PCM: Heart Exam

=Heart Exam=

Demonstrate appropriate methods for gown and drape for heart exam.
Patient dresses into gown. With patient supine on exam table, place sheet over abdomen and lower extremities.

2 draping methods (as presented in “Heart Exam DVD”)
 * Expose entire left side of chest wall for examination
 * “To preserve modesty of patient” (more conventional method)
 * First, pull gown down from neck to upper chest – expose just enough for inspection and then auscultation of Aortic and Pulmonic valve areas
 * Pull gown up at waist from under sheet (with sheet still over abdomen) to allow auscultation of Tricuspid and Mitral areas

Demonstrate normal jugular venous pressure and what an elevation means.

 * JVP measures pressure in jugular veins that empty into SVC and estimates filling pressure of right heart.

From here, there are two different methods of measuring JVP:
 * Instructions
 * Place patient in supine position (allows engorgement of jugular veins)
 * Raise head of exam table until jugular venous pulsations are evident between jaw and clavicle

(This accounts for the fact that center of right atrium is approximately 5 cm below angle of Louis). This does not account for the variable position of the patient.
 * Measuring JVP from angle of Louis, basically the outlet of the aorta
 * Use one ruler to measure highest level of jugular vein pulsations from the angle of Louis
 * Add 5 cm to measurement determined in previous step
 * Final value is Jugular Venous Pressure (in centimeters water)

OR


 * Standard technique
 * Place one ruler vertically with tip at mid-axillary line, at level of nipple
 * Place second ruler at highest level of jugular vein pulsations, extending it horizontally to where it intersects first ruler (vertical ruler)
 * Vertical distance above level of heart is noted as mean Jugular Venous Pressure (in centimeters water)


 * Normal Values:
 * less than or equal to 8 cm water (Sallay’s Lecture)
 * less than 9 cm water (Mosby)
 * Elevation represents a JVP greater than 9 cm water.

Describe normal location of point of maximal impulses (PMI) and what causes it.

 * Normal Location of PMI should be at the apex of the heart: within midclavicular line, in 5th left intercostal space (below 5th Rib)
 * Apical impulses are caused by contraction of left ventricle and the resulting thrust of blood.
 * PMI is the point at which apical impulse is most readily seen/felt.
 * Use the ulnar side of your hand, or lateral side of your 5th digit for greatest sensation

Describe the location of the following areas: aortic, pulmonic, base, tricuspid, apex (apical), mitral.

 * 1) Aortic valve area: second right intercostal space (below Rib 2), on right side of body at right sternal border
 * 2) Pulmonic valve area: second left intercostals space (below Rib 2), on left side of body at left sternal border
 * 3) Base: third left intercostal space (below Rib 3), at left sterna border (sometimes omitted)
 * 4) Tricuspid: fourth left intercostals space, along lower left sternal border
 * 5) Apex (Apical)/Mitral: fifth left intercostal space (ie, apex), at midclavicular line

Describe what is meant by “systole” and “diastole.”
**Blood flow:
 * Systole: ventricles contract, atria relax.
 * Blood flow:
 * left ventricle→ aorta
 * right ventricle → pulmonary artery
 * Diastole: ventricles relax/dilate, atria contract
 * left atrium → left ventricle
 * right atrium → right ventricle

Describe and identify the midsternal, mid clavicular, anterior axillary, scapular and vertebral line, costal margin, and suprasternal notch.

 * Midsternal line: vertical line down midline of sternum
 * Mid clavicular lines: vertical lines beginning at middle of each clavicle, running parallel to midsternal line
 * Anterior axillary: vertical lines beginning at anterior axillary folds (runs along lateral border of pectoralis major), parallel to midsternal lines
 * Scapular lines: vertical line that runs through inferior angle of scapula
 * Vertebral line: line that runs vertically down spinous process of vertebrae, parallel to vertebral line
 * Costal margin: bottom edge of ribcage, formed by ribs 7 – 10 joining medially to attach to sternum
 * Suprasternal notch (Jugular notch): depression or notch at superior border of manubrium of the sternum

Demonstrate the location of the angle of Louis (the Manubrial-sternal junction and the structures corresponding to this level).
Other structures at this level:
 * Angle of Louis: the point at which the manubrium meets the body of the sternum
 * Right & Left Ribs #2 (attach to sternum at angle of Louis)
 * Aortic valve (to the right of the angle of Louis)
 * Pulmonic valve (to the left of the angle of Louis)

Identify and be able to describe locations of radial, brachial, carotid, femoral, popliteal, dorsalis pedis, and posterior tibial pulses.

 * 1) Radial: ventral side of wrist, lateral – above radius
 * 2) Brachial: medial to biceps tendon
 * 3) Carotid: in the neck, medial to and below angle of jaw (do NOT palpate both carotids at same time)
 * 4) Femoral: upper part of inner thigh, in groin area, within femoral triangle
 * 5) Popliteal: in popliteal fossa (posterior side of leg). Place patient in prone position with knee flexed – press firmly to feel pulse.
 * 6) Dorsalis pedis: medial side of dorsum of foot, with foot slightly dorsiflexed
 * 7) Posterior tibial: behind and slightly inferior to medial malleolus of ankle

Demonstrate proficiency in Heart Exam using DVD checklist.

 * 1) Elevate trunk, head, and neck to 30 degrees (by raising exam table), have patient turn head to left, shine penlight obliquely across right neck so that Jugular Venous Pulsations are visible. If no jugular venous distension visible, return patient to supine position and check again for a visible right internal jugular vein.
 * 2) Expose apical area and inspect for an observable apical impuse.
 * 3) Identify aortic area, pulmonic area, tricuspid area, and apical area
 * 4) Place finger pads on Aortic area to feel for thrill or pulsation
 * 5) Place finger pads on Pulmonic area to feel for thrill or pulsation
 * 6) Place ulnar surface of palm on tricuspid area to feel for thrill or heave
 * 7) Place finger pads on apical area and feel for location/strength of apical impuse
 * 8) With diaphragm of stethoscope, auscultate:
 * 9) Aortic area
 * 10) Pulmonic area
 * 11) Tricuspid area
 * 12) Mitral (apical) area
 * 13) Using bell of stethoscope, auscultate:
 * 14) Aortic area
 * 15) Pulmonic area
 * 16) Tricuspid area
 * 17) Mitral area

Demonstrate proficiency in Pulses Exam using DVD checklist.

 * 1) Instruct the patient to hold breath as you auscultate each carotid artery (use bell of stethoscope).
 * 2) Palpate:
 * 3) carotid pulses one at a time (Note: do not palpate if you heard bruits in step 1)
 * 4) 	femoral pulses one at a time
 * 5) 	popliteal pulses one at a time
 * 6) 	dorsalis pedis pulses bilaterally (top of foot)
 * 7) 	posterior tibial pulses bilaterally (at the ankle behind the medial malleolus)

Pitting edema: swelling that can be demonstrated by depressing skin with finger. Indentation in skin after release of pressure indicates pitting edema.
 * 1) 	Check each shin for pitting edema by pressing on the lower tibia for 3 - 5 seconds.