CM Cardiac Exam Flashcards
What are the five elements of the cardiac exam?
IPIPA
Inspection of general appearance Palpation of the arterial pulse Inspection of the jugular venous pulse Palpation of the precordial impulses Auscultation of heart sounds
What signs may be found on general appearance in the cardiac exam?
Cyanosis, clubbing, peripheral edema
Point to cardiac pathologies
What can be determined by palpating the carotid artery?
Peripheral pulse/heart rate
What does a slow rate of rise in the arterial pulse suggest?
Aortic stenosis
What is the jugular venous pulse and why do we use it?
The jugular venous pulse is a measure of the right atrial pressure, since the right atrium itself is not directly accessible on physical exam
What is a normal jugular venous pulse?
5-9 cm of water at the angle of Louis
What is the angle of Louis?
The junction of the sternal body and the manubrium, found 5 cm above the right atrium and acts as a reference point to measure jugular venous pulse
How do the carotid pulse and JVP differ in terms of palpability?
The carotid pulse is easily palpable, the JVP is not
How do the carotid pulse and JVP differ in terms of peaks per cardiac cycle?
The JVP has 2 peaks and 2 troughs for each cardiac cycle
The carotid pulse has 1 pulsation per cycle
How do the carotid pulse and JVP change with position?
The JVP changes with patient position, while the carotid pulse does not change with position
How do the caroid pulse and JVP change with inspiration?
The JVP decreases with inspiration, while the carotid pulse does not vary with the respiratory cycle
What do the 2 peaks of the JVP represent?
The a wave and v wave in each cardiac cycle
What do the 2 troughs of the JVP represent?
The x descent and y descent in each cardiac cycle
What does Point of Maximal Impulse refer to?
PMI typically refers to the apex of the left ventricle
Where is PMI normally found?
Point of Maximal Impulse is normally found in the 5th intercostal space, 1-2cm in diameter and medial to the midclavicular line
What does a PMI lateral to the midclavicular line suggest?
Cardiomegaly
During ausculation, what pathologies are found in the Left Lateral Decubitus positoin?
While the patient is in the LLD position, 3rd and 4th heart sounds as well as Mitral Stenosis murmurs can be found
During ausculation, when the patient is seated upright and leaning forward, what can be heard and where?
Aortic regurgitation murmur can be heard at the left sternal border
What causes S1?
S1 is caused by closure of the Mitral and Tricuspid valves
What causes S2?
S2 is caused by closure of Aortic and Pulmonic valves
When does the Carotid pulse occur?
During Systole, between S1 and S2
Where is S1 loudest?
S1 is loudest at the apex of the heart (APTM)
Where is S2 loudest?
S2 is loudest at the base of the heart (APTM)
At what heart rate is Diastole longer than Systole?
HR < 120
What causes split S2?
Inspiration causes a more negative intrathoracic pressure, causing the pulmonary valve to close slower than the aortic valve and splitting the S2 sound
What causes an S3 sound?
S3 sounds are due to blood flowing against a distended or incompliant ventricle, and suggests that too much blood is flowing into the ventricle
What conditions cause an S3 sound?
Congestive Heart Failure, Restrictive Cardiomyopathy
How can an S3 sound be heard?
S3 sounds are heard at the apex with the patient in the LLD position during early diastole (immediately after S2)
What causes an S4 sound?
S4 sounds are found when atrial contraction forces blood into a stiff ventricle
What conditions cause an S4 sound?
Left Ventricular Hypertrophy
How can an S4 sound be heard?
S4 sounds are heard at the apex with the patient in LLD position, low pitch sound during late diastole
How are S3 and S4 sounds different?
S3 sounds are early diastole immediately after S2 while S4 are late diastole right before S1
What characteristics describe a murmur?
Timing (Systole/diastole) Timing within Systole/diastole (early, mid, late, holo) Shape (crescendo/decrescendo) Location of maximal intensity Radiation of murmur Intensity rating out of 6 Quality (blowing/harsh)
What are the common systolic murmurs?
Aortic stenosis and mitral regurgitation
Describe aortic stenosis?
Systolic murmur
Crescendo-decrescendo
Heard in the aortic area and radiates to the carotid arteries
Describe mitral regurgitation?
Holosytolic murmur heard best at the apex, radiates to the axilla
What sounds should be heard in Diastole?
No sound should be heard in diastole; should be totally silent and all murmurs are pathologic
What are common diastolic murmurs?
Aortic regurgitation and Mitral stenosis
Describe Aortic regurgitation?
Blowing, decrescendo murmur heard best along the sternal border
Associated with widened pulse pressure
What pressure change is Aortic regurgitation associated with?
Aortic regurgitation is associated with a widened pulse pressure
Describe Mitral regurgitation?
Low pitched rumbling diastolic murmur heard at the apex, best heard in the LLD position
What should be palpated to obtain a heart rate?
Carotid artery, better than radial
What pulse contour would be expected with aortic stenosis?
Delayed and diminished arterial pulse
What pulse contour would be expected with aortic regurgitation?
Bounding arterial pulse
What pulse contour would be expected with shock?
Weak and thready arterial pulse
What are the two properties of the JVP and what are they used for?
Height of JVP = volume status
Contour of JVP = clues to cardiac disease
How is JVP calculated from the angle of Louis?
Measure the vertical distance from the angle of Louis to the meniscus of the JVP, then add 5cm
Normal JVP <= 9cm
How should an inability to find the JVP be reported?
If the JVP cannot be found, report as “JVP not visualized”
Do NOT say “No JVD”, because this implies no distension/elevation
Why is a visible JVP in an upright patient automatically a sign that they are fluid overloaded?
Normally, the angle of Louis is 5cm from the R. Atrium (which is why we add +5cm to our verticle measure from the angle of Louis)
In an upright patient with visible JVP, the distance of the JVP from the angle of Louis + 5cm is always >= 9cm
When does S1 occur on a venous pressure tracing?
S1 occurs after the A wave (atrial contraction) and during the C wave (ventricular contraction)
What is the X descent?
Relaxation of the right atrium
What is the V wave?
Venous return to the right atrium with a closed tricuspid valve
What is the Y descent?
Rapid transfer of blood from the Right atrium to the Right ventricle after the tricuspid valve opens
What is a thrill?
A murmur that can be felt, at least a 4/6
When can an S3 sound be normal?
During periods of increased cardiac output, such as pregnancy
When can an S4 sound be normal?
Never
What is a murmur?
An extra heart sound due to turbulent flow across a vavle
Differentiate a murmur and a bruit?
A murmur is turbulent flow across a vale while a bruit is turbulent flow across an artery
