PDII E3: cardio examination

What occupies most of the anterior cardiac surface?

RV

What lies behind just left of the sternum and join at the sternal angle?

RV and pulmonary artery

Where is the inferior border of the RV?

below the junction of the sternum and xyphoid process

What sits behind the RV?

LV

what creates the apex and produces the apical impulse?

tapered inferior tip of LV

where is PMI normally found?

left 5th ICS just medial to MCL

(approx 1-2.5 cm)

What lies above the heart?

great vessels- PA, SVC, aorta

what are pathologic, diastolic sounds that are correlated w/ HF and AMI?

S3 & S4

what sound is an abrupt deceleration of inflow across the mitral valve?

S3

what sound is an increased LV stiffness which decreases compliance?

S4

What position should the patient be in for the cardiac examination?

supine w/ head elevated 30-45 degrees

What area?

2nd ICS, R sternal border

aortic

What area?

2nd ICS, L sternal border

Pulmonic

What area?

3rd ICS, L sternal border

Erb’s point

What area?

4th ICS, L sternal border

Tricuspid

What area?

5th ICS, L midclavicular line

Mitral

What part of the stethoscope are you using to auscultate the mitral area in the left lateral decubitus position?

bell

How do you listen for the physiologic split of S2?

2nd and 3rd L ICS, ask pt to breath quietly and slightly more deeply than normal

How do you listen for murmur of aortic regurgitation?

Have pt sitting, lean forward, exhale completely and hold while auscultating over left sternal border and apex w/ diaphragm

When do you use the bell of the stethoscope?

low pitched sounds → mid diastolic murmur of MS, S3 in HF

when do you use the diaphragm of the stethoscope?

high pitched sounds → ejection, mid systolic clicks and early diastolic murmur of AR

what brings the apex of the heart closer to the chest wall and accentuates S2, S4, and mitral murmurs?

left lateral decubitus position

Sitting, leaning forward and full exhalation accentuates _____

aortic murmurs

What rash has wavy margins and truncal distribution and is assoc w/ acute rheumatic fever?

erythema marginatum

what are Aschoff bodies?

present over bony prominences of elbow in patients w/ chronic rheumatic heart dz from previous rheumatic fever, gout, syphilis, or RA

what are janeway lesions?

small, painless nodules caused by micro septic emboli (bacterial endocarditis)

what are Osler nodes?

painful erythematous nodular lesions that result from infective endocarditis

what are splinter hemorrhages?

hemorrhagic lesions / petechia seen w/ acute bacterial endocarditis

What would accentuate PMI or ventricular movements of S3/S4?

tangential lighting

What does JVP reflect?

pressures in RA (central venous pressure) best assessed from pulsations in right internal jugular vein

JVP is difficult to assess in _____

children under 12

What are visualized pulsations of the IJV from?

pressure changes from atrial filling, contraction, and emptying

What JVP waveform is positive wave due to contraction of RA?

A

What JVP waveform is a positive deflection due to bulging of tricuspid valve toward the atria at onset of ventricular contraction?

C

What JVP waveform is a negative deflection due to atrial relaxation?

X

What JVP waveform is a positive deflection due to filling of RA against the closed tricuspid valve during ventricular contraction?

V

What JVP waveform is a negative deflection due to emptying of the RA?

Y

What is an increased A wave associated with?

• tricuspid & pulmonic stenosis

• 1, 2, 3 degree AB blocks

• SVT

• junctional tachycardia

What might an absent A wave indicate?

A-Fib

What is an increased V wave seen in?

• tricuspid regurgitation

• ASD

• constrictive pericarditis

At Carter’s Xing Vehicles Yield

• Atrial contraction

• ventriCle Contraction

• atrial relaXation

• Atrial Villing passively

• blood from atrium to ventricle (Y not?)

How do you estimate JVP?

• find highest point of oscillation of IJV

• measure vertical distance from sternal angle (2nd rib joins the manubrium)

where is the sternal angle?

5cm above the RA, regardless of position of pt

How is JVP reported?

y + 5 = x

(y = measure; x = JVP)

If the bed is raised to 30 deg, the JVP …

cannot be measured bc meniscus is above jaw line

If the bed is raised to 60 deg, the JVP …

can be measured bc meniscus is visible

If the pt is upright, the JVP …

can’t be measured bc the veins are barely discernible above the clavicle

What is considered an elevated and abnormal JVP?

>3cm above sternal angle

>8cm above RA

obstructive lung dz will have an elevated venous pressure, but _____

the veins collapse on inspiration

How do you evaluate hepatojugular / abdominojugular reflex?

• pt supine at 20-40 degrees

• pressure applied above umbilicus for 30-60 s

• normal: ≤ 3 cm inc in meniscus

• abnormal: ≥ 4 cm inc in meniscus

what does a sustained impulse indicate?

pressure overload seen in aortic stenosis or HTN

what does a diffuse or widened PMI indicate?

dilatation of LV seen in chronic volume overload

what does a PMI > 3cm indicate?

LVH

When evaluating PMI, if hypertrophy you may palpate _____

S4 gallop

when evaluating PMI, if dilatation you may palpate ____

S3 gallop

PMI amplitude is _____ after exercise, in hyperthyroidism, HTN, or severe anemia.

increased

PMI amplitude is _____ in dilated cardiomyopathy.

decreased

How long into systole would a normal apical impulse last?

first 2/3s

What would an apical impulse that’s sustained through systole indicate?

LVH

What should you do if you cannot identify PMI w/ pt in supine?

plate pt in left lateral decubitus position and ask them to exhale fully and hold for a few seconds

What are heaves or lifts?

large area of sustained outward motion

what are thrills?

superficial vibratory sensations felt on skin overlying a loud murmur (like vibrating cell phone)

How do you palpate thrills?

with metacarpal heads

When palpating anterior chest wall, what would a marked increase in amplitude be seen in?

chronic volume overload of RV such as ASD or pulmonary HTN

Percussion is not typical in a cardiovascular exam. When would you use percussion?

if unable to feel the apical impulse bc it suggests where to search

Explain how you would use percussion to locate the apical impulse.

• percuss 3rd, 4th, and 5th ICS starting from left anterior axillary line and moving towards sternum

• note the distance form left sternal border at which resonance changes to dullness

• normal: ~6cm

How many different positions are you auscultating in?

4

(supine, sitting, leaning forward, and left lateral decubitus)

Where is S1 usually loudest?

at apex (tricuspid and mitral valve)

Where is S2 usually loudest?

at base (aortic and pulmonic valve)

what are distinct heart sounds that are distinguished by their pitch and their longer duration that is secondary to turbulent flow?

murmurs

which murmurs are almost always pathologic?

diastolic

When would splitting of S1 be heard?

only w/ coexisting RBBB and pulmonary HTN

Where and how would you hear physiologic splitting of S2?

• heard in pulmonic area

• loudest at base of 2nd ICS

• sound at the end of systole

• accentuated by inspiration

What should you suspect if splitting of S2 is heard at apex or P2 ≥ A2?

pulmonary HTN

S1 =

M1 + T1

S2 =

A2 + P2

when is S1 normally heard?

beginning of systole (softer at base, louder at apex)

What might be reasons for innocent/benign murmurs?

pregnancy, anemia, HTN, fever, hyperthyroidism

what are 3 things that impair forward blood flow?

• the pump fails; LV has been damaged → signs of HF

• the valve fails; blood goes in wrong direction → signs of valve failure

• the arteries are obstructed, preventing blood flow to tissues

what are mid systolic murmurs typically due to?

blood flow across the semilunar valves

innocent, physiologic, or pathologic (AS, HOCM, pulmonary stenosis)

What is a pansystolic murmur usually due to?

chamber of high pressure to low pressure through an incompetent valve (MR, TR, VSD)

Continuous murmurs through systole and diastole are typically ____

non-valvular

(venous hum, pericardial friction rub, PDA, AV fistula)

What murmurs are high frequency?

• MR

• TR

• AR

• VSD

What murmurs are low frequency?

• MS

• TS

What murmurs are medium frequency?

• AS

• PS

• HOCM

What grade murmur is very soft and not immediately apparent?

I

What grade murmur is soft but immediately audible?

II

What grade murmur is loud, but no palpable thrill?

III

What grade murmur is audible w/ palpable thrill?

IV

What grade murmur can be heard w/ stethoscope barely touching the skin and has a thrill?

V

What grade murmur can be heard w/ stethoscope not even touching the skin and has a thrill?

VI

what ssx correlate w/ murmurs?

• EKG changes

• extra heart sounds

• abnormal CXR (widened mediastinum, cardiomegaly)

• SOB

• CP

• palpitations

• advanced age

who are innocent systolic murmurs common in?

young adults

describe innocent systolic murmurs

• no evidence of physiologic / structural abnormalities in CV system

• almost always < grade 3 intensity (NOT assoc. w/ thrill)

• no radiation to the carotid arteries or axillae

• systolic ejection in nature

what conditions increase the forward flow therefore increase murmur intensity?

exercise, anxiety, fear, increased SV assoc w/ long diastolic filling after a premature beat

Intensity of ejection murmurs closely parallel ____

changes in CO

Causes of aortic stenosis?

• stenosis or narrowing of aortic valve

• causes LVH due to obstructed blood flow → LV enlarges and holds less blood

• causes: usually congenital, bicuspid aortic valve, rheumatic fever

where is aortic stenosis heard?

R 2nd ICS

what sx are associated w/ aortic stenosis?

• syncope

• angina

• dyspnea

• (SAD)

What tests should be performed for aortic stenosis?

ECHO or CT/MRI

shows dec mobility of aortic valve w/ small opening; valve often thickened and calcified