Normal Heart and Cardiovascular Exam

Question 1

THe five finger model to a normal heart exam

Answer 1

• History
• Physical
• ECG
• X-Ray
• Lab Tests

Question 2

What part of the history is critical in obtaining information about a persons heart isssues

Answer 2

The Family History

• Familial clustering is common in patients with certain heart diseases
• Hypertrophic cardiomyopathy
• Marfans syndrome
• Prolonged QT syndrome

Question 3

What are the principles of the Physical exam

Answer 3

Look: Inspection
Feel: Palpation
Tapping: Percussion
Listen: Auscultation

Question 4

what is significant if the patient appears to have clubbing of the nails?

Answer 4

Possible Interstitial Lung disease

-or congenital heart disease

Question 5

What are 3 possible Chest shapes?

Answer 5

Barrel Chest - Think COPD
-increased A-P diameter

Pectus Carinatum (pigeon chest
-central protrusion

Pectus Excavatum (funnel chest)

• Central Depression
• can have some exertional dyspnea

Question 6

where is the Apex of the heart Located?

Answer 6

5th intercostal space, left, 1 cm Medial to the Mid clavicular line

Question 7

When is the S1 sound heard

Answer 7

“Lub”

• Mitral and tricuspid closure
• Beginning of systole
• Loudest at apex

Question 8

when is S2 sound heard

Answer 8

“Dub”

• Aortic and Pulmonic closure
• Marks end of systole and beginning of diastole
• loudest at the base

can be split into a A and P sound during inspiration because of increased venous return during inspiration and more time for the RV to deliver blood to the lung

will hear A then P

Question 9

what are thrills?

Answer 9

Turbulent blood flow causing murmurs

Question 10

where is the point of Maximal Impulse and if you cant find it, what is a strategy to find it?

Answer 10

when patient is supine, or left lateral decubitus
-4th-5th intercostal space at the mid clavicular line

If cant find it, percuss from the fafr left and will heal resonance from the lungs until get to dull sound which is the heart

Question 11

what does the Jugular Venous pulse reflect? and what is a normal JVP

Answer 11

Jugular veins reflect the activity of the right side of the heart

Level of the JVP visibility gives an indication of the RAP

-Internal Jugular vein is a better indicator of RAP than the external Jugular vein

Normal JVP is 0-9

Question 12

what is the most common cause of an elevated JVP?

Answer 12

is an elevated RV diastolic pressure

tend to come with a tricuspid regurgitation and increase the V wave

Question 13

what is the a wave? and what are some causes of a giant a wave?

Answer 13

Right atrial contraction with Tricuspid valve open. Coincides with S1, preceds carotid pulsation

Giant a wave seen in:

• Obstruction between RA and RV
• Increased pressure in RV
• Pulmonary hypertension
• Recurrent pulmonary emboli
• A-V dissociation (complete heart block, V.T.) cannon a waves. RA contracts against closed Tricuspid valve

Question 14

what is the c wave?

Answer 14

Backward push by closure of TV during isovolumetric systole and by impact of carotid artery adjacent to the JV

Question 15

what is the X wave/slope? and what does it mean if their is a steep X descent?

Answer 15

• Passive atrial filling and atrial relaxation. blood flows into the RA from the cava and closure of Tricuspid valve
• Steep X descent in cardiac tamponade and constructive pericarditis

Question 16

what is the V wave? and when is it prominent

Answer 16

Atrial filling
-Increasing volume and pressure in RA when tricuspid valve is closed

-prominent V wave in Tricuspid regurgitation

Question 17

what is the Y slope or Y descent? and when is it deep or slow?

Answer 17

• Open tricuspid valve and rapid Right ventricle filling in Right ventricle diastole
• Deep Y descent in severe tricuspid regurgitation
• A slow Y descent suggests obstruction to RV filling

Question 18

when do we see an increase in JVP?

Answer 18

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

Question 19

when do we see a positive HJR

Answer 19

Hepatojugular reflex

• Poorly compliant RV, RV failure
• Constructive pericarditis
• Obstructive RV filling by TS or RA tumor

Question 20

What does an abnormal S3 mean? and what does it sound like?

Answer 20

Due to high pressure and abrubt deceeleration of inflow across the mitral valve at the end of the rapid filling phase

physiologic in children and young adults, pathologic in greater than 40 years old

“ken-tuck-Y

After S2

Question 21

what does an abnormal s4 mean? and what does it sound like?

Answer 21

Atrial gallop form forceful contraction of atria against a stiffened (low compiant) ventricle. can be normal in trained athletes

Ten - Nes - See

before S1

Question 22

what are the listening post locations to best hear each valve

Answer 22

Aortic: right 2nd intercostal space at sternal border

Pulmonary: Left 2nd intercostal space at sternal border

Tricuspid: Left 4th intercostal space at sternal border

Mitral: Left 5th intercostal space at mid-clavicular line

Question 23

Murmurs grading system

Answer 23

1 = Barely audible
2= Soft, but easily heard
3= Loud, without a thrill
4= Loud with a thrill
5= Loud with a minimal contact between stethoscope and chest thrill
6= Loud, can be heard without a stethoscope thrill

Question 24

Edema testing and scale

Answer 24

Dorsum of foot
Behind M malleolus
Anterior tibia

Bilateral = Heart, kidney, lung issue
unilateral: issue on that side

0 = absent
1 = barely detectable, nonpitting (2mm)
2= slight indentation (4mm); 10-15 sec
3= Deeper indentation (6mm); can be >1min
4= Very marked indentation (8mm); 2-5 min