Tutorial 1- Cardiac Examination

Question 1

If a patient complains of SOB, what 3 things do you want to know?

Answer 1

1. Exercise tolerance
2. SOB lying down (orthopnea)
3. SOB waking you from sleep
   (Paroxysmal nocturnal dyspnea)

Question 2

If you suspect a cardiac problem, what 5 signs/symptoms could you look for?

Answer 2

1. Chest pain/epigastric pain
2. Pain radiating to left jaw/arm
3. SOB (dyspnea)
4. Diaphoretic
5. Syncope (fainting)

Question 3

If a patient has xanthelasma or corneal arcus, what does that tell you?

Answer 3

They have high cholesterol (hypercholesterolemia)

Question 4

What does the JVP waveform and hepatojugular reflux tell you?

Answer 4

Right heart failure

Question 5

What does IPA stand for?

Answer 5

Inspect, palpate, auscultate

Question 6

How do you palpate for heaves?
What does a heave tell you?

Answer 6

Place palm on left chest, fingers off firm.
Fingers move, palm feels banging = right ventricular hypertrophy

Question 7

What are thrills?
What will they feel like on palpation?

Answer 7

Heart murmurs felt as vibration

Question 8

When palpating the apex beat, what are you looking for?

Answer 8

Checking for lateral displacement indicating ventricular hypertrophy or acute MI

Question 9

When auscultating in the cardiac examination, what are we auscultating?

Answer 9

Carotid, heart valves and lungs

Question 10

When listening to heart sounds,
What do S1 and S2 sounds represent?

Answer 10

1. S1 is the closing of the atrioventricular valves during systole
2. S2 is the closing of the semilunar valves during diastole

Question 11

What is an S3 heart sound?
How is it described?
Where do you find it?

Answer 11

Extra heart sound after S2.
Ken-tu-cky
Cardiac apex (5th intercostal space, mid clavicle at the mitral valve with the bell of the stethoscope)

Question 12

What is the cause of the S3 sound?
What can an S3 sound indicate?

Answer 12

Compliant ventricle

Benign in young people, athletes and pregnancy

May signify atrioventricular regurgitation, heart failure or cardiomyopathy

Question 13

Where is the S4 sound best heard?

Answer 13

At the apex beat with the bell of the stethoscope

Question 14

What does an S4 sound indicate?

Answer 14

Diastolic heart failure, Severe left ventricular hypertrophy resulting in a non compliant ventricle or active cardiac ischemia.

Question 15

When do you hear the S4 sound and what does it sound like?

Answer 15

Before S1. Tennessee.

Question 16

What does a murmur sound like with a stethoscope?
What does a murmur signify?

Answer 16

Whooshing sound.
Mitral/tricuspid (atrioventricular) regurgitation or ventricular septal defects.

Question 17

Where is the best point of auscultation to hear tricuspid regurgitation?

Answer 17

4th intercostal space, lower left of sternum (T)

Question 18

Where is the best point of auscultation to hear mitral regurgitation?

Answer 18

Apex beat, 5th intercostal space, mid clavicle

Question 19

Where is the best point of auscultation to hear ventricular septal defect?

Answer 19

3rd/4th intercostal space left of sternum

Question 20

What could a murmur indicate?

Answer 20

Ischemic heart disease, rheumatic fever, mitral valve prolapse.

Question 21

Which auscultation point would you best hear aortic stenosis?

Answer 21

2nd intercostal space, right of sternum, over aortic valve.

Question 22

With an aortic stenosis murmur, besides auscultation of the aortic valve, what 2 other sites can you check that will indicate the same thing?

Answer 22

Carotid artery whoosh and peripheral pulse delay

Question 23

What does aortic stenosis indicate?

Answer 23

A calcified aortic valve.

Question 24

When auscultating lung sounds from the front, which anatomical sites do we use?

Answer 24

Apex - above each collar bone
Upper Mid - 2nd intercostal spaces
Lower mid - 4th intercostal spaces
Base - 6th intercostal spaces
Base - back 8th intercostal spaces

Question 25

Describe vesicular lung sounds.

Answer 25

Soft, low pitch, rustling with longer inspiration than expiration.

Question 26

What do wheezes sound like on auscultation?

Answer 26

High pitch, continuous whistling on expiration. Longer expiration than inspiration.

Question 27

Which cardiac condition results in wheezes on auscultation?

Answer 27

Cardiogenic APO (interstitial fluid causing bronchial swelling)

Question 28

How would you describe crackles in the lungs on auscultation? Where would you hear it best?

Answer 28

Low pitched, discontinuous popping on inspiration at the bases.

Question 29

What causes crackles in the lungs?

Answer 29

The surfactant and fluid mix and alvioli stick together. The crackle is the snapping open of the alvioli on inspiration.

Question 30

What cardiac condition will you hear crackles on auscultation?

Answer 30

Cardiogenic APO in left sided heart failure

Question 31

When palpating and percussing the liver, what are you looking for?

Answer 31

Liver distension due to fluid backing up from the right heart

Question 32

When palpating the epigastric region, what are you feeling for?

Answer 32

Pulsations wider than 3cm indicating an aortic aneurism

Question 33

What does sacral pitting oedema indicate? How long do you palpate for?

Answer 33

Right sided heart failure. 6 seconds

Question 34

When inspecting a patients hands/arms, you find they are cool, pale, disphoretic, they have a cap refill over 2 seconds and a weak radial pulse. What does this indicate?

Answer 34

Poor perfusion status

Question 35

What would unequal strength radial pulses indicate?

Answer 35

Aortic dissection

Question 36

What does clubbing indicate? What do osler nodes, janeway lesions and splinter haemorrhage indicate?

Answer 36

COPD which complicates cardiac conditions. Infective endocarditis.

Question 37

1. You find radiofemoral delay. What condition does this indicate? 2. If femoral pulse is absent what would this indicate?

Answer 37

1. Aortic coarctation 2. Shock or ruptured AAA/aortic dissection