Cardiac Exam

Question 1

Cardiac symptoms

Answer 1

chest pain
* myocardial ischemia

Low cardiac output symptoms
* dyspnea
* HF symptoms
* syncope

Question 2

Women’s S/S of Acute myocardial infarction

Answer 2

New or different Symptoms in weeks prior to event
* unusual fatigue (70%)
* Sleep disturbance (48%)
* SOB. (42%)
* Indigestion (39%)
* Anxiety (35)

Symptoms during ACS
* SOB (58%)
* Weakness (55%)
* Unusual fatigue (43%)
* Diaphoresis (39%)
* Dizziness (39%)
* Chest pain or pressure (30%)
* No chest discomfort during the event (43%)

Question 3

ACS in the elderly

Answer 3

Unrecognized MI by age
* 18% in men 45-54
* 42% in men 75-84
* 60% in men over 85

Presentation >75 yrs
* Dyspnea
* neuro symtoms - syncope, weakness, acute confusion
* Chest pain or pressure < 50%

Weakness and fatiuge are most often reported

Question 4

Point of maximal Impulse

Answer 4

Normal
* palpabel sensation of underlying left ventricle
* 5th ICS @MCL
* about the area of a nickle
* gentle tap by one finger, single impule
* about 1/3 of systole

Abnormal
* Displaced PMI - usually laterally toward axillary line: indicates increased LV volume
* Unusually forceful, sustained: pressure overload, HTN

Unable to palpate
* Left lateral decubitus position enhances
* may be due to : thick chestwall, obesity, COPD

Question 5

Aortic heart sound

Answer 5

• 2nd intercostal space, right ternal boarder
  (left side of heart)
• Heard during S2

Question 6

Pulmonic Area

Answer 6

• 2nd intercostal space left sternal boarder
• right side of heart
• heard during S2

Question 7

Erbs Point

Answer 7

• 3rd intercostal space, left sternal boarder
• hear both S1 and S2

Question 8

Tricuspid area

Answer 8

• 5th intercostal space, Left sternal border
• right A/V valve
• heard during s1

Question 9

Mitral area

Answer 9

• 5th intercostal space, MCL
• Left AV valve
• heard during S1

Question 10

S1

Answer 10

• begining of systole
• closure of the miral and tricuspid (AV) valves
• beast heard at the apex (bottom) with diaphram
• simultaneous with carotid upstroke (pulse)

Question 11

S2

Answer 11

• Marks the end of systole
• closure of the aortic and pulmonic valves
• beast heard at the base (top) with diaphram

Question 12

Physiologic S2

Answer 12

• widening of normal interval between aortic and pulmonic valve
• caused by a delay in pulmonic component
• heard best in pulmonic region (2nd ICS, left sternal border)
• Split INcreases with INspiration
• found in adults <30 yrs

Question 13

Pathologic split S2

Answer 13

• fixed split - no change with inspiration
• paradoxical split - narrows with inspiration
• heard best at pulmonic region (2nd ICS, left sternal border)
• fixed split: often found in uncorrected septal defect
• Paradoxical: found in conditions that delay aortic clossure such as LBBB
• will resolve with treatment of underlying condition

Question 14

S3

Answer 14

• marker of ventricular overload, and or systolic dysfunction
• heard in early diastole like its hooked on the end of S2 (lub dub-dub) (Kentucky)
• low pitched-best heard with bell
• for Dx of HF correlate with additional findings (dyspnea, tachycardia, crackles
• may not be heard in HF if pt is euvolemic and relatively symptom free

Question 15

S4

Answer 15

• marker of poor diastolic function
• most often found in poorly controlled HTN (off meds for weeks) or recurrent myocardial ischemia
• heard late in diastole, hooked to the front of S1 (presystolic sound)
• Soft low pitch (higer than s3) best heard with bell
• dub-lub dub

Question 16

Heart valve dysfunction

Answer 16

• failure to open - Stenosis
• Failure to close - Incompetent valves cause regurgitant murmurs

Question 17

Systolic murmurs

Answer 17

• Can be pathologic or benign
• Mr. Pass MVP

Mitral Regurgitation, Physiologic (innocent, functional): holosystolic

Aortic Stenosis: cresendo-decresendo

SYSTOLIC

Mitral Valve Prolapse: mid systolic with mid systolic click

Question 18

Diastolic Murmurs

Answer 18

• Always Pathologic
• Ms. Ard

Mitral Stenosis: late diastolic
Aortic Regurgitation: early diastolic
DIASTOLIC

Question 19

Heart murmur grading

Answer 19

1. very faint
2. quiet but immediately heard
3. moderately loud without thrill - about as loud as S1/S2
4. Loud with thrill
5. very loud with thrill
6. audible without stethascope

Question 20

Systolic murmur pysiologic vs pathologic

Answer 20

Likely benign if all are noted
* negative Hx
* lower grade <4
* no radiation beyond pericordium
* S1 and S2 intact
* no heave or thrill
* PMI WNL
* Softens or disappears with supine to stand position change

Pathologic - echo next step unitl proven otherwise if 1 or more of the following
* abnormal Hx
* higher grade 4 or more
* radiation beyond the pericordium to neck, axilla, other
* S1, S2 obliterated
* Thrill or heave
* PMI displaced
* Increases in intensity with supine to stand

Question 21

Character of murmurs

Answer 21

Harsh
* Hears well with bell and diaphram
* aortic stenosis

Rumble
* Low, best with bell
* Mitral stenosis

Blowing
* high, best with diaphram
* aortic regurge

Musical
* Vibratory quality
* still murmur

Question 22

Carotid bruit Vs Radiating murmur

Answer 22

Carotid Bruit
* softer
* often unilateral
* differnet sound than chest
* presence of high grade athlersclerotic disease

Radiating murmur
* Louder
* bilateral
* same sound and timing as found in chest