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PE OF ADULT CARDIAC PATIENT

General Greet patientExplain

• what we are going to do: PE of your neck and chest• aim :• procedure :• Understand my explanation???Have question?? May I proceed with the

examination???Ask patient lay down on exmntn table take off shirt

Wash hand dry itStand at RIGHT SIDE PATIENTDO GENERAL PHYSICAL EXM ON PATIENT

NECK JVPMake sure patient comfortable

↓Ask patient to raise head slightly on pillow to relax sternomastoid muscle

↓Head of the bed OR table raised to about 30 o

Patient’s head turn slightly away from the side you are expecting↓

Identify internal jugular vein and highest point of pulsation in the right internal(if hard to see, identify external vein in the lower half of the neck)

↓

Extend a long rectangular object horizontally from this point andput a centimeter ruler vertically from the sternal angle↓

Measure the vertical distance in centimeter above the sternal angle where the horizontalobject across the ruler

↓ The sternal angle is roughly 5 cm above the right atrium.

Pressure measured is recorded as 5+ ….. cmH2O The distance is the JVP

CAROTID PULSEi. Amplitude and contour

Patient still lying down with head of the bed still elevated (30-45 o)↓

Inspect the neck for carotid pulsation↓

Place left index and middle fingers (or left thumb) on the right carotid artery on the lowerthird of the neck, press posteriorly and feel the pulsation

↓Increase pressure until you feel a maximal pulsation and contour

↓NEVER press both carotid artery at the same time

ii. thrills and bruitsDetect the presence or absence of humming vibration or thrills. Listen over bothcarotid arteries with the DIAPHRAGM of your stethoscope for a bruit

Put the diaphragm of your stethoscope on the carotid area

↓Ask the patient to hold breath↓

Listen over both carotid arteries for a bruit

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ARM BRACHIAL ARTERY The patient’s arm should rest with elbow extended, palm up

↓Flex the elbow to a varying degree to get optimal muscle relaxation

↓Cup your hand under the patient’s elbow/ arm

↓Use the index and middle finger to feel the pulse (medial to biceps tendon)

Try to assess :amplitude of the pulse (small, weak pulses & large)contour of the pulse wave (the speed of its upstroke)

Duration of its summit, and the speed of its (downstroke).Any variation in amplitude

Bruit and thrills

THORAX INPECTIONi. point of maximal impulse (PMI)

Supposed to be done in a well illuminate/GOOD LIGHT room↓

Determine the location of PMI Normally in Midclavicula line, Intercostal space V)

PALPATIONUse your finger pads to palpate the impulse

Ventricular impulse may heave/lift your finger

Check for thrill by pressing the ball of your hand firmly on the chest.

PMI at left ventricular are PMI at Right Ventricular area Try to assess the PMI in the supine position

If you fail to assess the PMI try:Left lateral decubitus position

↓Ask the patient to exhale fully & stop breathing for a few

seconds** examining woman displaces the left breast upward

or laterally.↓

Assess the location:Normally on the interspaces 4th or 5 th and LMCL

Patient rest supine at 30 0

↓

Place tips of curved fingers inthe

3rd, 4th, and 5th interspace.↓

Feel the systolic impulse of right ventricle, breathe out,

hold breath few seconds

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PERCUSSIONCareful percussion AND should use the lightest percussion

i. determin e the right border of the heartDetermine the liver-lung border first and move 2 ICS cranially.

↓Percussion should begin at the lateral side and percuss toward the sternum.

↓ The dullness usually begins along the right sternal line

↓ The RIGHT BORDER at the sternal line and the UPPER BORDER (base of the heart)

in the 2nd left interspaceii. determine the left border of the heart

percuss from left lateral toward medial↓

Normally, the LEFT BORDER is in the left midclavicular line.

AUSCULTATION Listen to entire precordium with the patient supine

i. Heart sound

ii. valve area

iii. detect presence or absence of heart murmur if heart murmur washeard identify and describe its

1. TIMING Systolic murmur (falls between S1 and S2) Diastolic murmur fallsbetween S2 and S1

2. SHAPE Crescendo,Decrescendo,Crescendo Decrescendo, Plateau

3. LOCATION OF MAXIMAL INTENSITY

4. RADIATION / transmission from the PMI

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5. INTENSITY grade 1- grade 6

6. PITCH high, medium, low

7. QUALITY blowing, rumbling, musical

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S1 S2 S3 S42 components

Mitral valve closure &tricuspid closure

S1:deeper and longer S2carotid pulse is a reliable

timing device as itoccurs immediatelyfollowing the S1

2componentsAorticcomponentprecedesthepulmoniccomponent

normal finding inyoung adults (below40)

audible after S2Put the bell of your

stethoscope and presslightly over the apex

↓a very low pitched sound

S4 precedes theS1↓

very low frequency andis heard most clearly atthe apex, near xyphoidor in the suprasternal

notch