Clinical Skills

Question 1

Where can you palpate the apex of the heart?

Answer 1

5th left intercostal space in the midclavicular line (mitral area)

Question 2

Where do you auscultate the aortic valve?

Answer 2

2nd right ICS sternal edge

Question 3

Where do you auscultate the tricuspid valve?

Answer 3

4th left ICS sternal edge (lower left sternal edge)

Question 4

Where do you auscultate the pulmonary valve?

Answer 4

2nd left ICS sternal edge

Question 5

Where do you auscultate the mitral valve?

Answer 5

5th left ICS midclavicular line

Question 6

Why is JVP a good measure of right atrial pressure?

Answer 6

There are no valves between the internal jugular vein and the right atrium

Question 7

How is JVP estimated?

Answer 7

the vertical distance between the manubriosternal angle and the top of the venous column

Question 8

IJV pulsations are _____1_____ but compression of the _____2____ causes a temporary increase in venous pressure making the JVP more visible. This is known as _____3_____

Answer 8

1 not usually visible
2 right upper abdomen
3 the hepatojugular reflex

Question 9

Is the JVP pulse palpable?

Answer 9

No

Question 10

Stenosis is…. so will be heard when….

Answer 10

Narrowing of valve causing turbulent blood flow so will be heard when the valve is open

Question 11

Regurgitation results in …. so will be heard when ….

Answer 11

blood leaking back so will be heard when the valve is closed.

Question 12

Systolic Murmurs?

Answer 12

Mitral regurgitation
Tricuspid Regurgitation
Pulmonary Stenosis
Aortic Stenosis

Question 13

Diastolic Murmurs?

Answer 13

Mitral stenosis
Tricuspid stenosis
Pulmonary regurgitation
Aortic Regurgitation

Question 14

The murmur of mitral stenosis will be accentuated if you listen….

Answer 14

At the apex and roll the patient onto their left

Question 15

Check for aortic regurgitation by…

Answer 15

Asking the patient to lean forward, exhale and auscultate over lower left sternal edge.

Question 16

A third heart sound is an ______1_______

It occurs ___2____ and is related to _____3_____ They are best heard at ___4____

Answer 16

1) early diastolic low frequency filling sound
2) immediately after the 2nd heart sound
3) acceleration and deceleration of blood during early passive filling of the ventricle
4) apex with the bell of the stethoscope

Question 17

Are third sounds always pathological?

Answer 17

In young people they can be physiological in older patients with suspected or known cardiac disease it is likely to be due to left ventricular dysfunction and they should be referred for an echo

Question 18

A fourth heart sound is a _____1________ it occurs ____2_____ It is due to ___3_____
Common causes of this are _____4_______

Answer 18

1) late diastolic low frequency filling sound
2) shortly before the first heart sound
3) Atrial contraction causing rapid blood flow into a less compliant or stiff ventricle
4) myocardial ischaemia, hypertension and aortic stenosis

Question 19

Are fourth heart sounds always pathological?

Answer 19

Yes

Question 20

Describe the a wave of JVP

Answer 20

This is produced by atrial systole

Question 21

When are a waves increased and when do you get giant cannon waves?

Answer 21

a waves are increased with right ventricular hypertrophy. Giant cannon waves occur in complete heart block and VT

Question 22

Describe the c wave of JVP

Answer 22

The c wave occurs during the x descent and is due to transmission of right ventricular systolic pressure before the tricuspid valve closes

Question 23

When does the x descent of JVP occur?

Answer 23

When atrial contraction finishes

Question 24

When does the v wave occur?

Answer 24

Occurs with venous return filling the right atrium.

Question 25

When do massive v waves occur?

Answer 25

Massive v waves occur in tricuspid regurgitation

Question 26

When does the y descent occur?

Answer 26

This follows the v wave when the tricuspid valve opens

Question 27

When is a steep y wave seen?

Answer 27

constrictive pericarditis and tricuspid incompetence

Question 28

Anatomical position of the carotid pulse?

Answer 28

anterior to the sternocleidomastoid muscle at the level o the superior border of the thyroid cartilage

Question 29

Anatomical position of the brachial artery?

Answer 29

Medial to the biceps brachia tendon in the cubital fossa

Question 30

Anatomical position of the radial artery?

Answer 30

Lateral to the tendon of the flexor carpi radialis

Question 31

Anatomical position of the femoral artery?

Answer 31

Inferior to the midpoint of the inguinal ligament

Question 32

Anatomical position of the popliteal artery?

Answer 32

In the popliteal fossa which is immediately posterior to the knee

Question 33

Anatomical position of the posterior tibial artery?

Answer 33

Between the posterior border of the medial malleolus and the achilles tendon

Question 34

Anatomical position of the dorsals pedis artery?

Answer 34

Medial to the tendon of extensor hallucis longus on the dorsum of the foot

Question 35

Tests used to assess CVD risk?

Answer 35

urinalysis for protein, funds examination for hypertensive retinopathy, 12 lead ECG, blood tests for glucose, electrolytes, creatine, eGFR and cholesterol

Question 36

What heart enlargement is difficult to see on x-ray?

Answer 36

Right sided