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PMI is normally found in the _________
Left 5th ICS at MCL
The PMI is approx. ______cm
1-2.5 cm
Heart sound of the abrupt deceleration of inflow across the mitral valve
S3
Heart sound of the increased left ventricular stiffness which decreases compliance
S4
2nd ICS RSB
Aortic area
2nd ICS LSB
Pulmonic area
3rd ICS LSB
Erb's point
4th ICS LSB
Tricuspid area
5th ICS left MCL
Mitral area
Patient position for a cardiac exam
Supine with head elevated 30-45 degrees
You should auscultate over the mitral valve with the ______ of the stethoscope
Bell
Aortic murmurs are head with the _______ of the stethoscope
Diaphragm
Palpate the RV in the __________
Left lower sternal border/subxiphoid area
Leaning forward and full exhalation accentuates __________ murmurs
Aortic
What position accentuates S3, S4, and mitral murmurs?
Left lateral recumbent
The _____ is used to listen for low-pitched sounds
Bell
The _____ is used to listen for high-pitched sounds
Diaphragm
Bell or Diaphragm: Mid-diastolic murmur of mitral stenosis
Bell
Bell or Diaphragm: S3 in HF
Bell
Bell or Diaphragm: Ejection clicks
Diaphragm
Bell or Diaphragm: Mid-systolic clicks
Diaphragm
Bell or Diaphragm: Early diastolic murmur of aortic regurgitation
Diaphragm
Rash associated with acute rheumatic fever, wavy margins and truncal distribution
Erythema marginatum
Erythema marginatum is associated with ________
Acute rheumatic fever
Subcutaneous nodules over the bony prominences of the elbow in a patient with chronic rheumatic heart disease from previous rheumatic fever
Aschoff bodies
Aschoff bodies can also be seen with __________
Rheumatic fever, Gout, syphilis, RA
Small, painless nodules caused by minute, septic emboli
Janeway lesions
Janeway lesions are associated with _______
Bacterial endocarditis
Painful erythematous nodular lesions resulting from infective endocarditis
Osler nodes
Osler nodes are associated with __________
Infective endocarditis
Splinter hemorrhages are associated with ________
Acute bacterial endocarditis
Funnel chest
Pectus excavatum
Bird chest
Pectus carinatum
Pectus excavatum is seen in 20% of cases of _______
MVP
The JVP reflects pressure in the ________
Right atrium (central venous pressure)
The JVP is best assessed from pulsations in the __________
Right internal jugular vein
What JVP wave:
Positive wave due to the contraction of the right atrium
A wave
What JVP wave:
A positive deflection due to bulging of the tricuspid valve toward the atria at the onset of ventricular contraction
C wave
What JVP wave:
Negative deflection due to atrial relaxation
X wave
What JVP wave:
Positive deflection due to filling of the right atrium against the closed tricuspid valve during ventricular contraction
V wave
What JVP wave:
Negative deflection due to emptying of the right atrium upon ventricular
Y wave
An absent A wave may indicate ____
Afib
An increased V wave may indicate _______
Tricuspid regurgitation, ASD, constrictive pericarditis
An increased A wave may indicate _______
Tricuspid stenosis, AV blocks, SVT, junctional tachy, pulmonic stenosis
What JVP wave: atrial contraction
A wave
What JVP wave: Ventricle contraction
C wave
What JVP wave: Atrial relaxation
X wave
What JVP wave: Atrial filling passively
V wave
What JVP wave: Blood from atrium to ventricle
Y wave
The JVP must be measured with the bed raised to ______
60 degrees
Abnormal JVP is ______ cm above the sternal angle
> 3 cm
Abnormal JVP is ______ cm above the right atrium
> 8 cm
Normal hepatojugular/abdominojugular reflex
≤ 3cm increase in the meniscus
Abnormal hepatojugular/abdominojugular reflex
≥ 4cm increase in the meniscus
The patient should be laying ________ to measure the hepatojugular/abdominojugular reflex
Supine at 20-40 degrees
Diffuse or widened PMI would indicate LV dilation seen in _________
Chronic volume overload
Sustained PMI would indicated pressure overload seen in _______
Aortic stenosis or HTN
What are other causes for PMI displacement?
Pregnancy, chronic lung disease, deformities of the thorax
Normal PMI diameter
≤ 2.5 cm
Normal PMI amplitude
Brisk and tapping
Normal PMI duration
≤ 2/3 of systole
A PMI with a diameter > 3cm indicates _______
LVH
Hypertrophy of PMI may palpate _____ gallop
S4
Dilation of PMI may palpate _____ gallop
S3
PMI amplitude is decreased in ________
Dilated cardiomyopathy
PMI amplitude is increased in ________
Exercise, hyperthyroidism, HTN, severe anemia
PMI duration is sustained in ______
LVH
If you cannot identify the PMI in the supine position, place the patient in the _______
Left lateral decubitus position and ask patient to exhale and hold
Palpate the chest for thrills with the ________
Metacarpal heads
Superficial vibratory sensations felt on the skin overlying a loud murmur
Thrill
When should you percuss the chest in a cardio exam?
If unable to feel the apical impulse
Where should you percuss when attempting to identify the apical impulse?
3rd, 4th, and 5th ICS starting from the left anterior axillary line moving towards the sternum
Diaphragm or bell: S1
Diaphragm
Diaphragm or bell: S2
Diaphragm
Diaphragm or bell: AR
Diaphragm
Diaphragm or bell: MR
Diaphragm
Diaphragm or bell: VSD
Diaphragm
Diaphragm or bell: Pericardial friction rub
Diaphragm
Diaphragm or bell: S3
Bell
Diaphragm or bell: S4
Bell
Diaphragm or bell: MS
Bell
S1 loudest at ______
Apex
S2 loudest at ______
Base
Systolic murmurs can be ______
Benign
Diastolic murmurs are ______
Pathologic
S1 is _______ than S2 at the base
Softer
S1 is _______ than S2 at the apex
Louder
Splitting of S1 occurs with _____
RBBB and Pulmonary HTN
Physiologic splitting of S2 is accentuated by ______
Inspiration
Physiologic splitting of S2 is loudest at the ______
Base 2nd ICS
If S2 is heard at the apex, or if P2 ≥ A2, suspect ______
Pulmonary HTN
Causes for paradoxical splitting of S2
LBBB, AS
Cause for fixed splitting of S2
ASD
Causes for wide splitting of S2
PS, RBBB, MR, VSD, PDA
Low, Medium or High Frequency: MR
High
Low, Medium or High Frequency: TR
High
Low, Medium or High Frequency: AR
High
Low, Medium or High Frequency: VSD
High
Low, Medium or High Frequency: MS
Low
Low, Medium or High Frequency: TS
Low
Note 
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