Physical exam: CV exam Flashcards
1
Q
CV exam: Learning objectives
A
- Assess JVP and pulsation
- Assess the carotid upstroke
- Palpate heaves, lifts, thrills, and the PMI
- Auscultate heart sounds and murmurs in six positions on the chest using diaphragm and bell
- Identify S1 and S2
- Distinguish systole from diastole
- Identify extra sounds such as S3 and S4
- Correctly identify valvular murmurs
2
Q
Correlate observations with the patient’s cardiac findings and:
A
- Blood pressure
- Arterial pulses
- Venous pulsations
- Jugular venous pressure
- Remainder of physical examination
- Patient’s history
3
Q
Jugular venous pressure (JVP): Definition
A
- Measurement of the highest oscillation point (“meniscus”) of the jugular venous pulsations
- Reflects pressure in the right atrium (central venous pressure), volume status, and cardiac function
- Abnormal: 3-4 cm above sternal angle (head at 30-or 45- degrees) or 7-8 cm in total distance above right atrium
4
Q
JVP technique
A
- Best assess in right internal jugular vein
- Bed in 30 degrees, with a pillow below the head.
- Internal jugular pulsations:
- Soft, undulating; with 3 elevations, 2 thoughts per beat.
- Rarely palpable.
- The level drops with upright position and inspiration. - Technique:
- Extend card starting from the meniscus while extending a ruler from the sternal angle.
- Place card at a 90 degrees angle from ruler. - Special tests:
- Kussmaul test: Normal it decreases with inspiration.
- Positive in: Restrictive cardiomyopathy, pulmonary embolism!!, constrictive pericarditis!, tricuspid stenosis, right heart failure.
- Hepato-jugular-reflex: Increase of > 3 cm is positive (right-heart failure).
5
Q
Carotid pulse: technique (09:00)
A
- Provides Aortic stenosis and insufficiency
- Anterior to sternocleido and at crycoid level
- Assessment includes:
- Palpation: Contour and amplitude (good correlation with pressure)
- Auscultation: Bruits (diaphragm, while holding breath)
6
Q
Heart exam (13:34)
A
- Inspection
- Palpation:
- Thrills
- Apical impulse: Diameter, location, amplitude.
- Diffuse: suggests LV Dilation
- Sustained tapping impulse: LV hypertrophy
- If chest has increased anteroposterior diameter: Palpate for RV impulse high in the epigastric area (seen in COPD due to increased right ventricular pressure and hypertrophy from pulmonary hypertension - Auscultation:
- S1: Closure of mitral valve (& tricuspid)
- S2: Closure of aortic valve (& pulmonic)
7
Q
When to use diaphragm?
A
High-pitched sounds:
- S1 and S2
- Murmurs of aortic and mitral regurgitation
- Pericardial friction rubs
8
Q
When to use the bell?
A
Low-pitched sounds:
- S3 and S4
- Murmur of mitral stenosis
- Carotids
9
Q
6 listening areas:
A
- Aortic area: Right 2nd interspace
- Pulmonic area: Left 2nd interspace
- Left 3rd interspace (Erb’s space)
- Tricuspid area: Left 4th and 5th interspace
- Mitral area: Apex
10
Q
What to hear on the aortic area:
A
- Cardiac rate
- Cardiac rhythm
- S2 louder than S1
11
Q
What to hear on the pulmonic area:
A
- S2 louder than S1
2. Inspiratory physiologic splitting: (A2 from aortic and P2 from pulmonic)
12
Q
What to hear in 3rd interspace
A
- S2 diminishes, S1 gets louder
2. Leaning forward: Aortic regurgitation
13
Q
What to hear in tricuspid and mitral areas
A
- Bell to detect S3 and S4
2. Mitral stenosis
14
Q
Attributes of Heart murmurs: Timing (00:23)
A
Timing: Related to carotid upstroke.
- Systolic-during;
- diastolic-following the upstroke
- Midsystolic murmur gap before S2:
- Physiologic
- Crescendo-decrescendo->Aortic stenosis - Pansystolic murmur: Continuos from S1 to S2.
- Mitral regurgitation - Middiastolic murmur: Short time after S2 and follows an Opening Snap
- Mitral stenosis
- Austin-Flint murmur: Mitral stenosis like, but due to aortic regurgitation - Early diastolic:
- Decrescendo blowing-> Aortic regurgitation.
15
Q
Attributes of Heart murmurs: Shape (00:25:43)
A
Shape: Determined by its intensity over time
- Crescendo: Grows louder
- Decrescendo: Grows softer
- Plateau: Same intensity
