CV Exam Lab OSCE Flashcards
General inspection of CV:
look for distress, bleeding, diaphoresis, pale, tachypneic, wheezing, LOC
peripheral (lips+fingers) or central (mucosa) cyanosis
peripheral edema
clubbing, tobacco stains
What should you inspect on the precordium (thorax in front of heart)?
shape of chest (pectus excavatum/carinatum, kyphosis, scoliosis) scars sternal heaves pulsations PMI
General palpation in CV:
Carotid A.: note thrills and pulse (amplitude, contour, rate, rhythm)
areas of tenderness or pain
What should you palpate on the precordium?
aortic, pulmonic, tricuspid area, mitral area
PMI for location, diameter, amplitude, duration (2/3 systole)
epigastrium(subxyphoid)- note any pulsations
note any heaves or thrills
What is the pulse grading scale?
0- absent, not palpable 1- diminished, barely palpable 2-expected 3-full, increased 4- bounding
Special pulses: normal carotid feeling? abnormal?
Feels like sharp knock;
abnormal is a weak nudge then slight pulsation or push
Special pulses: pulsus alternans feeling?
Alternating strong and weak pulses palpable at radial or femoral arteries
Special pulses: Water-hammer pulse feeling?
Due to large SV and backflow of blood from the aorta into LV
-palpate radial pulses while pt lies on exam table, applying pressure until pulse is obscured; raise arm straight over pts head perpendicular to table and palpate pulse for sudden rise and collapse of radial pulse that feels “jumpy”
What is a water-hammer pulse feeling indicative of?
aortic regurgitation
What can Paradoxical pulse be used to assess for?
pericarditis or tamponade (varied pulse strength and amplitude as pt breathes)
What does a positive Kussmaul’s sign indicate?
impaired venous return to the heart (when increase in JVP or no change on inspiration)
Explanation: normal JVP shows decline in inspiration but the a wave amplitude increases
in the left lateral decubitas position, a diffuse PMI with a diameter of >3 cm signals what? What does it mean if there is a diameter >4
> 3: left ventricular englargement
> 4: makes left ventricular overload almost 5x more likely
What is important to auscultate in CV exam?
Carotid arteries and precordium
carotid arteries for bruits
all areas previously palpated using diaphragm and bell
Note S1 + S2
murmurs
presence of S3, S4
pericardial rubs
compare to carotid pulse
Where are the points you should auscultate?
A- 2nd right IC space
P- 2nd left IC space
T-lower left sternal border (3-5th ICS)
M- 5th ICS, mid sternal line
Describe the sound of an Aortic Stenosis murmur:
harsh quality
right 2nd/3rd ICS
delayed pulses (pulsus tardus et parvus)
Describe the sound of a mitral regurg murmur:
blowing quality, holosystolic
prominent at apex, radiates to LEFT axilla
loudness correlates w/ degree of valve insufficiency
Describe the sound of a pulmonary stenosis murmur:
harsh, loud, ejection click
left 2nd/3rd ICS
radiates to left shoulder
increases with inspiration
Describe the sound of a tricuspid insufficiency murmur:
blowing quality, increases with inspiration
holosystolic
lower LEFT sternal border
What murmurs have blowing qualities to them?
mitral regurg, tricuspid insufficiency, aortic regurg, and pulmonary insufficiency
Describe the sound of an aortic regurg murmur:
blowing, decrescendo murmur
left 2nd ICS to 4th ICS
ausc. with diaphragm
Describe the sound of a mitral stenosis murmur:
rumbling, low pitched
best heard at apex
auscultate w/ bell
Describe the sound of a pulmonary insufficiency murmur:
blowing quality
Describe the sound of a tricuspid stenosis murmur:
increases in intensity w/ inspo, decreases in intensity with expo and valsalva
Which murmurs are systolic?
aortic stenosis
mitral regurg
pulmonary stenosis
tricuspid insufficiency
Which murmurs are diastolic?
aortic regurg
mitral stenosis
pulmonary insufficiency
tricuspid stenosis
Pneumonic for heart murmurs in diastole (lol might help):
ARMS + P(a)RTS
Aortic
Regurge
Mitral
Stenosis
Pulmonary
Regurge
Tricuspid
Stenosis
den all the others r systolic, flipped
remember: regurg= insufficiency
Not LO/but useful- what is left lateral decubitus and it allows increased chance of:
pt on left side w/ left arm above head, palpate PMI, auscultate for systolic murmurs
increase chance of hearing mitral stenosis and extra heart sounds
not LO/but useful-sitting and leaning fwd allows an increased chance of hearing:
aortic regurgitation
not LO/but useful-straining/valsalva allows an increased chance of hearing:
mitral regurg
not LO/but useful- what does valsalva differentiate?
bw aortic and mitral prolapse or hypertrophic cardiomyopathy
not LO/but could be useful- Abdominojugular reflex
also hepatojugular reflex; adjunct to measuring JVP
pt relaxes and breathes normally, apply firm pressure of 20-35 mmHg w/ palm of hand to mid-abdomen for 15-30 seconds; observe JVPwaveform before, during, and after compression
test = + = sustained increase in JVP >4 cm within 3-5 sec after pressure removed
not LO/but useful- does Valsalva increase or decrease murmur duration in HCM/MVP?
increase
not LO/but useful- what does Sitting and squatting do in a CV pt?
used to differentiate aortic stenosis and MVP, and hypertrophic cardiomyopathy
have pt stand–> squat (squatting increases venous return, PVR, SV, and blood pressure, while standing= opposite)
Auscultate during squatting and standing phases
Squat–> MVP and HCM delay in click, DECREASE in murmur intensity
How do you perform JVP estimation?
- Make the patient comfortable. Raise the head slightly on a pillow to relax the SCM muscles.
- Raise head of the bed to about 30°. Turn pt’s head slightly away from the side you are inspecting.
- Use tangential lighting and examine both sides of the neck. Identify the external jugular vein on each side, then find the internal jugular venous pulsations.
- If necessary, raise or lower the head of the bed until can see the oscillation point or meniscus of the internal jugular venous pulsations in the lower half of the neck.
- Focus on the R INTERNAL JUGULAR VEIN. Look for pulsations in the suprasternal notch, between the attachments of the SCM muscle on the sternum and clavicle, or just posterior to the SCM. Distinguish the pulsations of the internal jugular vein from those of the carotid artery.
- Identify HIGHEST POINT OF PULSATION in the right jugular vein. Extend a long rectangular object or card horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right angle. Measure the vertical distance in centimeters above the sternal angle where the horizontal object crosses the ruler and add to this distance 5 cm, the distance from the sternal angle to the center of the right atrium. The SUM is the JVP.
If you had a hypovolemic or septic pt, how would you modify measuring JVP?
they may have to lie flat before u see the neck veins
If you had a hypervolemic pt (vol overload), how would you modify measuring JVP?
you may need to elevate pt’s head to 60 or even 90 degrees to locate the oscillation point
What is an elevated JVP highly correlated with?
both acute and chronic HF
also seen in tricuspid stenosis, chronic pulm HTN, SVC obstruction, cardiac tamponade, and constrictive pericarditis
In patients with obstructive lung dz, JVP can appear:
elevated on expiration
veins collapse on inspo
DOES NOT INDICATE HF
An elevated JVP is 95% specific for an ___.
INCREASED LV end diastolic pressure and
LOW LV EF
not a clear predictor of hospitalization and death from HF tho
the last LO in this DSA is to review EKGs (simple ones)
cool
