ARTERIAL PULSE: RADIAL Method Of Exam Consultant: R Gunnar, MD and R.

Lichtenberg, MD

Author: A. Chandrasekhar, MD

Simultaneously palpate both radial pulses. Note the rate, rhythm, character, amplitude and compare both pulses. Feel the pulse with one finger. To evaluate character of pulse - compress brachial artery against humerus and let up part way to feel percussion and tidal peaks. Raise the patient's forearm and feel for a bounding pulse by feeling with the flat of your palm. Normal:

Pulse is symmetrical, regular and between 60-90 per minute. You have to learn to appreciate the character and amplitude of the normal pulse.

Abnormal Finding Rate o o

Bradycardia: Less than 60/min (Myxedema, heart block, raised IC tension, obstructive jaundice) Tachycardia: Faster than 100/min. (Sinus tachycardia, PAT, atrial flutter, ventricular tach)

Rhythm o Irregular: (Sinus arrhythmia, extra systoles, atrial fib, pulses bigemini)

Alternating weak and strong pulse: Pulses bigemini: Normal beat alternating with extra systole (Dig toxicity) Pulses alternans: Normal beat alternating with low amplitude beat Amplitude o Slow small sustained (Aortic stenosis) o Large bounding pulse: Water hammer pulse: (Aortic insufficiency, high output states, slow heart rates) o Double systolic peak: Bisferiens pulse (Aortic regurgitation) o Decrease in amplitude during inspiration: Paradoxical pulse Exaggerated in (Pericardiac tamponade, obstructive lung disease) Compare o Missing or feeble on one side: (Prior cath, Takayasu's disease, subclavian steel syndrome) Grading Pulse 4 = Normal 3 = Slightly diminished 2 = About half 1 = Barely palpable 0 = Absent

VEINS: NECK VEINS

Author: A. Chandrasekhar, MD

Method Of Exam Consultant: R. Lichtenberg, MD and R. Gunnar, MD

Inspect for internal jugular vein pulsations in the neck, in supine position and with neck and trunk raised to o approximate angle of 45 . Internal jugular vein pulsation are visible at the root of the neck between clavicular and sternal heads of sternoclidomastoid muscle. Internal jugular vein corresponds to a line drawn from this point to infra auricular region. Inspection with simultaneous palpation of the carotid and/or auscultation of the heart will assist in identification and timing of the waves. Inspect the vein from different angles. Apply light tangentially and observe for venous pulsations in the shadow of neck on the pillow. At 0 jugular veins should be filled. An impulse visible just prior to S1 or the upstroke of the carotid is the "a-wave". This will be followed by a x-descent. The 'c' wave is usually not visible. The 'v' wave occurs after the start of the carotid upstroke and during ventricular systole (which is atrial diastole). When the tricuspid valve opens there is a brisk descent (y-descent). Observe the venous pressure changes with respiration. There is normally a drop in intrathoracic pressure with inspiration. This decrease is also reflected on the intracardiac pressures. Therefore, an increase in the pressure difference between the SVC/IVC and the RA increases cardiac filling. Normal: 1. Neck veins are not visible at 45 inclination. 2. Neck veins should be visible in supine position. 3. JVP should decrease with inspiration. Abnormal Finding Neck vein distension at 45 inclination is abnormal and is indicative of increased central venous pressure. Describe the level to where the pulsations are seen in relationship to the angle of Louis. Note the effect of inspiration. Apply gentle pressure to right upper quadrant and note its effect on neck veins (hepatojugular reflux). If neck vein distension is present identify a, c and v waves and describe their amplitude. Distended pulsatile neck veins ( CHF, Tricuspid insufficiency) Hepatojugular reflux: Right ventricular non-compliance to increased filling Distended non- pulsatile neck veins: ( SVC syndrome , cardiac tamponade, Constrictive pericarditis). These patients usually have prominent descents. Quick Y descent and X descent: (Constrictive pericarditis) Distended veins during expiration only: (COPD, Asthma) Prominent "a" wave: "a" waves are due to atrial contraction and when abnormally prominent indicate atrial contraction into a noncompliant right ventricle or through a stenotic or closed tricuspid valve. In complete heart block and with premature ventricular contraction there is loss of a-v synchrony. When the atrial and ventricular contractions coincide a prominent wave is seen. This is called cannon a-wave. A noncompliant right ventricle can be hypertrophied (secondary to pulmonary hypertension) or "stiff" due to scar (ischemia/infarct) or infiltrative disease (amyloid). JVP which increase with inspiration indicate restricted filling of the right sided chambers (Kussmaul's signs).
o o o

Absent "a" waves: (Atrial fibrillation). "v" waves are most commonly due to an insufficient tricuspid valve with the ventricular systolic pressure reflected in the atrium during atrial filling (diastole). Prominent "v" wave: (Tricuspid regurgitation). Cannon wave: (Heart block, Premature ventricular contraction).

PRECARDIUM: INSPECTION

Author: A. Chandrasekhar, MD

Method Of Exam Consultant: R. Gunnar, MD and R. Lichtenberg, MD

Inspect the precordium tangentially while the patient is laying flat in bed from either the patient's head or foot for symmetry and pulsations. Normal: The precordium is symmetrical. In thin individuals, the apical impulse is recognizable. Apical impulse is located in 5th interspace just internal to midclavicular line. The left precordium will dip slightly during systole.

Abnormal Finding Bulge o Precordial: Implies onset during childhood (RV hypertrophy) o Aortic area bulge:(Aortic aneurysm) Pulsations o Precordial: RV hyperactivity o Displaced apical impulse: (Cardiac hypertrophy or dilatation, Mediastinal shift, Deformities of thorax, Raised intra-abdominal pressure) o Apical impulse on right: (Dextrocardia) o Aortic: (Aneurysm or dilatation) o Pulmonary: (Pulmonary artery dilatation) o Epigastric: (RV hypertrophy)

PRECARDIUM: PALPATION

Author: A. Chandrasekhar, MD

Method Of Exam Consultant: R. Lichtenberg, MD and R. Gunnar, MD

Palpate the precordium with the palmar surface of your hand over the aortic, pulmonary, parasternal and apical areas of the heart. Determine the lower and outermost precardiac impulse, the apical impulse. Press your finger over the apical impulse identify its location, amplitude, duration and assess the rapidity of the upstroke and downstroke.

Normal: In thin individuals, the apical impulse is recognizable. Apical impulse is normally in 5th interspace just medial to midclavicular line and is about 1-2 cm in diameter. The apical impulse feels like a gentle tap and is small in amplitude and corresponds to first two thirds of systole.

Abnormal Finding Bulge: Note the site of bulge. o Precordial bulge: RV hypertrophy, LA enlargement, LV aneurysm o Aortic area bulge: Aortic aneurysm, Dilation (e.g., post stenotic dilation) Thrust: Note the site, size, amplitude , duration, upstroke and downstroke characteristics. o Parasternal area : Marked increase in amplitude with little change in duration; Volume overload of RV (ASD) Marked increase in amplitude and duration; Pressure overload of RV (Pulmonic stenosis, Pulmonary hypertension) o Aortic area: (Aortic aneurysm) o Pulmonic area: Prominent pulsation (Pulmonary artery dilatation, Increased flow , Pulmonary hypertension) o Apical impulse Sustained lift : Pressure overload, LV hypertrophy (Aortic stenosis) Hyperdynamic: Marked increase in amplitude Volume overload (Mitral insufficiency, Aortic insufficiency) Undetectable apical impulse: (Obesity, Emphysema, Muscular chest, Pericardial effusion) Hypokinetic apical impulse and displaced to left:(Dilated failing Heart) Thrill: It is a purring sensation. Note its location and timing. o Parasternal area: (PDA, ASD, VSD) o Aortic area: ( Aortic stenosis) o Pulmonic area: ( Pulmonary stenosis) o Apical area: ( Mitral insufficiency, Mitral stenosis) Tap: Loud sounds evoke a palpable feeling like a tap. o Aortic area: Palpable A2 ( Hypertension) o Pulmonic area: Palpable P2 ( Pulmonary hypertension) Rub: Scratchy feeling. o ( Pericardial) Szorsy Gallops: Can be palpable

SUPRASTERNAL NOTCH: PALPATION

Author: A. Chandrasekhar, MD

Method Of Exam Consultant: and R. Gunnar, MD

R.

Lichtenberg,

MD

Palpate the suprasternal notch with your index or middle finger. Normal: In normal (young) patients, there will be no palpable pulse. In older patients, the aortic pulsations will be recognizable. Abnormal Finding Prominent suprasternal pulsation: (Aging, uncoiled aorta, arch aneurysm) Thrill: (Aortic stenosis, pulmonic stenosis, PDA)

HEART: AUSCULTATION Method Of Exam Consultant: R. Gunnar, MD and R. Lichtenberg, MD

Author: A. Chandrasekhar, MD

Auscultate the heart in five locations in a systemic fashion, starting at the apex, move to the lower left sternal border (include epigastrium), and extend to the base of the heart. o PMI o epigastrium o left sternal border o second right (aortic) o left (pulmonic) intercostal space Do this once with the following: o diaphragm (which best facilitates hearing high pitched sounds including S1 and S2) and repeat with the o bell (which best facilitates hearing low pitched sounds including S3 and S4). Give special attention to the intensity of S1 at the apex , to the intensity of S2, and the splitting of S2 in the left second intercostal space.

Identify any extra sounds in systole or diastole. Listen to each cardiac event with focus on that event, excluding all other cardiac sounds, i.e., listen to S1 at all areas determining if it is split, where it is split. If splitting changes with respiration and if it is soft or accentuated, then move and repeat for another cardiac event. Placing the patient in the left lateral decubitus position will facilitate hearing diastolic filling sounds and mitral valve related murmers. Normal:

S1 is louder than S2 in apex.

S1 is softer than S2 at base. S2 is single over apex. S2 is normally split in base and left lower sternal border accentuated by inspiration and becomes single during expiration.

EDEMA: DEPENDENT Method Of Exam Author: A. Chandrasekhar, MD

Observe for edema of the foot, ankles and legs. Gently compress the patient's soft tissue with your thumb over both shins for a few minutes.

Observe for indentation.

Note: In bed-ridden patients, examine for edema over the sacral and coccygeal areas. Normal: Normally, there is no indentation.

Abnormal Finding When edema is noted, describe whether it is unilateral or bilateral, severity graded from 1 to 4+ and whether it is soft or hard pitting. Congestive heart failure: Bilaterally symmetrical soft pitting edema. Deep vein thrombosis: Unilateral soft pitting . Chronic venous stasis: Firm pitting with hyperpigmentation and thickening of skin. Hypoalbuminemia: Extremely soft pitting, bilateral and thin skin. Lymphoedema: Hard non-pitting with thick pew-de-orange skin. Pretibial myxedema: Hard non-pitting. Cellulitis: Unilateral, soft to firm tender with red warm skin.