DEBBIE KING MSN, FNP-C, PNP-CFALL 2009

Cardiac, Thorax, Peripheral Vascular System Assessment

Chest Exam

Visual Inspection/Palpation Skin for cyanosis, venous distention, nail beds for

capillary refill Asymmetry of the chest cage (A/P & lateral) PMI (point of maximal impulse) at the left 5th ICS

at the midclavicular line usually (may be slightly displaced in the muscular, pregnant, obese and elderly)

Place patient in the supine position to palpate the heart

Palpate for thrills at the apex, left sternal border, and the base (prominent impulses may suggest heart enlargement)

Land Marks

Count interspaces Identify your ...

o Midsternal lineo Midclavicular lineo Anterior axillary

lineo Midaxillary line

Auscultation

Five ausculatory areas Aortic valve area- second right intercostal space

at the right sternal boarder Pulmonic valve-2nd left ICS at LSB Second pulmonic area-3rd LICS at LSB Tricuspid area- 4th LICS Lower LSB Mitral or apical area- apex:5th LICS at the

midclavicular line

Auscultation

Systole: the ventricles contract The right ventricle pumps blood into the pulmonary

arteries (pulmonic valve is open)

The left ventricle pumps blood into the aorta(aortic valve is open)

Diastole: the ventricles relax Blood flows from the right atrium → right ventricle

(tricuspid valve is open)

Blood flows from the left atrium → left ventricle (mitral valve is open)

Auscultation

Use the diaphragm, then the bell to assess the 5 cardiac areas Patient sitting, leaning slightly forward Best to focus on heart sounds during expiration-

best for high pitch murmurs Patient supine Patient left lateral recumbent, best to hear low

pitched sounds in diastole with bell Other positions-PRN Inch don’t jump

Heart Sounds

S1 Mitral/Tricuspid close (atrioventricular valves)

S2 Aortic/Pulmonic close (semilunar valves close) S2 splitting inspiration (physiologic) expiration

(pathologic) S2 splitting common and normal in children and young adults

S3 Atrial ejection “Ken-tuc-ky”S4 Ventricle filling “Tenn-es-see”

S3 & 4 should be quiet and may be difficult to hear.

Heart Murmurs

Disruption of blood flow through the heart due to Stenosis - narrowed or thicken, stiff valve Regurg - slack valve leaflets causing

retrograde flow Other causes – pregnancy, anemia,

thyrotoxicosis, CAD, Arteritis Evaluate using the bell and the diaphragm

Murmur Grading

Grade I –barely audible in quiet roomGrade II – quiet but clearly audibleGrade III – moderately loudGrade IV – loud, associated with thrillGrade V – very loud, thrill easily palpableGrade VI – very loud audible w/stethoscope

not contacting chest wall, thrill palpable & visible

Characteristics of murmurs

Timing & duration (early, mid, or late systolic) Refer all diastolic murmurs!

Pitch (high, medium, or low)Intensity (grades)Pattern (crescendo, decrescendo)Quality (harsh, raspy, vibratory, blowing,

musical)Location (anatomic landmarks)Radiation (anatomic landmarks )Variation w/respiratory phase (intensity,

quality, timing)

Murmurs

Most are innocent, esp. in children and young athletes Result of vigorous myocardial contraction

Some are benign- result of a mild anomaly

Comparison of systolic Murmurs

Right sided chamber with inspiration gets louder With expiration gets softer

Hypertrophic cardiomyopathy With Valsalva gets louder With rapid squat to stand for 30 sec gets louder With standing to squatting rapidly gets softer Passive leg elevation to 45 degree gets softer

Mitral regurg With handgrip gets louder

Aortic stenosis Diagnosis made by exclusion

Chest Pain(Rarely originates in the heart)

Differential Diagnosis Angina Pectoris

Cardiac risk factors, specific onset, forces pt to stop, relief with nitro, often in am, more likely if cold

Musculoskeletal Trauma, vague onset, >with effort, continues with rest, heat and

Advil helpful, worse with day of physical effort, worse with cold damp temps

Gastrointestinal Indigestion, vague, related to food, lasts hours, unrelated to effort,

may awaken, relief with antacids, no other triggers, occurs any time Pulmonary

Pneumonia, asthma, pleurisy, cancer, list is endless. Improves with bronchodilators, antibiotics ECT

Chest Pain-Specific diagnosis

Angina Coronary

insufficiency MI Mitral valve prolapse Dissection of the

aorta Pericarditis Pleurisy Pneumothorax Cocaine use Shoulder disorder

Emphysema Hiatal hernia Reflux Esophageal spasm Cholecystitis Ulcer Pancreatitis Pneumonia Embolus Cervical

radiculopathy Costochondritis

History for patient with chest pain

History of present illness Describe the Pain, onset, frequency, location, severity,

associated symptoms

Past medical historyFamily historyPersonal and social history

Peripheral Vascular System Blood Vessels

Palpate the arterial pulses, the best are close to the surface and over boney areas Carotid-most useful, close to the heart Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibial

Peripheral Vascular System Palpation

Palpate with the digital pads of the second and third fingers

You may use the thumb and is sometimes helpful with moving vessels

Palpate firmly without occluding the arteryLack of symmetry suggests impaired circulationFemoral is as strong as radial if its not or its absent

suggests coarctation of the aortaMay also measure capillary refill time to assess

severity of arterial occlusion

Techniques of Examination – Palpate Pulses

Femoral pulse Press deeply below inguinal ligament, midway between

anterior superior iliac spine and symphysis pubis Popliteal pulse

Flex knee some, leg relaxed Place fingertips of both hands to meet midline behind

knee and press deeply into popliteal fossa Dorsalis pedis pulse

Feel dorsum of foot, lateral to extensor tendon of great toe Posterior tibial pulse

Curve fingers behind and slightly below medial malleolus of ankle

Evaluation of pulses

Rate – 60-90 bpmRhythm – regularContour – pulse wave should be smooth,

rounded or domed shapeAmplitude – scale of 0-4

4 = bounding 3 = full, increased 2 = expected 1 = diminished 0 = absent or no pulse

Pulse Abnormalitiesbradycardia less than 60,tachycardia over

100

Alternating pulse Weak/strong

Left ventricular failure

Pulsus bisferiens Two strong separated with dip

Aortic regurg with or without stenosis

Bigeminal pulse Two pulses rapid followed by

longer interval Ventricular premature beats

Bounding pulse Rapid rise, brief peak, rapid fall

Atherosclerosis, PDA, hyperthyroid, anxiety, fever, anemia

Labile pulse Amplitude increased with

sitting or standing Not associated with disease

Paradoxic pulse Decreases on inspiration

COPD, pericarditis or effusion

Trigeminal pulse Three beats then pause

Often benign, or severe disease

Water-hammer pulse Jerky pulse with full

expansion then sudden collapse Aortic regurgitation, patent ductus arteriosus

History of present illness with abnormal pulse findings

Leg pain or cramps (claudication) Describe- onset, duration, what relieves,

character IE burning or cramping, skin changes or hair loss or sores ECT

DizzinessSevere headachesSwollen anklesTreatment attempted

Compartment syndrome

The Ps Pallor Pain Pulselessness Paresthesias if major artery occluded Paralysis, is rare

Auscultation for Bruits

CarotidThyroidTemporalAbdominal aortaRenal IliacFemoral

Auscultation for bruits

Should be done after the cardiac assessmentUsually low pitched and hard to hearUse the bell directly over the artery

Auscultation of the neck

Carotid bruits heard best at the anterior margin of the sternocleidomastoid muscle as the patient holds their breath, may be one of three types A murmur transmitted from aortic stenosis, ruptured chordae

tendineae of the mitral valve or severe aortic regurg Vigorous left ventricular ejection-heard more in children Obstructive disease in carotid arteries-complete obstruction will

eliminate May also hear a venous hum

Heard at medial end of clavicle and anterior border of sternocleidomastoid muscle

Usually of no significance, but in adults may mean anemia, thyrotoxicosis or intracranial arteriovenous malformation

Confused with bruits

Inspection of Extremities

Color (pink)Skin texture (elasticity)Nail changes (brittle, cracked, dry)Presence of hair (lack of)Muscular atrophy (thinning, wasting)Edema or swelling (fat ankles)Varicose veins (dilated or swollen)

Techniques of Examination - Arms

Inspect both arms from fingertips to shoulders

Note the following:

o Size, symmetry, and any swelling

o Venous pattern

o Color of skin and nail beds; texture of skin

Palpate radial pulse

Use finger pads on flexor surface of wrist

Partially flex patient’s wrist

Compare pulse in both arms

Techniques of Examination-Arms

Palpate brachial pulse

Flex elbow slightly

Palpate artery medial to biceps tendon in antecubital crease

Epitrochlear nodes

Flex elbow 90°

Support forearm

Feel in groove between biceps and triceps muscle, 3 cm above medial epicondyle

Techniques of Examination-Legs

Patient should lay down, draped so external genitalia is covered and legs are fully exposed

MUST remove patient’s stockings or socks

Inspect both legs from groin and buttocks to feet

Note the following: Size, symmetry, and any swelling

Venous pattern/venous enlargement Pigmentation, rashes, scars, or ulcers

Color and texture of skin, color of nail beds, distribution of hair on lower legs, feet, and toes

Techniques of Examination-Legs

Palpate superficial inguinal nodes

Horizontal/vertical groups

Note size, consistency, and discreteness and tenderness

Nontender, discrete nodes up to 1-2 cm are palpable in normal people

Palpation of extremities Summary

Warmth Pulse qualityTenderness along a superficial veinPitting edema

1+ slight pitting, disappears rapidly 2+ slightly deeper pit, disappears in 10-15 sec 3+ noticeable deep, last > 1 min. (extremity

looks full & swollen) 4+ deep pit lasting 2-5 min., grossly distorted

(if edema is unilateral suspect occlusion of a major vein & edema w/o pitting suspect arterial disease or occlusion)

Evaluation of Edema

Compare one foot and leg with the other Note relative size and prominence of veins,

tendons, and bonesCheck for pitting edema

Press firmly with thumb for 5 seconds over dorsum of each foot, behind medial malleolus and shins

Severity of edema graded on four-point scale (slight to very marked)

Evaluation of Edema

If edema is present, look for causes Recent deep venous thrombosis Chronic venous insufficiency Lymphedema

Note color of skin Local area of redness Brownish areas near ankles Ulcers and where Thickness of skin

Blood Pressure

Bilateral measurements, supine & standing Better to use a larger cuff than smaller

Measured by the width of the bladder than the cloth Mercury column is most reliable, but no longer

permitted Aneroid sphygmomanometer lose accuracy with

age and use Preferred position is seated and the cuff at heart

level Advise patients not to have caffeine, rushing, ECT

before the appointment

How to take a BP

Both arms with arms flexed and supported, free of clothing Use the appropriate size cuff that is snug and secure Center the deflated bladder over the brachial artery, just

medial to the biceps tendon, with the lower edge 2-3cm above the antecubital

Checking the palpable systolic pressure first with avoid being mislead in auscultatory gap Inflate to 20-30 mm HG above the point where you do not feel

pulse. Deflate slowly until you feel pulse. Place bell over brachial artery pausing for 30 seconds inflate

to 20-30 MM Hg over the palpable systolic pressure Deflate slowly

Review Korotkoff sounds

JVD measurement

Evaluate jugular vein distention (JVD) Use a ruler at least 15 cm long Use a light for tangential illumination across the neck Patient is initially in supine position which results in

engorgement of veins. Raise the head of the bed gradually until pulsations are

seen between the jaw and the clavicle Palpating the contralateral carotid pulse helps distinguish

them from the carotid pulsation To assess for hepatojugular distention which is seen in right heart

failure; apply firm and sustained pressure to the midepigastric area with patient breathing normal, if RHF is present the JVD will get measure larger

CHEST & LUNG EXAM

HPI, PMH, FHX, Social & Personal HXHave pt sit up w/o support, w/o shirt.Clothing is a barrierWarm hands, warm stethoscope,

lightingLook for landmarks: refer to text

Midsternal line, R&L midclavicular lines, R&L anterior, midaxillary, and posterior lines, vertebral line, R&L scapular lines

Anatomy and Physiology

Anatomy of the chest wall

Anatomy and Physiology (cont.)

To locate findings around the circumference of the chest, imagine a series of vertical lines

Lungs, fissures, and lobes Each lung is divided roughly in

half by an oblique (major) fissure

The right lung is further divided by the horizontal (minor) fissure

These fissures divide the lungs into lobeso The right lung is divided

into upper, middle, and lower lobes

o The left lung is divided into upper and lower lobes

Anatomy and Physiology (cont.)

Chest -Bone Structures

Anatomy of the chest to assess Larynx Trachea Manubrium Sternum Xiphoid Clavicle Acromion Process Scapula Ribs

Anatomy of the back to assess Scapular –height and prominence Spinal curve and muscle equality

Scoliosis Kyphosis

Chest –Muscles to assess

Anterior Sternocleidomastoid Scalenus Pectoralis minor Intercostal muscles Serratus anterior Rectus abdominus

Posterior Serratus posterior

superior Intercostal Transverse Diaphragm Serratus Posterior inferior

Anatomic/Topographic Landmarks of the chest

Suprasternal notchClavicleSecond ribBody of sternumNippleXiphoid

ClavicleManubriumManubriosternal

junction or angle of Louis

Costal angle

Inspection of Chest

Size & shape: barrel chest-result of compromised respiration, structural Carinatum pectus or pigeon chest Pectus excavatum or funnel chest

Symmetry: (AP < transverse diameter) Skin color - inspect nails, lips, & supernumerary nipples

(pink, no pallor or cyanosis) Superficial venous patterns (heart disorder, vascular disorder

or disease) Prominence of ribs (underlying fat clue to nutritional state) Bone and muscle landmarks Anatomic/Topographic landmarks

Respirations and Chest Movement

Rate – normal 12-20 bpmRhythm/pattern – note movement of chest,

expansion should be bilaterally symmetric, breathes easily w/o distress, breathing should be even, non labored.

Use of accessory musclesNo bulging of the Intercostal muscles.

Descriptions of abnormal Respirations

Dyspnea- SOB-difficult, labored-lung or cardiac issues, sedentary life style, obesity.

Orthopnea-SOB when pt lies down, sleeps on more than 1 pillow.

Paroxysmal nocturnal dyspnea-sudden onset of SOB after a period of sleep

Platypnea- dyspnea increases in upright position.

Irregular patterns of respirations

Tachypnea- increased RR 20 rpmBradypnea- slower than 12 rpmHyperpnea- faster than 20 breaths, deep

breathing.Kussmaul- rapid, deep, labored- Metabolic

acidosis.Hypopnea- abnormally shallow breaths IE: pleurisy.Cheyne-Stokes- depth along with apnea, seriously

ill pt’s.Air trapping- difficulty in getting breath out d/t

prolonged inefficient expiratory effort.

Palpation of Thorax

Feel for pulsations, areas of tenderness (rib fx), bulges, depressions, unusual movements, and unusual positions.

Crepitus-crackly or crinkly sensation Pleural friction rub- inflammation of pleural surfaces

(leather rubbing on leather) Thoracic expansion

Assess both anterior and posterior Thumbs should move equally

Tactile fremitus Use palmar or ulnar aspects at the same time, or move dominant

hand Ask patient to say ‘99’ Should be symmetrical fremitus

Palpation of Thorax

Position of trachea Put index finger in suprasternal notch and move

gently side to side at the upper edges of each clavicle and in the spaces above to the inner borders of the sternocleidomastoid muscles Spaces should equal on both sides, trachea should be

midline directly over the suprasternal notch Simultaneously palpating with both thumbs on

either side of the thyroid, again the thyroid should be midline, but may deviate slightly to the right

Percussion

Compare bilaterally Use one side as control for the other Patient sitting head bent arms folded in front Move systematically side to side at intervals of several

centimetersDullness- thud like- atelectasis, asthma, pleural

effusion, pneumothoraxResonance- hollow-heard all areas of lungsHyperresonance- booming-hyperinflation

(asthma, emphysema, pneumothorax).Tympanic- drum like-usually over abdomen

Percussion

Diaphragmatic excursion. Patient takes a deep breath and holds Percuss scapular line until dullness is heard Mark this point Allow patient to breath normally Repeat deep breath then exhale and hold Percuss up from the mark until resonance is

heard Mark the area Repeat on other side in real practice, one side for

the video

SMELL

Smell the breath Fruity-ketoacidosis Fishy-uremia Halitosis-Tonsillitis, gingivitis, GERD Feculent-intestinal obstruction Putrid- sinusitis, FB, cancer lung abscess Cinnamon-pulmonary TB

Auscultation

Thoracic Landmarks Anterior thorax Right lateral thorax Posterior thorax

Procedure- use diaphragm Patient upright, same position as percussion breathe slow and deep Comfortable pace Elderly begin low and go up All others begin up and go low Use side to side as in percussion listening to ins and exp

AuscultationNormal breath sounds

Vesicular-most lung fields, soft pitch with low intensity

Bronchovesicular-main bronchus and upper right posterior lung-medium pitch E=I

Bronchial/tracheal- heard only over trachea, high pitch E is louder than I

Abnormal Breath Sounds

Crackles- heard during middle or end of inspiration, not cleared by cough.

Rhonchi- loud, low, coarse, coughing may clear.Wheeze-musical-louder during inspiration

A more significant finding if heard in expirationPleural Friction rub- dry rubbing.Hamman Sign- crackling, clicking crunching

and gurgling with heart beat, heard better when pt lies or leans to left and indicates mediastinal emphysema

Cough

Preceded by deep inspiration, followed by closure of the glottis and contraction of the chest and abdominal muscles the spasmodic expiration, forcing opening of the glottis.

May be voluntary, but usually reflexive to irritants Differentials of coughs include:

Infection Irritants and allergens Compression Congenital malformation Acquired abnormally- yelling, FB, tumor Neurogenic or vocal cord paralysis

Cough description

Dry or Moist- may have sputumOnset- acute or slow onsetFrequency –seldom or oftenRegularity –irregular is the most common,

regular is seen in pertussisPitch/loudness- loud/quiet, high or low pitchPostural- worse when supine with PNDQuality- brassy with compression, hoarse

with croup, inspiratory whoop with pertussis

Other Breath Sounds

Bronchophony- increased loudness of spoken words

Whispered pectoriloquy- with consolidation even a whisper can be heard

Egophony- nasal quality E to A with increased intensity also seen with consolidation All the above will be diminished with blockage such

as in emphysemaCroup- seal like bark