4.2 PHYSICAL EXAMINATION OF THE CARDIOVASCULAR SYSTEM Flashcards
OBTAIN a cardiovascular history IAW corresponding PCL.
a. History of Present Illness
(1) Chest pain
(a) Patients with pain should be assessed for onset, duration, characteristics,
location, severity, associated symptoms, and treatment of pain.
(b) Specific data include factors that influence the pain, the type of discomfort
(e.g., radiation of pain or position related relief), symptoms (e.g., dizziness
or cyanosis), and use of nitroglycerin.
(c) Other considerations include cough, difficulty breathing, and loss of
consciousness.
(2) Fatigue
(a) Relevant data include associated symptoms (e.g., dyspnea or anorexia), as
well as any interruption in usual activities or bedtime changes.
(3) Cough
(a) Patients with a cough should be assessed for the onset and duration of the
cough, as well as the character of the cough (dry, wet, night-time, aggravated
by lying down).
(4) Difficulty breathing (dyspnea, orthopnea)
(a) Relevant data include aggravating factors (e.g., with exertion, lying down, or
climbing stairs) and paroxysmal nocturnal dyspnea.
(5) Loss of consciousness (transient syncope)
(6) Leg pain or cramps
(a) Patients having leg discomfort should be assessed for onset and duration of
pain and whether leg elevation or immobilization changes pain.
(b) The character of discomfort should be described, and questions should be
directed toward any burning in toes, changes in skin color or temperature,
dizziness, limping, or discomfort during the night.
(7) Severe headaches
(a) Patients having severe headaches should be assessed for onset and duration,
location, character, and known history of hypertension.
(8) Swollen ankles
(a) Patients having swollen ankles should be assessed for onset and duration,
related circumstances, and associated symptoms.
(b) Treatment includes rest, massage, heat, elevation, and medication.
(9) Family History. Pertinent data includes family members with diabetes, heart disease,
hyperlipidemia, hypertension, obesity, congenital heart defects, sudden death, and risk
factors related to the cardiovascular system.
(10) Associated symptoms/complaints with respect to the initial CC of Chest Pain:
(a) Anxiety
(b) Dyspnea
(c) Diaphoresis
(d) Dizziness
(e) Nausea
(f) Vomiting
b. Personal and Social History
(1) Relevant data include employment risks, tobacco habits, nutritional status, alcohol
consumption, personality assessment, usual exercise activities, relaxation patterns, and
drug use.
c. Age and Condition- Related Variations:
(1) Pregnant women
(a) History of cardiac disease or surgery; dizziness or faintness on standing;
indications of heart disease during pregnancy: progressive or severe dyspnea,
progressive orthopnea, paroxysmal nocturnal dyspnea, hemoptysis, syncope
with exertion, and chest pain related to effort or emotion.
(2) Elderly
(a) Lower extremity swelling, reproducible lower extremity pain with exertion
resolving with rest (claudication), venous-stasis ulcers
IDENTIFY the components of a heart examination.
a. Exam Room Equipment
(1) Before any examination can be completed, you must have the following equipment
available to you during the exam:
(a) Sphygmomanometer with appropriately sized cuff
(b) Marking pencil
(c) Centimeter ruler
(d) Stethoscope with bell and diaphragm
1) The bell is used for low frequency sounds
2) The diaphragm is used for high frequency sounds
b. Components of a Heart Examination
(1) There are four (4) components to a heart examination and must be completed in this
order:
(a) Inspection
(b) Palpation
(c) Percussion (Omitted for the heart examination)
(d) Auscultation
CONDUCT a heart examination IAW Corresponding PCL.
a. Inspection
(1) Inspect the chest wall, carotid arteries and jugular veins for pulsations, lifts, heaves, and
thrusts. Check for symmetry.
(2) Inspect for cyanosis of the skin and cyanosis of the nailbeds and capillary refill
(3) Apical impulse
(a) 5th L intercostal space
(b) Midclavicular line
b. Palpation
(1) Palpate the base, left sternal border, right sternal border, apex, epigastrium and left
axillae.
(2) Palpate for an apical impulse.
(a) 5th L intercostal space
(b) Midclavicular line
(3) Palpate for thrill or rushing vibration, primarily over the base of the heart.
(4) Palpate the carotid pulses, one at a time, avoiding carotid sinuses.
c. Percussion
(1) If other facilities are unavailable, you can estimate the size of the heart by percussion.
But is better assessed by the size of the PMI.
(2) Of limited value in defining borders of heart or determining its size.
(3) Left ventricular size is better judged by the location of the apical impulse.
(4) Obesity, unusual muscular development, and some pathologic conditions can easily
distort the findings.
(5) Chest radiograph is far more useful in defining the heart borders.
(6) The change from a resonant to a dull note marks the cardiac border.
d. Auscultation
(1) Preparation and Positioning
(2) The following techniques are performed with patient sitting and leaning forward, supine,
and in the left lateral recumbent positions. All these positions are used to compare
findings or enhance the assessment.
(3) Auscultate heart sounds with patient sitting, supine, and in left lateral recumbent
position.
(4) Describe rate, rhythm, duration of cycle, timing, intensity, frequency, splitting or
murmurs, and quality.
(5) Isolate each sound.
(6) Auscultate the carotid arteries for bruits or murmurs.
(7) A pericardial friction rub can be easily mistaken for cardiac-generated sounds.
(8) Listen over aortic, pulmonic, second pulmonic, tricuspid and mitral posts.
DETERMINE heart examination findings
a. Lifecycle variations
(1) Basic Heart Sounds
(a) S1/S2, most distinct
1) S1- closure of mitral/tricuspid valves
2) S2- closure of aortic/pulmonic valves (sometimes split)
(b) S3 and S4 difficult to hear
(c) S3- early diastole (passive filling) vibration of ventricular walls
(d) Normal in children/young adults. Pathological in 40+ y/o.
(e) S4- ventricular filling from atrial kick (late diastole) loss of compliance or
increase stroke volume secondary to high output.
(f) Potential causes: HTN, CAD, aortic stenosis, cardiomyopathy
(2) Adults
(a) Normal findings
1) Resting heart rate is 60 to 90/min and regular
2) No bruits or murmurs are present.
(b) Typical variations:
1) Heart:
a) In a slender person, the heart is more vertical and central.
b) In stocky person, the heart lies horizontally and to the left.
(c) Findings associated with Pathology/Disease
1) Wide apical pulsation may indicate left ventricular hypertrophy. Loss of palpable
apical pulsation may indicate fluid, air, or displacement.
2) Thrills are associated with failure of semilunar valve to close, aortic or
pulmonary stenosis, or atrial septal defect.
3) Loud S1 suggests increased blood velocity, mitral stenosis, heart block,
hypertension, or calcification of mitral valve.
4) Loud S2 suggests hypertension, valve disorder, stenosis, or fluid.
5) Murmurs and the characteristics
a) Disruption of blood flow into, through, or out of the heart
b) Timing and duration
c) Pitch
d) Intensity - graded I-VI
e) Pattern - crescendo-decrescendo, plateau, etc.
f) Quality
g) Location and radiation
h) Mitral snaps-MV stenosis
i) Ejection clicks-semilunar valves
j) Mid-to-late non-ejection systolic clicks-MV prolapse
k) Mitral/Tricuspid Stenosis – diastolic
l) Aortic/Pulmonic Regurgitation – diastolic
m) Mitral/Tricuspid Regurgitation – systolic
n) Aortic/Pulmonic Stenosis – systolic
o) Mitral Valve Prolapse – mid systolic click with late high pitched murmur
(3) Friction rubs
(a) Pericardial sac inflammation
(b) Rough parietal and visceral layers make a sound like grating, machine-like
rubbing.
1) Unexpected splitting, extra heart sounds, and heart murmur should be carefully
assessed.
(4) Pregnant Women
(a) Normal findings
1) Heart rate and position shift during pregnancy.
2) Audible splitting of S1 or S2.
3) Murmurs may be heard.
(b) Typical variations
1) None listed.
(c) Findings associated with disorders:
1) None listed
IDENTIFY the components of a blood vessel examination
a. Exam Room Equipment
(1) Before any examination can be completed, you must have the following equipment
available to you during the exam:
(a) Marking pencil
(b) Centimeter ruler, both tape and folding rulers (at least 15cm long)
(c) Stethoscope with bell and diaphragm
(d) Sphygmomanometer with appropriately sized cuff
b. The examination of the vascular system includes the following:
(1) Inspection
(a) Inspecting the veins, particularly the jugular veins.
(b) Inspect extremities for findings of arterial and venous insufficiencies.
(2) Palpation
(a) Observing and palpating the pulses, comparing each with the contralateral
pulse and comparing pulses of the upper extremity with those of the lower.
(b) The pulse pressure is the difference between systolic and diastolic pressures.
The following variables contribute to the characteristics of the pulse.
1) Volume of blood ejected (stroke volume)
2) Distension of the aorta and large arteries
3) Viscosity of the blood
4) Peripheral arteriolar resistance
(3) Auscultation:
(a) Listening for various abnormal sounds.
1) Potential bruits (turbulent blood flow)
(4) Blood Pressure:
(a) Measuring blood pressure in both upper and lower extremities with patient
sitting, standing, and supine when indicated.
CONDUCT a blood vessel examination IAW corresponding PCL.
a. Blood pressure
(1) Measure blood pressure in the upper extremities bilaterally in the sitting, standing, and
supine positions.
(a) Blood pressure/pulse: Normal systolic BP: 120, Diastolic BP: 80
(b) Systolic BP is more responsive to a range of stimuli.
(c) The difference between the systolic and diastolic pressures is the pulse
pressure.
1) The pulse pressure should range from 30 to 40 mm Hg, even to as much as 50
mm Hg.
(d) Systolic pressure drops and diastolic pressure rises on standing.
(e) A difference of less than 10mm Hg is expected between arms.
(2) Sphygmomanometer is the device to measure B/P. Usually used on brachial artery
(a) Inflate cuff to a pressure greater than systolic BP (can be up to 200 mmHg),
which briefly stops blood flow to the area distal the artery.
(b) Slowly lower the pressure in the cuff until the flow just starts.
1) First Korotkoff sound indicated systolic B/P
(c) Lower pressure further until sound becomes faint then disappears.
1) The last Korotkoff sound heard before it disappears is the diastolic B/P.
b. Inspection
(1) Inspect the chest wall, carotid arteries and jugular veins for pulsations, lifts, heaves, and
thrills. Check for symmetry.
(a) Inspect for the color of the extremities, hair distribution, and venous
distention.
(b) Inspect for the apical and carotid pulses.
(c) Inspect for cyanosis of the skin, cyanosis of the nailbeds and capillary refill.
c. Palpation of Arteries
(1) Warmth, pulse quality, tenderness
(2) Pulses are in arteries, to assess press against bone.
(3) Palpate the carotid pulses, one at a time.
(4) Palpate for carotid, brachial, radial, femoral, popliteal, posterior tibialis, and dorsalis
pedis pulses.
(a) The amplitude of the pulse is described on a scale of 0 to 4:
1) 4 Bounding, aneurysmal
2) 3 Full, increased
3) 2 Expected
4) 1 Diminished, barely palpable
5) 0 Absent, not palpable
d. Auscultation of arteries
(1) Isolate each sound.
(2) Auscultate the carotid arteries for bruits or murmurs.
(3) Listen to the jugular veins for venous hums over right clavicle.
(4) Auscultate the temporal, abdominal aorta (midline), renal, iliac and femoral arteries for
bruits.
e. Peripheral Veins
(1) Palpate the extremities for temperature and venous distention and edema.
(a) Pitting Edema
1) 1+ Slight pit, disappears rapidly (2-3 mm in depth)
2) 2+ Somewhat deep pit, disappears in 10 to 15 seconds (4-5 mm in depth)
3) 3+ Noticeable deep pit that lasts more than a minute (6-7 mm in depth)
4) 4+ Very deep pit that lasts 2 to 5 minutes (8-9 mm in depth)
(2) Palpate and assess for thrombosis
(a) Redness, thickness of the vein, tenderness along superficial vein, and
warmth
(b) Can be indicated through taking a good history and exam
(c) Use Doppler for confirmation of diagnosis
(d) Clinical test for thrombosis, use Homan’s sign
(3) Varicose veins
(a) Dilated, swollen veins
(b) Have patient stand on toes 10 times in succession to build pressure in veins
1) Varicose veins are palpable veins that do not disappear within a few seconds.
f. Hand Veins
(1) Place patient in semi-recumbent with hands resting on table
(2) Palpate hand veins (should be engorged) and ensure they are compressible/not
thrombosed
(3) Slowly rise hand until hand veins collapse
(4) Place a ruler between the mid-axillary line and level of collapse of hand veins
(5) Should be identical to mean JVP
g. Jugular Venous Pressure (JVP)
(1) Lay patient Supine to cause engorgement of jugular veins.
(2) Slowly raise the head of bed (about 45 degrees) until jugular venous pulsations become
evident between the angle of the jaw and the clavicle.
(3) Pulsatile areas around the right sternocleidomastoid are usually caused by the top of the
column of blood in the jugular vein system.
(4) The top of the column is called the meniscus.
(5) Place first ruler tip at mid-axillary line at level of nipple and extend vertically.
(6) Place second ruler at level of meniscus of JVP extended horizontally to intersect 1st
ruler.
(7) The vertical distance above level of heart is the mean. A value of less than 9cmof H2O is
expected.
DETERMINE blood vessel examination findings.
a. Adults
(1) Patient exhibits no visible pulsations or heaving chest.
(2) Pulses are symmetric.
(3) Bilaterally, pulse amplitude is 2+.
(4) Bilateral extremities are warm and pink with hair present.
(5) Blood pressure/pulse: Systolic BP: 100 to 140 Diastolic BP: 60 to 90 Systolic BP is
more responsive to a range of stimuli.
(6) The difference between the systolic and diastolic pressures is the pulse pressure.
(a) The pulse pressure should range from 30 to 40 mm Hg, even to as much as
50 mm Hg.
(7) Systolic pressure drops and diastolic pressure rises on standing.
(8) Typical variations
(a) Pulse rate:
1) Rate is labile, bounding, or increased after exercise; bradycardia may be present
in the athlete.
(b) Jugular veins:
1) Venous hums are usually not significant.
(9) Findings associated with Pathology/Disease
(a) Arterial insufficiency or pulse abnormalities are exhibited.
(b) Jugular distention >9 cm suggests ventricular failure.
(c) Positive Homan’s sign indicates venous thrombosis.
(d) Positive Trendelenburg sign suggests venous insufficiency. Varicosities are
present. Right-left pulse asymmetry suggests impaired circulation.
b. Pregnant Women
(1) Normal Findings
(a) Blood pressure initially falls, then gradually rises to pre-pregnancy
levels at term
(b) Varicose veins
(2) Findings associated with Pathology/Disease
(a) Development of hypertension during pregnancy with/without
proteinuria and seizures (pre-eclampsia/eclampsia).
c. Older Adults
(1) Normal findings
(a) Blood pressure <140/90
(b) The systolic blood pressure increases with age, while the diastolic
blood pressure decreases, with an overall increase in blood pressure as
patients’ age.
(c) Lower extremity arterial pulses are harder to palpate.
(2) Findings associated with Pathology/Disease
(a) Incidents of heart disease and peripheral vascular disease increases
with age.
