Lab Refresher: Normal Cardiac/Vascular exam

Question 1

When do you use the Diaphragm vs. Bell, what does each help you listen to?

Answer 1

Diaphragm - high pitched sounds (S1, S2, AR, MR, Friction Rubs)

Bell - low pitched (S3, S4, MS, carotid bruit)

Question 2

A central protrusion of pt’s chest indicates what; while a central depression indicates?

Answer 2

Protrusion - Pectus carinatum

Depression - Pectus excavatum

Question 3

What are thrills?

Answer 3

Turbulent blood flow causing murmurs (humming vibrations)

Question 4

Point of maximal impulse (PMI) is usually palpated where, position of the patient can be?

Answer 4

• Near 4th-5th intercostal space in MCL

- Supine or left lateral decubitus

Question 5

When percussing for estimation of heart size what is proper procedure?

Answer 5

Start far left (resonance) and move medially to find cardiac dullness

Question 6

Criteria (size) when palpating for impulse?

Answer 6

Small, brisk beat measuring less than 2.5 cm, should last the first 2/3 of systolic period (or less).

Question 7

Where is Erb’s point listening post and what is heard there?

Answer 7

L 3rd ICS at SB; point at which S1 and S2 heard equally

Question 8

What is an S3 sound?

Answer 8

• Dull, low pitch (heard w/ bell)

- Due to high pressures and abrupt deceleration of inflow across the mitral valve at the end of rapid filling phase

Question 9

When is S3 normal and abnromal, what does it sound like (name that state!)?

Answer 9

• Normal in children/young adults
• Pathologic >40 y/o

(Kent-Tuck-Y)

Question 10

What is the S4 sound?

Answer 10

• Dull, low pitch (heard w/ bell)

- Atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle

Question 11

When is an S4 normal and what is the sound (state)?

Answer 11

Normal in trained athletes (Ten-Nes-See)

Question 12

Jugular veins reflect the activity of which side of the heart, indicates which pressure?

Answer 12

Right side - gives indication of the RAP

Question 13

Most common cause of an elevated JVP?

Answer 13

Elevated RV diastolic pressue

Question 14

Systolic murmurs are heard between?

Answer 14

S1 and S2

Question 15

Systolic murmurs may indicate which pathologies?

Answer 15

• Aortic stenosis
• Pulmonic stenosis
• Mitral regurgitation
• Tricuspid regurgitation

Question 16

Diastolic murmurs are heard between?

Answer 16

S2 and S1

Question 17

Diastolic murmurs may indicate which pathologies?

Answer 17

• Aortic regurgitation
• Pulmonic regurgitation
• Mitral stenosis
• Tricuspid stenosis

Question 18

How is JVP measured and what is normal?

Answer 18

• Pt placed supine to allow veins to engorge, then raise to 30-45 degrees

Normal: 0-9

Question 19

Where is carotid pulse felt, and how do you assess both?

Answer 19

• Medial to the SCM

- Only assess ONE AT A TIME!!!

Question 20

How are pulses graded?

Answer 20

4+ Bounding
3+ Strong, full, increases
2+ Normal, average intensity
1+ Diminished, barely palpable
0 Absent, not palpable

Question 21

What is the normal capillary refill time?

Answer 21

2 seconds or less

Question 22

Examining for pitting edema is done by pressing firmly for 5 seconds in which 3 locations?

Answer 22

1) Dorsum of foot
2) Anterior tibia
3) Behind medial malleolus

Question 23

What is the 4 point grading for edema?

Answer 23

• Absent
• 1+ Barely detectable, slight pitting (2mm); disappears rapidly

2+ Slight indentation (4mm); 10-15 secs

3+ Deeper indentation (6mm); may be >1 min

4+ Very marked indentation (8mm); 2-5 minutes

Question 24

Increased JVP in?

Answer 24

• SVC obstruction
• Severe heart failure
• Constrictive pericarditis, cardiac tamponade, RV infarction
• Restrictive cardiomyopathy

Question 25

What is the normal ejection fraction %?

Answer 25

50-60%

Question 26

Steps to CV exam in order

Answer 26

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Question 27

When palpating PMI what are the normal characteristics that should be felt and should last how long?

Answer 27

• Small, brisk beat and measure <2.5 cm

- Should last the first 2/3 of systolic period (or less)