Physical exam: CV exam

Question 1

CV exam: Learning objectives

Answer 1

1. Assess JVP and pulsation
2. Assess the carotid upstroke
3. Palpate heaves, lifts, thrills, and the PMI
4. Auscultate heart sounds and murmurs in six positions on the chest using diaphragm and bell
5. Identify S1 and S2
6. Distinguish systole from diastole
7. Identify extra sounds such as S3 and S4
8. Correctly identify valvular murmurs

Question 2

Correlate observations with the patient’s cardiac findings and:

Answer 2

• Blood pressure
• Arterial pulses
• Venous pulsations
• Jugular venous pressure
• Remainder of physical examination
• Patient’s history

Question 3

Jugular venous pressure (JVP): Definition

Answer 3

• 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

Question 4

JVP technique

Answer 4

• 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).

Question 5

Carotid pulse: technique (09:00)

Answer 5

• 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)

Question 6

Heart exam (13:34)

Answer 6

• 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)

Question 7

When to use diaphragm?

Answer 7

High-pitched sounds:

• S1 and S2
• Murmurs of aortic and mitral regurgitation
• Pericardial friction rubs

Question 8

When to use the bell?

Answer 8

Low-pitched sounds:

• S3 and S4
• Murmur of mitral stenosis
• Carotids

Question 9

6 listening areas:

Answer 9

1. Aortic area: Right 2nd interspace
2. Pulmonic area: Left 2nd interspace
3. Left 3rd interspace (Erb’s space)
4. Tricuspid area: Left 4th and 5th interspace
5. Mitral area: Apex

Question 10

What to hear on the aortic area:

Answer 10

1. Cardiac rate
2. Cardiac rhythm
3. S2 louder than S1

Question 11

What to hear on the pulmonic area:

Answer 11

1. S2 louder than S1

2. Inspiratory physiologic splitting: (A2 from aortic and P2 from pulmonic)

Question 12

What to hear in 3rd interspace

Answer 12

1. S2 diminishes, S1 gets louder

2. Leaning forward: Aortic regurgitation

Question 13

What to hear in tricuspid and mitral areas

Answer 13

1. Bell to detect S3 and S4

2. Mitral stenosis

Question 14

Attributes of Heart murmurs: Timing (00:23)

Answer 14

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.

Question 15

Attributes of Heart murmurs: Shape (00:25:43)

Answer 15

Shape: Determined by its intensity over time

• Crescendo: Grows louder
• Decrescendo: Grows softer
• Plateau: Same intensity

Question 16

Attributes of Heart murmurs: Location of maximal intensity (00:26)

Answer 16

Location of maximal intensity

• Determined by site of origin
• Explore where murmur is loudest

Murmur’s position relative to:

     - Sternum
     - Apex
     - Midsternal
     - Midclavicular
     - Axilary lines

Question 17

Attributes of Heart murmurs: Radiation

Answer 17

Radiation: Transmission from the point of maximal intensity

• Reflects
  - site of origin
  - Intensity of murmur
  - Direction of blood flow

Question 18

Attributes of Heart murmurs: Intensity

Answer 18

Intensity: 6 point scale

• Grade 1: Very faint, heard after “tuning in”
• Grade 2: Quiet, heard immediately
• Grade 3: Increasingly loud
• Groud 4,5,6: Accompanying thrill

Question 19

Attributes of Heart murmurs: Quality

Answer 19

Quality:

• Harsh
• Blowing (decrescendo): Aortic regurgitation
• Musical: Mitral valve prolapse
• Rumbling: Mitral stenosis

2 maneuvers to be used:

     - Aortic regurgitation: Sitting up and leaning forward, and exhaling completely (by moving the left ventricle to the chest wall)
              - 2nd interspace to the apex: decrescendo diastolic
     - Handgrip maneuver

     -Mitral stenosis: Left lateral decubital position: Opening snap and rumbling sound

Question 20

When to perform CV exam?

Answer 20

• Symptoms suggesting MI
• Chest pain
• Shortness of breath
• Pedal edema
• Syncope
• Palpitations

Question 21

CV exam: Sequence

Answer 21

1. Introduction
2. Vital signs
   - Ask the patient to lie down, “I am going to assess your blood pressure twice, one while lying down, the other after you sit up”
   - HR for 10 seconds; “HR is which is normal”
   - BP: Get the systolic by pulse palpation, then increase 30 mmHg, then auscultate BP is _______ which is normal
   - “Can you please sit up on the edge of the bed”, “normally I would wait for two minutes and measure the BP again to check for any orthostatic hypotension”: (no changes: no ↓ 20 mmHg in systolic, no ↓ 10 mmHg in diastolic, no ↑ 20 in HR)
3. General Inspection (HEENT)
   - General status
   - “Can you please open your mouth”
   - Bilateral radial pulse: “Pulse is normal, regular, equal on both sides, with no delay”
   - Hands
   - I would like to do a fundoscopic examination. Mr/Ms., I am going to shine a light in your eyes to examine the back of your eyes, ok? Tell the examiner what are you looking for: Disc edema, cotton wool exudates, retinal hemorrhage, a-v nicking
4. Position and drape
   - Carotids
   - JVP
   - Kussmaul test
   - Hepato-jugular reflex
5. Chest inspection
6. Palpation: https://freemedicalvideos.com/parasternal-heave-physical-exam/
   - Apex (whole hand)
   - Right ventricular heave: Left paraesternal edge, with palm heel.
   - Thrills (4 spots, with finger tips)
7. Auscultation
   - Starting at Aortic, Pulmonary, Tricuspid, Mitral: “Normal S1 and S2, no murmurs or additional heart sounds were noted”
   - Flip the bell: Check for S3 and S4 at the apex.
   - Left paraesternal border: “Can you please take a deep breath and exhale, hold it, and lean forward”: “No enhancement of aortic insufficiency murmurs”
   - Lung bases: “Base is clear, No crackles”
8. Others:
   - Press against sacrum for edema
   - Press on the lower limbs, for edema.
9. Thank the patient.