Examination of the Cardiovascular System

Question 1

Where is S1 the loudest, and why? When does splitting occur?

Answer 1

Loudest over mitral area -> LV apex, because S1 is caused by the closing of the AV valves at the beginning of systole.

No splitting should ever occur in S1

Question 2

What is S2 best heard and why? What time in the cardiac cycle does this correspond to?

Answer 2

Best heard at the left upper sternal border, since the pulmonic valve tends to have a quieter closing than aortic valve, so you listen it its area

Corresponds to the beginning of diastole (isovolumic relaxation)

Question 3

When is an aortic ejection click heard in the cardiac cycle? In what pathology is it typically heard?

Answer 3

Heard just after S1 -> just after beginning of systole.

Typically heard in bicuspid aortic valve -> will snap open aggressively

Ejection click will be lost with worsening calcification (cannot be ripped open so fiercely)

Best heard in right 2nd ICS (aortic area)

Question 4

What is the mitral stenosis opening sound and when is it heard? Where is it best heard?

Answer 4

Opening snap best heard at apex of heart

Occurs just after S2

Question 5

How do you tell a mitral stenosis opening snap apart from an S3?

Answer 5

Mitral stenosis - high-pitched, best heard with diaphragm

S3 - Low-pitched, best heard with bell

Question 6

What causes S3? When does it occur?

Answer 6

Like opening snap - early diastole

Due to sudden ventricular distension due to rigorous rapid filling

Question 7

When is S3 pathologic vs not pathologic?

Answer 7

Not pathologic in: Children and young adults, athletes

Pathologic: States w/increased filling pressures - Heart failure, mitral regurgitation, dilated ventricles

Question 8

What causes S4 and when is it pathologic vs not pathologic? When does it occur in the cardiac cycle?

Answer 8

Occur in late diastole when atrial contracts to push blood against a stiff ventricle

ALWAYS pathologic

Question 9

What can S4 be easily confused with and how do you tell them apart?

Answer 9

S4 - easily confused with aortic ejection click
S4 is best heard at apex of heart in left lateral decubitus position

Aortic ejection click is best heard in the aortic area

Question 10

When does physiologic splitting of S2 typically occur, and why?

Answer 10

Typically occurs during inspiration, because decreased intrathoracic pressure causes blood to fill lungs and right ventricle, increasing pulmonary pressures. This delays P2. Normal splitting has P2 later than A2.

Splitting often goes away during expiration, which LV filling is increased, and RV pressure is decreased, allowing A2/P2 to close at the same time.

Question 11

What is the first part of the cardiac exam? Why is this important?

Answer 11

Inspection of the jugular venous pulsations -> important because the jugular vein is a surrogate for right atrial pressure

Question 12

What are the three major jugular waves and what causes them? Which one is most liable to be absent?

Answer 12

These are transient rises in venous pressure seen as bulging
a wave = atrial contraction
c wave = carotid pulse pressing against vein / bulging of triscupid valve into atrium
v wave = venous return into left atrium peaking just before AV valves open during early diastole

C wave often absent, so it will just look like two pulses

Question 13

What causes the pressure to drop in the right atrium between the a/c and c/v waves?

Answer 13

This is called the x descent
-> due to contraction of ventricles and subsequent dilatation of the atria towards these ventricles, leading to a drop in pressure

Question 14

What is the value of the JVP at the sternal angle of Louis, and what is the best way to measure the JVP above this?

Answer 14

5cm at sternal angle

Measure the extra height of the venous blood column by putting the patient at 45 degree angle, and measuring the height of the JVP pulse above that, measured parallel to the ground

Question 15

Where do you measure the JVP?

Answer 15

Between the clavicular and sternal heads (posterior and anterior heads) of the SCM, and the clavicle.

This is the “jugular triangle” -> where you may be able to two pulsations per beat of the internal jugular vein.

Can also measure the JVP via the external jugular vein, which will be more lateral and over the SCM -> okay because they are contiguous.

Question 16

What does a large a wave indicate? When will the a wave disappear?

Answer 16

Large a wave -> Tricuspid stenosis -> blood backs up during atrial contraction

a wave disappears in atrial fibrillation -> no atrial contraction

Question 17

What can cause a large v wave?

Answer 17

Tricuspid regurgitation (extra venous pressure during systole)

Question 18

What should you be looking for when inspecting the precordium?

Answer 18

Scars (i.e. a past sternotomy for CABG), bulges (i.e. pacemakers, closer to axilla), abnormal pulsations (especially at apex)

Question 19

What does the pulse amplitude correlate with?

Answer 19

Pulse pressure -> the difference between diastolic and systolic

Will be elevated in aortic regurgitation (widened), and decreased in aortic stenosis (narrowed)

Question 20

A normal pulse upstroke is brisk. What does a slow upstroke indicate?

Answer 20

Aortic stenosis (crescendo-decrescendo murmur)

Question 21

What type of valvular problem is indicated via palpable thrills? Anything else? Where are they best felt?

Answer 21

Stenosis -> pulmonic or aortic. These are vibrations

Also small VSDs with turbulent flow

Best felt at left sternal border

Question 22

What is the normal point of maximal impulse (PMI)? What position should the patient be in? Give the following characteristics: Location, diameter, amplitude, duration.

Answer 22

Location: LV apex
Diameter: Quarter size
Amplitude: small, brisk
Duration: Brief

Question 23

What happens to the PMI in dilated cardiomyopathy?

Answer 23

It is displaced laterally and inferiorly, and the size is much larger -> silver dollar sized

Question 24

In what condition will the PMI have a longer duration?

Answer 24

LV hypertrophy

Question 25

What does a parasternal heave indicate?

Answer 25

Elevated RV pressure, usually due to pulmonary hypertension

Question 26

What do palpable aortic pulsations in the suprasternal notch of young thin adults and older adults indicate?

Answer 26

Young thin adults - normal

Older adults - ascending aortic aneurysm

Question 27

Where is aortic regurgitation best heard?

Answer 27

Left sternal border -> especially 3rd ICS

-> THIS IS COUNTERINTUITVE. Everything else is normal.

Question 28

What is the best way to hear S3/S4 and mitral murmurs?

Answer 28

With patient in left lateral decubitus position

Question 29

What is paradoxical splitting of S2 and why does it happen?

Answer 29

When S2 splits during expiration, happens due to conditions where A2 closes later than usual, as in aortic stenosis or left bundle branch block

Question 30

What is wide splitting and why does it happen?

Answer 30

Exaggerating normal splitting -> splitting heard on expiration and even more on inspiration

Happens due to conditions causing a delay in RV emptying, including pulmonic stenosis and right bundle branch block

Question 31

What is fixed splitting and why does it happen?

Answer 31

Closure of pulmonic valve is consistently delayed, with no regard for inspiration / expiration

Happens typically due to atrial septal defect causing a left to right shunt

Question 32

What causes a mid-systolic click and when is it best heard?

Answer 32

Sudden tensing of deformed, redundant mitral valve or triscupid valve (mitral or tricuspid prolapse)

Best heard in that valvular area (i.e. cardiac apex = mitral)

Question 33

What pathologies can an S4 be indicative of, and when is it always absent?

Answer 33

Conditions of a stiff left ventricle due to hypertrophy

1. Hypertension
2. Aortic stenosis

Absent: Atrial fibrillation

Question 34

How are murmur intensities graded?

Answer 34

Grade 1-3: Based on loudness. 1 is barely audible, 3 is loud

Grade 4+: Palpable thrill is associated

Question 35

What murmur is aortic stenosis associated with? Where does it radiate to? What should you listen with?

Answer 35

Mid-systolic murmur, often crescendo-decrescendo, with an ejection click. Heard best at aortic area.

Radiates to the carotids.

Listen with diaphragm -> high pressure

Question 36

What murmur is mitral valve prolapse with mitral regurgitation associated with? How and where is it best heard? Does it radiate?

Answer 36

Late systolic crescendo murmur following mid-systolic click

Heard best via the diaphragm at the apex (high pressure = high pitch)

Does not radiate

Question 37

What murmur is associated with chronic mitral regurgitation? Where is it best heard? Does it radiate?

Answer 37

Holosystolic, blowing murmur

Best heard at the apex, mediumpitched so audible no matter what.

Radiates to axilla

Question 38

What murmur is associated with aortic regurgitation? Where and how is it best heard? Does it radiate?

Answer 38

Decrescendo diastolic murmur (lessens as arterial pressure dissipates)

Best heard at 3rd LICS with diaphragm (high pressure) with patient leaning forward at end exhalation (patient has just exhaled and pushed all of his blood into LV, and it’s going to push backward after leaving aorta)

Does not radiate

Question 39

What murmur is associated with mitral stenosis? Where and how is it best heard? Does it radiate?

Answer 39

Low-pitched, diastolic rumble best heard at apex in LLDP

Associated with an opening snap best heard in same place, but with diaphragm (high pitch)

Question 40

What heart sounds can result from a VSD?

Answer 40

More exaggerated RV S3 due to left-right shunt, also flow rumble at left ventricular apex due to shunt.

Question 41

What pathology will cause a constant murmur throughout systole and diastole? When will it be loudest?

Answer 41

Patent ductus arteriosus, as blood rushes from aorta to pulmonary artery

Loudest around S2, which is end systole early diastole, when the pressure in the aorta is the highest. S2 will often be difficult to detect.

Question 42

What causes a pericardial rub and what are its three components? Best heard?

Answer 42

Friction caused by inflamed serosal surfaces rubbing together (pleural rubs may also occur)

All three occur when ventricles are very distended:

1. Late diastole - atrial contraction
2. Systole - ventricular contraction
3. Early diastole - isovolumic relaxation

Often only 1 or 2 components may be heard - best over left lateral sternal border

Question 43

What causes knocks and when do they occur? What is their frequency? Best heard?

Answer 43

High frequency, sharp diastolic sounds best heard at apex, occurring early in diastole (similar timing to S3)

Thus, they may confused with an opening snap
-> sudden tensing of pericardium during rapid filling, as in constrictive pericarditis

Question 44

What is a bruit and how is it best heard? What does it indicate?

Answer 44

Medium-high pitched murmurs over a blood vessel, best heard with diaphragm

Indicates turbulent blood flow due to vascular stenosis (i.e. femoral bruit)

Question 45

When are bruit typically loudest, and when might this not be the case?

Answer 45

Loudest during systole

Can be continuous if you have an AV communication (i.e. AV fistula) -> as in dialysis