Normal Heart and Cardiovascular Exam Flashcards
What is the five finger method?
History Physical ECG Imaging Lab
What symptoms indicate that you should do a cardiac exam?
fatigue, dyspnea, chest pain, palpitations, syncope - non specific
What may be listed in family history indicating that you should do a cardiac exam?
- hypertrophic cardiomyopathy
- Marfan’s syndrome
- prolonged QT syndrome
- CAD
In what order should a cardiac exam be done?
- inspection
- palpation
- percussion
- auscultation
- grading of murmurs
- JVP
What should you look for during inspection during a cardiac exam?
general appearance, chest shape, landmarks, scars and signs of trauma • Face – acromegalic, cushnoid, Down’s Syndrome, hyperthyroid, hypothyroid • Neck - JVD • Skin - jaundice, cyanosis, pallor • Body/chest wall shape • Breathing – fast or slow, labored or not • Extremities – Edema? – Nails – Clubbing? Hemorrhages? • Position of patient • Overall Appearance – Distress or not • Body Habitus • Hydration • Vitals – temperature, HR, RR, BP, pulse oximetry
What do you palpate for in a cardiac exam?
point of maximal intensity
What is Grave’s disease associated with for a cardiac exam?
tachycardia and palpitations
What are Osler’s nodes, Janeway lesions, and splinter hemorrhages indicative of?
Endocarditis
Pale skin indicates ___ hemoglobin. Pale conjuctiva indicates a hemoglobin of ____.
low;
8 or less
Cyanosis is a sign of ____
cystic fibrosis or congenital heart problem
What does clubbing indicate?
chronic hypoxia
What are the chest shapes?
- barrel chested
- pectus carinatum
- pectus excavatum
What do barrel chested people normally have?
COPD
What is the ratio of a normal chest?
1:2
What is the ratio for barrel chest?
1:1
increased AP diameter
What is pectus carinatum?
pigeon chest
central protrusion
What is pectus excavatum?
funnel chest
central depression
What is the midclavicular line important for?
pneumothorax thoracentesis at the 2nd rib on top (neurovascular bundle runs underneath)
Where do you put in a chest tube?
anterior axillary line 4-5th ICS
Where is the apex beat/PMI palpated when the pt is sitting?
mid clavicular line left 5th ICS 1 cm medial
Where is the apex beat/PMI when pt is supine?
supine at 45 degrees at 4-5th ICS at mid clavicular line
What are thrills?
turbulent blood flow causing murmurs. A murmur you feel.
When do you percuss in a cardiac exam?
when PMI is not detectable.
Start far left “resonance” and move medially to “dullness”
How do you check for bruits in the carotids?
have pt hold breath and place stethoscope over carotid
What does S1 mark?
Where is it loudest?
beginning of ventricular systole
mitral and tricuspid closure
loudest at apex
What does S2 mark?
Where is it loudest?
end of systole, beginning of diastole
aortic and pulmonic closure
loudest toward the base
Which valve closes first: tricuspid or mitral?
Mitral valve THEN tricuspid valve
Which valve closes first: aortic or pulmonary?
AORTIC then PULMONARY
What is physiologic splitting of S2?
occurs during inspiration because increased venous return during inspiration and more time for RV to deliver blood to the lung
What causes S3? What does it sound like? Who is it physiologic in? Pathologic?
due to high pressures and abrupt deceleration of inflow across the MITRAL valve at end of rapid filling phase
“ken-tuck-y”
physiologic: children/young adults
pathologic: >40 yo
What causes S4? What does it sound like? Who is it physiologic in? Pathologic?
atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle
“ten-nes-see”
normal in trained athletes
pathologic: everyone else
What side of the heart do jugular veins reflect?
right pressure indicating a “bad pump” = heart failure
What does the level of JVP visibility indicate?
CVP and RAP
Which is a better estimate: internal jugular or external jugular?
internal jugular (IJ)
How do you measure JVP? What is normal? What is the most common cause of elevated JVP?
Pt supine to allow veins to engorge, then raise to 30-45 degrees. Measure from RV to sternal notch + height from sternal notch.
Normal JVP is 0-9.
Most common cause of elevated JVP is elevated RV diastolic pressure.
What are the normal venous waves?
a, c, v
What are the normal venous descents?
x, y
What is the a wave?
atrium contracting and tricuspid valve open
What is the x descent?
atrium relaxing then filling, tricuspid closed
What is the v wave?
atrium tense, full; tricuspid closed
What is the y descent?
atrium emptying, tricuspid open
What are the differences between veins and arteries?
veins: diffuse, biphasic, varies with position, height falls on inspiration, non-palpable, can be occluded
arteries: single, sharp waveform, no variation with position, no respiration variation, palpable not compressible
What causes increased JVP/JVD?
- SVC obstruction
- severe heart failure
- constrictive pericarditis
- cardiac tamponade
- RV infarction
- restrictive cardiomyopathy
What causes hepatojugular reflux (HJR)? pushing on liver and JVD elevates. stays elevated when released.
- poorly compliant RV, RV failure
- constrictive pericarditis
- obstructive RV filling by TS or RA tumor
Documenting pulses:
0 absent
2 average
4 bounding
What is normal capillary refill time?
<2s
Where do you check for edema?
dorsum of foot, behind medial malleolus, anterior tibia
How do you grade 2 mm edema non pitting?
1+
What is 2+ edema?
4 mm 10-15 seconds
What is 3+ edema?
6 mm >1 min
What is 4+ edema?
very marked indention 8 mm 2-5 min
What is normal right atrial pressure (RAP)?
0-8 mm Hg
What is normal right ventricle pressure (RV)?
25/6 mm Hg
What is normal pulmonary artery pressure (PAP)?
systolic 15-30 mm Hg
diastolic 5-12 mm Hg
mean 10-20 mm Hg
What is the normal pulmonary capillary wedge pressure?
8-15 mm Hg
What is normal cardiac output?
3.5-7 liters/min
What is normal cardiac index (CI)?
2.5-4 liter/min^2
What is normal systolic vascular resistance (SVR)?
900-1500 dynes/s/cm
What is normal pulmonary vascular resistance (PVR)?
155-255 dynes/s/cm
