CMR wk 1 Flashcards
basic CV exam components
cardiac auscultation + palpation:
-chest inspection
-heart + carotid a. auscultation
-palpation (chest wall pain, PMI, pulses [carotid, b/l UE, b/l LE])
advanced CV exam (vascular system) components
inspection (extremities)
-clubbing
-cyanosis
palpation
-capillary refill
-edema
-JVP
which heart sounds are diaphragm used for? how much pressure is applied?
valvular heart sounds (A, P, T, M), firm pressure
which heart sounds are bell used for? how much pressure is applied?
non-valvular heart sounds, light pressure
what you look for during visual inspection of chest
-pectus excavatum/carinatum
-symmetry of chest
-skin lesions/rashes
-bruising
-tattoos
what do you listen to at the 2nd right intercostal space?
aortic valve
what do you listen to at the 2nd left intercostal space?
pulmonic valve
what do you listen to at the 4th left intercostal space?
tricuspid valve
what do you listen to at the 5th left intercostal space?
mitral (bicuspid) valve
valve behavior during systole
aortic + pulmonic valves open
mitral + tricuspid valves close
what creates the 1st heart sound (S1)?
mitral + tricuspid valves closing
what are the ventricles doing during systole?
contracting
what are the ventricles doing during diastole?
relaxing
valve behavior during diastole
aortic + pulmonic valves close
mitral + tricuspid valves open
what creates the 2nd heart sound (S2)? and what is the main valve you are hearing?
aortic + pulmonic valves closing
mainly hearing aortic valve
where is S1 loudest? why?
apex
bc of contraction of left ventricle
where is S2 loudest?
base
is timing of systole longer or shorter than diastole?
systole is shorter
what are S3 and S4 heart sounds called?
gallops (extra heart sounds)
where are S3 and S4 heard best?
apex
are S3 and S4 high or low-pitched?
low-pitched
what part of stethoscope do you use to listen to S3 and S4? why?
bell, they’re low-pitched
is S3 normal or pathologic
can be both
is S4 normal or pathologic
always pathologic
what are you hearing with S3
too much blood sloshing into left ventricle
what are you hearing with S4
blood hitting stiff left ventricle wall (hypertrophic) while filling ventricle
when does S3 occur
early diastole, right after S2
lub_de-bub
when does S4 occur
late diastole, just before S1
be-lub_dub
pathologic causes of S4
-restrictive cardiomyopathy
-uncontrolled HTN
in what pt population is S3 usually normal
young children, some adults
pathologic causes of S3
-volume overload (too much fluid in heart)
-CHF
what you hear during gallops vs murmurs
gallops = fluid sloshing into ventricle / hitting ventricle wall
murmurs = turbulent flow
why do murmurs occur?
valves too tight / not closing fully / hole in the wall
what does laminar flow mean
smooth flow
what does turbulent flow mean
rough flow
what is stenosis
stiffness / narrowing of the valve, FORWARD flow
what is regurgitation / insufficiency
valve unable to close fully, BACKWARD flow
types of systolic murmurs
early
mid
late
holosystolic
types of diastolic murmurs
early
late
what is a continuous murmur
throughout both systole and diastole
how many numbers on a murmur grading scale
1-6
1/6 murmur
quiet, heard if listening hard
2/6 murmur
quiet, heard immediately
3/6 murmur
loud, no thrill
4/6 murmur
loud, palpable thrill
5/6 murmur
very loud, palpable thrill, may hear it with stethoscope partially off chest
6/6 murmur
very loud, palpable thrill, may hear it with stethoscope entirely off chest
does bell listen for low-pitched or high-pitched heart sounds?
low-pitched
does diaphragm listen for low-pitched or high-pitched heart sounds?
high-pitched
are murmurs high-pitched or low-pitched
high-pitched, EXCEPT
diastolic murmurs (mitral stenosis, aortic regurg) are low-pitched
PMI stands for
point of maximal impulse
what do you feel at PMI
apex of the heart- where it’s closest to the anterior chest wall, feeling it contract at 1 beat per cycle
where is PMI located
5th left intercostal space, mid-clavicular line, 2-3 cm in diameter
pt positions to best feel PMI
-supine
-sitting slightly leaning forward
-left lateral recumbent
hand positioning to feel PMI
open right hand with MCPs of 2-5 fingers, then localize with finger pads
what are you concerned for if PMI is laterally displaced
cardiomegaly is one concern
grading of pulses
+0,1,2,3 / 3
normal pulse for age newborn - 2 years
100-180 bpm
normal pulse for age 2-10 years
60-140 bpm
normal pulse for age 10 - adult
60-99 bpm
documentation of cardiac exam for SOAP note
RRR. No murmurs, rubs, gallops. PMI is non-displaced. Carotid, radial, dorsalis pedis pulses equal 2+ b/l. No carotid bruit.
Capillary refill <2 seconds at fingertips b/l. No cyanosis, clubbing, LE edema b/l. JVP is 6 cm from right atrium.
do you use diaphragm or bell to listen to S1 and S2?
diaphragm, bc they are high-pitched
what is “physiologic splitting” of S2
slightly delayed closing of pulmonic valve, heard best during inspiration
where do you best hear a split S2? why?
2nd left intercostal space, pulmonic valve located here
which type of heart murmur is always considered pathologic?
diastolic
the 2 most common systolic murmurs related to heart valves
-aortic stenosis
-mitral regurgitation
normal aortic valve function vs aortic stenosis
normal aortic valve = opens as left ventricle closes to expel blood into peripheral circulation
stenotic aortic valve = restricts blood flow and causes murmur
what happens during mitral regurgitation
left ventricle contracts to expel blood to peripheral circulation across aortic valve -> but mitral valve cannot close -> blood moves backwards across mitral valve causing murmur
most common diastolic murmur related to heart valves
mitral stenosis
what disease most commonly causes mitral stenosis
rheumatic heart disease
