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1. 2. 3. 4. HEART Anterior: R ventricle Empties blood to pulmonary circulation Most anterior part of heart Cant be seen in an AP view xray; lateral view xray must be done Right: R atrium Fills RV Left: L ventricle Posterior to RV Apical portion protrudes Posterior: L atrium Most posterior part of heart Vital signs JVP Carotid artery pulse & peripheral pulses Heart

Localized pulsation: apex beat (use tip of finger) Palpate for: o Thrills (palpable murmurs) indicates that there is turbulence o Heaves/lifts (use palm)

Apex beat


Heaves & Lifts

**All blood will go to the heart -> R atrium via SVC & IVC -> pass through tricuspid valve -> R ventricle ** Lungs -> go back to heart via pulmonary veins -> empty into L atrium -> mitral valve -> L ventricle -> aortic valve -> systemic circulation ** All valves are tricusp except mitral! ** Pulmonary circulation and systemic circulation are simultaneous SYSTOLE SA node: pacemaker Between RA and SVC Depolarize both atria first (P wave) = atrial contraction AV node: there is a time delay Bundle of His, Purkinje: depolarize ventricles = ventricular contraction (ventricular systole)

Areas where vibrations are detected: Sternoclavicular Aortic Pulmonic thrill Mid-precordial/mid-sternum Lower parasternum Over epigastric area Over apex area Landmarks Suprasternal notch: concavity at angle of Louis -> go nd laterally = 2 rib Parasternal line Midclavicular line Anterior axillary line Midaxillary line 1. HEAVES & LIFTS Lift nd If aorta is dilated, there will be an impulse at 2 ICS R parasternum nd If pulmonary artery is dilated, PA lift will be felt at 2 ICS at L parasternum If L atrium is dilated, pulsation at mid L parasternum (LA lift) will be felt Heave If R ventricle is dilated/hypertrophied, pulsation at L lower parasternum over epigastrium will be felt (RV heave) If L ventricle is dilated, pulsation is felt at apical area; very strong (LV heave) LV and RV heave are both felt and seen 2. APEX BEAT Most lateral palpable ventricular impulse Contact of L ventricle and chest wall during contraction/systole If visible = dynamic precordium Check for the following: o Location o Diameter o Amplitude o Duration o Ask px to breathe out and briefly stop breathing to decrease the lung volume that covers the heart Px must be sitting down when checking the apex beat


1. 2. 3. Inspect Palpate Auscultate


Report: a. b. c. Stay on right side of patient Go eye level Flash light tangentially and check for visible impulses Adynamic: no visible impulses Dynamic: 1 visible impulse Hyperdynamic: several pulsations (2 or more)

Apex beat: o Midleft thorax (10 cm from midsternal line AT MOST) th th o Level of 4 5 ICS o Felt only over 1 ICS (<2.5cm) If you feel that it is more than 2 ICS, it is a diffuse apex beat o Not more than 1 fingertips wide o Small, must feel like a gentle tap Cause atrial contraction and will eject any residual blood

Remember: Opening of valves DO NOT NORMALLY PRODUCE SOUND unless there is a disease process present!

Produced by closure of mitral & tricuspid valves Coincides with apex beat or upstroke Heard immediately before carotid upstroke S1 to S2 has shorter interval than S2 to S1 When listening over APEX: S1 > S2 (w/ regards to loudness) When listening over BASE: S2 > S1

Character of the Apex Beat: NORMAL Rises & retracts quickly by the first of systole May last up to the first 2/3 of systole **Remember: between S1 & S2 is SYSTOLE Between S2 and S1 is DIASTOLE LVH Sustained = falls after S2 pa Sustained apical thrust Hypertrophies inward -> therefore, apex beat is not displaced but is very strong! If there is dilatation of the ventricle, apex beat is displaced laterally and downward

Factors affecting loudness of S1: 1. Rate of rise of LV pressure 2. Timing of mitral valve closure in relation to onset of ventricular contraction 3. Position of the mitral valve at the beginning of ventricular contraction o If mitral valve is still widely open when ventricles contract, it produces a very loud sound 4. Stiffness of the AV valves The stronger the LV contracts, the louder the S1. The longer the MV opens, the louder the S1.

Coming from: Mitral valve Tricuspid valve Pulmonic valve Aortic valve Auscultatory area Apex L lower parasternum along th th 4 /5 ICS nd L parasternum, 2 ICS nd R parasternum, 2 ICS

Normal splitting of S1 Usually heard over the tricuspid auscultatory area th Differential diagnosis: 4 heart sound, ejection sound

Closure of semilunar valves (pulmonic & aortic) Sudden deceleration of forward flow during aortic and pulmonic valve closure Best heard at the base of the heart Normal split widens during inspiration

Diastole Mitral and Tricuspid valves are open S1 Closure of mitral & tricuspid valve = start of systole

Isovolumetric/Isometric contraction phase Because systemic pressure is always HIGHER than ventricular pressure, ventricles build pressure by contracting No movement of blood Contraction against closed valve = builds up pressure Rapid ejection phase Rapid movement of blood upon opening of aortic valve LV pressure drops -> aortic & pulmonic valve will close = S2 Isovolumetric/Isometric relaxation Atria cannot build up pressures as high as ventricles o Not pressure builders They need the ventricles to actively relax When ventricular pressure drops and becomes less than atrial pressure, mitral & tricuspid valves open Rapid filling phase Slow filling phase When the pressures between atria and ventricles equilibriate Atrial depolarization

Cause of physiologic split When a person inhales, the intrathoracic pressure becomes more NEGATIVE. This increases the blood returning to the right side of the heart. Therefore in SYSTOLE, more blood is present in the right atrium = thus, a LONGER time is needed for blood to empty from the right atrium to the right ventricle Component delayed is the pulmonic component Split S2 1. Persistent splitting o Split on both inspiration & expiration but more on inspiration o Ex. Pulmonary stenosis, mitral regurgitation, complete right bundle branch block 2. Fixed splitting o Split on both inspiration and expiration, SAME intensity o Ex. ASD Paradoxical/Reverse splitting o During expiration o Physiologic during inspiration o Component delayed: aortic component o Ex. Left bundle branch block


During rapid filling phase Rapid filling sound Early filling gallop sound Protodiastolic gallop Heard best near apex Occurs at end of the rapid expansion phase of ventricle Heard best with bell applied with light pressure JVP WAVEFORM (not sure if accurate drawing to but nilagay ko lang para mas madali intindihin :D)

Physiologic S3 Due to increase in velocity of ventricular expansion Ex. Tachycardia Pathologic S3 Loss of compliance/distensibility Ex. Heart failure

Atrial gallop, presystolic gallop, s4 gallop Rarely physiologic Mechanism: decreased distensibility or compliance of left ventricle o During atrial contraction Best heard with the bell applied at apex PERIPHERAL PULSES 1. Carotid: systole lang! o In aortic stenosis, it takes a longer time to eject blood to aorta 2. Brachial o Use thumb o Simultaneous: check if symmetrical on both sides 3. Femoral = Radial o Delayed pulses = obstruction 4. Popliteal pulse: the only pulse that needs both hands o Ask px to bend knees slightly 5. Dorsalis pedis o Ask px to flex big toe 6. Posterior tibialis o Behind medial malleolus


Use internal jugular vein which is behind SCM (external jugular vein may also be used) Look for maximal movement of that column of blood In getting JVP, use the RIGHT jugular vein because it reflects right atrial pressure

JVP vs. Carotid Pulse JVP More VISIBLE than palpable Soft, rapid, undulating with 2 elevations and 2 troughs Pulsations eliminated by pressure Elevation of patient makes pulse go down? Level changes with inspiration

CAROTID More PALPABLE More vigorous thrust w/ 1 outward component Not eliminated by pressure Unchanged by position Unaffected by respiration

Reminders in taking the JVP o 1. Px must be seated at 30-45 2. Measure the highest angulation o Put ruler horizontally o Put ruler vertically at angle of Louis o Height will be your JVP o Use cm mark

CARDIO PE Order: 1. 2. 3. 4. JVP Always use RIGHT IJV! o Right atrial pressue is transmitted to the jugular vein because there is no competent valve between them o IJV: located behind SCM (ask patient to look slightly to the left; shine light tangentially) Measure the highest angulation o Put ruler horizontally o Put ruler vertically at angle of Louis o Height will be your JVP o Use cm mark What you can see most visibly is the a wave o Report: JVP is 1.5cm at 45 PALPATION Report: th th Apex beat is felt from the 6 to the 7 ICS (from the midclavicular to midaxillary line), width is 9cm (normal is 2.5cm). it is 18cm from the midsternum (normal is 10cm) Apex beat is displaced laterally & downward (usually due to enlarged LV) There is a sustained apical thrust (normal: apex beat must be very short and soft) If you are unable to feel the apex beat, ask patient to sit, inhale and exhale, and hold -> this lessens the lung tissue that is covering the heart Check for thrills, heaves, and lifts. Be sure to use the right area of your hand in checking for them.

Vital signs JVP Carotid artery pulse + Peripheral pulses Precordial exam

Apex beat


Heaves & Lifts

Aortic lift: this means that there is a lift over the aortic auscultatory area Others: RA lift, LA lift, PA lift, RV heave, LV heave

CAROTID Ask patient to look at the same side Do not press above the thyroid cartilage because you might press on the carotid body, which may cause bradycardia or asystole Report: Carotid pulse +2 (peak must be smooth, hinde dapat nangingineg :D) Listen for bruits PERIPHERAL PULSES Ex. Brachial artery pulse on both right and left are +2 Femoral Radial Popliteal Dorsalis pedis Posterior tibialis PRECORDIAL EXAM INSPECTION Inspect the ff: o Apex o Left lower parasternum/epigastric o Midsternum o Right ICS R parasternum

Aortic and PA lift: felt over 1 ICS Thrill: palpable murmur (must at least have a grade of 4) GRADE 1 Room must be very quiet for you to hear the murmur 2 Murmur is soft, but you can hear it in a noisy room 3 Moderately loud murmur, but NO thrill 4 Loud murmur with thrill; stethoscope is applied to skin 5 Murmur is still heard even if only half of the stethoscope is placed on the skin 6 The murmur can be heard even before the stethoscope touches the patient AUSCULTATION

Radiation will follow the flow of sound In mitral and tricuspid valves: If you hear a murmur during systole, your valve is incompetent = regurgitation If you hear a murmur maximally during diastole, your valve is not opening properly = stenosis In aortic and pulmonic valves If murmur is heard during systole = stenosis o In aortic stenosis, you can also check for the murmur in the carotid artery, which is the immediate branch of your aorta If murmur is heard during diastole = regurgitation Remember: When volume increases, turbulence also increases and the murmur becomes LOUDER For S1 and S2, use the DIAPHRAGM o S1 coincides with your apex beat o If apex beat is not palpable, feel for the carotid pulse. Sound that almost coincides with it is your S1. o S1 is louder over the apex, S2 is louder over the base o If patient is in the L lateral decubitus position, S1 and sounds from mitral and tricuspid auscultatory areas are LOUDER For S3 and S4, use the BELL o Gently applied o Used in apex & L lower parasternum only o Applying the bell too hard can cause the diaphragm effect

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