above sternal angle where the horizontal object crosses the ruler. Round to nearest cm.
- •RA to sternal angle is always 5 cm above RA (in any position)•Measured distance + 5 cm = JVP
What is an abnormal JVP?
JVP >9cm above RA is abnormal
What can cause increased JVP?
–Right sided CHF
–Less common-constrictive pericarditis, tricuspid stenosis, superior vena cava obstruction
Elevated JVP is
•98% specific for…
… low LV ejection fraction and increases risk of death from heart failure.
Identify and describe the JVP waves
•A-wave: RA contraction
•
•X-descent: RA relaxation
•
•V-wave: RA filling and inc. pressure
●
•Y descent: RA emptying
What abnormalities might lead to a prominent a wave and increased resistance to RA contraction?
•Tricuspid stenosis, 1st degree AV bock, SVT, junctional rhythms, pulm. HTN and pulm. stenosis
§Absent a waves-in
atrial fibrillation
Large v waves in
tricuspid regurgitation
How do you check the hepatojugular reflex?
- •Patient supine
- •Apply firm pressure for 10 seconds over liver while observing for distention of neck veins
- •Normal to see transient distension of jugular veins for 2-3 seconds
- •If venous distension is higher than normal or lasts longer (usu. 8-10 sec) then abnormal
- •Assesses for right ventricular function and elevated pulmonary wedge pressure
What are 5 things you auscultate for?
- oTiming of S1/S2
- oEvaluate rate & rhythm
- oPhysiological splitting S2
- oAbnormal sounds-S3,S4, murmurs, or rubs
- oCarotid arteries-bruits
What is the diaphagm good for? What is the bell good for?
- High pitched sounds of S1/S2, certain murmurs
- Low pitched sound of S3/S4, bruits/thrills, & certain murmurs
What positions may be used to enhance cardiac sounds, particularly murmurs?
oSquatting
oStanding
oValsalva strain/release
oHand grip
Having a patient lean forward and exhale completely may help you to hear what? Where should you listen, and with what?
Using diaphragm listen along left lower sternal border
Optimal to listen for aortic insufficiency
oInnocent/physiological heart murmur more often heard in children than adults due to :
- Thin chest wall in children
- More angulated great vessels in children
- More dynamic circulation in children
What are two examples of innocent murmurs?
Stills murmur
Venous hum
Describe a venous hum
- Continuous humming, best right upper sternal border
- Flow of venous blood from head & neck into thorax
- Continuous while sitting
- Disappear light pressure over the jugular vein, when the child’s head is turned or when the child is lying supine
Describe Still’s murmur
- Mid-systolic, best left lower sternal border
- Musical quality
- Louder in supine position
