Cardiovascular examination quiz Part 1

The JVP height is measured from the manubriosternal angle. (link)

Calcification of aortic valve and aortic regurgitation cause a soft second heart sound. RBBB causes splitting of the first heart sound. (link)

The normal JVP height at 45 degrees is 1 – 3 cm (link).

In the sitting position with the head turned slightly away from the examiner, the normal JVP is best visualised medial to the clavicular head of the sternocleidomastoid. (link)

The accuracy of clinical examination when measuring the JVP within 2cm of its actual value is about 50% (link)

The specificity of the presence of a visible venous column above the clavicle in a patient sitting upright is approximately 85% and about 65% sensitive. (link)

Feature of the JVP that help to differentiate it from carotid pulsation includes;the venous pulse is not usually palpable; pressure over the base of the vein or over the liver (hepatojugular reflex) makes the vein more prominent; the venous pulse alters with changes in posture; the venous pulse usually decreases with inspiration; the venous pulse has a double impulse for each arterial pulsation; the venous pulsation is prominent during diastole and the vein fills from above. (link)

SVC obstruction usually has an absent venous waveform.(link)

Tricuspid regurgitation causes a combined c-v wave as the R atrial pressure is elevated throughout ventricular systole and is visible during all of systole. (link)

Pure concentric LV hypertrophy (as occurs in pure aortic stenosis) does not cause an increase in the external LV diameter until the AS becomes severe, so does not displace the apex beat in most cases. Displacement of the apex beat is 75% sensitive and 70% specific for cardiomegaly. (link)

VSD produces a murmur in 90% of cases, mitral regurgitation and aortic stenosis in 70% and aortic regurgitation in only 30%. (link)

A prolonged diastolic filling time (e.g.,1st degree HB), delayed ventricular systole (e.g., LBBB) or mitral regurgitation cause a soft first heart sound.

A 3rd heart sound is low pitched, early to mid diastolic and is caused by tautening of the mitral and tricuspid papillary muscles at the end of rapid diastolic filling. It is best heard with the bell of the stethoscope and a RVH H2 is best heard over the left sternal edge. I has a cadence similar to ‘Kentucky’ and may be physiological in children and young adults. (link)

The 3rd heart sound is only about 25% sensitive, but 95% specific, for LVF. It has a cadence like ‘Kentucky’ (Tennessee is the cadence of the 4th heart sound) and is caused by tautening of the mitral and tricuspid papillary muscles. Apart from LVF it is caused by aortic regurgitation, mitral regurgitation, VSD or patent ductus arteriosus. Hypertension causes a 4th heart sound. (link)

The 4th heart sound is higher pitched than a 3rd heart sound, but still best heard with the bell of the stethoscope. It occurs in late diastole and has a cadence similar to ‘Tennessee’ . It is caused by a reflected high pressure atrial wave from a poorly compliant ventricle and is never physiological. It is absent in atrial fibrillation, as there is no atrial contraction. (link)