Pe: Cardiovascular Exam

Front 1

Use the bell of the stethoscope, with firm pressure, to pick out these sounds

Back 1

To hear *high-pitched sounds of S1 and S2, murmurs of aortic and mitral regurgitation, a pericardial friction rubs* use this

Front 2

Use the diaphragm of the stethoscope, maintaining light pressure, to pick out these sounds

Back 2

To hear *low-pitched sounds of S3 and S4 and the murmur of mitral valve stenosis* use this

Front 3

Diastole - what happens

Back 3

During this phase, pressure in the blood-filled atria exceeds that in the relaxed ventricles and blood flows from the atria to the ventricles across the atrio-ventricular valves. Just before the onset of systole, atrial contraction produces a slight pressure rise in all chambers

Front 4

AV valves

Back 4

Tricuspid (on right) and Mitral (on left)

Front 5

Systole - what happens

Back 5

During this phase, the ventricle starts to contract and ventricular pressure rapidly exceeds atrial pressure, causing the closure of the AV valves and forcing the aortic valve open (when the pressure exceeds that of the aorta). The ventricular pressure falls as the ventricle ejects blood until it falls below that of atrial pressure causing the aortic valve to shut.

Front 6

S1 is the sound of what

Back 6

AV valve closing at the start of systole produces this sound

Front 7

S2 is the sound of what

Back 7

Aortic valve closing at the end of systole produces this sound

Front 8

What is an early systolic ejection sound

Back 8

In pathologic conditions this sound accompanies the opening of the aortic valve during systole

Front 9

S1 starts and S2 ends this phase

Back 9

Systole starts and ends with these sounds

Front 10

S2 starts and S1 ends this phase

Back 10

Diastole starts and ends with these sounds

Front 11

What is physiologic splitting of S2

Back 11

Sounds A2 and P2 are heard, separate, just after S1 but only during inspiration

Front 12

In what patients can you hear an *S2 split* the best and most often

Back 12

*Young patients* have this physiological finding often

Front 13

What is splitting of S1

Back 13

M1 and T1 are harder to hear and do not vary with respiration - asynchronous closing of the valves can be physiological

Front 14

Characteristics of S3 and S4

Back 14

These sounds are lower-pitched and will sound louder upon exertion

Front 15

S3 - when and where to listen?

Back 15

This sound occurs early in diastole and is best heard at the apex or at the left lower sternal border

Front 16

When is S3 normal or pathological?

Back 16

This sound is pathological when the patient is >40 years old

Front 17

S4 - when and where to listen?

Back 17

This sound occurs late in diastole and is best heard at the apex with the patient supine or in left lateral decub position

Front 18

When is S4 normal or pathological?

Back 18

This sound is pathological when patient is >20 years old and is due to ventricles receiving increased diastolic volume or if the ventricles have decreased compliance

Front 19

What is a pathological opening snap

Back 19

If the mitral valve leaflets have restricted motion, such as in stenosis, this sound will be audible when the mitral valve opens

Front 20

How the position of the patient influences JVD

Back 20

Regardless of the patient's elevation the sternal angle remains 5cm atop the right atrium - the position of the patient is varied so that the "top" of the internal jugular vein can be seen - start at 30 degrees and move up or down as necessary to expose the top of the vein

Front 21

What does Jugular venous pressure represent?

Back 21

The right atrial pressure, which in turn equals central venous pressure and right ventricular end-diastolic pressure.

Front 22

Best anatomical place to assess JVP?

Back 22

The right internal jugular vein as it passes between the clavicular and sternal heads of the SCM

Front 23

How is JVP measured and what are the limits?

Back 23

The highest point of oscillation in the IJV is measured in vertical distance above the sternal angle; >4 is elevated and considered JV distension (JVD); low pressure is from hypovolemia

Front 24

JVD indications

Back 24

elevated JVP (JVD) happens in heart failure, pulmonary HTN, tricuspid stenosis, and pericardial compression or tampanade

Front 25

Normal location of the PMI (left border of the heart)

Back 25

In the 5th interspace, 7-9cm lateral to midsternal line, typically just at the midclavicular line

Front 26

Auscultate the aortic valve here

Back 26

At the right 2nd intercostal space

Front 27

Auscultate the pulmonic valve here

Back 27

At the left 2nd intercostal space

Front 28

Auscultate the tricuspid valve here

Back 28

At the left lower sternal border

Front 29

Auscultate the mitral valve here

Back 29

On the left at the 4th/5th intercostal spaces

Front 30

How are heart murmurs distinguished from normal heart sounds?

Back 30

These sounds will have a longer duration than a normal heart sound

Front 31

What is a midsystolic murmur

Back 31

This murmur begins after S1 and stops before S2 with brief gaps between the murmur and the heart sounds.

Front 32

What midsystolic murmurs typically arise from

Back 32

These murmurs arise from abnormalities in blood flow across the semilunar valves

Front 33

What is a pansystolic (holosystolic) murmur

Back 33

This murmur starts with S1 and stops at S2 without gaps between it and the normal heart sounds

Front 34

What pansystolic murmurs typically arise from

Back 34

These murmurs typically arise with regurgitant flow across the AV valves

Front 35

What is a late systolic murmur

Back 35

this murmur starts in mid to late systole and persists up to S2
This is mitral valve prolapse and is often preceeded by a systolic click

Front 36

What diastolic murmurs arise from

Back 36

Pathological processes: turbulence across the AV valves or regurgitant flow across semilunar valves

Front 37

Crescendo-decrescendo murmurs

Back 37

These murmurs are from aortic stenosis but can also be innocent flow

Front 38

Murmur for aortic insufficiency

Back 38

Early diastolic decrescendo murmur indicates this

Front 39

Grade 1 cardiac murmur

Back 39

Very faint murmur, heard only once the examiner has tuned in

Front 40

Grade 2 cardiac murmur

Back 40

Quiet murmur but heard immediately after placing the stethoscope on the chest

Front 41

Grade 3 cardiac murmur

Back 41

Moderately loud murmur

Front 42

Grade 4 cardiac murmur

Back 42

Loud murmur, with thrill

Front 43

Grade 5 cardiac murmur

Back 43

Very loud murmur, with thrill; may be heard when stethoscope is partly off the chest

Front 44

Grade 6 cardiac murmur

Back 44

Very loud murmur, with thrill; may be heard when stethoscope is entirely off the chest

Front 45

JVP in pediatric patients

Back 45

This is not discernible in pediatric patients