Cardiac Bugando

1. Stephen Gimple, MD, FACC
June 2022

2.  Blood pressure
 Pulse
 Respiratory rate
 Oxygen saturation

3.  At rest for 5-10 minutes prior to exam
 Arm should be at heart level
 Slow pressure release (<3mmHg per second)
 Correct cuff size
 First Korotkoff sound is systolic pressure; last
sound is diastolic

4.  Regular or irregular
 Regularly irregular vs irregularly irregular
 Rate
 Character: normal, bounding, thready, water-
hammer

5.  Breathing pattern
 Appear acutely ill, chronically ill, or well
 Mental status
 Physical development

6.  Diaphoresis
 Cyanosis
◦ Central- deoxygenated blood
◦ Peripheral- reduced blood flow
 Skin changes
◦ Jaundice
◦ Bronzing from hemochromatosis
◦ Chronic venous stasis changes from edema

7.  Edema from CHF or medications
 Warm or cool
 Capillary refill
 Clubbing from central shunting

8.  Internal jugular more reliable than external
 Best with patient reclined to 45 degrees, with
head slightly turned away from you
 Shine a light across the neck to help.
Lighting is important.

9.  Most important determination is
◦ Normal
◦ Elevated
 Vertical distance from sternal angle to top of
JVP should be less than 3cm.
 If above clavicle with patient sitting up, the
JVP is elevated.

10. JVP Carotid
 Biphasic (two peaks
and two troughs)
 Falls with inspiration
 Not palpable
 Can obliterate with
gentle pressure
 Monophasic:single
brisk upstroke
 No respiratory change
 Palpable
 Cannot be obliterated

12.  a wave: atrial contraction
 x descent: fall in right atrial pressure as atria
relaxes
 c wave: caused by ventricular systole pushing
closed tricuspid valve into atrium
 v wave: atrial filling
 y descent: fall in RA pressure after tricuspid
valve opens

15.  Best felt at carotid
 Also check radial, femoral, DP, PT
 Symmetry, volume, timing, contour, size, and
strength

17. Pulses parvus et tardus
What causes this?
Aortic Stenosis

18.  What is it?
◦ Drop in systolic blood pressure greater than
10mmHg with inspiration
 What causes it?
◦ Pericardial tamponade
◦ Massive pulmonary embolism
◦ Severe obstructive lung disease
◦ Tension pneumothorax

19.  Point of maximal impulse. Where?
◦ Mid-clavicular line
◦ 5th intercostal space
 How large?
◦ Smaller than 2cm in diameter
◦ Felt best at end expiration when heart is closest to
chest wall

21.  S1
◦ Closure of mitral and tricuspid valves
 S2
◦ Closure of aortic and pulmonic valves

22.  Physiologic
◦ A-P interval increases with inspiration and narrows
with exhalation
 Widened
◦ RBBB
 Fixed
◦ ASD (atrial septal defect)
 Paradoxical
◦ LBBB, severe aortic stenosis, HOCM

23.  Occurs during rapid filling of ventricle
diastole
 Normal in children and young adults
 Indicates systolic CHF in older adults
 Low pitched, heard best over apex or LLSB
 Heard best in left lateral decubitus position

24.  Occurs during atrial filling phase of
ventricular diastole (just before systole)
 Evidence of poorly compliant ventricle: left
ventricular hypertrophy or myocardial
ischemia.
 With what cardiac condition will you never
hear an S4?
◦ Atrial fibrillation

25.  Timing
◦ Systolic
◦ Diastolic
◦ Continuous
 Which type of murmur can be benign and
warrants no further evaluation?
◦ Systolic: innocent flow murmur
◦ 1-2/6, mid systolic murmur at left sternal border
with no other signs/symptoms of heart disease
◦ Worse during pregnancy

26.  Mitral regurgitation
 Aortic stenosis
 Hypertrophic obstructive cardiomyopathy
 Ventricular septal defect
 Tricuspid regurgitation
 Pulmonic stenosis

27.  Holosystolic murmur
 Often early in systole if acute
 Late systole if from mitral valve prolapse
 Is it heard anteriorly or posteriorly?
◦ Depends on the location of the jet, can be either.

28.  Crescendo-decrescendo
 The longer the murmur, the more severe
 Severe AS softens S2 and often covers over
S2.

29.  Right sided murmurs increase with
inspiration
 Left sided murmurs are louder during
expiration

30.  Most murmurs will get softer
 HOCM gets louder
 MVP may get longer and louder

31.  There is brief pause, so longer diastolic time,
so heart fills more
 Aortic stenosis or pulmonic stenosis will get
louder
 Systolic murmurs due to mitral regurgitation
or tricuspid regurgitation do not change.

32.  Murmur sounds like AS, but dynamic.
 Increases with maneuvers that decrease LV
filling such as Valsalva or standing.
 Squatting can make murmur disappear

33.  Aortic regurgitation
 Mitral stenosis
 Pulmonic regurgitation
 Tricuspid stenosis

34.  High pitched, decrescendo
 Early to mid diastolic murmur
 Left sternal border

35.  Heard over the apex, in left lateral decubitus
position
 Low pitched rumbling
 Often hear a opening snap
 Mid to late diastolic murmur
 Can have presystolic accentuation (gets
louder during atrial contraction due to
increased flow)

36.  Patent ductus arteriosus
 Ruptured sinus of valsalva aneurysm
 Arteriovenous fistula