CVS Physical Exam

Question 1

General approach to CVS exam

Answer 1

general appearance, including ABCs, GCS

VITALS

inspection

palpation

percussion

auscultation

Question 2

how to check BP

Answer 2

palpate first

5 phases of korotkoff sounds
–systolic is first sound heard, diastolic is when sounds disappear

recheck supine, sitting, standing, both arms and maybe both legs if suspect aortic regurgitation or coarctation

Question 3

which pulses should you feel for

Answer 3

carotid
brachial 
radial
femoral 
politeal
dorsalis pedis 
posterial tibial (medial aspect of ankle)

*compare R and L sides in upper and lower extremities

Question 4

describe approach to palpating pulses

Answer 4

1. palpate/feel for all peripheral pulses
2. attempt to palpate abdominal aorta and define its width
3. characterize rate, rhythm, contour, amplitude, symmetry
4. grade the pulse
5. listen for bruits over carotids, abdominal aorta, femorals, renal arteries

Question 5

how do you grade a pulse

Answer 5

0 absent
1+ dim, barely palpable
2+ expected
3+ full
4+ bounding

Question 6

5 Ps of ischemic limb

Answer 6

pain
pallor
pulselessness
paresthesia
paralysis

Question 7

where should you listen for bruits

Answer 7

carotids
abdominal aorta
femorals
renal arteries

Question 8

how do you assess the JVP

Answer 8

patient at 45 degree with tangential light

if volume deplete, may only see if patient is lying flatter than 45 degrees

if peripheral tamponade or tension pneumo can get kussmaul sign

Question 9

what is the maximum normal JVP

Answer 9

3cm above angle of Louis (sternum)

Question 10

how do you differentiate JVP from carotid pulse

Answer 10

biphasic 
nonpalpable
occludable 
varies with respiration and position
transiently increases with abdominal pressure (abdominal-jugular reflex)

Question 11

what is kussmauls sign and what does is represent

Answer 11

increased JVP on respiration

suggests peripheral tamponade or tension pneumothorax

Question 12

what would you see on JVP in AV dissociation

Answer 12

cannon A waves

Question 13

what would you see on JVP in tricuspid regurg

Answer 13

C V waves

Question 14

what signs suggest thrombosis

Answer 14

red, hard, tender along superficial vein –> superficial

unilateral limb swelling, positive homan’s sign (knee extended, raise leg, dorsiflex foot while squeezing the same calf), has risk factors–> deep

Question 15

what are signs of venous insufficiency

Answer 15

evidence of thrombosis

edema

varicosities

Question 16

how do you grade edema

Answer 16

pitting or non pitting

press over anterior tibia

1–slight, less than 2 mm, disappears rapidly

2–2-4 mm, disappears in 10-15 sec

3–4-6 mmm, may last over a minute

4–6-8mm, may last 2-5 min

Question 17

for CV exam: inspection

Answer 17

cyanosis?
clubbing?
venous distension?

cap refill time (should be less than 2 sec)

visible pulsations, exaggerated lift/heaves

apex beat (coincident with carotid pulse and S1)–position offers clue to heart size

Question 18

for CV exam: palpation

Answer 18

use proximal half of 4 fingers and feel for lifts, heaves, apex beat and thrills

if unable to feel apex beat supine rolle patient into left lat decubitus and describe the area covered and duration of systole if occupies
–simultaneously palpate carotid pulse

Question 19

for CV exam: percussion

Answer 19

note useful

Question 20

for CV exam: ausculate

Answer 20

over the aortic, pulmonic, tricuspid, mitral

aortic–> patients right, 2nd intercostal
pulmonic–> patients left, 2nd intercostal
tricuspid–> patient left, 4th intercostal
mitral–> apex

Question 21

where is S1 best heard

Answer 21

towards apex

Question 22

where is S2 best heard

Answer 22

aortic or pulmonic

Question 23

what should you use to listen for S3 and what causes it

Answer 23

bell

due to volume overloaded ventricle like in CHF

Question 24

what causes S4

Answer 24

non compliant ventricle like in LVH

Question 25

how do you describe murmurs

Answer 25

phase of cycle (diastole, systole)
quality
duration
intensity (I-VI for systolic)
radiation
variation with respiration or valsalva

Question 26

what system should you also examine in a cardiac patient

Answer 26

respiratory system

listen to lungs as well

also in pulmonary stations, listen to heart, check JVP