HEART PHYSICAL ASSESSMENT

Patient Identity
Name : Ny.A
Gender : Male
Age : 45
Religion : Moslem
Last educatin : Vocational High School
Occupation : Housewife
Address : Housing Permai A6
Date of entry : November, 11 2021 || 08:00 O’clock
Review date : November, 11 2021 || 12:00 O’clock

1. General condition
Severe pain in chest when activity
2. History of present illness and reason for admission
Admitted to hospital on November, 11 2021. Severe pain in chest when
activity. Like pinched when lift heavy things and pain scale 5. Pain goes away
when take a rest.
3. History of past medical
High blood pressure and never took medications.
4. History of family health
Not history of hereditary or infectious disease.
5. Physical Assessment
- General Condition: weak, consciousness: composmetis
- Vital sign :
- Blood Pressure : 140/100 mmHg
- Pulse : 95 x/minute
- Respiratory rate : 25 x/minute
- Body Temperature: 36,50C
6. Heart Assessment
a. Inspection
- Shape of Chest : Normal chest
- Shape of Precordial: Symmetrical
- Pulsation : Visible pulsation
- Edema : No edema
- Clubbing finger : No clubbing finger

b. Palpation
- Ictus Cordis : Located on ICS V in the left midclavicular line (1-
2 cm)
- Pulsation : Palpable pulse

c. Perccussion : Deaf, heart border 1 finger below ICS VI

The boundaries of the heart :
- Left : ICS space III parasternal linea left to ICS space V linea left
anterior axillary.
- Right : ICS space III-V on the right parasternal line.
- Above : Right ICS III linea parasternal to ICS III linea left parasternal.
- Bottom : ICS space V linea parasternal right to space ICS V linea left
 anterior axillary.

d. Auscultasion
- Heart sounds 1(S1) : The lup, in the left sternal ICS IV
space, ICS V Medioclavicular left.
- Heart sound II (S2) : Dump, in the ICS space II linea
sternalis right and ICS II-III left sternal
line.
- Additional heart sounds (S3 & S4): No additional heart sounds
- Noise / Murmur : No noise and murmur
- Heart rate frequency : 90x/minute