Physical Assessment Fan

Inspection of Blood Vessels

  • Inspect the skin on arms and legs for:

cyanosis, erythema, or pallor

decreased hair growth

muscle atrophy

edema

varicosities

  • Inspect and estimate the Jugular Venous Pulse (JVP) — jugular veins reflect the activity of the right side of the heart and can be used to estimate right heart pressure

Technique for Estimating JVP

  • Position patient in supine position at ~ 45 degrees so the external jugular pulsation can be seen
  • Measure the distance between the Angle of Louis (top of sternum) and the top of the pulsation, then add 5 cm
  • You can also measure the distance between the Midaxillary line and the top of the pulsation, but don’t add 5 cm this time
  • If JVP ; 9 cm, + JVD
  • Indicates right side volume, such as pulmonary edema

Palpation of Blood Vessels

  • Hepatojugular Reflux
  • Palpate for pulses
  • Palpate the capillary refill
  • Palpate the lower extremities for temperature and edema

Technique for determining Hepatojugular Reflux (HJR)

  • Place patient in supine position
  • Gently but firmly press on the RUQ of abdomen, just below the rib cage for 30-60 sec
  • JVP will elevate in all patients, but normally returns to original JVP within 10 sec
  • If HJR remains elevated after 10 sec, it may suggest HF

Force (amplitude) of pulse is defined as:

0 = absent

1+ = weak, thready

2+ = normal

3+ = increased

4+ = bounding

Capillary Refill

  • Extend patient’s hands near heart level
  • Squeeze nail bed of each finger
  • Release and note time of color return (1-2 sec is normal)

Physical Assessment Findings: Peripheral Arterial Disease

  • Weak or absent pulses
  • Loss of body warmth at affected area
  • Leg muscle atrophy and hair loss
  • Cyanosis or pallor of LE
  • Ulcer or gangrene of LE
  • Pain or weakness with exertion and relieved with rest
  • Numbness in toes or feet

Physical Assessment Findings: Venous Thrombosis

  • Constant pain
  • Positive Homan’s Sign
  • Erythema and/or cyanosis
  • Unilateral leg swelling

Bruit

  • A blowing, murmur-like sound of vascular origin, which may suggest narrowing or partial occlusion of lumen (atherosclerosis)
  • Lightly place bell of stethoscope over the carotid artery
  • Ask the patient to hold breath
  • Listen for presence of bruit
  • Other sites to listen for bruit include temporal, subclavian, abdominal aorta, renal, iliac, and femoral arteries

Mitral Valve
Left Atrioventricular Valve
Tricuspid Valve
Right Atrioventricular Valve
1st Heart Sound

Isovolumetric Ventricular Contraction

  • Ventricles start to contract and pressure in ventricles increase, leading to AV valve closure
  • All valves are now closed
  • Pressure and tension continue to build up

2nd Heart Sound

  • Once ventricular pressure drops below aortic or pulmonary artery pressure, the semilunar valves close

Inspection: Apical Impulse

  • Can be seen in the 5th (sometimes 4th) intercostal left space at the midclavicular line

Displaced Point of Maximal Impulse
Left Ventricular Hypertrophy
Thrill

  • A fine, palpable (over base), rushing vibration (palpable murmur) which indicates disruption of the expected blood flow
  • Indicates valvular or septal defects

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S1 Sounds

  • Produced by closure of AV valves
  • Signals the beginning of systole
  • Loudest over the apex of the heart

S2 Sounds

  • Produced by closure of SL valves
  • Signals the end of systole
  • Loudest over the base of the heart

S3 Gallop

  • Normal in children and young adults
  • Represents HF in ; 30 yo

S4 Gallop

  • Normal in children and young adults
  • ; 30 yo, indicates resistance of filling secondary to noncompliant ventricle (aortic stenosis)

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