Cardiovascular 1 Flashcards
How can you break down examinations? How do you remember this?
- Position and exposure
- Inspection
- Palpation
- Percussion
- Auscultation
- PIPPA
What should the position and exposure of the patient be?
- Patient to be lying on the couch, at a 45 degree angle
- exposed from the waist upwards
- offer the patient a blanket so they will only be exposed when appropriate, and if relevant patients do not need to remove their bras
How do you inspect the patient?
perform a general inspection from the end of the bed
How can you feel an arterial pulse?
- in any artery that lies near the surface of the body
- especially when it can be compressed against bone or any firm structure
How do you palpate the pulse?
index and the middle fingers (the ring finger is optional) t
Which fingers should you not use to palpate the pulse?
index
How do you assess pulse rate?
- palpating right radial pulse
- expressed in beats per minute
How do you asses rhythm?
- palpating right radial pulse
- regular or irregular
What can irregular rhythm be due to?
cardiac problems such as atrial fibrillation or ectopic beats
How do you assess character and volume?
- palpating the right carotid artery pulse
- closest to the heart than the radial pulse
How do you assess symmetry of radial, brachial, femoral, popliteal, and pedal pulses?
comparing pulses on both sides
What delays are abnormal?
Radio-femoral delays between major arteries might observed and are abnormal
What is useful to know when palpating arteries?
anatomical landmarks where the arteries are easily accessible
What arteries do you palpate and in what order?
- Radial pulse
- Ulnar pulse
- Brachial pulse
- Common carotid pulse
Where do palpate the radial artery?
- at the wrist over the distal end of radius
- lateral to the tendon of flexor carpi radialis muscle
- superficial and easily accessible
- most common artery used to measure patient’s pulse rate and rhythm
Where do you palpate the ulnar artery?
- at the wrist over the distal end of the forearm
2. lateral to the tendon of flexor carpi ulnaris muscle
Where do you palpate the brachial artery?
- medial side of the tendon of biceps muscle
2. easier to palpate the pulse when the elbow is fully extended
Where do you palpate axillary artery?
- medial side of humerus (lateral wall of the axilla) 2. posterior to the tendon of the short head of biceps
What are the upper limb arteries to palpate?
- Radial artery
- Ulnar artery
- Brachial artery
- Axillary artery
How do you palpate a common carotid artery?
- palpated in the neck
- between the lateral side of thyroid cartilage and medial border of sternocleidomastoid muscle
- strongest pulse of all
How do you palpate the carotid pulse?
- ideal for the assessment of the amplitude, shape and volume of the pulse
- that are important in the diagnosis of underlying heart disease
How do you palpate the superficial temporal artery?
- palpated the in front of the tragus of the ear
2. this vessel is a terminal branch of the external carotid artery
How do you palpate the subcalvian artery?
- palpated in the supraclavicular fossa region
- at the angle between clavicle and sternocleidomastoid muscle
- at this site you can compress and occlude the artery completely
What are the arteries to palpate in the head and neck region?
- Common carotid artery
- Carotid pulse
- Superficial temporal artery
- Subclavian artery
How do you palpate the femoral artery?
at the mid inguinal point
How do you palpate the popliteal artery?
- with the knee semi flexed and the fingers of both hands palpating in the inferior part of the popliteal fossa
- compressing the artery against the posterior surface of the tibia
- located very deep in the popliteal fossa on the back of the knee
How do you palpate the dorsalils pedis artery?
- mid dorsum of the foot
2. lateral to the tendon of the flexus hallucis longus
How do you palpate the posterior tibial artery?
1/3 of the way from the medial malleolus to the calcaneus
What is the apex beat pulsation caused by?
apex of the left ventricle of the heart when it is forced against the anterior chest wall during contraction
Is the anatomical apex of the heart at the point where you feel the apex beat?
- no
- the most lateral and inferior point at which the palpating fingers raise with each systole defines the position of the apex beat
Is the apex beat always palpable?
not necessarily
What are the steps to palpate the apex beat?
- Use your palm and 4 fingers of your right hand to palpate
- Align your fingers along the left 4th, 5th and 6th intercostal spaces
- Start palpation from the left lateral chest wall (near the mid-axillary line)
- move to the anterior chest wall (towards the mid-clavicular line)
What should you do if you cannot find the apex beat / difficult to palpate?
a brisk “jogging on the spot” by your colleague (for 1 minute) may increase the heart rate and strength of the heart beat that enables easier palpation
In females how could the palpation be different?
examiner’s hand should be laid beneath the breast along its lower border (a mitral valvotomy scar could be missed if the apex beat is not visualised)
Where is the apex beat found in an adult and child?
- healthy adult is usually found in the left 5th intercostal space around the mid-clavicular line 2. children, it is slightly higher on the 5th rib
What would shift in the apex beat laterally or inferiorly or both normally indicate?
enlargement (cardiomegaly) of the heart
What could the shift of the apex beat be due to?
- chest wall deformity
- mediastinal shift
- underlying pleural and lung disease
Where is the apex beat palpable in dextrocardia?
right side of the sternum
In what conditions could the apex beat might not be palpable?
- thick chest wall
- emphysema
- pericardial effusion
- shock
What is a heave in the apex beat?
- Since the apex beat is a result of the left ventricle beating
- hypertrophy of the left ventricle produces a forceful beat
- called a ‘heave’ and may extend outwards towards the axilla
How are heaves palpated?
- by placing you hand vertically on the left of the sternum
- a heave will lift the heel of you hand with each beat
What is a thrill?
- A hyperkinetic and more sustained apex beat called a ‘thrill,’
- more characteristic of volume overload
- may occur in heart failure, and mitral and aortic regurgitation
How are thrills palpated?
- placing the flat of you hand at the apex
- upper praecordium and a thrill will be a palpable vibration under you hands
How do you percuse in the cardiovascular exam?
There is no percussion in the intermediate cardiovascular examination
How do you ausculate the aortic valve?
- right 2nd intercostal space next to sternum
- Diaphragm
How do you ausculate the pulmonary valve?
- left 2nd (or 3rd) intercostal space next to sternum
- Diaphragm
How do you ausuclate the tricuspid valve?
- left 5th intercostal. space near sternum
- Diaphragm
How do you ausculate the mitral valve?
- left 5th intercostal space at mid-clavicualr line (= apex beat area)
- bell
In what order to you auscultate the heart valve?
- Aortic
- Pulmonary
- Tricuspid
- . Mitral
What is the S1 sound?
“lub”
Why is there a S1 sound?
closure of atrioventricular valves (low pitched)
What is the S2 sound?
“dub”
Why is there an S2 sound?
closure of aortic and pulmonary valves (high pitched)
Where will the composite heart sound be heard (both lub & dub)?
if a stethoscope is applied anywhere on the anterior chest wall over the cardiac or the adjacent areas
Which areas are best for auscultation?
- The areas best for auscultation do not correlate with the anatomical location of the valves.
- The sound produced by a given valve is carried by the blood stream along the direction of flow via the valve
- Placing the stethoscope superficial to the blood filled space downstream of a given valve may allow the sound of that valve (including abnormal sounds) to be distinguished clearly from the sounds of other valves.
When do you hear aortic stenosis?
- Murmur between S1 and S2
1. Ejection systolic murmur
2. Auscultate at the carotid artery
When do you hear aortic regurgitation?
- Murmur after S2
1. Early diastolic murmur
2. Auscultate at the aortic valve with the patient leaning forward
How do you carry out position and exposure?
- Patient lying down at 45 degrees
2. Patient adequately exposed from the waist upwards
How do you carry out inspection?
General inspection
How do you carry out palpitation?
- Palpation of the radial artery including rate and rhythm
- Palpation of the ulnar artery
- Palpation of the brachial artery
- Palpation of the common carotid artery
- Palpation of the apex beat
- Palpation of heaves
- Palpation of thrills
How do you carry out percussion?
N/A
How do you carry out auscultation?
- Auscultation of the aortic valve
- Auscultation of the pulmonary valve
- Auscultation of the tricuspid valve
- Auscultation of the mitral valve
