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X Physical Diagnosis > L5 Cardiovascular Exam > Flashcards

L5 Cardiovascular Exam Flashcards

1
Q

Where should you stand for the cardiovascular exam?

A

On their right side

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2
Q

Precordium

A

Anterior chest wall overlying the heart

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3
Q

Point of maximal impulse

A

Apical impulse, location where the cardiac impulse can be best palpated on the chest wall

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4
Q

What do you use the bell for?

A

Low pitched sounds of S3 and S4, apply light pressure (just enough to make seal against chest wall)

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5
Q

What do you use the diaphragm for?

A

High pitched sounds of S1 and S2, apply firm pressure against chest wall

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6
Q

4 routine areas of cardiac auscultation (what are the others that might be needed)

A

Aortic, pulmonic, tricuspid, mitral (apex

Second pulmonic or you can also “inch” the stethoscope along

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7
Q

Aortic auscultation

A

2nd ICS, RSB (on one side of angle of Louis)

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8
Q

Pulmonic auscultation

A

2nd ICS, LSB (on one side of angle of louis)

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9
Q

Tricuspid auscultation

A

4th and 5th ICS, LSB

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10
Q

Mitral auscultation

A

5th ICS, MCL (apex)

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11
Q

Second pulmonic ausculation

A

As needed, 3rd ICS, LSB

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12
Q

Normal heart rate range

A

60-100 bpm

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13
Q

First heart sound (S1)

A

SYSTOLE: closure of mitral and tricuspid valves and contraction of the ventricles (aortic and pulmonic valves forced open to eject blood into arteries)
“LUB”

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14
Q

Where is S1 best heard?

A

At the apex

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15
Q

When would there be an accentuated/louder S1?

A

Diseased AV valve or more forceful closure of AV valve

Ex: tachycardia, fever, HTN, exercise, anemia, hyperthyroidism, mitral stenosis

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16
Q

When would there be a diminished/softer S1?

A

Weak contraction of the heart of reduced sound transmission (from thick chest wall or emphysematous lungs)

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17
Q

Second heart sound (S2)

A

DIASTOLE: closure of the aortic and pulmonic valves, relaxation of the heart and atrial contraction (mitral and tricuspid valves open allowing ventricles to refill passively)

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18
Q

Where is S2 best heard?

A

At the base

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19
Q

When do the coronary arteries fill?

A

Diastole

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20
Q

Which heart sound is longer?

A

Diastole is slightly longer

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21
Q

A2 vs P2

A

Right sided pressures are lowering than corresponding pressures on the left side so sounds occur slightly later on the right than the left
A2: aortic valve tends to close first
P2: pulmonary valve is a little after

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22
Q

What causes a wide split of S2?

A

Delayed closure of the pulmonic valve

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23
Q

What is a fixed split of S2?

A

Tends to be wide and fixed and it does not vary between inspiration and expiration

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24
Q

What is a paradoxical split of S2?

A

Split is present during expiration and gone during inspiration
Occurs when there is a delay in the contraction of the left ventricle due to a left bundle branch block causing A2 after P2

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25
Q

What pathologies cause a wide split in S2?

A

Pulmonic stenosis, mitral regurgitation (leak) or right bundle branch block

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26
Q

What pathologies cause a fixed split in S2?

A

Atrial septal defect or right ventricular failure

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27
Q

What pathologies cause a paradoxical split in S2?

A

Left bundle branch block

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28
Q

Third heart sound (S3)

A

Low-pitched sound created in early diastole by passive, rapid filling of ventricles (produced by blood filling a chamber that is already volume overloaded that causes rapid distension of ventricular wall leading to VIBRATION)
*ventricular gallop (KEN TUCK Y)

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29
Q

Where is S3 best heard?

A

At the apex with the bell

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30
Q

Who might have an S3?

A

Children, healthy young adults or pregnant women

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31
Q

When is an S3/S4 usually pathologic?

A

When the patient is over 40

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32
Q

What might cause a pathologic S3?

A

Heart failure, anemia, volume overload of ventricle, decreased myocardial contractility

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33
Q

Fourth heart sound (S4)

A

Low-pitched sound created by second phase of ventricular filling in diastole as atria contract and eject blood intro ventricle (rush of blood causes vibration of valves, papillary muscles and ventricular walls)
*atrial gallop (TENESS EE)

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34
Q

Where is S4 best heard?

A

At the apex with the bell

35
Q

Who might normally have an S4?

A

Trained athletes and some older individuals

36
Q

What might cause a pathologic S4?

A

HTN, CAD, aortic stenosis, cardiomyopathy

*right-sided S4 from pulmonary HTN or pulmonary stenosis

37
Q

What causes a murmur?

A

Sound made by blood rushing through a narrowed valve, leaking valve or wall between chambers of the heart
*can be systolic or diastolic

38
Q

Gradations of murmurs

A

1/6: barely audible in quiet room
2/6: quiet, but clearly audible
3/6: moderately loud
4/6: loud, associated with thrill
5/6: very loud, heard with stethoscope partially off chest, obvious thrill
6/6: very loud, hear with stethoscope entirely off chest, obvious thrill

39
Q

Systolic ejection murmur

A

Usually crescendo-decrescendo

Usually due to blood flow across semilunar valves

40
Q

Pansystolic (holosystolic) murmur

A 
Usually plateau (continuous and not change over systole)
Usually regurgitation across AV valves or ventricular septal defect
41
Q

Late systolic murmur

A

Delay between S1 and hearing the murmur

Typical of mitral prolapse

42
Q

What can aortic/pulmonic stenosis cause?

A

Systolic ejection murmur due to narrowed valve (congential or calcific disease process)
From high pressure to high pressure (so narrowing of the valve slows the force of it trying to come into the high pressure)

43
Q

Where do you listen for a systolic ejection murmur?

A

At the base along right and left sternal borders

44
Q

Description of crescendo-descrescendo systolic murmur

A

From left ventricle blood goes through the valve and the murmur gets louder
Aortic pressure increases as blood enters which creates resistance so the murmur softens due to reduced blood flow
Similar principles in pulmonic system but pressure is not as great

45
Q

Characteristics of innocent systolic murmur

A

Common in kids/young adults
Physiologic in pregnancy, anemia, fever, hyperthyroidism
Features: grade <2 intensity, softer when sitting vs supine, short systolic duration, minimal radiation, musical/vibratory quality

46
Q

Atrial septal defect

A

Congenital anomaly that results in left to right shunt of blood to right atrium with RV enlargement and increased flow through pulmonic valce
Hear systolic ejection murmur
Fixed splitting of S2

47
Q

Mitral/tricuspid regurgitation

A

Causes pansystolic (holosystolic) murmur
Continuous leakage of blood from LV to LA (or RV to RA)
From high to low pressure so plateau
*Mitral can be due to rheumatic heart disease

48
Q

Ventricular septal defect

A

Causes pansystolic (holosystolic) murmur
Left to right shunt (LV to RV), harsh or blowing systolic murmur at lower left sternal border
Usually associated with thrill

49
Q

Types of diastolic murmurs

A

Early, mid or late diastolic (presystolic)

50
Q

Early diastolic murmur

A

Usually decrescendo from regurgitant flow across leaking semilunar valve

51
Q

Mid diastolic murmur

A

From turbulent flow across AV valves

52
Q

Late diastolic murmur

A

Usually continues up to S1, usually decrescendo

53
Q

Aortic regurgitation

A

Causes early diastolic murmur from a leaking aortic valve

54
Q

Mitral/tricuspid stenosis

A

Causes mid diastolic murmur due to a narrowed valve

Mitral: “opening snap and diastolic rumble,” narrowed valve obstructs flow from LA to LV

55
Q

Systolic-diastolic murmur

A

Due to aortic stenosis with aortic regurgitation
Obstruction to outflow due to narrowed valve AND failure of complete closure of aortic valve during diastole with leakage of blood back into left ventricle
Crescendo-decrescendo murmur

56
Q

Continuous murmur

A

Patent ductus arteriosus (failure of channel between aorta and pulmonary artery to close after birth)

57
Q

“To-and-fro” murmur

A

What systolic/diastolic murmurs are called (severe aortic regurgitation, aortic stenosis/regurgitation)

58
Q

Positions to enhance murmurs

A

Leaning forward or left lateral decubitus position

59
Q

Altering hemodynamics to enhance murmurs

A

Alters preload/afterload, squatting, valsalva, isometric exercise

60
Q

What is the specialized exam of having the patient lean forward doing?

A

Best for hearing soft murmurs at the base (aortic/pulmonic regurgitation)

61
Q

Standing or strain phase of valsalva

A

Causes decreased left ventricular volume from decreased venous return to the heart
Decreased vascular tone, BP and peripheral vascular resistance
Most murmurs decrease in intensity except HCM

62
Q

Squatting (or release phase or valsalva)

A

Causes increased left ventricular volume from increased venous return to heart
Increases vascular tone, BP and peripheral vascular resistance

63
Q

Ejection sounds

A

Aortic or pulmonic ejection click

High-pitched, indicates valve disease or dilated aorta or pulmonary artery or pulmonary hypertension

64
Q

How is ejection sound heard best?

A

Diaphragm of stethoscope

65
Q

Systolic click

A

Indicates mitral valve prolapse, which is ballooning of mitral leaflets into the left atrium during systole
Mid-late click is often present
Variable pitch
Mitral regurgitation may also occur with late systolic murmur

66
Q

Venous hum

A

Turbulent blood flow through jugular veins, both systolic and diastolic sounds, common in kids

67
Q

Pericardial friction rub

A 
Inflammation of pericardial sac
3 component (triphasic) sound
Scratchy/squeaky, intermittent
68
Q

Where do you want the head of the bed during the supine exam?

A

Elevated 30 degrees

69
Q

Jugular venous pressure

A

Indication of pressure in the right atrium (central venous pressure), related to intravascular fluid volume

70
Q

What does jugular venous pressure reflect?

A

Right heart function

71
Q

What is the dominant movement of the pulsations of the internal jugular vein?

A

Inward (carotid is outward)

72
Q

Differences between internal jugular and carotid pulsations related to:

  • Being palpable
  • Quality
  • Elimination
  • Height
  • Inspiration effect
A

Jugular-rarely palpable, soft biphasic undulating quality usually with 2 elevations and characteristic inward deflection, eliminated with light pressure on veins above sternal end of clavicle, height of pulsations usually drops as patient becomes more upright, height usually falls with inspiration
Carotid- palpable, vigorous thrust with single outward component, pulsations not eliminated with pressure, height unchanged with position of inspiration

73
Q

Reasons for elevated JVP

A

Heart failure, pulmonary HTN, increased vascular tone, pericardial tamponade

74
Q

Reasons for decreased JVP

A

Blood loss, hypovolemia, decreased venous vascular tone

75
Q

What does hepatojugular (abdominojugular) reflux test for?

A

Observe for increase in JVP followed by decrease as hand is released from abdomen (exaggerated in right heart failure)

76
Q

Thrill

A

Buzzing or vibratory sensation, may be caused by vigorous blood flow through any narrowed opening
When present, auscultate area for murmur

77
Q

Lifts or heaves

A

Vigorous cardiac impulse that can be seen/felt through chest wall, usually palpable
Can be caused by ventricular hypertrophy or hyperdynamic ventricular activity

78
Q

3 places of palpation at LSB and base

A

Base, over sternum, over apex

79
Q

What is best to hear in left lateral decubitus position?

A

Low-pitched filling sounds like gallops (S3, S4) or murmurs (mitral stenosis)

80
Q

When is bisferiens pulse seen?

A

Aortic regurgitation

81
Q

When do you see bigeminal pulse?

A

Conduction disorders

82
Q

Bruit

A

Murmur like sound arising from turbulent arterial blood flow

83
Q

Where is pitting edema mostly seen?

A

Over dorsum of each foot, behind each medial malleolus, over shins

84
Q

Homan sign

A

Calf pain on passive dorsiflexion of foot, unreliable for presence of DVT

X Physical Diagnosis (3 decks)

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