Cardiovascular Exam Flashcards
What is the only vein that carries O2 rich blood?
The Pulmonary veins
The Normal Lateral Chest X-ray allows you to look at what part of the heart?
Allows you to look behind the heart
What is the most common chief complaint for cardiac events?
Chest pain
What is Angina?
The consequence of hypoxia of the myocardium resulting from an imbalance of coronary blood supply and myocardial demand
What is the Levine’s sign?
A classic sign seen from people who are experiencing sharp CV pain caused by angina or MI. The Patient places a tight closed fist in front of his chest.
Other causes of chest pain other than problems of the heart?
Pulmonary, intestinal, gallbladder and musculoskeletal problems.
Questions to ask for those with chest pain
1) Location
2) Duration
3) Ever happen before
4) How often
5) Anything make it better?
6) Does anything make it worse
Common symptoms of CV disorders
1) Confusion/syncope/dizziness
2) Palpations
3) Cough/wheezing
4) Hemoptysis
5) SOB
6) Chest pain/tightness
7) Incontinence/impotence/heat intolerance
8) Fatigue
9) Leg Edema
What questions would you ask in the Family History in a CV exam
1) Diabetes
2) Heart disease
3) Hyperlipidemia
4) HTN
5) Congenital heart defects, VSD
6) Sudden death
Define systole
The action of the ventricles contractions
What are the 2 systolic events of the heart?
1) The right ventricle pumps blood into the pulmonary arteries (thru the pulmonic valve)
2) The left ventricle pumps blood into the aorta (thru the aortic valve
Define diastole
When the ventricles are relaxed
What are the 2 diastolic events of the heart?
1) Blood flows from the right atrium into the right ventricle (via the tricuspid valve)
2) Blood flows from the left atrium into the left ventricle (via the mitral valve)
What the equation for Cardiac Output?
CO = SV x HR
What is stroke volume?
The volume of blood pumped from one ventricle of the heart with each beat.
What is preload?
The end diastolic volume at the beginning of systole directly related to the stretch .
Preload is associated with what law?
Starling’s
What is contractility?
The ability for the ventricles to contract during systole. (ejection fraction)
What is afterload?
The amount of resistance that the left side of the heart has to overcome to eject blood. (squeeze)
What is the equation for blood pressure?
BP = CO x systemic vascular resistance (SVR)
What are the relations between HR and temperature?
Fever may increase HR and respirations
Hypothermia may decrease HR and respirations
What are the accepted regular pulse ranges and irregular definitions?
Normal for adults - 60 - 100 bpm
Bradycardia - under 60 bpm
Tachycardia - over 100 bpm
With children there is a range based on age.
What are the accepted regular respiration ranges and irregular definitions
Normal for adults - 12 - 20 breaths/m
Tachypnea - More than 20 breaths/min
Agonal - Irregular breathing (can be slow or fast)
What are the accepted regular ranges of blood pressure?
Systolic - btwn 100-140
Diastolic - btwn 60-80
Blood pressure more concerns which side of the heart?
the left
What are three methods of taking a blood pressure
1) Direct measurement - Involves the insertion of an intra-arterial catheter (arterial line or A-line)
2) Indirect measurement - Involves a blood pressure cuff and stethoscope
3) Measurement by palpation - Hold arm at the level of the heart and palpate brachial or radial artery
What happens in the blood pressure cuff is the wrong fit?
Too small - artificially elevated BP
Too large - artificially lowered BP
What is a problem with the measurement by palpation method of taking a blood pressure
It only identifies the systolic BP
How do you test someone for orthostatic hypotension?
Have the patient lie down flat for 5 min., then take a BP. Sit them up and repeat. Also repeat in a standing position if no symptoms occur with sitting them up
How do you determine if someone has orthostatic hypotension?
If there is more than a 20 mmHg systolic or 10 mmHg diastolic drop in BP from lying down to sitting/standing or if patient becomes dizzy
How would you define Supravalvular Aortic stenosis in a physical exam
If there is a difference in BP of more than 20 mmHg between arms
How might you be able to define a Coarctation of the aorta in a physical exam?
If the BP is elevated in both arms and you take the BP of the legs and if the legs are lower it may be an indication
How might you be able to define a pulses paradoxus in a physical exam?
Deflate the BP cuff until pulses are heard in expiration only, then until heard during inspiration. There is a pulses paradoxus if the difference is more than 10 mmHg.
What might a pulses paradoxus be a sign of?
You should consider a cardiac tamponade, pericardial effusion, constrictive pericarditis, asthma or emphysema.
How/where do you feel the pulse on the radial artery?
You palpate on the volar surface radial aspect of the wrist with the 2nd, 3rd and 4th fingers
What will you will be measuring for with the radial pulse
The rate, rhythm, contour & amplitude of the pulse.
How do you measure the rate of the pulse
Count for 30 seconds and multiply by 2 (most accurate for regular rhythms)
What would you be checking for on the skin for the CV exam…
1) Temperature
2) Central & peripheral cyanosis
3) Pallor
4) xanthomata (hypercholesterol)
5) Erythema marginatum (acute rheumatic fever)
What would you be checking for on the nails for the CV exam…
Splinter hemorrhages (non-specific finding in ineffective endocarditis.
What would you be checking for on the face for the CV exam…
1) Wide set eyes, strabismus, low set ears, upturned nose, hypoplasia of the mandible (supravalvular aortic stenosis)
2) Moon face and wide set eyes (pulm stenosis)
3) Expressionless face & puffy eyes (hypothyroid/cardiomyopathy)
What would you be checking for on the eyes for the CV exam…
1) Xanthelasma - (hypercholesterol)
2) Arcus senilus (hypercholesterol if under 40 y/o)
3) Opacities in cornea (cor pulmonale, or myocardial involvement
4) Displacement of lens (Marfan’s/aortic regurgitation
5) Conjunctival hemorrhages (ineffective endocarditis)
6) Sausage link vessels ( HTN, eclampsia)
What would you be checking for on the neck for the CV exam…
Webbing ( Turner’s syndrome, Coarctation of aorta, pulmonic stenosis.
What would you be checking for on the mouth for the CV exam…
High arched palate (Congenital heart prob/MVP) Palate petachiae (ineffective endocarditis
What would you be checking for on the chest for the CV exam…
Pectus excavatum or caranutum (Marfan’s/MVP)
What would you be checking for on the extremities for the CV exam…
Extra phalanx (finger or toe) - (ASD) Long slender fingers - (Marfan's)
What does the Jugular Venous Pulse reflect?
Right atrial pressure
How should the patient be to measure the Jugular Venous Pressure?
Lying with the head up at a 30 or 45 degree angle with the patient’s head turned gently to the left
Which vein should you measure to get the Jugular Venous Pressure?
Internal or external Jugular Vein (internal preferred)
Where should the Ruler be placed to get the Jugular Venous Pressure?
On the sterno-menubrial angle
What is a normal reading when measuring the Jugular Venous Pressure?
Upper limit of normal is 4-5 cm at 45 degrees, 6 cm at 30 degrees
What is the a wave in a Jugular Venous Pulsation?
(Atrial contraction) It reflects the sight rise in atrial pressure that accompanies atrial contraction.
When does the A wave occur?
Before the S1 and the carotid pulse
What is the X decent in a Jugular Venous Pulsation?
(atrial relax) When the atrial relaxation occurs and the ventricles contract
What is the V wave in a Jugular Venous Pulsation?
(venous filling) When the atria begin to fill
What is the Y descent in a Jugular Venous Pulsation?
(Atrial emptying) When blood flows into the right ventricle
Why does the Hepatojugular Reflex occur?
Due to the inability of the right side of the heart to accommodate the increased venous return
What does the Hepatojugular Reflex assess
Right ventricular function
How should the patient be when assessing the Hepatojugular Reflex?
Lying flat on the bed, with their mouth open and breathing normally
How do you perform the Hepatojugular Reflex?
Lying flat with mouth open, observe the jugular height. Then press firmly under the right costal margin for 10-15 seconds .
What results would you see when performing the Hepatojugular Reflex?
Normal - Jugular veins show a transient increase during the 1st few cardiac cycles followed by a fall to baseline during later parts of compression
Not normal - Jugular veins will remain distended during entire period of compression in Right Ventricular failure and pulm artery wedge pressure
What do you need to do before taking a carotid Pulse
Always listen for a bruit before palpating and palpate one at a time (never simultaneously)
How should the patient be when taking a carotid pulse?
Head should be elevated 30-45 degrees
What are three ways the carotid upstroke could be when taking a carotid pulse.
Brisk - normal
Delayed - suggests AS
Bounding - suggests Aortic sufficiency
What are you evaluating when palpating the chest wall?
1) Apical pulse
2) RV, PA and LV motion
3) Presence or absence of thrills
4) PMI (Point of maximum impulse)
How should the patient be when palpating the chest wall?
Supine, sitting and LLD positions
What part(s) of the hand should you use when palpating the chest wall?
Finger pads for heaves and lifts
Ball of hand for thrills or turbulance
Where would you begin to look for the PMI (Point of Maximum Impulse?
in the left anterior chest wall. Palpate the apex (5th ICS, midclavicular line)
How should your patient be when checking for the PMI?
In the sitting position
What should you note when finding the PMI?
Locate t he PMI by interspace and distance in cm from the midsternal line. Assess the location, amplitude, duration and diameter of the PMI
What is a normal and abnormal finding of a PMI (what might an abnormal PMI indicate)
Normal: The PMI is usually within 10cm of the midsternal line and is usually no larger than 2-3 cm in diameter.
Abnormal: A PMI that is laterally displaced or felt in 2 interspaces during the same phase of respiration. It would suggest cardiomegaly
What are 3 ways in which PMI may be described
1) Tapping - Normal
2) Sustained - Suggests LV hypertrophy from HTN or AS
3) Diffuse - Suggests a dilated ventricle from CHF or cardiomyopathy
PMI is felt in the sitting position in _____ percent of normal individuals
70 percent
If you can’t feel PMI sitting, what should you do?
Try finding it in the supine or LLD positions
What are some other conditions that you may think of if the PMI is displaced
1) In LLD position, a PMI greater than 3m could mean LV enlargement
2) PMI may be displace to right in RVH
3) PMI may be displaced to epigastrium in those with COPD
In the patient exam what are the 4 main cardiac areas that you can palpate?
1) Aortic - Right 2nd ICS sternal border
2) Pulmonic - Left 2nd ICS sternal border
3) Tricuspid - Left 4th ICS sternal border
4) Mitral - Left 5th ICS mid-clavicular line
How do you palpate the main cardiac areas?
With fingertips and heel of hand
What may the presence of a systolic impulse on fingertips of 2nd left ICS indicate?
Pulmonary HTN
What may a heave with lateral retraction along the left parasternal border suggest
Large right Ventricle
What may a 2nd impulse felt after the main LV impulse in the PMI indicate?
An S3 caused by an increased rate of ventricle filling
What does the presence of a thrill indicate?
A large murmur
How do you best feel for a thrill (get your mind out of the gutter!)
By using the metacarpal heads using light pressure
What are the 5 areas you would want to auscultate during a cardiac exam?
1) Aortic - Right 2nd ICS sternal border
2) Pulmonic - Left 2nd ICS sternal border
3 Erb’s point - Left 3rd ICS sternal border
4) Tricuspid - Left 4th ICS sternal border
5) Mitral - Left 5th ICS mid-clavicular line
What positions should the patient be when auscultating the heart
Sitting, supine and LLD positions
Where should you be when auscultating the heart when the patient is supine?
ON the right side of the patient
What is the best way to listen for the diastolic murmur of mitral stenosis
With the patient in the LLD position with the bell of the stethoscope
S1 is ?
The sound that precedes the carotid pulse. Its the closure of the mitral and tricuspid valves
S2 is ?
The sound the follows the pulse. Its’ the closure of the aortic and pulmonary valves (semilunar valves)
The aortic and pulmonary valves aka
Semilunar valves
What is the diaphragm of the stethoscope best used for when doing the cardiac exam
For high pitches sounds like S1, S2, and most murmurs
What is the bell of the stethoscope best used for when doing the cardiac exam
For low pitches sounds like S3 and S4 andd the rumble of Mitral stenosis
What are S3 and S4 and most murmurs from the right side of the heart accentuated by
Inspiration
Why are most murmurs accentuated by inspiration?
D/t an increased return of blood t hat occurs and increased RV output.
If there is a question of an aortic murmur what should you do?
Have patient sit up and lean forward, exhale and then hold breath (listen with diaphragm at r/l 2nd and 3rd ICS
What is S1 influenced by
Ventricular contractility - sharp rise in vent. pressure causes a faster closure of AV valves leading to a louder S1 (mitral stenosis)
What would a diminished rate in ventricular pressure produce
A softer S1
What is the relationship btwn S1 and the PR interaval
A shortened PR interval leads to a louder S1
A lengthened PR interval (Wenchebach) leads to a softer S1
What is the relationship of the valve leaflets and S1?
The farther apart the leaflets the louder the S1
The closer they are, the softer the S1
When would you hear a muffled S1
With AV valve regurgitation, pleural and pericardial effusions, COPD, obesity and pneumothorax
Why normally do you hear an S1 split?
Because the mitral valves close a split second before the tricuspid
What conditions could produce a more prominent S1 split?
PVC of LV origin, RBBB, LV pacing Atrial Septal Defect and severe TS
Why would you hear a reverse splitting of the S1?
If the tricuspid valve closes before the mitral
What conditions could produce a reverse splitting of S1?
LBBB, RV pacing, severe MS and left atrial myxoma
When would you hear an increased S2?
With Pulm HTN, Coarctation of the aorta, Aortic aneurism, tetralogy of Fallot, and transposition of great vessels/.
Why normally would you hear a split in S2
Because the aortic valve closes slightly before the pulmonary valve
When does a split in S2 become more prominent?
With inspiration
When would you hear a wider S2 split?
with exhalation, or from a delayed closure of the pulm. valve or early closure of the aortic valve
When might you hear a reversed splitting of S2?
When the RV contraction is completed before the LV contraction in LBBB, PVCs of RV origin, WPW syndrome, obstruction of LV or Aortic stenosis.
When is S3 best heard
When arising in LV - At apex in LLD position with bell
When arising in RV - Left lower sternal border or xyphoid, supine with bell
What is S3 due to
A low pitched early diastolic sound d/t rapid entry of blood from atrium to ventricle that is decelerated d/t ventricle reaching its elastic limit
When is S3 a bad prognostic sign?
In the presence of heart failure
What are conditions associated with S3
1) ischemic heart disease
2) Hyperkinetic states (anemia, fever, preggo, etc)
3) MR or TR
4) Chronic/Acute AR
5) Systemic or pulm HTN
6) Volume overload (renal failure)
What is S4
A late diastolic sound heard just before S1
What’s the best way to hear S4
LV origin - at apex in LLD at end of expiration
RV origin - in Left lower sternal border
What are conditions associate with S4
1) LVH from HTN, AS or hypertrophic cardiomyopathy
2) RVH from pulm HTH or stenosis
3) Ischemic heart disease from acute MI or angina
4) Ventricular aneurysm
5) Hyperkinetic states
When are systolic ejection clicks best heard?
During the early part of ventricle systole after S1
Describe how systolic ejection clicks would sound and what would be the best way to hear them?
Generally they’re high pitched and heard best with the diaphragm of the stethoscope.
What would decrease the intensity of systolic ejection clicks?
Valve calcification or with inspiration
Where part of the vascular system would you hear systolic ejection clicks?
In the aorta and pulmonary artery (mostly due to stenosis or aneurysms.
What are non systolic ejection clicks associated with?
Mitral and tricuspid valve prolapse (mitral more common)
Describe the sound produced with non systolic ejection clicks
A high pitched systolic sound that follows S1 and is best heard at the apex or tricuspid area. Best heard with the diaphragm
What are three factors that may produce murmurs
1) High flow rate thru normal or abnormal orifices
2) Forward flow thru a constricted or irregular orifice or into a dilated vessel or chamber
3) Backward or regurgitant flow thru an incompetent vein
If the murmur coincided with the carotid upstroke it is _____ If not, it’s _______
Systolic/diastolic
Murmurs are graded from 1 to 6. Which must have a thrill associated with them?
4 through 6
What are factors that are used to describe murmurs?
1) Timing - systolic/diastolic
2) Location - 5 areas
3) Radiation (neck, back,etc)
4) Duration - early/late syst/dias
5) Intensity - 1 thru 6
6) Pitch
7) Quality - musical/harsh, etc
8) Relation to inspiration
9) Relaion to position (supine, LLD)
What are 4 ways to describe the shape of a heart murmur?
1) Crescendo - rises in intensity from S1 to S2
2) Decrescendo - decreases in intensity after S2
3) Crescendo/decrescendo - rises and falls btwn S1-S2
4) Plateau - remains the same thru systole/diastole
A crescendo/decrescendo murmur is associated with…
Aortic stenosis
What are the systolic murmurs?
Atrial/pulmonary stenosis Mitral/Tricuspid stenosis Ventral septal defect (VSD) Venous Hum Innocent murmur
Describe the qualities of a murmur associated with aortic stenosis
1) Crescendo/decrescendo
2) Mid to late systolic in aortic area
3) radiates to neck
4) Harsh and medium pitch
5) Decreased S2 and presence of S4
6) Narrow pulse pressure
Describe the qualities of a murmur associated with mitral Regurgitation
1) Best heard in apex in early systole
2) Radiates to axilla
3) high pitched/blowing/plateau
4) Holosystolic
5) decreased S1 and presence of S3
6) PMI is laterally displaced
Describe the qualities of a murmur associated with Pulmonary stenosis
1) Best heard in pulmonic area in mid to late systole
2) Radiates to neck
3) medium pitched
4) Crescendo/decrescendo diamond shaped
Describe the qualities of a murmur associated with Tricuspid Regurgitation
1) Best heard in tricuspid area in early systole
2) Radiates to right of sternum
3) High pitched and blowing
4) Holosystolic
Describe the qualities of a murmur associated with a Ventral Septal defect
1) Best heard in tricuspid area in early systole (with muscular or non-restrictive pulmonary HTN_
2) Holosystolic (with left to right shunt)
3) Radiates to right of sternum
4) High pitched and harsh
Describe the qualities of a murmur associated with a Venous hum
1) Best heard above clavicle
2) Continuous
3) Radiates to right side of the neck
4) High pitched/roaring/humming
Describe the qualities of a murmur associated with a Innocent murmur
1) Widespread with minimal radiation
2) Diamond shaped
3) Medium pitched
4) Twangy/vibratory
What are the Diastolic murmurs?
Mitral stenosis
Aortic regurgitation
Describe the qualities of a murmur associated with a Mitral stenosis
1) Decrescendo with no radiation
2) Mid diastolic at apex
3) low pitch and rumbling
4) Increased S1 with an opening snap
5) Presystolic accentuation
Describe the qualities of a murmur associated with a Aortic Regurgitation
1) Best heard in aortic area in early systole
2) Decrescendo with no Radiation
3) high pitched/blowing
4) Laterally displaced PMI
5) Presence of S3
6) Wide pulse pressure
What is a Austin Flint murmur?
An apical diastolic murmur that is in association with Atrial regurgitation but mimics MS
What is Patent Ductus Arteriosus (PDA)?
An abnormal communication btwn the aorta and pulmonary artery
Describe the murmur associated with Patent Ductus Arteriosus (PDA)
1) Occurs during the end of systole into diastole
2) Blowing and high pitched
3) Heard best at the left upper sternal border near the left 2nd ICS
4) Most pronounced at S2
When using a stethoscope that only has a diaphragm (that is best at hearing high pitched sounds) what technique should you use to listen to low pitched sounds
Press very lightly on the diaphragm.
