Week 6 - Cardiovascular Exam

Question 1

What is the normal location and diameter of PMI? What happens to PMI in LVH?

Answer 1

in the 5th interspace 7 cm to 9 cm lateral to the midsternal line, typically at or just medial to the left midclavicular line.

In supine patients the diameter of the PMI may be as large as a quarter, approximately 1 to 2.5 cm. A PMI greater than 2.5 cm is evidence of left ventricular hypertrophy (LVH), or enlargement

Question 2

What are the two components of second heart sound? In which phase of breathing can you hear these two components?

Answer 2

A2 and P2, caused primarily by closure of the aortic and pulmonic valves, respectively.

Inspiration

Question 3

What are the locations on the chest wall where you hear the murmurs originating each of the mitral valve, tricuspid valve, pulmonic valve, and aortic valve?

Answer 3

Mitral valve - cardiac apex
Tricuspid - lower left sternal border
Pulmonic - 2nd and 3rd left interspaces close to the sternum
Aortic - anywhere from the right 2nd interspace to the apex

Question 4

What is the importance of JVP? From which vein is it best estimated?

Answer 4

Jugular venous pressure (JVP) reflects right atrial pressure, which in turn equals central venous pressure (CVP) and right ventricular end-diastolic pressure.

The JVP is best estimated from the right internal jugular vein, which has a more direct anatomical channel into the right atrium

Question 5

What are the conditions included in acute coronary syndrome?

Answer 5

Acute coronary syndrome is increasingly used to refer to any of the clinical syndromes caused by acute myocardial ischemia, including unstable angina, non-ST elevation myocardial infarction, and ST elevation infarction

Question 6

What are the characteristics of chest pain in acute aortic dissection?

Answer 6

Anterior chest pain, often tearing or ripping, often radiating into the back or neck

Question 7

Define palpitation. Which arrhythmia of the heart can reliably be identified on the bedside without an EKG?

Answer 7

Palpitations involve an unpleasant awareness of the heartbeat

Only atrial fibrillation, which is “irregularly irregular,” can be reliably identified at the bedside

Question 8

What are the causes of weak pulse and bounding pulse?

Answer 8

Weak - (1) decreased stroke volume, as in heart failure, hypovolemia, and severe aortic stenosis, and (2) increased peripheral resistance, as in exposure to cold and severe congestive heart failure

Bounding - (1) increased stroke volume, decreased peripheral resistance, or both, as in fever, anemia, hyperthyroidism, aortic regurgitation, arteriovenous fistulas, and patent ductus arteriosus; (2) increased stroke volume because of slow heart rates, as in bradycardia and complete heart block; and (3) decreased compliance (increased stiffness) of the aortic walls, as in aging or atherosclerosis.

Question 9

Define pulsus alternans and paradoxical pulse. What are the causes of each?

Answer 9

Pulsus alternans - The pulse alternates in amplitude from beat to beat even though the rhythm is basically regular. Indicates left ventricular failure

Paradoxical pulse - a palpable decrease in the pulse’s amplitude on quiet inspiration. Found in pericardial tamponade, constrictive pericarditis (though less commonly), and obstructive lung disease

Question 10

What are the causes of sudden dyspnea?

Answer 10

Left-Sided Heart Failure, Spontaneous Pneumothorax, Acute Pulmonary Embolism

Question 11

Define orthopnea. What are its causes?

Answer 11

dyspnea that occurs when the patient is lying down and improves when the patient sits up.

left ventricular heart failure or mitral stenosis; also in obstructive lung disease

Question 12

Define paroxysmal nocturnal dyspnea. What are its causes?

Answer 12

episodes of sudden dys- pnea and orthopnea that awaken the patient from sleep, usually 1 or 2 hours after going to bed, prompting the patient to sit up, stand up, or go to a window for air.

left ventricular heart failure or mitral stenosis

Question 13

What are the locations and causes of dependent edema?

Answer 13

Dependent edema appears in the lowest body parts: the feet and lower legs when sitting, or the sacrum when bedridden. Causes may be cardiac (congestive heart failure), nutritional (hypoalbuminemia), or positional.

Question 14

What is the US Preventive Services Task Force recommendation of BP screening?

Answer 14

screening all people 18 years or older for high blood pressure.

Question 15

What are the AHA guidelines for screening of BP, BMI, waist circumference, fasting lipoprotein profile and fasting glucose in adults for prevention of cardiovascular diseases and stroke?

Answer 15

Risk factor screening for adults beginning at 20 years

Global absolute CHD risk estimation for all adults 40 years and older.

Question 16

What is the US Preventive Services Task Force recommendation of screening of LDL?

Answer 16

routine screening of LDL for men 35 years or older and for women 45 years or older. Screening should begin at 20 years for those with risk factors for CHD

Question 17

What are the steps in assessing JVP? What is normal JVP? What are the causes of increased JVP?

Answer 17

Elevate the head of the bed to 30°. Identify the external jugular vein on each side, then find the internal jugular venous pulsations transmitted from deep in the neck to the overlying soft tissues. The JVP is the highest oscillation point, or meniscus, of the jugular venous pulsations that is usually evi- dent in euvolemic patients.

The sternal angle usually remains about 5 cm above the right atrium.

Increased pressure suggests right- sided congestive heart failure or, less commonly, constrictive pericarditis, tricuspid stenosis, or superior vena cava obstruction

Question 18

How will you distinguish between internal jugular and carotid pulsations?

Answer 18

internal jugular - Rarely palpable
Soft, biphasic, undulating quality, usually with two elevations and two troughs per heart beat
Pulsations eliminated by light pressure on the vein(s) just above the sternal end of the clavicle
Height of pulsations changes with position, dropping as the patient becomes more upright
Height of pulsations usually falls
with inspiration

Carotid - palpable
A more vigorous thrust with a single
outward component
Pulsations not eliminated by this pressure
Height of pulsations unchanged by position
Height of pulsations not affected by inspiration

Question 19

What are the causes of decreased carotid pulsations? What are the effects of application of pressure on carotid sinus?

Answer 19

decreased stroke volume and local factors in the artery such as atherosclerotic narrowing or occlusion

Pressure on the carotid sinus may cause a reflex drop in pulse rate or blood pressure

Question 20

What is the cause of delayed carotid upstroke?

Answer 20

Aortic stenosis

Question 21

Define bruit. What is the cause of carotid bruit? What is the signficance of asymptomatic carotid bruit?

Answer 21

A murmur-like sound of vascular rather than cardiac origin.

Carotid bruit may indicate carotid artery stenosis.

asymptomatic carotid bruits - a three- fold increased risk of ischemic heart disease and stroke

Question 22

What are the sequences of cardiac examination?

Answer 22

Supine, with the head elevated 30° - Inspect and palpate the precordium: the 2nd right and left interspaces; the right ventricle; and the left ventricle, including the apical impulse

Left lateral decubitus - Palpate the apical impulse if not previously detected. Listen at the apex with the bell of the stethoscope.

Supine, with the head elevated 30° - Listen at the 2nd right and left interspaces, along the left sternal border, across to the apex with the diaphragm.
Listen at the right sternal border for tricuspid murmurs and sounds with the bell.

Sitting, leaning forward, after
full exhalation - Listen along the left sternal border and at the apex with the diaphragm.

Question 23

Which positions are good for mumurs of mitral stenosis and aortic insufficiency?

Answer 23

mitral stenosis - Left lateral decubitus

aortic insufficiency - Sitting, leaning forward, after full exhalation

Question 24

Define thrill. What are the causes?

Answer 24

turbulence of underlying murmurs

aortic stenosis, patent ductus arterio- sus, ventricular septal defect, and, less commonly, mitral stenosis.

Question 25

Define dextrocardia. What are the physical findings?

Answer 25

a heart situated on the right side

The apical impulse will then be found on the right.

Question 26

Define apical impulse. What are its normal location, diameter, duration and amplitude?

Answer 26

The apical impulse represents the brief early pulsation of the left ventricle as it moves anteriorly during contraction and touches the chest wall.

In the left 5th interspace, medial to midclavicular line.

Diamete - 2.5cm
Duration <= 1st 2/3 of systole
Amplitude - brisk or tapping

Question 27

What are the causes of displacement of apical impulse?

Answer 27

Pregnancy or a high left diaphragm
cardiac enlargement in congestive heart failure, cardiomyopathy, ischemic heart disease. Deformities of the thorax and mediastinal shift

Question 28

What is the significance of increased amplitude of apical impulse? sustained, high-amplitude apical impulse? sustained, low-amplitude apical impulse?

Answer 28

hyperthyroidism, severe anemia, pressure overload of the left ventricle (as in aortic stenosis), or volume overload of the left ventricle (as in mitral regurgitation)

Question 29

What are the two sequences of auscultation of heart (inching the stethoscope)?

Answer 29

1) starting at the apex and inching to the base

2) start at the base and inch your stethoscope to the apex

Question 30

What are the relations of timing of heart sounds S1 and S2 with carotid pulse?

Answer 30

S1 is just before the carotid upstroke, and S2 follows the carotid upstroke

Question 31

How will you determine systole and diastole from heart sounds?

Answer 31

At the base the S2 is louder than S1 and may split with respiration. At the apex, S1 is usually louder than S2 unless the PR interval is prolonged.

Question 32

What are the sounds you hear better with each of the diaphragm and the bell of stetho? How will you apply them on the chest?

Answer 32

The diaphragm is better for picking up the relatively high-pitched sounds of S1 and S2, the murmurs of aortic and mitral regur- gitation, and pericardial friction rubs. Listen throughout the precordium with the diaphragm, pressing it firmly against the chest

The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Apply the bell lightly, with just enough pressure to produce an air seal with its full rim.

Question 33

How will you determine whether a murmur is systolic or diastolic?

Answer 33

Systolic murmur falls between S1 and S2, diastolic murmur falls between S2 and S1

Question 34

Which way does a murmur of aortic stenosis radiate?

Answer 34

A loud murmur of aortic stenosis often radiates into the neck, especially on the right side.

Question 35

What are the grades of heart murmurs? Which grades have palpable thrills?

Answer 35

Grades 4 - 6 have palpable thrills

Question 36

Which murmur does increase in intensity with Valsalva maneuvers?

Answer 36

The murmur of hypertrophic cardiomyopathy (systolic murmur)

Question 37

What are the timing, radiation, and quality of murmur of patent ductus arteriosus?

Answer 37

Timing - Continuous murmur in both systole and diastole, often with a silent interval late in diastole.

Radiation - Toward the left clavicle

Quality - Harsh, machinery-like