Cardiovascular Examination

GENERAL INSPECTION

If not already done:

• assess for signs of peripheral and central cyanosis

• observe for signs of clubbing

• check capillary refill time

• record blood pressure

Rate and Rhythm of Arterial Pulses

• Compress the radial artery with your index and middle fingers.

• Note whether the pulse is regular or irregular.

Normal pulse rate

60-100 beats per minute

Bradycardia

Less than 60 beats per minute

Tachycardia

Greater than 100 beats per minute

Figure 1.6. Heart rate table.

Regular rhythm

Evenly spaced beats - may vary slightly with inspiration

Regularly irregular

Regular pattern with regular skipped or extra beats

Irregularly irregular

No pattern. Atrial fibrillation - always record apex beat for 1 minute

Figure 1.7. Heart rhythm table.

Figure 1.7. Heart rhythm table.

• Count for a full minute if the pulse is irregular and record apex rate.

• Record the rate and rhythm.

Auscultation for Bruits

• Auscultate for bruits.

• Place the bell of the stethoscope over each carotid artery in turn.

• Ask the patient to stop breathing momentarily.

• Listen for a blowing or rushing sound - a bruit.

Jugular Venous Pressure

• Position the patient supine with the head of the table elevated 45°.

• Look for a rapid, double (sometimes triple) wave with each heart beat.

• Identify the highest point of pulsation.

• Using a horizontal line from this point, measure vertically from the sternal angle.

• This measurement should be less than 4 cm in a normal healthy adult.

AUSCULTATION

• Position the patient supine with the head of the table slightly elevated (see Figure 1.8).

• Listen with the diaphragm at the right 2nd intercostal space near the sternum (aortic area).

• Listen with the diaphragm at the left 2nd intercostal space near the sternum (pulmonary area).

• Listen with the diaphragm at the left 3rd, 4th, and 5th intercostal spaces near the sternum (tricuspid area).

• Listen with the diaphragm at the apex (mitral area). Apex beat should be heard at the 5th intercostal space in the mid clavicluar line.

• Listen with the bell at the apex.

• Listen with the bell at the left 4th and 5th intercostal space near the sternum.

• Ask the patient to roll onto their left side.

• Listen with the bell at the apex. This position brings out S3 and mitral murmurs.

• Ask the patient to sit up, lean forward, and hold their breath in exhalation.

• Listen with the diaphragm at the left 3rd and 4th intercostal space near the sternum. This position brings out aortic murmurs.

• Record all heart sounds including any murmurs heard and the severity of the murmur.

Murmur grades

Grade

Volume

Thrill

1/6

very faint, only heard with optimal conditions

no

2/6

loud enough to be obvious

no

3/6

louder than grade 2

no

4/6

louder than grade 3

yes

5/6

heard with the stethoscope partially off the chest

yes

6/6

heard with the stethoscope completely off the chest

yes

Figure 1.9. Heart murmurs table.

/

epigastric region

left hypochondrium

right lu

mbar / flank

umbillical region

left lumbar / flan

k

right iliac fossa

hypogastric region \ /

left iliac fossa

Figure 1.10. Abdominal examination.

Figure 1.10. Abdominal examination.

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