CVS clinical exam

Question 1

What are the steps of the CVS physical exam?

Answer 1

1. inspect the neck veins
2. auscultate the carotid a.
3. palpate the carotid a.
4. palpate the pulses
5. inspect and palpate the PMI
6. inspect and palpate precordium
7. percuss the precordium
8. auscultate the precordium

Question 2

how do I begin examining the neck veins?

Answer 2

1. explain to the patient what I will be doing
2. position pt supine w/ head of exam table elevated 30-45 degrees above horizontal
3. remove the pillow

Question 3

how do examin the pt’s neck veins?

Answer 3

1. ask the pt to turn his head to the left (I always stand to the right of the pt)
2. locate the sternal angle
3. inspect the EJV and IJV
4. auscultate the PMI w/ my diaphragm at the PMI and observe the venous pulsation.
5. locate the highest level of the IJV pulse

Question 4

How do I locate the highest level of the IJV pulse?

Answer 4

1. shine my pen light on to the location of the IJV
2. place the ruler vertically on the sternal angle
3. place the swab at the highest point and extend it horizontally to the ruler (it should be ≤ 1 cm).

Question 5

how do I auscultate the carotid a.?

Answer 5

1. place the bell of the stethoscope over EACH carotid a.
2. ask pt. to hold his breath and listen for bruits

Question 6

how do I palpate the carotid a.?

Answer 6

1. ask pt to turn his head slightly left
2. place the tip of my middle and ring fingers betw. the pt’s trachea and SCM
3. palpate one side at a time

Question 7

How do I palpate the pulses?

Answer 7

1. palpate the temporal pulse, then ask pt to clench teeth while feeling temporal pulse
2. ask pt to flex then place my fingers over the brachial a., ask pt to relax and palpate the brachial pulses
3. palpate the radial a.
4. ask pt. to look at his hands, turn them over, then push down on finger pad/nail bed to assess capillary refill time
5. palpate the femoral a.
6. ask pt to flex his foot (point toes to the ceiling) and palpate the dorsalis pedis a.
7. ask pt to point his foot (point toes to the ground) and palpate the post. tibial a.

Question 8

How do I inspect and palpate the PMI?

Answer 8

1. shine my penlight tangentially onto the left side of the chest, 5th intercostal space, and mid clavicular line
2. observe for mvmnt of apex medially (in normal pt should not see anything)
3. palpate the PMI by placing my fingers in the left 5th intercostal space, midclavicular line
4. place my hand over the PMI and palpate the PMI w/ my carpal bones

Question 9

How do I inspect and palpate the precordium?

Answer 9

1. inspect the precordium for colors, scars, striae, etc.
2. palpate the sternoclavicular area
3. palpate the 2nd right intercostal space and sternal border
4. palpate the 2nd left intercostal space and sternal border
5. palpate the apical area
6. slip my fingers under the pt’s right costal argin near the xyphoid process and palpate for right ventricular enlargement

Question 10

how do I percuss the precordium?

Answer 10

1. percuss in 1 in intervals from the ant. axillary line to the sternum in the 3rd, 4th, and 5th intercostal space and note where the sound changes
2. percuss in 1 in intervals from the ant. axillary line to the sternum in the 4th intercostal space and note where the sound changes
3. percuss in 1 in intervals from the ant. axillary line to the sternum in the 5th intercostal spaces and note where the sound changes
4. these 3 lines should form a point that is ≤ 6 cm from the axillary line to the sternum.

Question 11

How do I auscultate the precordium?

Answer 11

1. place the diaphragm on the apex and listen for the S1 and S2 while pt is supine
2. while pt is still supine, auscultate APTM using the diaphragm
3. while pt is still supine auscultate APTM using the bell
4. have pt turn onto his left side an auscultate the apex using the bell
5. have pt sit up and auscultate APTM using the diaphragm
6. while pt is still sitting auscultate the APTM using the bell
7. have pt lean slightly forward and auscultate APTM using the diphragm
8. while pt is still leaned forward, ask pt to expire then hold his breath and auscultate 2nd intercostal space, 3rd intercostal space, and 4th intercostal space using the diaphragm
   
   1. I should hold my breath with the pt so I know when to let them breath