Cardiovascular Exam Flashcards
most anterior cardiac surface
R ventricle (has thin walls, under lower pressure)
most prominent heart sounds
left ventricle
lateral margin of the heart
left ventricle
base of the heart
Superior aspect of the heart
Right and left 2nd ICS
Apex of the heart
Inferior aspect of the heart
Apex at 5th ICS, 7-9 cm from midsternal line
systole
ventricular contraction
in systole, aortic and pulmonic valves open while mitral and tricuspid close
begins after S1
diastole
ventricular relaxation
begins with S2
S1
mitral valve closing
systole begins after S1
S2
aortic valve closing
S3
rapid ventricular filling
S4
atrial contraction
heart sounds
closure of valves is responsible for heart sounds
cardiovascular exam
Assess Jugular Venous Pressure (JVP) Assess Carotid Pulse Examine the Heart -Inspection -Palpation -Auscultation Peripheral vascular exam
jugular venous pressure
- Position: patient comfortable, supine with head raised to 30˚, tilted slightly away from side you are inspecting
- Use tangential lighting to identify landmarks
- Identify amplitude and timing of venous pulsations, lateral to SCM
- Arterial pulsations look and feel like single strong impulses
- -Compare with apical or radial pulse
- Venous pulses look like billowing sails with gentler wave forms
- -Press on RUQ to accentuate hepato-jugular reflux if JVD is suspected
- JV Distention indicates increased pressure in the Right heart (usually due to heart failure)
how to measure JVP
- Identify highest point of venous pulsation of the internal jugular along SCM border
- Measure vertical distance above sternal angle
- Elevation is defined as JVD
carotid pulse
- Inspect for carotid pulsations
- -Patient supine with HOB elevated to 30˚
- -Inspect medial to the sternocleidomastoid muscles
- -Medial to IJ
- -Matches radial pulse
carotid pulse
Auscultate for bruits (before palpation)
-Have patient hold breath
-Use bell of stethoscope to listen for bruit
–rumbling sound of turbulent blood flow through artery
Palpate for amplitude, rate, contour, thrills
cardiac exam
- Starting patient position is supine with 30 degrees head elevation
- Examiner stands on right side of patient
- Other positions
- -Left lateral decubitus (LLD)
- -Sitting up and leaning forward
- Inspection
- -Heaves
- -Point of maximum intensity (PMI) or apical impulse
- Palpation
- -Lifts and heaves, thrills, PMI
- -Cardiac silhouette
- Auscultation
- -Heart sounds
- -Murmurs
apical impulse
Location -usually 4th or 5th intercostal space, 7-9cm from MSL Diameter -usually less than 2.5cm Amplitude -usually small, brisk, tapping Duration -listen, feel and estimate proportion
cardiac auscultation
- Start with patient supine, HOB at 30⁰
- Listen to entire precordium
- -Right 2nd intercostal space (ICS)
- -Left 2nd through 5th ICS
- -Apex
- Use both diaphragm and bell
- -Diaphragm for higher pitched sounds
- -Bell for lower pitched sounds
- Left lateral decubitus position (bell)
- -Brings LV closer to chest wall
- -Accentuates S3, S4 and mitral murmurs
- Sitting up, leaning forward (diaphragm)
- -Accentuates aortic murmurs
- Squatting, Valsalva maneuvers: make different murmurs louder or softer
heart sounds
-S1 usually loudest at apex (mitral valve closing)
-S2 usually loudest at base (aortic valve closing)
-Systole is between S1 and S2
-Diastole is between S2 and S1
-Systole is shorter than diastole
-Pulses are palpable during systole
-First identify S1 and S2, then figure out what else you hear
Heart Sounds
-Both R and L sides of heart are contracting, so heart sounds are composed of two components
-Left heart
–S1 = Mitral closure; S2 = Aortic closure
-Right heart
–S1 = Tricuspid closure; S2 = Pulmonic closure
-R side of heart contracts slightly later than L
–S1 = M1T1
–S2 = A2P2
heart sounds: splitting
- Splitting refers to the separation of heart sounds into 2 components (R/L)
- Though both S1 and S2 can be split, the splitting of S2 is more important clinically
- Physiologic splitting
- -Separation of S1 or S2 into separate sounds accentuated by inspiration, disappears with expiration
- Right heart normally moves a little more slowly than left heart
- Lag is accentuated by increased intrathoracic pressure (inspiration)
- In people that are older, splitting it a sign of pathology
extra heart sounds: systole
- Ejection sounds are pathologic, caused by opening of valves that should be closed (early in systole, immediately after S1, affect either aortic or pulmonic valves, High pitched, Sharp clicking quality, Heard best with diaphragm)
- Clicks (mid to late systole, Mitral Valve Prolapse (MVP) most common, High pitched, use diaphragm)
extra heart sounds: diastole
- Opening snap (caused by opening of stenotic MV, Loud, high pitched snapping sound)
- S3 (ventricular gallop) (Physiological or pathological, can be physiologic in children but usually pathologic in pts over 40)
- S4 (atrial gallop) (Dull low pitched sound, heard best with bell, more often pathologic)
