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History & Physical Examination > Exam 2 - Cardiovascular and Peripheral Vascular System Physical Exams > Flashcards

Exam 2 - Cardiovascular and Peripheral Vascular System Physical Exams Flashcards

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1
Q

What are the most common complaints in the cardiovascular exam?

A

Common Complaints

Chest pain, palpitations, SOB, swelling/edema

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2
Q

What questions do you ask to quantify baseline level of activity when patient is experiencing positive symptoms?

A

Worsens with going up stairs? How many?
How far can you walk? Can you carry groceries?
Compare ability “before” to ability “now”

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3
Q

When a patient is experiencing chest pain, what should you ask them? Why?

A

Tell me about the chest pain.
Does it radiate? When did it start? What were you doing when it started? How long did it last? How often does this occur?

Purpose of these questions it to differentiate between cardiac vs. pulmonary, musculoskeletal, and GI causes

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4
Q

What are palpitations? How do you assess for them?

A

Palpitations - Racing, fluttering, pounding, stopping of heart beat.
Same assessment used for chest pain: How long? Onset? How often? Any pain associated with it? Any SOB associated with it? Does anything make it better? What makes it worse?

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5
Q

What are the types of SOB?

A

Orthopnea and Paroxysmal Nocturnal Dyspnea

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6
Q

What is orthopnea?

A

Orthopnea
Worse with lying down, better upright
Quantified as number of pillows

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7
Q

What is paroxysmal nocturnal dyspnea?

A

PND (paroxysmal nocturnal dyspnea)
Sudden episodes of dyspnea that awakens patient from sleep
Episodes come and go = paroxysmal

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8
Q

Edema - Where can it occur? What do you ask to assess for it?

A

Local (ex: Michelle’s arm or a trauma) versus systemic (ex: lymphedema of legs and wrists).

Ask about feet/ankles swelling, tight fitting rings/jewelry, clothes tight around abdomen?

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9
Q

What is dependent edema?

A

Lower extremities, occurs after standing upright for a period of time

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10
Q

What is edema?

A

Periorbital/face, upper extremities, abdomen

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11
Q

When does pitting edema usually begin?

A

10% weight gain before pitting edema begins

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12
Q

Whats in the Cardio ROS?

A

Heart failure, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past EKGs or other heart tests.

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13
Q

How do you perform a Cardiovascular Physical Exam?

A
  1. Note vital signs
  2. Carotid arteries - Palpate then auscultate with bell
  3. Point of Maximal Impulse (PMI) - Inspect with tangential lighting, palpation
  4. Heart sounds
    Ausculate in 5 areas with bell, then with diaphragm.
  5. Ausculate using bell with patient in left lateral decubitus position.
    >Mitral valve murmurs
  6. Auscultate using diaphragm with patient sitting up and leaning forward (exhale then hold breath)
    >Aortic murmurs
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14
Q

Where do you find the apical impulse (PMI)?

A

Apex of the heart, palpated on exam, usually at the 5th interspace, just medial to the midclavicular line.

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15
Q

Visualize the circulation of the heart.

A 
Visualize circulation:
Superior and inferior vena cavae
Right atrium and the right ventricle
Pulmonary arteries 
Left atrium and left ventricle
Aorta and the aortic arch
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16
Q

How do you know where to listen to the heart?

A

Count interspaces

Identify the midsternal line, midclavicular line, anterior axillary line, and midaxillary line

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17
Q

When you palpate the carotid upstroke, what do brisk, delayed, and bounding upstrokes suggest?

A

Carotid upstroke - Upstroke may be:
>Brisk = normal
>Delayed= suggests aortic stenosis (narrowing).
>Bounding = suggests aortic insufficiency (when valve doesn’t fully close and blood flows back, retrograde direction).

Insufficiency and regurgiation are the same.

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18
Q

What do you do when you notice a pulse varies with respirations?

A

If pulse varies with respirations or you suspect pericardial tamponade (increased JVP, rapid/diminished pulse, dyspnea), check BP.

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19
Q

What is pericardial tamponade?

A

Compression of the heart caused by fluid collecting in the sac surrounding the heart.

Pressure around the heart makes it so the heart can’t pump blood out as quickly (diminished arterial flow or pulse and causes increase in venous jugular pressure).

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20
Q

How do you evaluate the Point of Maximal Impulse (apical pulse)?

A 
The PMI (apical pulse) may be:
Tapping = normal
Sustained = suggests LVH from HTN or aortic stenosis
Diffuse = suggests a dilated ventricle from CHF or cardiomyopathy
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21
Q

How do you auscultate during CVS exam?

A

Auscultation
Listen in all 5 areas for S1 and S2 using the diaphragm of the stethoscope
Then listen in all 5 areas for S1 and S2 using the bell of the stethoscope

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22
Q

Where is the stethoscope placed in CVS auscultation?

A

Stethoscope placement
Right 2nd interspace = aortic valve
Left 2nd interspace = pulmonic valve
Left 3rd interspace = Erb’s point = S2 heard best here
Left 4th interspace = tricuspid valve
Left 5th interspace midclavicular line = mitral valve

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23
Q

Where is S2 heard the best?

A

Erb’s point (3rd ICS)

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24
Q

What creates S1 heart sound? “Lub”

A

Mitral and tricuspid valves close due to pressure differentials, create S1 heart sound
Softer, shorter

25
Q

What creates S2 heart sound?

A

Aortic and pulmonic valves close due to pressure differentials, create S2 heart sound
Louder, longer
**Heard best at Erb’s point (Left 3rd intercostal space, lateral sternal border).

26
Q

How do you assess for mitral valve murmurs?

A

To assess mitral valve murmurs

Have patient lay in the left lateral decubitus position

Brings left ventricle close to lateral chest wall

Accentuates mitral stenosis (pressure).

Use the bell over apical impulse

27
Q

How do you assess for aortic murmurs?

A

To assess aortic murmurs

Have the patient sit up, lean forward, exhale completely, then hold breath

Brings left ventricle close to anterior chest wall

Accentuates aortic murmurs (pressure).

Use the diaphragm at the left sternal border and apex.

28
Q

How do you assess murmurs in a CVS exam?

A

Identify and describe any murmurs

Timing: are the murmurs systolic or diastolic?

Palpate the carotid upstroke (occurs in systole) as you listen

If the murmur coincides with the carotid upstroke, it is a systolic murmur

Duration
>Early, mid, or late systolic
>Early, mid, or late diastolic

29
Q

How do you tell if the murmur is systolic or diastolic?

A

Palpate the carotid upstroke (occurs in systole) as you listen

If the murmur coincides with the carotid upstroke, it is a systolic murmur. – Carotid palpation helps you evaluate systolic murmurs.

30
Q

How do you describe heart murmurs?

A

Shape, intensity, and quality

31
Q

What shapes are used for describing heart murmurs?

A

SHAPE
>Crescendo, decrescendo, or both (sometimes called diamond-shaped)
>Example, crescendo-decrescendo systolic murmur of aortic stenosis

> Plateau is a “machinery” murmur
Example, holosystolic murmur of mitral regurgitation

32
Q

How do you rate intensity of a heart murmur?

A

INTENSITY
>Grade the murmur on a scale of 1 to 6 (I-VI)
>Grades IV, V, and VI must have accompanying thrill

33
Q

What qualities are used to describe heart murmurs?

A

Quality
Apply terms like harsh, musical, soft, blowing, or rumbling
Pitch
Apply terms like high, medium, or low-pitched

34
Q

Description of heart murmur:

A

Examples

  1. Harsh II/VI medium-pitched holosystolic murmur best heard at the apex describes mitral regurgitation
  2. Soft, blowing III/VI decrescendo diastolic murmur best heard at the lower left sternal border describes aortic regurgitation
35
Q

Documentation of a normal CVS exam

A

Bilateral carotid upstrokes are brisk, without bruits. The PMI is tapping, 7cm lateral to the midsternal line in the 5th intercostal space. RRR (regular rate and rhythm), +S1/S2, no murmurs, rubs, or gallops.

36
Q

What arterial pulses are on the arms? How do you find them?

A

Brachial: at bend of elbow just medial to biceps tendon
Radial: lateral flexor surface at wrist
Ulnar: medial flexor surface (overlying tissues may obscure)

37
Q

What arterial pulses are on the legs? How do you find them?

A

Femoral: below inguinal ligament
Popliteal: passes medially behind the femur; palpable behind knee
Dorsalis pedis: dorsum of foot; lateral to extensor tendon of big toe
Posterior tibial: behind medial malleolus of ankle

38
Q

What are common and concerning symptoms of a PVS exam?

A

Pain in arms or legs
Intermittent claudication
Cold, numbness, pallor in legs, hair loss
Swelling in calves, legs, or feet
Color change in fingertips or toes in cold weather
Swelling with redness or tenderness
Abdominal, flank, or back pain

39
Q

Peripheral Vascular ROS

A

Peripheral Vascular: intermittent claudication, leg cramps, varicose veins, clots in the veins, Raynaud’s disease.

40
Q

How do you ask about peripheral arterial disease?

A

Peripheral Arterial Disease (PAD)
Intermittent claudication
Ask patients, “Have you ever had any pain or cramping in the legs when walking or with exercise?” “Does the pain get better with rest?”

41
Q

How do you ask a patient if they have Raynaud’s disease?

A

Arterial spasms- fingers and toes (Raynaud’s Disease)

Ask patients, “Do your fingertips or toes ever change color in cold weather or when you handle cold objects?

42
Q

How do you notice if a patient has peripheral venous disease?

A

Peripheral Venous Disease (PVD)

Swelling of feet and legs, varicosities

43
Q

What important areas do you look at in a PVS exam?

A

Important areas of examination

Arms
Size, symmetry, skin color
Radial pulse, brachial pulse

Legs
Size, symmetry, skin color
Femoral pulses
Popliteal, dorsalis pedis, and posterior tibial pulses
Peripheral edema
44
Q

Upper body PVS exam and upper arterial pulses (upper extremities):

A

Size, symmetry, and any swelling
Venous pattern
Color of skin and nail beds (capillary refill

45
Q

Lower body PVS exam:

A

Patient should lay down, draped so external genitalia is covered and legs are fully exposed
MUST remove patient’s stockings or socks
Inspect both legs from groin and buttocks to feet

Note the following:
Size, symmetry, and any swelling
Venous pattern/venous enlargement
Pigmentation, rashes, scars, or ulcers
Color and texture of skin, color of nail beds (including capillary refill,
46
Q

Lower arterial pulses:

A

Femoral pulse
Press deeply below inguinal ligament, midway between anterior superior iliac spine and symphysis pubis
During physical exam skills assessment, state you would palpate for femoral pulses, point to the area, but do not perform exam

Popliteal pulse
Flex knee some, leg relaxed
Place fingertips of both hands to meet midline behind knee and press deeply into popliteal fossa

Dorsalis pedis pulse
Feel dorsum of foot, lateral to extensor tendon of great toe

Posterior tibial pulse
Curve fingers behind and slightly below medial malleolus of ankle

47
Q

How do you grade arterial pulses?

A 
Grading Amplitude of Arterial Pulses
3+	Bounding 
2+	Brisk, expected (normal)
1+	Diminished, weaker than expected
0	Absent, unable to palpate
48
Q

How is severity of edema graded?

A

Severity of edema graded on four-point scale

1+, 2+, 3+, 4+ and slight, pitting, or very marked

49
Q

How do you check for pitting edema?

A

Check for pitting edema

Press firmly with thumb for 5 seconds over dorsum of each foot, behind medial malleolus and shins

50
Q

How do you assess carotid arteries in CVS PE?

A

Assessing carotid pulses - Place your index and middle fingers on the right then the left carotid arteries, and palpate the carotid upstroke.

Upstroke may be:
>Brisk = normal
>Delayed= suggests aortic stenosis (narrowing).
>Bounding = suggests aortic insufficiency

Listen with the stethoscope bell in same place you palpated, for any bruits
Indicates atherosclerosis, carotid stenosis

51
Q

What is pulses alterans?

A

Pulses alternans
When palpating the carotid arteries, the force will alternate between strong and weak, from the strong and weak ventricular contractions

52
Q

What is paradoxical pulse?

A

Paradoxical pulse
Greater than normal drop in systolic pressure during inspiration.
If pulse varies with respiration or you suspect pericardial tamponade (increased JVP, rapid/diminished pulse, dyspnea), check BP

53
Q

How do you assess PMI?

A

Assessing the PMI
Inspect the left anterior chest for a visible PMI
Using your finger pads, palpate at the apex for the PMI
The PMI (apical pulse) may be:
Tapping = normal
Sustained = suggests LVH from HTN or aortic stenosis
Diffuse = suggests a dilated ventricle from CHF or cardiomyopathy
Locate the PMI by interspace and distance in centimeters from the midsternal line
Assess location
5th ICS, 3 cm medial to MCL, amplitude (tapping), duration (during systole), and diameter(2.5cm)

54
Q

Carotid upstroke: Brisk?

A

> Brisk = normal

55
Q

Carotid upstroke: Delayed?

A

> Delayed= suggests aortic stenosis (narrowing).

56
Q

Carotid upstroke: Bounding?

A 
>Bounding = suggests aortic insufficiency (when valve doesn't fully close and blood flows back, retrograde direction).
>B = Bounding = Backflow (regurge of aorta)
57
Q

Tapping apical impulse

A

Tapping = normal

58
Q

Sustained apical impulse

A

Sustained = suggests LVH from HTN or aortic stenosis

59
Q

Diffuse apical impulse

A

Diffuse = suggests a dilated ventricle from CHF or cardiomyopathy

History & Physical Examination (19 decks)

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