Lecture 4.2 physical exam section (incl. in 8%)

Question 1

List the 6 steps of palpation/ inspection of the heart

Answer 1

(1) Palpate for lifts and heaves
(2) Palpate for thrills
(3) Apical pulse
(4) Radial pulses
(5) Ausculation
(6) Aortic regurgitation and mitral stenosis

Question 2

1) How should you palpate for lifts and heaves?
2) What should you consider if they’re found?

Answer 2

1) Lightly hold fingertips against the patient’s chest, feeling for any rise
-Observe this as well
2) Consider ventricular enlargement

Question 3

1) How should you palpate for thrills?
2) What should you consider if they’re found?

Answer 3

1) Feel with the ball of your hand or padded palm; place on pt’s chest to feel for any “buzzing” or “vibratory” sensation, which results from turbulent flow
2) Murmur

Question 4

1) How should you find apical pulse?
2) What can displacement indicate?

Answer 4

1) Counting intercostal spaces, palpate for the apical pulse, which should be the point of maximal impulse
2) Displacement esp. to the left, can indicate hypertrophy of the L ventricle

Question 5

When may apical pulse be felt?

Answer 5

Can be felt upright, but if not, consider trying this part of the exam later, once the patient is supine in left lateral decubitus

Question 6

1) What should apical pulse diameter be?
2) What can enlargement indicate?
3) What may increased amplitude indicate?

Answer 6

1) 2.5 cm (or felt with one finger)
2) Hypertrophy
3) Hyperthyroid, severe anemia, or overload of left ventricle

Question 7

What 4 places should you auscultate during a PE of the heart?

Answer 7

1) Listen at the R 2nd intercostal space
2) Listen to the L 2nd intercostal space
3) Listen at the base of the L sternal border
4) Listen at the 5th intercostal space, medial to the midclavicular line
-Listen with the diaphragm and the bell

Question 8

1) Describe what you may hear when auscultating the base of the heart.
2) Describe what you may hear when auscultating the apex of the heart.

Answer 8

1) S2 may be louder than S1 and may “split” during inspiration
2) S1 may be louder than S2

Question 9

What should you ask the pt to do before you listen for aortic regurgitation? Why?

Answer 9

“Breathe out all the way”; decrease the preload and give
time for the regurgitant murmur (during diastole)

Question 10

1) How should you listen for mitral stenosis? (occurs during diastole)
2) What should you try if needed?

Answer 10

1) Bring left ventricle closer to the chest wall, then listen
2) Try PMI again if needed

Question 11

1) What vessel is JVP measured from? Where is it?
2) What the dominant movement of the JVP?

Answer 11

1) The internal jugular vein, which is directly in line with the SVC and Right Atrium
2) Inward – with the x wave

Question 12

What adjustments should be made during your assessment of jugular venous pressure?

Answer 12

1) When pt is laying at 30’ the meniscus is above the jaw
2) When pt is laying at 90’ the meniscus is too low
3) When pt is sitting straight at 60’ the level is juuuuuust right

Question 13

1) What heights are consistent when measuring JVP?
2) What moves?

Answer 13

1) The height of VP from sternal angle is consistent
-sternal angle is consistently 5 cm above the right midatrium
2) Your ability to measure the oscillations

Question 14

List the 5 steps of looking for JVP

Answer 14

1) Start at 30 degrees, and make the patient comfortable to relax the SCM
2) Examining the right side and turning the head away
3) Look with tangential light for pulsations
-Make sure you’re not looking at the carotid (next slide)
4) Find the oscillation point and adjust the bed as needed
5) Extend vertical line to measure the height above the sternal angle
-Use an actual straight edge to do this

Question 15

When internal jugular pulsations are eliminated by light pressure on the vein(s) just above the sternal end of the clavicle, what are carotid pulsations like?

Answer 15

Carotid pulsations are not eliminated by this pressure

Question 16

1) When internal jugular pulsations have a soft, biphasic undulating quality, usually with 2 elevations and a characteristic inward deflection (X descent),
what are carotid pulsations like?
2) What about when internal jugular pulsations are rarely palpable?

Answer 16

1) A more vigorous thrust with a single outward component
2) Carotid pulsations are palpable

Question 17

1) What does the JVP measure?
2) Where is the sternal angle in relation to this?
3) What have you just measured?

Answer 17

1) The distance above the mid right atrium
2) 5cm above this
3) Just measured X centimeters above the sternal angle; X + 5 = JVP