Cardiovascular System Examination

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What are the 4 basic components of a physical examination of the cardiovascular system?

Observation, Palpation, Percussion, Auscultation

Which valves are responsible for the first heart sound (S1)?

Mitral and Tricuspid valves

Physiologic splitting of the second heart sound is audible during expiration.

False

Aortic regurgitation is a type of diastolic __________.

murmur

Match the following heart sounds with their descriptions:

S3 = Occurs after S2; associated with blood from LA colliding with leftover blood in LV; related to heart failure S4 = Precedes S1; caused during atrial systole; associated with squeezing blood into non-compliant LV; often seen in patients with hypertension

Study Notes

Cardiovascular Exam

  • Includes:
    • Appropriate history
    • Vital Signs: Blood pressure, Pulse (rate, rhythm, volume)
    • Assessment of distal vasculature (legs, feet, carotids)

Respectful and Effective Exam

  • Keys to performing a respectful and effective exam:
    • Explain what you're doing and why before doing it
    • Expose minimum amount of skin necessary
    • Enlist patient's assistance
    • Don't rush
    • Don't examine through clothing

Observation

  • Pay attention to:
    • Chest shape
    • Shortness of breath (at rest or walking)?
    • Sitting upright?
    • Able to speak?
    • Visible impulse on chest wall from vigorously contracting ventricle (rare)

Surface Anatomy

  • Finding the sternal manubrium junction (angle of Louis)
  • Identifying valve areas

Palpation Technique

  • Fingers across chest, under breast (explain first)
  • Point of Maximal Impulse (PMI)
    • Apex ventricle that pinpoints with finger tip
    • ~70% of patients - if not palpable, repeat with patient on L side
  • Size of LV – increased dimension if PMI shifted to L of mid-clavicular line
  • Vigor of contraction
  • Palpable thrill (rare) - associated with regurgitant or stenotic murmurs

Auscultation

  • What are we listening for?
    • Normal valve closure creates sound
    • First Heart Sound (S1) - closure of Mitral, Tricuspid valves
    • Second Heart Sound (S2) - closure of Pulmonic, Aortic valves
  • Systole - time between S1 & S2; Diastole - time between S2 & S1
  • Physiologic splitting of S2 - two components of second heart sound (Aortic & Pulmonic valve closure) audible with inspiration

Auscultation Technique

  • Patient lying @ 30-45 degree incline
  • Chest exposed (male) or loosely fitted gown (female)
  • Stethoscope must contact skin
  • Stethoscope with diaphragm (higher pitched sounds) engaged

Murmurs

  • Murmurs: Sound created by turbulent flow across valves:
    • Leakage (regurgitation) when valve closed
    • Obstruction (stenosis) to flow when normally open
  • Systolic murmurs:
    • Aortic stenosis
    • Mitral regurgitation
  • Diastolic murmurs:
    • Aortic regurgitation
    • Mitral stenosis

Extra Heart Sounds & S3-S4

  • Ventricular sounds, occur during diastole
  • Normal in young patient (~ < 30 yo)
  • S3 - follows S2, caused by blood from LA colliding with "left over" blood in LV; associated with heart failure
  • S4 - precedes S1, caused during atrial systole when blood squeezed into non-compliant LV; associated with HTN

Carotid Arteries

  • Anatomy
  • Palpation (each side separately)
  • Rhythm
  • Fullness
  • Auscultation
  • Radiation of murmurs

Jugular Venous Pressure (JVP)

  • Anatomy of Internal Jugular Vein
  • Straight line with RA
  • Manometer - reflecting Central Venous Pressure (CVP)

Lower Extremity Vascular Exam

  • General observation including femoral region
  • Expose both legs, noting:
    • Asymmetry
    • Muscle atrophy
    • Joint (knee, ankle) abnormalities
  • Focus on Femoral Area:
    • Inspect - ?Obvious swelling - femoral hernia v large lymph nodes (rare)
    • Palpate lymph nodes
    • Identify femoral pulse
    • Listen over femoral artery with diaphragm stethoscope for bruits

Feet and Ankles

  • Observe:
    • Swelling (edema)
    • Discoloration
    • Ulcers
    • Nail deformities
  • Palpation:
    • Temperature: Use back of examining hand - warm - inflammation; cool - atherosclerosis &/or hypoperfusion
    • Capillary refill: push on end of toe or nail bed & release - color returns in < 2-3 seconds; longer - atherosclerosis &/or hypoperfusion

This quiz covers the key aspects of examining the cardiovascular system, including taking a patient's history, vital signs, and physical examination techniques. It also highlights the importance of assessing distal vasculature and recognizing vascular disease as a systemic illness.

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