Cardiovascular Exam

Statement of Goals

Understand and perform a cardiovascular examination.

Learning Objectives

A. Describe the anatomy of the heart in relationship to the anterior chest wall. Identify overlapping regions of the chest where valvular sounds are usually heard best. B. Describe the location, diatmeter, amplitude and duration of a normal left ventricular (apical) impulse. C. Describe S3 and S4 in relationship to the cardiac cycle. Indicate when each might be heard in a normal heart exam. Define the term gallop. D. Define a murmur as a prolonged heart sound caused by turbulent blood flow. Describe gradation of murmurs. Identify childhood and pregnancy as situations when murmurs may be normal or “innocent.” E. Describe the importance of assessing jugular venous pressure as a reflection of right atrial pressure. Describe the a wave, x descent, v wave and y descent of the jugular venous pulse in relation to the cardiac cycle. Describe measurement of jugular venous pressure. F. Describe the arterial pulse and its relationship to systole and diastole. Define pulse pressure. G. Describe the normal response of blood pressure and pulse to changes in position (supine to sitting to standing.) Define orthostatic hypotension as a drop in systolic BP by more than ~ 15­20 mm Hg and/or drop in diastolic BP by more than ~ 5­10 mm Hg. H. Describe the location of arterial pulses: temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis. I. Use the diaphragm of the stethoscope for high frequency sounds (S1, S2) and the bell of the stethoscope for low frequency sounds (S3, S4). J. Be able to recognize a normal S1 and S2, physiologically split S2, S3, S4 and midsystolic murmur. K. Prepare for the cardiac examination with adequate lighting, quiet room, and positioning / draping the patient. L. Demonstrate the cardiovascular examination:

• Heart rate and rhythm (radial pulse) • Blood pressure sitting (supine, sitting, standing if indicated) • Carotid auscultation and palpation (in older patients it is prudent to auscultate prior to palpating) • Jugular venous inspection • Inspection and palpation of the anterior chest (apical, left sternal border, left and right 2nd interspaces) • Auscultate the precordium in the supine position (apex, left sternal border at 2nd, 3rd, 4th, 5th interspaces, right 2nd interspace) • Auscultate the apex in the left lateral position • Auscultate the left sternal border and apex in the forward, sitting position with exhalation • Palpate peripheral pulses (temporal, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis.) Auscultate over femoral arteries.

M. Describe the usual biological changes of the cardiovascular system that occur with the aging process and how they affect physical findings. N. Describe aspects of the cardiovascular exam unique to infants and children. O. Document the cardiovascular examination in the format of a medical record.

Student’s Preparation for the Unit

Bates required reading is very important for this session:

Pages: 279­286, 289­292, 302­316, gradation of murmurs on page 318, page 332

“Harvey Heart Sounds “will be used as an additional learning resource this year. You will have the benefit of working with “Harvey” during your Small Group Session.

Curriculum Comments Cardiovascular:

The cardiovascular examination is covered in the text. Note that texts differ in the definition of orthostatic hypotension, so a range is given in the syllabus. The checklist provides one possible sequence for the exam. Note that vital signs and peripheral pulses may be done along with other parts of the physical examination instead.

Objective M:

In older adults the PMI may be harder to detect due to changes in the shape of the chest (increased AP diameter). An S4 can sometimes be found in apparently healthy older adults, but is also associated with heart disease. Sclerosis of the aortic valve produces a systolic murmur.

Objective N:

In addition to the first and second heart sounds (S1 and S2 ), a physiologic third heart sound (S3 ) is often heard in normal children and young adults. A fourth heart sound (S4 ) is always pathologic when present in children. Heart murmurs are common in childhood. Many newborns have a heart murmur and many children have an innocent heart murmur at some time during their childhood. The femoral pulses should be evaluated on newborns and infants. They may be examined at the inguinal ligament between the iliac crest and the symphysis pubis. Diminished pulses or absent pulses is an exam finding associated with coarctation of the aorta. Bates pp 714­722;762­763

Objective O:

Examples of documentation of the cardiovascular exam can be found in Bates pages 20 and 321.

Apply Your Skills:

The cardiovascular examination is challenging. Examine as many people as possible to become familiar with normal findings.

Record in your patient encounter note one cardiovascular examination that you performed.

Utilize computer­based reources to practice your auscultation skills.

Cardiovascular Exam Checklist Appropriate draping for all aspects of the examination (note difference for female exam) Appropriate guidance given to the patient throughout the examination

Feel radial pulse for heart rate and rhythm Measure blood pressure (sitting) Orthostatic BP and HR, if indicated (supine, sitting, and standing at least 2 minutes)

Palpate and auscultate each carotid artery (supine, head of bed 30 0) Inspect jugular venous pulsations and note the appropriate vertical distance above the sternal angle (supine, head of bed 30 0) Inspect and palpate anterior chest (supine, head of bed 30 0)

• apex • left sternal border • left 2nd interspace • right 2nd interspace

Palpate apex again, if indicated (left lateral position) Auscultate with bell (left lateral position)

• apex

Auscultate with bell (supine, head of bed 30 0)

• left 4th, 5th interspaces

Auscultate with diaphragm (supine, head of bed 30 0)

• apex • left 5th, 4th, 3rd, 2nd interspaces • right 2nd interspace

Auscultate with diaphragm (sitting forward, exhalation)

• apex • left 5th, 4th, 3rd, 2nd interspaces

Palpate peripheral pulses.

• temporal • brachial, radial • femoral, popliteal, posterior tibial, dorsalis pedis

Auscultate over femoral arteries NOTE:This is just oneexample of how this exam might be done. Study Questions:

1. Do you know how the heart lies in relation to the anterior chest wall?

2. What cardiac cycle events form the S1 and S2 (including A2 and P2) sounds? What is physiologic splitting, and when does it occur?

3. Where do S3 and S4 fall in relation to the cardiac cycle? What physiological phenomena are responsible for these sounds? When can they be normal?

4. What is the physiological basis of a murmur? When might a murmur be “innocent” or normal?

5. What is jugular venous pressure an indirect marker for? Where do you measure it? How do you measure it?

6. When does a peripheral arterial pulse occur in relation to systole and diastole?

7. What is pulse pressure?

8. How would you check for orthostatic hypotension? What amount of change in the systolic pressure/diastolic pressure and heart rate would raise concern?

9. Can you locate the temporal carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses?

10. Which heart sounds are heard best with the diaphragm? Which sounds are heard best with the bell of the stethoscope?

11. Can you recognize a normal S1, SE, physiological split S2, S3, S4, and medseptolic murmur?

12. What is the optimal positioning of the patient for the different aspects of the cardiovascular exam?

13. Can you describe and perform a complete cardiovascular exam?