Normal Heart and CV Exam Flashcards
5 finger method
1) history
2) physical
3) eck
4) Xray
5) lab tests
Physical
- inspection
- JVP
- precordial palpation
- percussion
- auscultation-heart sounds
- grading system of murmurs
- ecg
- x rays
- lab tests
Proper physical exam sequence
1) inspection
2) palpation
3) percussion
4) auscultation
- quiet rooms
- listen on bare skin
- sitting, supine, left lateral decubitus, leaning forward, standing
S1
- mitral and tricuspid closure
- beginning of ventricular systole
S2
- aortic and pulmonic closure
- marks end of systole, beginning of diastolic
Palpation and Percussion
- point of max impulse: 4th and 5th intercostal space at mid clavicular line
- estimate cardiac size when PMI not detectable
- start far left and move medial to find cardiac dullness
JVP
- reflects activity of right side of the heart
- level of JVP visibility gives an indication of the right atrial pressure
- internal jugular is better than external jugular
- normal JVP: 0-9cm
- most common cause of an elevated JVP is an elevated right ventricle diastolic pressure
A Wave
- right atrial contraction
- tricuspid open
- coincides with S1
- precedes carotid pulsation
- giant wave seen in: obstruction between RA and RV, increased pressure in RV, pulmonary hypertension, recurrent pulmonary emboli, A-V dissociation (complete heart block)
C Wave
-backward push by closure of tricuspid during isovolumetric systole and by impact of carotid artery adjacent to the jugular vein
X wave
- passive atrial filling and atrial relaxation
- blood flows into the right atrium from the cava and closure of tricuspid
- steep X descent in cardiac tamponade and constrictive pericarditis
V wave
- atrial filling
- increasing volume and pressure in RA when tricuspid is closed
- prominent V wave in TR and pulm hypertension
Y slope
- open tricuspid and rapid right ventricle filling
- deep Y in severe TR a slow Y descent suggests obstruction to RV filling
Increased JVP
- SVC obstruction
- severe heart failure
- constrictive pericarditis
- cardiac tamponade
- RV infarction
- restrictive cariomyopathy
Positive HJR (hepatojugular reflux)
- poorly compliant RV (RV failure)
- constrictive pericarditis
- obstructive RV filling by TS or RA tumor
Systole
ventricular contraction, ejection
Diastole
ventricular relaxation, filling
Normal Heart Sounds
S1- closing of mitral and tricuspid valves
S2- closing of aortic and pulmonary valves
Abnormal Heart Sounds
S3- due to high pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling stage (physiologic in children and young adults; pathologic in adults >40)
S4- atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle (can be normal in trained athletes)
S1
- mitral closure 1st component
- tricuspid closure 2nd component
- beginning of systole
- loudest at apex
S2
- aortic valve closure 1st component
- pulmonic valve closure 2nd component
- loudest at the base
- end of systole
Normal inspiration and expiration
Expiration = single sound for S1 and S2 Inspiration = splitting of S2 (increased venous return during inspiration and more time for RV to deliver blood to the lung)
Heart Sound Locations
Mitral- apex of heart; 5th left intercostal space at mid clavicular line
Tricuspid- 4th left intercostal space
Aortic valve- 2nd intercostal space to the right of the sternum
Pulmonary valve- 2nd intercostal space left of the sternum
Auscultation Listening Posts
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
Murmur grading scale
1- barely audible
2- soft, but easily heard
3- loud, without a thrill
4- loud with a thrill
5- loud with minimal contact between stethoscope and chest
6- loud, can be heard without a stethoscope
Documenting Pulse
0 = absent 1 = barely palpable 2 = average 3 = strong 4 = bounding
R/R/A = rate, rhythm, amplitude
Edema
- dorsum of foot
- behind medial malleolus
- anterior tibia
Edema grading scale
0 absent
1+ barely detectable, nonpitting (2mm)
2+ slight indentation (4mm); 10-15 seconds
3+ deeper indentation (6mm); can be >1 minute
4+ very marked indentation (8mm); 2-5 min
Right Atrial Pressure
0-8 mmHg
RV pressure
25/6 mmHg
Pulmonary Artery Pressure
Syst 15-30 mmHg
Diastolic 5-12 mmHg
Mean 10-20 mmHg
Pulm Capillary Wedge pressure
8-15 mmHg
Cardiac Output
3.5-7 liters/min
Cardiac index (CO/BSA)
2.5-4 liters/min^2
Systolic Vascular Resistance (SVR)
900-1500 dynes/sec/cm
Pulm Vascular Resistance (PVR)
155-255 dynes/sec/cm
