Ch15 cardiac exam

Question 1

start with health history

Answer 1

-chest pain: MI
-low cardiac sx’s: dyspnea, HF sx’s, syncope

Question 2

older woman with history of HTN and comorbidities (DM 2) sus with ACS.. most likely to report…

Answer 2

unusual fatigue

Question 3

older WOMEN early warning sx’s of acute MI…

Answer 3

unusual fatigue
sleep disturbances
SOB
indigestion
anxiety
chest pain (only 30%)

Question 4

ACS in elderly > 75 years old symptoms..

Answer 4

dyspnea
syncope, weakness, confusion
chest pain/pressure (< 50%)

Question 5

left sided heart valve diseases

Answer 5

more common than right sided since it carries more pressure to entire body
Mitral valve and aortic valve disease more common than pulmonic and tricuspid

Question 6

examine what area that is the left ventricle?

Answer 6

point of maximum impulse (PMI)
-5th ICS, MCL
size of impulse: nickel
gentle tap of 1 finger, single impulse (1/3 of systole)

Question 7

displaced PMI?

Answer 7

usu laterally = increased LV volume

Question 8

PMI unusually forceful, sustained?

Answer 8

pressure overload, HTN

Question 9

best position to palpate PMI

Answer 9

put pt in left lateral decubitus position enhancement

consider thick chest wall, obesity, COPD (barrel chest)

Question 10

increase AP diameter in COPD changes

Answer 10

might not hear PMI

Question 11

S1 best heard where?

Answer 11

apex of heart with diaphragm
-beginning of systole
“LUB dub”
put finger on carotid to feel for upstroke = that is systole (vs diastole)

Question 12

S2 heard where?

Answer 12

marks end of systole
heard best at the base with diaphragm
lub DUB

Question 13

physiologic split S2

Answer 13

benign normal finding in 30 year olds or younger
-split INCREASES on pt INSPIRATION (have pt breathe in and hold, the split opens. then blow out and split should close)

-widening of normal interval b/t aortic and pulmonic components of 2nd heart sound
-best heard in pulmonic region

Question 14

pathologic split S2

Answer 14

-fixed split (NO changes in inspiration, from uncorrected septal defect)
OR
-paradoxical split, closes with inspiration (delay aortic closure like LBBB)
-in pulmonic region

resolves when tx underlying condition

Question 15

S3 heart sound

Answer 15

-heart sound DOESN’T MEAN heart failure
-early diastole
-hooked onto S2, low pitched with using bell
-lub dub-DUB
-need sx’s like dyspnea

Question 16

S4 heart sound

Answer 16

POOR diastolic function (mostly from poor HTN control, recurrent MI)
-heard late in diastole “hooked” in front of S1
soft, low pitch (use bell)
-DUB-lub dub
-goes away with tx of underlying condition

Question 17

failure to open adequately

Answer 17

stenosis

Question 18

failure to close adquately

Answer 18

incompetent valves = regurgitant murmurs

Question 19

systolic murmurs.. benign or pathologic?

Answer 19

either

Question 20

diastolic murmurs.. benign or pathologic?

Answer 20

always pathologic

Question 21

Systolic murmurs

Answer 21

MR PEYTON MANNING AS MVP
-mitral regurgitation
-physiologic murmur
-aortic stenosis
-mitral valve prolapse

Question 22

diastolic murmurs

Answer 22

ARMS
-aortic regurgitation
-mitral stenosis

Question 23

grading murmurs

Answer 23

sound of blood flow/turbulent
I: very faint
II: quiet but immediate heard
III: moderately loud w/o thrill (as loud as S1 or S2)
IV: loud with thrill (FEEL/vibration on palpation)
V: very loud with thrill
VI: audible without stethoscope

Question 24

murmur characteristic
harsh:
rumble:
blowing:
musical:

Answer 24

harsh: aortic stenosis (bell & diaphragm)
rumble: mitral stenosis (low “bowling ball” = bell)
blowing: aortic regurgitation (high = diaphragm)
musical: still’s murmur

Question 25

systolic murmurs are ONLY benign IF…

Answer 25

all of these:
-negative history (chst pain, syncope, dsypnea etc)
-grade 2 or less
-no radiation beyond precordium (to carotids, axilla, abdomen)
-S1, S2 intact
-no heave or thrill when palpating PMI
-PMI WNL

auscultate supine/squatting preferred to hear murmur then do listen again to stand
or when supine to standing, radiation disappear when standing

Question 26

systolic murmurs pathologic IF…(refer)

Answer 26

ANY of these: (get echocardiogram)
-abnormal hx
-Grade 3-6
-radiation to neck, axilla, other locations
-S1, S2 obliterated
-with thrill or heave
-PMI displaced
-increases in intensity with supine to stand position change

Question 27

harsh systolic murmur, radiates to the neck
delayed carotid upstroke

Answer 27

assume it came off aortic valve!!
aortic stenosis

Question 28

which murmur heard best in mitral area?

Answer 28

mitral valve prolapse

Question 29

delayed carotid upstroke

Answer 29

when S1 sound is not simultaneosus to the pulse of the carotid

Question 30

carotid bruit vs radiating murmur

Answer 30

carotid bruit: usually softer, unilateral, different sound/tone than chest

radiating murmur: usu louder, bilateral, same sound and timing as chest

Question 31

holosystolic murmur that radiates to axilla

Answer 31

mitral regurgitation

Question 32

mid systolic click, late systolic murmur
murmur moves forward with position change from supine to stand

Answer 32

mitral valve prolapse
usu in women with mild pectus excavatum
get echo

Question 33

if hear murmur, must get diagnosis by getting an ___ before managing

Answer 33

echo!

Question 34

louder when standing and quieter when squating

Answer 34

mitral valve prolapse

Question 35

low pitche descrendo-crescendo rumbling diastolic murmur, best heard at apex

Answer 35

mitral stenosis