Normal Heart/CV Exam

Question 1

Normal Heart

-5 finger method?

Answer 1

• History
• Physical
• ECG
• X-ray
• Lab tests

Question 2

Physical

-6 components?

Answer 2

Inspection, jugular venous pressure (JVP), precordial palpation, percussion, auscultation-heart sounds, and grading system of murmurs

Question 3

History

Answer 3

Fatigue, dyspnea, chest pain, palpations, syncope-non-specific

Question 4

History

-Components of a complete cardiac diagnosis include consideration of?

Answer 4

• Underlying etiology-hypertensive, ischemic, congenital, infections
• Anatomic abnormalities
• The physiologic disturbance-presence of an arrhythmia or CHF?

Question 5

History

-Anatomic abnormalities-questions to find the answer to?

Answer 5

• Which chamber is involved?
• Which valve is affected?
• Is pericardium involved?
• Has there been an MI?

Question 6

Family history-familial clustering

Answer 6

Familial clustering is common in patients with certain heart diseases-i.e. hypertrophic cardiomyopathy, marfan’s syndrome, prolonged QT syndrome

Question 7

Physical-Common error when assessing cardiac function?

Answer 7

It is a common error to listen to the heart first

Question 8

Physical

-Follow the proper sequence?

Answer 8

-Inspection, palpation, percussion, auscultation

Question 9

Inspection

-3 components?

Answer 9

• Shape-barrel-chested, pectus carinatum or excavatum
• Landmarks
• Scars/signs of trauma

Question 10

Inspection

• Barrel chested
  
  • Increased?
  • Indicative of?

Answer 10

• Increased AP diameter

- Indicative of COPD

Question 11

Inspection

-Pectus carinatum

Answer 11

• Pigeon chest

- Central protrusion

Question 12

Inspection

-Pectus excavatum

Answer 12

• Funnel chest

- Central depression

Question 13

Landmarks-review slide 14

Answer 13

slide 14

Question 14

Principles of physical exam

-Inspection

Answer 14

• Precordium
• Scars, pacemaker, skeletal abnormalities
• Apex-5th ICS, left, 1 cm medial to MCL

Question 15

Principles of physical exam

-Palpation?

Answer 15

• Apex beat; gently lifts palpating fingers

- Thrills

Question 16

Palpation

-Thrills?

Answer 16

Turbulent blood flow causing murmurs

Question 17

Principles of physical exam

-Percussion?

Answer 17

-Estimate cardiac size: start far left (resonance) and move medially to find cardiac dullness

Question 18

Principles of physical exam

-Auscultation-S1?

Answer 18

• Mitral and tricuspid closure

- Beginning of ventricular systole

Question 19

Principles of physical exam

-Auscultation-S2?

Answer 19

• Aortic and pulmonic closure

- Marks end of systole, beginning of diastole

Question 20

Palpation and percussion

• Point of maximal impulse (PMI) or apical impulse
  - Position?
  - Normally found where?

Answer 20

• Supine or left lateral decubitus

- Normal-4th-5th intercostal space at the mid-clavicular line

Question 21

Percussion

- Used in order to?
- How do you do it?

Answer 21

• Used in order to estimate cardiac size when PMI not detectable
• Start far left (“resonance”) and move medially to find cardiac dullness

Question 22

Jugular Venous Pressure

• Jugular veins reflect?
• Level of JVP visibility gives an indication of?
• Which is better-External or internal jugular?

Answer 22

• Jugular veins reflect the activity of the right side of the heart
• Level of JVP visibility gives an indication of the RAP
• Internal jugular is better than external jugular

Question 23

• How do you obtain the JVP?
• Normal JVP range?
• Estimate of?

Answer 23

• Place patient in supine position to allow veins to engorge, then raise to 30-45 degrees
• Normal JVP is 0-9
• Estimate of CVP

Question 24

Most common cause of an elevated JVP?

Answer 24

Elevated RV diastolic pressure

Question 25

A wave | -What is going on when you see this wave?

Answer 25

- R atrial contraction - TV open - Coincides with S1 - Precedes carotid pulsation

Question 26

Giant A wave seen in?

Answer 26

- Obstruction between RA and RV (T.S., right atrial myxoma) - Increased pressure in RV (P.S.?) - Pulmonary hypertension - Recurrent pulmonary emboli - A-V dissociation (complete heart block, V.T.) (cannon A waves) RA contracts against the closed TV

Question 27

C Wave | -What is going on when you see this wave?

Answer 27

Backward push by closure of TV during isovolumetric systole and by impact of carotid artery adjacent to the JV

Question 28

X wave- X slope - What is going on when you see this wave? - Steep X descent seen in?

Answer 28

- Passive atrial filling and atrial relaxation - Blood flows into the RA from the cava and closure of TV - Steep X descent in cardiac tamponade and constrictive pericariditis

Question 29

V wave - What is going on when you see this wave? - Prominent V wave in?

Answer 29

- Atrial filling - Increasing volume and pressure in RA when TV closed - Prominent V wave in TR and pulmonary hypertension

Question 30

Y slope or Y descent - What is going on when you see this wave? - Deep Y descent in? - A slow Y descent suggests?

Answer 30

- Open TV and rapid RV filling in RV diastole - Deep Y descent in severe TR - A slow Y descent suggests obstruction to RV filling (i.e. TS or RA myxoma)

Question 31

Increased JVP in?

Answer 31

- SVC obstruction - Severe heart failure - Constrictive pericariditis, cardiac tamponade, RV infarction - Restrictive cardiomyopathy

Question 32

Positive HJR in?

Answer 32

- Poorly compliant RV, RV failure - Constrictive pericarditis - Obstructive RV filling by TS or RA tumor

Question 33

Cardiac cycle | -Systole?

Answer 33

Ventricular contraction, ejection

Question 34

Cardiac cycle | -diastole?

Answer 34

Ventricular relaxation, filling

Question 35

Abnormal heart sounds - S3 - Due to?

Answer 35

-Due to high pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase

Question 36

Abnormal heart sounds - S3 - Physiologic (normal) in?

Answer 36

Children or young adults

Question 37

Abnormal heart sounds - S3 - Pathologic in?

Answer 37

People over 40 years old

Question 38

Abnormal heart sounds - S3 - What does the rhythm sound like?

Answer 38

Ken-Tuck-Y

Question 39

Abnormal heart sounds - S4 - What is it?

Answer 39

-Atrial gallop from forceful contraction of atria against a stiffened (low compliant) ventricle

Question 40

Abnormal heart sounds - S4 - Can be normal in?

Answer 40

Trained athletes

Question 41

Abnormal heart sounds - S4 - What does the rhythm sound like?

Answer 41

Ten-Nes-See

Question 42

S1 | -2 components?

Answer 42

MV and TV closure

Question 43

S1 | -When does it occur relative to the cardiac cycle?

Answer 43

Occurs at the beginning of systole

Question 44

S1 | -At which part of the heart is it loudest?

Answer 44

Apex of the heart

Question 45

S2 | -1st component?

Answer 45

Aortic valve closure

Question 46

S2 | -2nd component?

Answer 46

-Pulmonic valve closure

Question 47

S2 | -At which part of the heart is it loudest?

Answer 47

-Loudest at the base of the heart

Question 48

S2 | -When does it occur relative to the cardiac cycle?

Answer 48

Occurs at the end of systole

Question 49

Slide 31?

Answer 49

?

Question 50

Heart sounds-location | -mitral?

Answer 50

- Apex of heart | - ***5th left ICS at mid-clavicular line***

Question 51

Heart sounds-location | -tricuspid?

Answer 51

-4th left ICS at LSB

Question 52

Heart sounds-location | -Aortic valve?

Answer 52

2nd ICS to the right of the sternum

Question 53

Heart sounds-location | -pulmonary valve?

Answer 53

2nd ICS to the left of the sternum

Question 54

Murmurs grading system | -Grade 1

Answer 54

Barely audible

Question 55

Murmurs grading system | -Grade 2?

Answer 55

Soft but easily heard

Question 56

Murmurs grading system | -Grade 3?

Answer 56

Loud without a thrill

Question 57

Murmurs grading system | -Grade 4?

Answer 57

Loud with a thrill

Question 58

Murmurs grading system | -Grade 5?

Answer 58

Loud with minimal contact between stethoscope and chest-thrill

Question 59

Murmurs grading system | -Grade 6?

Answer 59

Loud can be heard without a stethoscope-thrill

Question 60

Palpation of peripheral arteries (Rate-Rhythm-Amplitude) | -Grading peripheral pulses-scale?

Answer 60

``` 0-4/4 Bil. 0-absent 1-barely palpable 2-average intensity 3-strong 4-bounding ```

Question 61

Should probably know the upper and lower palpable pulses

Answer 61

Slides 36-39

Question 62

Capillary refill time | -Used to assess?

Answer 62

Digital perfusion

Question 63

Capillary refill time | -How do you do it?

Answer 63

- Patient's hands at heart level - Palms down - Doc presses on nail bed until it turns pale then lets go

Question 64

Capillary refill time - Normal? - Should also check?

Answer 64

- Less than 2 seconds | - Should also check skin color and turgor

Question 65

Edema-3 places to examine?

Answer 65

dorsum of foot, behind medial malleolus, anterior tibia (shin)

Question 66

Stethoscope | -Bell (small part)-used to hear what types of sounds?

Answer 66

Low pitched sounds (S3, S4, MS, carotid bruit)

Question 67

Stethoscope | -Diaphragm (large part)-used to hear what types of sounds?

Answer 67

High pitched sounds (S1, S2, AR, MR, friction rubs)

Question 68

Normal characteristics of the PMI?

Answer 68

- Should be a small, brisk beat and measure less than 2.5 cm - Should last through the first 2/3 of the systolic period (or less) - It should not be felt through the second heart sound

Question 69

Systolic murmurs fall between which heart sounds?

Answer 69

S1 and S2

Question 70

Diastolic murmurs fall between which heart sounds?

Answer 70

S2 and S1

Question 71

Assessment of carotid pulse - Where do you feel for this? - Assess for? - What should you not do?

Answer 71

- Medial to the SCM - Assess for thrills and bruits - DO NOT assess both carotid pulses simultaneously (could cause the patient to faint)

Question 72

Edema | -Graded on 4 point scale

Answer 72

``` 0-absent 1-barely detectable, slight or non-pitting-2mm 2-slight indentation-4mm 3-deeper indentation-6mm 4-very marked indentation-pitting-8mm ```