Proper sequence in PE
- Inspection
- Palpation
- Percussion
- Auscultation
- Positioning of patient
What is the PMI?
“point of maximal impulse”
-have patient lie at 45 degrees or left lateral decubitus
-if upright: 5th ICS, 1 cm medial to MCL
Normal: 4-5th ICS at mid clavicular line)
*the more laterally displaced, the more LV hypertrophy
When do you hear the third heart sound? fourth?
- HF, kids, athletes
2. HT, vascular resistance, NOT in a fib/flutter, Common
Common systolic murmurs? diastolic murmurs?
- Mitral/tricuspid regurgitation, aortic/pulmonic stenosis, ESD
- Mitral/tricuspid stenosis, aortic/pulmonic regurgitation
Where does mitral regurgitation radiate? pulmonic stenosis?
- left axillary
2. sternal notch/carotid
What is the clinical significance of JVP/JVD?
- reflects activity of the right side of the heart
- JVP visibility gives indication of CVP and RAP
- Internal Jugular is a better estimate than External
How do you measure JVP?
- pt. is supine to allow veins to engorge, and then move them to 30-45 degree angel
- normal is 0-9
*most common cause of elevation is RV diastolic pressure; SVC obstruction, severe HF (most common)
What do these waves mean: a? c? x? v? y?
- atrial contraction
- closure of tricuspid valve
- atria is filling
- atria under pressure with tricuspid still closed
- tricuspid opens
What does a prominent a wave indicative of?
tricuspid stenosis, pulmonary HT/stenosis, PE, tumor…basically blood is having a hard time leaving
How do you measure the Hepatojugular Reflux?
- have pt. lie at 30-45 degrees, and apply a steady pressure (thirty seconds) to costophrenic angel, and neck veins will become engorged
- caused by poorly compliant RV, RV failure, constrictive pericarditis, obstructive RV filling by TS or RA tumor
Grades for edema: 0, 1, 2, 3, 4
a. absent
b. barely detectable; 2mm
c. slight; 4mm, 10-15 sec
d. deeper; 6mm; can by >1 min
e. very marked; 8mm; 2-5 min
