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X Physical Diagnosis > L5 Cardiovascular Exam > Flashcards

L5 Cardiovascular Exam Flashcards

(84 cards)

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1
Q

Where should you stand for the cardiovascular exam?

A

On their right side

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2
Q

Precordium

A

Anterior chest wall overlying the heart

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3
Q

Point of maximal impulse

A

Apical impulse, location where the cardiac impulse can be best palpated on the chest wall

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4
Q

What do you use the bell for?

A

Low pitched sounds of S3 and S4, apply light pressure (just enough to make seal against chest wall)

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5
Q

What do you use the diaphragm for?

A

High pitched sounds of S1 and S2, apply firm pressure against chest wall

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6
Q

4 routine areas of cardiac auscultation (what are the others that might be needed)

A

Aortic, pulmonic, tricuspid, mitral (apex

Second pulmonic or you can also “inch” the stethoscope along

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7
Q

Aortic auscultation

A

2nd ICS, RSB (on one side of angle of Louis)

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8
Q

Pulmonic auscultation

A

2nd ICS, LSB (on one side of angle of louis)

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9
Q

Tricuspid auscultation

A

4th and 5th ICS, LSB

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10
Q

Mitral auscultation

A

5th ICS, MCL (apex)

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11
Q

Second pulmonic ausculation

A

As needed, 3rd ICS, LSB

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12
Q

Normal heart rate range

A

60-100 bpm

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13
Q

First heart sound (S1)

A

SYSTOLE: closure of mitral and tricuspid valves and contraction of the ventricles (aortic and pulmonic valves forced open to eject blood into arteries)
“LUB”

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14
Q

Where is S1 best heard?

A

At the apex

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15
Q

When would there be an accentuated/louder S1?

A

Diseased AV valve or more forceful closure of AV valve

Ex: tachycardia, fever, HTN, exercise, anemia, hyperthyroidism, mitral stenosis

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16
Q

When would there be a diminished/softer S1?

A

Weak contraction of the heart of reduced sound transmission (from thick chest wall or emphysematous lungs)

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17
Q

Second heart sound (S2)

A

DIASTOLE: closure of the aortic and pulmonic valves, relaxation of the heart and atrial contraction (mitral and tricuspid valves open allowing ventricles to refill passively)

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18
Q

Where is S2 best heard?

A

At the base

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19
Q

When do the coronary arteries fill?

A

Diastole

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20
Q

Which heart sound is longer?

A

Diastole is slightly longer

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21
Q

A2 vs P2

A

Right sided pressures are lowering than corresponding pressures on the left side so sounds occur slightly later on the right than the left
A2: aortic valve tends to close first
P2: pulmonary valve is a little after

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22
Q

What causes a wide split of S2?

A

Delayed closure of the pulmonic valve

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23
Q

What is a fixed split of S2?

A

Tends to be wide and fixed and it does not vary between inspiration and expiration

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24
Q

What is a paradoxical split of S2?

A

Split is present during expiration and gone during inspiration
Occurs when there is a delay in the contraction of the left ventricle due to a left bundle branch block causing A2 after P2

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25
What pathologies cause a wide split in S2?
Pulmonic stenosis, mitral regurgitation (leak) or right bundle branch block
26
What pathologies cause a fixed split in S2?
Atrial septal defect or right ventricular failure
27
What pathologies cause a paradoxical split in S2?
Left bundle branch block
28
Third heart sound (S3)
Low-pitched sound created in early diastole by passive, rapid filling of ventricles (produced by blood filling a chamber that is already volume overloaded that causes rapid distension of ventricular wall leading to VIBRATION) *ventricular gallop (KEN TUCK Y)
29
Where is S3 best heard?
At the apex with the bell
30
Who might have an S3?
Children, healthy young adults or pregnant women
31
When is an S3/S4 usually pathologic?
When the patient is over 40
32
What might cause a pathologic S3?
Heart failure, anemia, volume overload of ventricle, decreased myocardial contractility
33
Fourth heart sound (S4)
Low-pitched sound created by second phase of ventricular filling in diastole as atria contract and eject blood intro ventricle (rush of blood causes vibration of valves, papillary muscles and ventricular walls) *atrial gallop (TENESS EE)
34
Where is S4 best heard?
At the apex with the bell
35
Who might normally have an S4?
Trained athletes and some older individuals
36
What might cause a pathologic S4?
HTN, CAD, aortic stenosis, cardiomyopathy | *right-sided S4 from pulmonary HTN or pulmonary stenosis
37
What causes a murmur?
Sound made by blood rushing through a narrowed valve, leaking valve or wall between chambers of the heart *can be systolic or diastolic
38
Gradations of murmurs
1/6: barely audible in quiet room 2/6: quiet, but clearly audible 3/6: moderately loud 4/6: loud, associated with thrill 5/6: very loud, heard with stethoscope partially off chest, obvious thrill 6/6: very loud, hear with stethoscope entirely off chest, obvious thrill
39
Systolic ejection murmur
Usually crescendo-decrescendo | Usually due to blood flow across semilunar valves
40
Pansystolic (holosystolic) murmur
``` Usually plateau (continuous and not change over systole) Usually regurgitation across AV valves or ventricular septal defect ```
41
Late systolic murmur
Delay between S1 and hearing the murmur | Typical of mitral prolapse
42
What can aortic/pulmonic stenosis cause?
Systolic ejection murmur due to narrowed valve (congential or calcific disease process) From high pressure to high pressure (so narrowing of the valve slows the force of it trying to come into the high pressure)
43
Where do you listen for a systolic ejection murmur?
At the base along right and left sternal borders
44
Description of crescendo-descrescendo systolic murmur
From left ventricle blood goes through the valve and the murmur gets louder Aortic pressure increases as blood enters which creates resistance so the murmur softens due to reduced blood flow Similar principles in pulmonic system but pressure is not as great
45
Characteristics of innocent systolic murmur
Common in kids/young adults Physiologic in pregnancy, anemia, fever, hyperthyroidism Features: grade <2 intensity, softer when sitting vs supine, short systolic duration, minimal radiation, musical/vibratory quality
46
Atrial septal defect
Congenital anomaly that results in left to right shunt of blood to right atrium with RV enlargement and increased flow through pulmonic valce Hear systolic ejection murmur Fixed splitting of S2
47
Mitral/tricuspid regurgitation
Causes pansystolic (holosystolic) murmur Continuous leakage of blood from LV to LA (or RV to RA) From high to low pressure so plateau *Mitral can be due to rheumatic heart disease
48
Ventricular septal defect
Causes pansystolic (holosystolic) murmur Left to right shunt (LV to RV), harsh or blowing systolic murmur at lower left sternal border Usually associated with thrill
49
Types of diastolic murmurs
Early, mid or late diastolic (presystolic)
50
Early diastolic murmur
Usually decrescendo from regurgitant flow across leaking semilunar valve
51
Mid diastolic murmur
From turbulent flow across AV valves
52
Late diastolic murmur
Usually continues up to S1, usually decrescendo
53
Aortic regurgitation
Causes early diastolic murmur from a leaking aortic valve
54
Mitral/tricuspid stenosis
Causes mid diastolic murmur due to a narrowed valve | Mitral: "opening snap and diastolic rumble," narrowed valve obstructs flow from LA to LV
55
Systolic-diastolic murmur
Due to aortic stenosis with aortic regurgitation Obstruction to outflow due to narrowed valve AND failure of complete closure of aortic valve during diastole with leakage of blood back into left ventricle Crescendo-decrescendo murmur
56
Continuous murmur
Patent ductus arteriosus (failure of channel between aorta and pulmonary artery to close after birth)
57
"To-and-fro" murmur
What systolic/diastolic murmurs are called (severe aortic regurgitation, aortic stenosis/regurgitation)
58
Positions to enhance murmurs
Leaning forward or left lateral decubitus position
59
Altering hemodynamics to enhance murmurs
Alters preload/afterload, squatting, valsalva, isometric exercise
60
What is the specialized exam of having the patient lean forward doing?
Best for hearing soft murmurs at the base (aortic/pulmonic regurgitation)
61
Standing or strain phase of valsalva
Causes decreased left ventricular volume from decreased venous return to the heart Decreased vascular tone, BP and peripheral vascular resistance Most murmurs decrease in intensity except HCM
62
Squatting (or release phase or valsalva)
Causes increased left ventricular volume from increased venous return to heart Increases vascular tone, BP and peripheral vascular resistance
63
Ejection sounds
Aortic or pulmonic ejection click | High-pitched, indicates valve disease or dilated aorta or pulmonary artery or pulmonary hypertension
64
How is ejection sound heard best?
Diaphragm of stethoscope
65
Systolic click
Indicates mitral valve prolapse, which is ballooning of mitral leaflets into the left atrium during systole Mid-late click is often present Variable pitch Mitral regurgitation may also occur with late systolic murmur
66
Venous hum
Turbulent blood flow through jugular veins, both systolic and diastolic sounds, common in kids
67
Pericardial friction rub
``` Inflammation of pericardial sac 3 component (triphasic) sound Scratchy/squeaky, intermittent ```
68
Where do you want the head of the bed during the supine exam?
Elevated 30 degrees
69
Jugular venous pressure
Indication of pressure in the right atrium (central venous pressure), related to intravascular fluid volume
70
What does jugular venous pressure reflect?
Right heart function
71
What is the dominant movement of the pulsations of the internal jugular vein?
Inward (carotid is outward)
72
Differences between internal jugular and carotid pulsations related to: - Being palpable - Quality - Elimination - Height - Inspiration effect
Jugular-rarely palpable, soft biphasic undulating quality usually with 2 elevations and characteristic inward deflection, eliminated with light pressure on veins above sternal end of clavicle, height of pulsations usually drops as patient becomes more upright, height usually falls with inspiration Carotid- palpable, vigorous thrust with single outward component, pulsations not eliminated with pressure, height unchanged with position of inspiration
73
Reasons for elevated JVP
Heart failure, pulmonary HTN, increased vascular tone, pericardial tamponade
74
Reasons for decreased JVP
Blood loss, hypovolemia, decreased venous vascular tone
75
What does hepatojugular (abdominojugular) reflux test for?
Observe for increase in JVP followed by decrease as hand is released from abdomen (exaggerated in right heart failure)
76
Thrill
Buzzing or vibratory sensation, may be caused by vigorous blood flow through any narrowed opening When present, auscultate area for murmur
77
Lifts or heaves
Vigorous cardiac impulse that can be seen/felt through chest wall, usually palpable Can be caused by ventricular hypertrophy or hyperdynamic ventricular activity
78
3 places of palpation at LSB and base
Base, over sternum, over apex
79
What is best to hear in left lateral decubitus position?
Low-pitched filling sounds like gallops (S3, S4) or murmurs (mitral stenosis)
80
When is bisferiens pulse seen?
Aortic regurgitation
81
When do you see bigeminal pulse?
Conduction disorders
82
Bruit
Murmur like sound arising from turbulent arterial blood flow
83
Where is pitting edema mostly seen?
Over dorsum of each foot, behind each medial malleolus, over shins
84
Homan sign
Calf pain on passive dorsiflexion of foot, unreliable for presence of DVT

X Physical Diagnosis (3 decks)

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