1. Heart/Neck Vessels & Peripheral Vascular/Lymphatics

2. Anatomy Review 4 chambers 4 valves Right/left atrium
Right/left ventricle
4 valves
Tricuspid
Mitral
Pulmonic
Aortic

3. Anatomy and Physiology
Measure
Typical value
Normal range
end-diastolic volume (EDV)
120 ml[1]
ml[1]
end-systolic volume (ESV)
50 ml[1]
ml[1]
stroke volume (SV)
70 ml ml
ejection fraction (Ef)
58%
55 to 70%[2]
heart rate (HR)
70 bpm
60 to 100 bpm[3]
cardiac output (CO)
4.9 L/minute
L/min
Cardiac output
(L/min) determined by:
Heart rate (beats/min)
Stroke volume (L/beat)
CO = SV x HR

4. Health History Chest pain Dyspnea
Do you have any chest pain or discomfort?
OLDCART
Do you do you use any recreational drugs?
Do you have any increased life stress/anxiety?
Dyspnea
Do you have any labored or difficulty breathing (dyspnea)?
Related to exercise (exertional dyspnea)?
Quantify: Have far can you walk before getting short of breath?
Related to position/lying supine (orthopnea)?
How many pillows do you sleep on at night?

5. Health History Palpitations Dizziness or Syncope Fatigue
Ever have palpitations/or unpleasant awareness of heartbeat? (“fluttering/ pounding”)
Dizziness or Syncope
Have you felt dizzy or ever lost consciousness/passed out (syncope)?
Fatigue
Do you seem to tire easily?
Cyanosis or pallor
Ever noted your facial skin turn blue or ashen gray?

6. Health History Cough Edema Nocturia
Any pink or blood tinged frothy sputum?
Edema
Do you have any swelling in your feet or legs?
Nocturia
Do you awaken at night with an urgent need to urinate?

7. Health History Past Cardiac History
CHF, angina, MI, murmurs, rheumatic fever, congenital heart disease
Assess for risk factors of coronary artery disease
Hypertension, hyperlipidemia, diabetes, physical inactivity, obesity, smoking, stress, increasing age. family history of CAD (especially in 1st degree relatives F<65, M<55)
Additional for women: Menopause or use of oral contraceptives

8. What the History Can Tell You
Angina (pain resulting from ischemia)
Onset: Abrupt, often precipitated by event such as emotion, exertion, cold or eating.
Location: Substernal or retrosternal pain.
Duration: Usually lasts a few minutes and then subsides.
Characteristic: Described as squeezing or heavy pressure
Radiation: May radiate to the neck, jaw, or arms
Relieving Factors/Treatments Tried: Often relieved with sublingual nitroglycerin

9. What the History Can Tell You
Myocardial Infarction
Onset: Abrupt, often unrelated to precipitating event.
Location: Substernal or over precordium.
Duration: Prolonged
Characteristic: Severe, described as viselike or crushing
Associated Symptoms: dyspnea, dizziness, nausea, diaphoresis, palpitations, anxiety (sense of doom)
Radiation: May radiate to neck, jaw, arms or hands.
Treatments Tried: Sublingual nitroglycerin without relief

10. What the History Can Tell You
Congestive Heart Failure
Right-sided
Dependent Edema
Nocturia
Left-sided
Coughing/Hemoptysis (pink frothy)
Orthopnea
Dyspnea with exertion
Cyanosis or ashen color
Cold, moist extremities
Oliguria
Restlessness/anxiety

11. Carotid Artery Inspect for pulsation
Absent pulse wave with arterial occlusion
or stenosis
Palpate lightly & one at a time for:
Contour
Smooth with rapid upstroke
Amplitude
4+ Bounding
3+ Full
2+ Normal
1+ Weak
0 Absent
Diminished or unequal with atherosclerosis or other arterial disease
Auscultate
Over angle of jaw, mid-cervical, & base of neck with bell
For presence of bruit
Blowing, swishing sound indicating turbulence
Carotid arteries 2+ bilaterally without bruits.

12. Jugular Venous Pressure
Assessment of jugular veins gives estimation of heart function
Ie. CHF
Internal Jugular Vein
Position patient supine at
45 degrees without a pillow
Use Angle of Louis to read
CVP at highest level of pulsation
Normal-Pulsation <2.5cm
Abnormal- Pulsation >2.5cm
Indicates increased CVP associated with heart failure
If you cannot find internal jugular veins, use the external and note point where look collapsed

13. Jugular Venous Pressure
External jugular veins are lateral to sternomastoid muscle above the clavicles
Assess if:
Visible 45 °
External jugular veins 45 °

14. Hepatojugular Reflux
Very sensitive in detecting right-sided heart failure
Elevate to 30 degrees
Press firmly in right upper quadrant
Observe neck for elevation in JVP
Rise of >1cm is abnormal

15. Inspection & Palpation
Inspect & palpate precordium for:
Lifts/Heaves
Thrills
Use ball of your hand firmly on the chest
Apical impulse
Apical 5th intercostal space midclavicular line. No lifts, heaves, or thrills noted.
Note location of heart may also be determined by percussing for borders of dullness

16. Apical Impulse AKA: Point of maximal impulse (PMI)
Apical impulse specifically for apex beat.
Localize apical impulse using one finger. Ask to exhale and hold breath may help find. May need to roll midway to left.
Note: location, size (1cm x 2cm), amplitude (short gentle tap), duration (short, occupies only first half of systole
Not palpable in obese, thick chest wall
Increased size or location with volume overload, hypertrophy (HTN, CAD, CHF, cardiomyopathy)
Increased amplitude & duration with high cardiac output states (anxiety, fever, hyperthyroidism, anemia

17. Auscultation Wth the diaphragm auscultate @ the apex of the heart for:
Rate
Normal Adult Rate: beats/min
Bradycardia–heart rate less than 60
Tachycardia–heart rate greater than 100.
Rhythm
Regular vs. irregular
Sinus arrythmia (rhythm varies with breathing)
Regularly irregular, irregularly irregular
If pulse irregular assess for pulse deficit
Auscultate the apical beat while simultaneously palpating the radial pulse. Every beat hear should perfuse to periphery
Apical pulse 80bpm and regular. No pulse deficit noted.

18. Auscultation Proceed over precordium with bell Auscultate over: For:
Best for low pitch
Auscultate over:
Aortic area
Pulmonic area
Erb’s point
Tricuspid area
Mitral area
Epigastric
For:
Gallops (best with bell)
Murmurs (depends)
Rubs

19. Normal Heart Sounds S1 S2 http://www.youtube.com/watch?v=2aO0HKIP3vI
“Lubb”
Sound of mitral & tricuspid
valve closing simultaneously
Start of systole
Heard loudest at apex of heart
Approx 5th intercostal space, midclavicular line on left S
“Dubb”
Sound of simultaneous closing of pulmonic and aortic valves
End of systole
Heard loudest at base of heart
Best over 2nd intercostal space on right

20. Gallops: S3 & S4 Heart Sound Associated Heart Process
Normal Characteristics
Pathological
Characteristics
Cadence Word Clue S3
apex or LL sternal border with bell
Early diastolic
Occurs after S2
Heard more often in children and young adults
Waxes and Wanes
May disappear when pt sits up
Higher pitch
Louder
More constant sound
Associated with volume overload and left ventricular systolic dysfunction
“Ken-tu-cky.”
““SLOSH-ing-in” S4
apex with bell
Late diastolic (atrial filling)
Occurs before S1
No typical characteristics
Seen in uncontrolled hypertension
“Ten-nes-see”
“a-STIFF-wall”

21. Murmurs
Swishing or blowing noises that occurs with turbulent blood flow in heart or great vessels.
Categorized as:
Innocent
Always systolic & without evidence of physiological/structural abnormalities
Functional
Associated with physiological alterations such as high cardiac output states
i.e. exercise, anemia, hyperthyroidism or increased blood volume associated with pregnancy
Pathologic
Caused by structural abnormalities in valves or chambers
Stenosis, regurgitation, patent ductus arteriosis

22. Structural Abnormalities in Valves and Chambers

23. Murmur Characteristics
Timing
Systolic: Heard during systole
(between S1 and S2)
If possible note: early, late or mid systolic)
Diastolic: Heard during diastole (between S2 and S1)
If possible note: early, late or mid diastolic
Continuous: Heard in both systole and diastole

24. Valvular Disease & Murmur Locations
Valve
Systolic Murmur
Diastolic Murmur
Aortic
Aortic stenosis
Aortic regurgitation
Pulmonic
Pulmonic stenosis
Pulmonic regurgitation
Mitral
Mitral regurgitation
Mitral stenosis
Tricuspid
Tricuspid regurgitation
Tricuspid stenosis

25. Murmur Characteristics
Quality (Shape/Pattern & Sound)
Shape/Pattern
Crescendo/Decrescendo
AKA- Diamond shaped murmur; ejection type murmur
Primary causes: Stenotic valves
Holosystolic
AKA- Pansystolic
Decrescendo
Primary causes: Aortic and pulmonic regurgitation, Mitral and tricuspid stenosis

26. Murmur Characteristics
Quality
Sound
Musical, blowing, harsh, or rumbling
Pitch
High, medium, or low; Loud or soft
Location
Area of maximal intensity
Radiation
May be heard in another place on precordium or neck, back or axilla

27. Murmur Characteristics
Intensity (loudness)
1 - Very faint, heard only after listener has “tuned in;” may not be heard in all positions
2 - Quiet, but heard immediately after placing the stethoscope on the chest
3 - Moderately loud
4 – Loud, with palpable thrill
5 - Very loud, with thrill. May be heard when stethoscope is partly off the chest
6 – Very loud, with thrill. May be heard with stethoscope just removed from and not touching the skin.

28. Murmur Characteristic Example
Aortic Stenosis
Timing: Midsystolic
Pitch: Loud
Quality: Harsh
Location: 2nd right interspace
Radiation: Widely to side of neck, down left sternal border, or apex

29. Auscultation Pericardial friction rub
Membranous sac surrounding heart becomes inflamed
Differentiate pericardial from pleural friction rub by having patient hold breath

30. Physical Exam Findings for CHF
Right-Sided Failure
Left-Sided Failure
Distended neck veins
Dependent edema
Ascites
Hepatomegaly
Nocturia
Pulmonary Edema
Coughing
Hemoptysis
Orthopnea
Dyspnea/Tachypnea
Crackles in lungs
Cyanotic nail beds, ashen color
Cold, moist extremities
Restlessness/anxiety
S3 gallop rhythm
Tachycardia

31. Peripheral Vascular & Lymphatics

32. Peripheral Vascular System
Arteries
Supply oxygenated blood to the body from the heart
Veins
Return unoxygenated blood to the heart
Contain one-way valves that keep the blood from flowing backwards
Muscles help squeeze the blood in the veins to the heart

33. Health History Common or concerning symptoms Pain in the arms or legs
Intermittent claudication: leg or arm pain that is exercise induced
Cold, numbness, pallor in the legs; hair loss
Color change in fingertips or toes in cold weather
Swelling in calves, legs or feet
Swelling with redness or tenderness
High risk: Tobacco use, diabetes, HTN, Hyperlipidemia, CV disease
Severity of peripheral vascular disease closely parallels the risk for heart attack, stoke, and death from vascular causes

34. Inspection Inspect upper and lower extremities for: Color Symmetry
Lesions
Clubbing
Edema
Capillary refill
Pitting Edema- Apply pressure with finger for 5 seconds.
1+: Slight pitting, 1cm or less, disappears rapidly
2+: Deeper pitting, 1.5cm, disappears sec.
3+: Deep pitting, 2cm, disappears more than 1 minute
4+: Very deep pitting, 2.5cm, disappears 2-5 minutes
No pitting edema noted

35. Inspection Inspect lower extremities for Hair distribution
Varicosities
Muscle atrophy

36. Palpation Palpate upper and lower extremities for: Temperature Texture
Capillary refill
Lymph nodes
Epitrochlear, Inguinal

37. Lymph Nodes Epitrochlear Inguinal In antecubital fossa and drains:
Hand
Lower hand
Inguinal
In groin and drains most of the lymph
Lower extremities
External genitalia
Anterior abdominal wall

38. Palpation Peripheral Pulses
Brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
Assess for symmetry in limbs
Force
4+ Bounding
3+ Full, increased
2+ Normal
1+ Weak
0 Absent
If pulse is difficult to palpate use a Doppler (ultrasound stethoscope) to amplify sound of pulse wave

39. Peripheral Pulses- Brachial
Located medial to biceps tendon
Grade force bilaterally

40. Peripheral Pulses-Radial
Note:
Rate
Rhythm
Force

41. Peripheral Pulses-Ulnar
Modified Allen Test
Evaluate adequacy of collateral circulation prior to cannulating radial artery
Firmly occlude both ulnar and radial arteries
Release pressure on ulnar artery
Normal- return of color in 2-5 seconds

42. Peripheral Pulses-Femoral
Located just below inguinal ligament halfway between the pubis and anterior superior iliac spine.
Grade force bilaterally
If weak auscultate for bruit

43. Peripheral Pulses-Popliteal
Located just lateral to medial tendon
Grade force bilaterally

44. Peripheral Pulses-Posterior Tibial
Located behind the groove between the malleolus and Achilles tendon
Grade force bilaterally

45. Peripheral Pulses-Dorsalis Pedis
Located just lateral to & parallel with the extensor tendon of the big toe.
Force should be symmetrical

46. Assess for Deep Vein Thrombosis
Erythema
Calf Edema
Increased warmth
No calf erythema, edema, warmth
No longer widely practiced
Tenderness with palpation
Homan’s sign
No calf erythema, edema, or warmth.

47. Venous vs. Arterial Insufficiency
Assessment Criterion
Venous
Arterial
Color
Normal or cyanotic
Pale; worsened by elevation; dusky red when extremity is lowered
Temperature
Normal
Cool (blood flow blocked to extremity)
Pulse
Decreased or absent
Edema
Often marked
Absent or mild
Skin Changes
Brown pigment around ankles
Thin, shiny skin; decreased hair growth; thickened nails.

48. Arterial
Venous

49. Is that all? 
MIDTERM points all multiple choice
GOOD LUCK!!!!