[05.01b] History and Physical Examination of the Cardiovascular System (Part 2) V2.2.pdf

Position of the patient, Facies, Edema in the legs, Jaundice

What four findings should be checked for upon inspection as a patient enters the room?

Lying at a reclining angle (30º, 40º, or 50º)

What position would an orthopneic patient in the ER likely be in?

The apex, heaves, and thrills

What three things are necessary to know to begin palpation, according to Dr. Guerrero?

Point of maximal impulse (PMI)

What does the apex beat represent?

5th intercostal space (ICS), left midclavicular line (MCL)

Where is the point of maximal impulse (PMI) usually located?

Left ventricular (LV) enlargement

What condition is characterized by the lateral and downward displacement of the apex towards the left anterior axillary line and 6th ICS?

Right ventricular (RV) enlargement

What condition is characterized by the lateral and upward displacement of the apex towards the left anterior axillary line and 4th ICS?

Upward movement detected within 2-3 intercostal spaces

What defines a heave or lift, distinguishing it as "more than an impulse"?

Left parasternal border

Where is the thrust of a Right Ventricular (RV) heave directed?

MCL and the axillary line

Where is the thrust of a Left Ventricular (LV) heave directed?

Abnormal flow over a tight area

What does a thrill represent?

A higher grade of murmur

What does a thrill represent in terms of murmur intensity?

Systolic thrills

Which type of thrill is more commonly appreciated?

S1 and S2 (Systolic), S3 and S4 (Diastolic)

What are the four main heart sounds that should be assessed?

Timing, Intensity, Duration, and Location

What four characteristics of murmurs should be assessed during cardiac auscultation?

Before S1

When does a diastolic murmur occur relative to S1?

After S1

When does a systolic murmur occur relative to S1?

To find where the maximum sound can be appreciated for a particular valve

What purpose do valve areas (or valvular areas) serve?

Right 2nd ICS

Where is the best anatomic location for auscultating the Aortic valve?

Left 2nd ICS

Where is the best anatomic location for auscultating the Pulmonic valve?

4th ICS, left parasternal border

Where is the best anatomic location for auscultating the Tricuspid valve?

Apex area (5th ICS, left MCL)

Where is the best anatomic location for auscultating the Mitral valve?

Always Pray To Mary

What mnemonic can be used to recall the valve areas?

Aortic regurgitations

Which valve lesion is best heard over the right side, specifically the right 2nd ICS?

Aortic stenosis

A systolic murmur over the 2nd ICS would likely be indicative of what condition?

Mitral stenosis

A diastolic murmur best heard at the apex would likely be indicative of what condition?

Mitral regurgitation

Which specific murmur can be heard radiating towards the axilla?

Mitral stenosis

Which specific murmur is a diastolic murmur?

Mitral regurgitation

Which specific murmur is a systolic murmur?

Patients with valvular pathologies

In which patients are murmurs only heard, according to Dr. Guerrero?

Closure of the mitral and tricuspid valves

What mechanical event does the First heart sound (S1) represent?

Closure of the aortic and pulmonic valves

What mechanical event does the Second heart sound (S2) represent?

Diastole

When can S3 and S4 be heard?

Atrial contraction (last ⅓ of diastole)

What mechanical event does S4 represent?

S2 to S1

What time period defines Diastole?

S1 to S2

What time period defines Systole?

Period of rest or filling of the ventricle

Diastole is the period of what?

Rapid filling phase

What is the first ⅔ of diastole (S2 to S3-S4) called?

Passive filling of the atrium to the ventricle

What occurs during the rapid filling phase of diastole?

Y-descent

What JVP wave does the rapid filling phase (S2 to S3-S4) correspond to?

A-wave (atrial contraction)

What JVP wave does S4 correspond to?

Inspiration

When does the physiological splitting of S2 occur?

Increased flow towards the right side from the jugular vein, SVC, and IVC

What causes the normal delay in pulmonic valve closure during inspiration?

The pulmonic valve closure is delayed

What causes S2 to be split during normal inspiration?

Diaphragm

What part of the stethoscope is used to observe S2 splitting at the left ICS?

Ventricular contraction

What mechanical action produces S1?

Negative pressure that sucks blood back from the aorta and pulmonary artery

What action occurs during ventricular relaxation that produces S2?

Mitral and tricuspid areas (at the apex)

Where can a normally loud S1 be heard?

Aortic and pulmonic area (to the 2nd ICS)

Where can S2 be heard slightly louder compared to S1?

Low quality of heart contraction (low contractility)

What condition might a soft S1 indicate?

Heart failure, incompetent valve/papillary muscles (e.g., mitral regurgitation), or myocardial infarction (MI) of the anterior wall

What three conditions are seen when the valve distance is closer, producing a softer S1/S2?

Left-sided valves (mitral and aortic)

Which heart valves close earlier than the right-sided valves?

Higher pressure on the left side of the heart

Why do left-sided valves close earlier than right-sided valves?

Mitral and tricuspid valves

What two valves close first in the sequence of valve closure?

Delay in the closure of the pulmonic valve

What happens when pulmonary pressure is high?

Rapid heart action (e.g., exercise, anemia, hyperthyroidism) or mitral stenosis

What two situations cause an accentuated or louder S1?

Delayed conduction from atria to ventricles (first degree heart block) or calcified/immobile mitral valve (mitral regurgitation)

What conditions cause a Diminished S1?

Complete heart block or any totally irregular rhythm (e.g., atrial fibrillation)

What two conditions cause a Varying S1 intensity?

Tricuspid area

Where may S1 normally be split, making the tricuspid component audible?

S4 or to an early systolic ejection click

What two things can cause an apparently split S1 heard easily at the apex?

Low-pitched

What is the relative pitch of S4?

Bell

What part of the stethoscope is S4 better heard with?

Apex

Where is S4 usually heard (location)?

High-pitched

What is the relative pitch of a Split S1's components?

Diaphragm

What part of the stethoscope is a Split S1 better heard with?

Tricuspid area

Where is a Split S1 usually heard (location)?

High-pitched

What is the relative pitch of an Ejection Click?

Diaphragm

What part of the stethoscope is an Ejection Click better heard with?

Aortic area and at the apex

Where is an Aortic ejection click usually heard?

2nd or 3rd left ICS

Where is a Pulmonic ejection click usually best heard?

Normal splitting is accentuated by inspiration and usually disappears on expiration

What are the respiratory characteristics of Physiological Splitting of S2?

Pulmonic stenosis or right bundle branch block (RBBB)

What two conditions cause Wide Splitting of S2 due to delayed closure of the pulmonic valve?

Mitral regurgitation

What condition can also cause Wide Splitting of S2 due to early closure of the aortic valve?

Wide splitting that does not vary with respiration

What defines Fixed Splitting of S2?

Atrial septal defect (ASD) and right ventricular failure

What two conditions cause Fixed Splitting of S2?

Splitting that appears on expiration, disappears on inspiration

What defines Paradoxical Splitting of S2?

Left bundle branch block (LBBB)

What is the most common cause of Paradoxical Splitting of S2?

Arterial hypertension and aortic valve syphilis

What two conditions cause an increased intensity of S2 in the aortic area?

Aortic stenosis

What condition causes a decreased intensity of S2 in the aortic area?

Pulmonary hypertension (HTN)

Increased intensity of the pulmonic component of S2 suggests what condition in patients with cor pulmonale or any condition causing pulmonary HTN?

Pulmonic stenosis

What condition causes a decreased intensity of the pulmonic component of S2?

Opening Snap

What very early diastolic sound is produced by the opening of a stenotic mitral or tricuspid valve?

Mitral stenosis

When of mitral origin, what does an Opening Snap signify?

It is earlier, sharper, and higher in pitch than an S3

How does an Opening Snap differ from S3?

Lub-duh-dub

What is the sound pattern described for an Opening Snap?

Children and young adults

In whom is a Physiological S3 frequently heard?

Early in diastole during rapid ventricular filling

When does S3 occur?

Dull and low pitched

What are the qualities of S3?

Apex in the left lateral decubitus position

Where is S3 best heard?

Myocardial failure

What does a pathological S3 (ventricular gallop) usually indicate in an older person?

Volume overloading of a ventricle (e.g., aortic, mitral, or tricuspid regurgitation)

What conditions can less commonly produce a pathological S3?

Lower left sternal border

Where is a right-sided S3 best heard, often becoming louder on inspiration?

Just before S1

When does S4 (atrial sound or atrial gallop) occur?

Low pitched and best heard with the bell

What are the qualities of S4?

Increased resistance to ventricular filling following atrial contraction

What is S4 related to?

Hypertensive cardiovascular disease, coronary artery disease, myocardiopathy, or aortic stenosis

What conditions can cause a left-sided S4?

Lower left sternal border

Where is a right-sided S4 heard?

Pulmonic stenosis and cor pulmonale

What two causes are listed for a right-sided S4?

Atrial contraction

S4 is never heard in the absence of what event, such as in atrial fibrillation?

Luh-lub-dub

What is the sound pattern described for S4?