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Flashcards in Cardiac Physical Exam Deck (87):

Why is the eye exam important for a cardiac exam?

Because the eyes are the gateway to the kidneys


What 3 blood pressures must you take when doing a cardiac exam?

one in each arm and one in the leg (can be up to 10 mm Hg difference between arms).


Should the leg BP be higher or lower than the arm BP?

higher due to gravity (20-40 mm Hg higher). place 2 cm above the patellar tendon and auscultate the popliteal artery.


What could cause a lower BP in the leg?

coarctation (narrowing) of the aorta, which is a secondary cause of hypertension.


What are you looking for initially, when examining the patient lying at 30-45 degrees?

Internal jugular veins (can be hard in those who are obese) to assess for volume overload to the right side of the heart.


What should you use when you can't find the internal jugular vein?

the external jugular vein (not as accurate though)


What do distended neck veins reflect, along with lower extremity edema?

Right sided heart failure. Symptoms include sweating (diaphoresis) and SOB (dyspnea).


How do you assess jugular venous pressure (JVP) (RA pressure)?

1. Normal = 5 cm (above the sternal angle of Louis) meaning normal right atrial pressure. Look for the meniscus of the vein.
2. Bottom of angle of mandible = 10 cm (wet).
3. At the level of the earlobe= 12 cm (wet).


What is hepatojugular reflux?

maneuver to assess for right ventricular volume overload. You have the pt. bring their knees up and take a deep breath. You then place subxiphoid pressure on the patient for 10-60 seconds, and observe the neck veins fill from the bottom up, and stay up through inspiration and expiration. If it stays up, then this is a (+) hepatojugular reflex, consistent with right ventricular volume overload.


What is Kussmaul's sign?

Distention of neck veins with inspiration. This is a sign of pericardial effusion, impending respiratory failure.


What is an A wave of the jugular venous pulse?

Atrial contraction. Gives you 10-15% of the normal cardiac output in healthy people. In those with heart failure or valvular problems, it can contribute to 30-40% of the total cardiac output!
They will help show you rhythm and volume status.
Must be in sinus rhythm to get an A wave.


What are the 3 types of A waves?

1. A wave
2. large A
3. cannon A waves


With what heart sound are A waves associated?

S4 sounds. This helps you to form a differential diagnosis of what type of murmur you may have.


What are some issues that cause A waves?

Pulmonic Stenosis
tricuspid stenosis
IHSS (idiopathic hypertrophic subaortic stenosis)
ischemic heart disease
aortic stenosis
*These will give you A waves where you need a stronger cardiac output to augment contraction.


What will you see with large A waves?

two atrial beats to one ventricular beat.


What are the two causes of large A waves?

1. paroxysmal atrial tachycardia
2. atrial flutter


What causes cannon A waves?

large intermittent A waves caused by 3rd degree heart block (atria and ventricles are not firing at the same time)


What are c waves of the jugular venous pulse?

Isovolumetric contraction (occurs at the beginning of systole= R wave).


**When palpating the pulse while auscultating, if you feel the upstroke at the same time that you hear the first heart sound, are you in systole or diastole?



What is a v wave of the jugular venous pulse?

atrial filling (occurs at the beginning of diastole) and if you hear a late sound here, this is associated with tricuspid regurgitation.


What is the x descent?

atrial relaXation and closing of tricuspid valve during ventricular contraction. Associated with acute pericardial effusion (tamponade)


What is the y descent?

right atrial emptYing and associated with slow pericardial effusion (SLE, chronic renal failure)


What type of neck bruit is associated with aortic regurgitation?

rapid upstroke, rapid decline, wide pulse pressure


What does the apex tell you?

axis/displacement, enlargement. PMI (point of maximal intensity) should be felt in 5th intercostal space.


What heart sound will you hear if the ventricle is big and the apex is displaced?



Where is the S4 sound best heard?

Left lateral recumbent position


**What augments S3 and S4?

Hand grip


**What increases S1?



**What is S3?

diastolic filling sound (listen on the LEFT LATERAL RECUMBENT POSITION) heard best with the bell because it is low pitched. Have patient grip hand.


**What is S2 sound?

closure of aortic and pulmonic valves (aortic comes slightly before pulmonic)


How do you augment right sided murmurs?

use maneuvers that increase volume (inspiration/leg raising/squatting)


What do right sided murmurs reflect?

tricuspid/pulmonic issues


With what is cardiac tamponade associated?

infarcts, trauma, and infectious processes


With what is chronic pericardial effusion associated?

lupus, chronic renal failure, metastatic disease


Can you have an x descent pathology with a y descent pathology?

NO. You will either have one or the other, because they each have their own differential diagnoses.


What neck bruit is associated with aortic stenosis, syncope, angina, or dyspnea?

bilateral bruit: delayed upstroke, delayed decline


What neck bruit is associated with IHSS?

rapid upstroke, delayed decline


What neck bruit is associated with atherosclerosis?

unilateral bruit: slow upstroke, normal decline


What are you looking for on the bare chest with the patient on the table at 30-45 degrees for the cardio exam?

symmetry of the chest, scars of the chest, movement that is normal instead of paradoxical, and looking where the apex is.


Where should the apex of the heart be?

4th/5th intercostal space at the midclavicular line


What does it mean if the apex of the heart is shifted to the left?

there is enlargement


What can cause a big heart?

rapid upstroke, rapid decline, wide pulse pressure (aortic regurgitation)


If the PMI just touches your hand, do you have a small or large heart?

small heart associated with S4


If the PMI comes across your fingers, do you have small or large heart?

large heart associated with S3


Where is the right ventricle?

under the sternum


Should you be able to feel the right ventricle?

NO, and if you do the RV is enlarged


What is associated with a systolic murmur with right ventricular hypertrophy?

tricuspid regurg


What causes an enlarged left atrium?

mitral stenosis, mitral regurgitation, dilated cardiomyopathy, or atrial septal defect.


After we have checked the internal jugular veins, palpated for the apex, right ventricle, and left atrium, what do we do next in the cardiac exam?



Where do we listen for S1?

at the apex (problem is S4 and S3 are here also).


What sound will you hear if the ventricle is small, and you have hypertension, aortic stenosis, mitral stenosis, and sinus rhythm?



What is S1 sound?

closure of the mitral and tricuspid valves (mitral closes slightly before), but rarely hear them split.


How do you differentiate S1 from S4 if they are both heard at the apex?

S4 is an atrial contraction heard best over the ventricle in the LEFT LATERAL RECUMBENT POSITION. Also is accentuated with hand grip due to increased peripheral resistance.


Is S4 heard better with diaphragm or bell?

Bell because it is low pitched


Does aortic/pulmonic valve closures come together or go away from each other with inspiration?

go away


What is a normal S2 splitting?

split in INSPIRATION, together in expiration.
The decrease in intrathoracic pressure causes an increase in right venous return. This causes the right atrium and ventricle to fill slightly more than normal, and it takes the ventricle slightly longer during systole to eject this extra blood. This delay in ejection forces the pulmonary valve to stay open a bit longer than usual.


What is fixed splitting in S2?

Split in both inspiration and expiration


What is wide splitting in S2?

pulmonic closure occurs further away from aortic due to volume overload, patent ductus arteriosis, aortic regurg, delayed closure of PV


What is paradoxical S2 splitting?

split in EXPIRATION, together in inspiration


What will squatting due to left (aortic/mitral) and right (tricuspid/pulmonic) sided murmurs?

make them longer because it increases both preload and afterload.


What will inspiration do to right-sided murmurs?

make them longer due to increased preload.


What will valsalva/standing do to both left and right-sided murmurs?

make the shorter due to a decrease in both preload and afterload.


What will hand grip do to left-sided murmurs?

make them longer due to increased afterload (forcing the aortic valve to close sooner and remain closed longer).


Do benign flow murmurs respond to maneuvers?



**What are the 5 early-mid systolic murmurs?

1. pulmonic stenosis (PS)
2. tricuspid regurg (TR)
3. atrial septal defect (ASD)
5. Acute mitral regurg (MR)


What is important about pulmonic stenosis?

- right-sided murmur
- 2nd left intercostal space
- typically doesn't radiate elsewhere
- inspiration/leg raising/squatting (gets longer)
- expiration/standing (gets shorter)
- has a "click" that disappears with inspiration


What is important about tricuspid regurg?

- 4th left intercostal
- right-sided murmur
- inspiration/ leg raising/squatting (gets longer)
- expiration/standing (gets shorter)


Does ASD respond to any maneuvers?

NO. It does show a classic EKG of RBBB


What is important about acute mitral regurgitation?

- left-sided murmur that radiates to the base of the heart
- papillary muscle dysfunction
- hand grip/squatting (gets longer)
- any new murmur after acute MI= MR until proven otherwise


What is important about idiopathic hypertrophic subaortic stenosis (IHSS)?

- black sheep of left-sided murmur
- common cause of sudden death in young athletic males
- reason you have a murmur is because there is a gradient in the ventricle
- EXCEPTION TO THE RULE: valsalva/standing (murmur gets longer) and squatting (murmur gets shorter).


What 3 things must you do every time you auscultate the heart?

1. hand grip (increase systemic vascular resistance)
2. inspiration (increase venous return)
3. valsalva (decrease venous return)


**What are the 2 mid-late systolic murmurs?

1. mitral valve prolapse (MVP)
2. aortic stenosis (AS)


Who gets aortic stenosis?

old people who have hypertension, diabetes, smoke cigarettes and have high cholesterol


What is important to remember about mitral valve prolapse?

- left sided murmur (increases with HAND GRIP and squatting)
- FEMALES (not precipitated by exertion)
- click and murmur move closer to: S1 with valsalva and S2 with inspiration


What is important to remember about aortic stenosis?

- left sided murmur (increases with HANG GRIP and squatting)
- elderly with hypertension and diabetes
- worse with exertion, radiates to neck


**What are the 3 holosystolic murmurs?

1. chronic mitral regurg (MR)
2. tricuspid regurg (TR)
3. ventricle septal defect (VSD)


What is important to remember about chronic MR?

- left sided murmur (increases with HAND GRIP)
- murmur at apex radiating to axillary region


What increases tricuspid regurg?

- it's a right-sided murmur and therefore INSPIRATION or squatting


What is important to remember about VSD?

- left-sided murmur heard at the left sternal border at the 4th/5th intercostal space
- gets longer with HAND GRIP (because increasing systemic vascular resistance and therefore push more blood from the left to the right).
* shorter with INSPIRATION (because you are increasing venous return and hence pressure in the right side, preventing blood from seeping from the left to the right


**What are the 4 diastolic murmurs?

- Rumbles= 1. tricuspid stenosis, 2. mitral stenosis (opening snap, which is just the tightening of the chordae tendineae)
- Blows= 3. aortic regurg, 4. pulmonic regurg


Does tricuspid stenosis always come with mitral stenosis?

YES, but mitral stenosis can come by itself.


Who gets mitral stenosis?

young women (south-east Asia) 15-20 years after rheumatic heart disease. The longer the murmur the longer the disease.


What increases aortic regurgitation?



What increases pulmonic regurgitation?

INSPIRATION (think pulmonic; lungs)


What is a Carry Coombs murmur?

diastolic murmur from rheumatic heart disease


What is a Graham Steell murmur?

pulmonic regurgitation


What is an Austin flint murmur?

mitral murmur heard in aortic regurgitation. The mitral valve can't open as well in diastole because aortic regurgitation back into ventricle, but mitral valve is normal. Mid-diastolic rumble heard best at apex.