Normal Heart & CV Exam

Question 1

What are the 4 Steps to a CV Exam?

Answer 1

1. Inspection
   - General appearance
   - Chest shape, landmarks, scars/signs trauma
2. Palpation
   - Point of maximal intensity
3. Percussion
   - Estimating cardiac size
4. Auscultation
   - Listening posts, heart sounds, murmurs

Question 2

How does the AP Diameter change in an individual with a Barrel Chest?

Answer 2

AP Diameter is INCREASED compared to Lateral Diameter

2:1 AP:Lateral

Question 3

What is the difference between Pectus Carinatum and Pectus Excavatum?

Answer 3

Pectus Carinatum (Pigeon Chest)

• Central protrusion
• Higher instance of asthma, respiratory issues, and palpations

Pectus Excavatum (Funnel Chest)
- Central depression

Question 4

What is PMI?

Where do you measure PMI?

Answer 4

PMI is the Point of Maximal Impulse (also called Apical Impulse).

Measure at 4th-5th Intercostal Space about 1 cm medial to mid-clavicular line (MCL)

Palpation indicates TURBULENCE at PMI.

Question 5

How do you estimate cardiac size when PMI is not detectable?

Answer 5

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

Question 6

When do systolic and diastolic murmurs occur in relation to S1 & S2?

Answer 6

Systolic Murmurs - Between S1 & S2

Diastolic Murmurs - Between S2 & S 1

Question 7

When palpating the carotid arteries, what three items are assessed?

Which side of the stethoscope is used for auscultating the carotid arteries?

Answer 7

Assess: Rate, rhythm, and amplitude

Use the BELL side of the stethoscope.

Question 8

Which side of the heart if reflected in Jugular Venous Pressure? Which jugular vein is a better indicator?

Answer 8

Right side of the heart is reflected in Jugular Venous Pressure.

Internal Jugular Vein is a better estimate.

Question 9

What is the procedure for measuring Jugular Venous Pressure (JVP)?

What is a normal JVP?

What is most common cause of elevated JVP?

Answer 9

1. Patient supine then raise 30-45 degrees.
2. Place ruler at Angle of Louis and measure to Internal Jugular Vein. Add 5 cm to the total, which accounts for distance to right side of heart.

Normal JVP = 0-9

Elevated JVP - Due to Elevated Right ventricular diastolic pressure.

Question 10

What are the 4 causes of Increased JVD/JVP?

Answer 10

• SVC Obstruction
• Severe heart failure
• Constrictive pericarditis
• Restrictive Cardiomyopathy

Question 11

How do you assess the Hepatojugular Reflex?

Answer 11

1. Place the patient supine at a 30-45 degree angle.
2. Apply steady pressure for 30 seconds to the hepatic region.
3. May see neck veins engorge.

Question 12

What are the 3 causes of Hepatojugular Reflex (HJR)?

Answer 12

1. Poorly compliant RV, RV failure.
2. Constrictive pericarditis.
3. Obstructive RV filling by TS or RA tumor.

Question 13

How do you assess capillary refill time?

Answer 13

1. Place patient hands at heart level, fingers pointing up.
2. Press on nail bed till it turns pale then let go.
3. Normal refill time < 2 seconds.
4. Also check skin color and turgor if possible.

Question 14

Where are the 3 locations for assessing edema?

What is the grading for edema?

Answer 14

3 Locations:

• Dorsum of foot
• Behind Medial Malleolus
• Anterior Tibia (Shin)

Grading
0    Absent
1+  Barley detectable, non-pitting (2mm)
2+  Slight indentation (4mm) (10-15 sec)
3+  Deeper indentation (6mm) (> 1 min)
4+  Very marked indentation (8mm) (2-5 min)

Question 15

Which heart sounds are considered “high pitched”?

Which side of the stethoscope is utilized?

Answer 15

High pitched sounds
- S1, S2, AR, and MR

DIAPHRAGM IS USED!

Question 16

Which heart sounds are “low pitched”?

Which side of the stethoscope is utilized?

Answer 16

Low pitched sounds
- S3, S4, MS, and carotid bruit

USE THE BELL!

Question 17

Which murmurs fall between S1 & S2?

Answer 17

Systolic Murmurs

• Aortic Stenosis
• Pulmonic Stenosis
• Mitral Regurgitation
• Tricuspid Regurgitation

Question 18

Which murmurs fall between S2 & S1?

Answer 18

Diastolic murmurs:

• Aortic Regurgitation
• Pulmonic Regurgitation
• Mitral Stenosis
• Tricuspid Stenosis

Question 19

In what percent of the healthy population is the Dorsalis Pedis pulse absent?

Answer 19

10-12%

Note: If the patient’s lower extremity is intact, and you can only find the dorsalis pedis or posterior tibial — no need to worry! :-)

Question 20

What is the Allen Test?

Answer 20

Allen Test
- Evaluates functioning of radial and ulnar arteries.

Process: Occlude both arteries while patient makes a fist. Patient opens and closes fist. Palm should be pale.

Release pressure on ulnar artery and observe for color to return within 5-10 seconds.

Repeat with radial artery.

Indication: Lack of dual blood supply to the hand.