Which sounds do you use the diaphragm for?
high pitched sounds
S1, S2, AR, MR, Friction Rub
Which sounds do you use the bell for?
low pitched sounds
S3, S4, MS, carotid
Steps to CV exam
1) inspection
2) palpation
3) percussion
4) auscultation
Palpation of PMI
impulse should be small, brisk beat and measure less than 2.5 cm
should last through the first 2/3 of the systolic period or less, should not be felt through the second heart sound
S1
closure of tricuspid and mitral
S2
closure of aortic and pulmonary
may split with inspiration (normal)
S3 Ken-Tuck-Y
dull, low pitch, best heard with bell
due to high pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase
S4 Ten-Nes-See
dull, low pitch, best heard with bell
atrial gallop from forceful contraction of atria against a stiffened ventricle
Systolic Murmurs
- between S1 and S2
- Aortic Stenosis
- Pulmonic Stenosis
- Mitral Regurgitation
- Tricuspid Regurgitation
Diastolic Murmurs
- between S2 and S1
- Aortic Regurgitation
- Pulmonic Regurgitation
- Mitral Stenosis
- Tricuspid Stenosis
Heart Murmur Grading
1- very faint
2- quiet, but heard easily with stethoscope
3- moderately loud, no thrill
4- loud with palpable thrill
5- very loud with thrill
6- heard with stethoscope entirely off chest
Pulse Grading
4- bounding 3- string, full, increased 2- average 1- diminished, barely palpable 0- absent, not palpable
Cap Refill
- test of digital perfusion
- apply pressure to fingernail for several seconds
- release
- note time it takes for color to return
- normal refill is 2 seconds of less
Edema Locations
1) dorsum of the foot
2) anterior tibia
3) posterior medial malleolus
Grading for Edema
Absent
1- barely detectable, slight pitting (2mm); disappears rapidly
2- slight indentation (4mm); 10-15 seconds
3- deeper indentation (6mm); may be >1 minute
4- very marked indentation (8mm); 2-5 minutes
JVP
- raise head of bed or examining table 30 degrees
- turn patients head away from side inspecting
- identify right internal jugular pulsation
- identify the highest point of pulsation in the right internal jugular vein
- measure the vertical distance in cm above the sternal angle where the horizontal object crosses the ruler and add to this distance 5 cm
Allen Test
- evaluates functioning of radial and ulnar arteries
- occlude both arteries while patient makes a fist
- have patient open and close fist; palm should be pale
- release pressure on ulnar artery and observe for color to return to hand within 5-10 seconds
- repeat with radial ulnar
