M1 H&P: Cardiovascular
Devin Nickol, M.D.
I. Overview: Examining the Heart and Great Vessels
- Examine patient both ___________ and sitting up
- Tangential light helps
- Look for _________ and “heaves”
- It is normal to be able to see the apex pulsate in a sitting patient, and this can give an idea of cardiac size
- The normal location for the apex is ICS ____ in the __________________________ line
- Assess the jugular venous pulse
- Palpate the _____________________________________________ (PMI) and note its location
- Palpate for thrills
- Palpate the carotid pulse and note its intensity, duration, and timing relative to the PMI
- Palpate the following arteries: brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial
- Listen for bruits with the ____________ over the carotid, aortic and renal arteries
- Listen with both the bell and the diaphragm over the four main anatomic locations for a long time
- Listen for the first heart sound (aka _________ ) and determine if it is split or single
- Listen for the second heart sound (aka _________ ) and determine if it is split or single
- Listen to systole and diastole for extra sounds
- Identify an S3 or S4 if present
- Murmur Intensity:
Grade I: Barely audible in a quiet room
Grade II: Louder than grade I, but still soft
Grade III: A loud murmur
Grade IV: A loud murmur with a ______________
Grade V: Audible with just the edge of the stethoscope touching the chest, thrill easily palpable
Grade VI: Audible with stethoscope off the chest, visible and palpable thrill
V. Putting It All Together: Describing Murmurs
- When does the murmur occur?
- What does it sound like?
- Where is it best heard?
Example: A harsh, grade III/VI midsystolic murmur best heard over the apex, with radiation to the axilla.