08-0803101300 - Cardio - Physical Exam and Heart Sounds (Yonts)

1. cyanosis
2. capillary refill (> 2s in pediatric indicates early signs of shock)
3. clubbing
4. xanthomata (indicate hypercholesterolemia)
5. osler's nodes
6. janeway lesions
7. splinter hemorrhages (reddish-brown lines in the nail bed)

1. congenital cyanotic heart disease (most common heart disease)
2. atrial myxoma
3. subacute bacterial endocarditis
4. right-to-left shunting

both are manifestations of endocarditis. both are uncommon.

janeway lesions are painless, purple lesions on palms or souls

osler's nodes are painful lesions on the pulp of the finger, toes, palms, and soles

warts on the face, palms, soles, knees, hands, and surrounding tendons

diastolic blood pressure increasing to greater than 120 mmHg causes fibrinoid necrosis.

AV nicking occurs where an arteriole is fibrotic and hard and the vein that this arteriole shares a common sheath with is compressed and distally dilated. It's occlusive, duh.

cotton wool spots indicate CV ischemic infarcts. they cause thickening and swelling of terminal nerve fibers and show up as fluffy lesions.

retinal hemorrhages look like bruises on the retina and can be caused by hypertension

copper wiring is a fundoscopic finding in CV pathology where the retinal vessels are transparent and have a light reflex. atherosclerosis causes this and the retinal vessels enlarge and the copper wiring look is exaggerated.

lipid deposition from leaking capillaries cause hard exudates that show as small patches with sharply defined borders on the retina.

ausculatating the renal arteries for bruits and subsequent loss of blood flow.

BUN and creatinine monitoring allows us to see protein spilling into the urine caused by HTN (among other things).

left sided heart failure causes pleural effusion. parenchymal edema can also occur and rales or crackles in the bases often indicates cardiac dysfunction. basal congestion in the lungs and congestion around the heart can be seen on xray.

The pt lays in the supine position for at least 5 minutes, stands, and a second BP is immediately taken. A 20 mmHg systolic drop and a 10 mmHg diastolic drop is positive. An increase of the HR by 10 bpm is also (+).

The pt lays in the supine position for at least 5 minutes, stands, and a second BP is immediately taken. A 20 mmHg systolic drop and a 10 mmHg diastolic drop is positive. An increase of the HR by 10 bpm is also (+).

aortic stenosis

aortic regurgitation

paradoxical pulse increases in expiration and decreases in inspiration and is often a sign of tamponade, constrictive pericarditis or COPD.

edema

pitting edema is rated by pressing on the dependent area (usually the anterior tibia) for 2 to 3 seconds and then rating from 1+ to 4+.
1+ (<=2mm) is mild edema
2+ (<=4mm) is moderate edema
3+ (<=6mm) is some edema, legs clearly puffy
4+ (<+8mm) is some edema, legs clearly swollen

push over the liver with the patients mouth open and hold for at least 10 seconds. a positive test will be jugular venous distention throughout the 10 seconds. a pt with an overdistended system will not be able to compensate fast enough to not show.

thrills, heaves, or lifts can be felt by palpating at the PMI. when evaluating a murmur, one can often feel a thrill at the PMI that is pathological.

identify the PMI while they are supine @ 30 degrees. roll pt onto left side and wait for tissue to settle to bring PMI as close to the surface as possible.

1. identify S1 and S2 and sync with pulse to ID S1
2. identify regular, irregular, or regular with ectopic beats
3. evaluate for extra sounds/gallop (S3, S4)
4. evaluate for murmurs

at the apex or at the tricuspid and mitral sites... um... it's because the tricuspid and mitral vector project in a similar direction and S1 is the sound of the mitral valve closing.

near the base or in the aortic and pulmonic sites because the aortic and pulmonic project toward the base and the S2 sound is the aortic valve closing.

is the rhythm regular or irregular

S1 splitting is normal due to asynchronous funciton of th eAV valves but could be accentuated by a RBBB.

this is a normal finding in pts less than 40 and a change in systemic and pulmonic pressures cause a prolonged right and shortened left valve closure which increases right sided afterload and decreases left sided afterload.

a fixed split occurs during inspiration and expiration often caused by conditions that delay pulmonic closure or cause aortic valve to close early such as atrial septal defects. additionally, mitral insufficiency, ventricular septal defect, complete RBBB and complete LBBB can also cause this phenomenon.

this is splitting in inspiration only where aortic closure is delayed later than pulmonic. when pulmonic pressure increases during inspiration, pulmonic closure is delayed and the sounds rejoin.
1. delayed aortic closure is caused by LBBB, HTN CV disease, hypertrophic cardiomyopathy, or atheroclerotic heart disease

2. early pulmonic closure is most commonly caused by early activation of the right ventricle (aka Wolff-Parkinson White)

S3

left ventricular impairment or rapid ventricular filling secondary sometimes to CHF

decreased compliance or increased stiffness caused by systemic HTN and possibly hypertrophic cardiomyopathy.

prolaps of the AV leaflets because of paillary muscle dysfunction. most commonly the click of mitral valve prolapse and less commonly aortic or pulmonic valves will snap open late once pressure builds up indicating stenosis.

most are benign, but hypertrophic cardiomyopathy (HCM) can seem benign.

all diastolic murmurs are pathologic, so sqatting should decrease HCM murmur and standing/valsalve should increase HCM.

differential POWER!

systolic (1-6)
diastolic (1-4)

1, 2 - low intensity. 1 - audible to experienced listeners. 2 - audio to inexperienced listeners

3, 4 - medium. 3 - w/o thrill. 4 - w thrill.

5, 6 - loudest. 5 - audible only w/ stethoscope on chest. 6 - audible with stethoscope off chest.