Health Assessment (CVS Assessment)

• In assessing the heart, use the IPPA
• Sitting position is best to hear high pitched murmurs if present.
• Supine is common position to hear all sounds
• Left lateral recumbent is best position to hear low pitched sound.
• Landmarks:

  1. Aortic arch area- 2nd right ICS, sternal border 2. Pulmonic area- 2nd left ICS, Sternal border

  3. Erb’s point- 3rd left ICS, Sternal border

  4. Tricuspid area- 4th to 5th left ICS, sternal border

  5. Mitral area- 5th left ICS, midclavicular line
• Locate the point of maximal impulse (PMI) by palpating with fingertips along 5th intercostal space in midclavicular line.
• In the presence of serious heart disease, the PMI will be located to the left of midclavicular line.
• Normal sound S1 and S2 are high pitched and best heard with diaphragm.
• At normal slow rates S1 is high pitched and dull in quality and sounds like a “lub”. It precedes the systolic phase of contraction.
• S1 best heard at the apex
• S1 – 1 st heart sound S2 - 2 nd heart sound
• S2 - is best heard at the aortic area
• The second heart sound occurs due toclosure of semilunar valves which occurs at the end of 0.3 seconds and first heart sound which is due to the closureof the AV valves will occur at the end of 0.1 second and the time interval between these two sounds is 0.5 seconds.
• S3, or a ventricular gallop, occurs just after S2 at the end of ventricular diastole. - It sounds like “lub-dub- ee” or “kentucky”
• Atrial fibrillation- Rapid random contractions of atria cause irregular ventricular contraction beats 130 to 150 beats per minute.
• Premature ventricular contraction(PVC)- premature beat occurs before regularly expected heart contraction
• Sinus dysrhythmias- Pulse rate changes during respiration, increasing at peak of inspiration and declining during expiration.
• S1 heart sound corresponds to the closing of the mitral and tricuspid valves during systole. S2 heart sound corresponds to the closing of the aortic and pulmonary valves at the beginning of diastole.
• Gallops may be caused by premature rushes of blood into a ventricle or an atrial contraction pushing against a ventricle that is not accepting blood.
• Gallop rhythm is a mechanical event associated with a relatively rapid rate of ventricular filling and characterized by a ventricular bulge and a low-frequency sound.
• clicks- short high pitched extra sounds. These are caused by abnormalities such as mitral valve, prolapse aortic prosthetic valves.
• friction rubs- squeaky or rubbing sounds, result of inflamed visceral and parietal layers of the pericardium rubbing against one another.
• Murmurs are sustained swishing or blowing sound heard at the beginning, middle or end of systole or diastole. they are caused by increased blood flow through a normal valve
• Mitral murmurs are best heard at the apex and radiate to the axilla.
• The best way to listen heart murmurs is with the patient sitting up and leaning forward or lie on his left side.
• Recording of murmur: use Roman numerals as part of a fraction, always with VI as the denominator
• • Grade I is a barely audible murmur. Grade II is audible but quiet and soft.
• 1. Grade I is a barely audible murmur.
  2. Grade II is audible but quiet and soft.
  3. Grade III is moderately loud, without a thrust or thrill.
  4. Grade IV is loud, with a thrill.
  5. Grade V is very loud, with a thrust or a thrill.
  6. Grade VI is loud enough to be heard before the stethoscope comes into contact with the chest.
• Carotids are only sites to assess quality of pulse wave.
• Don’t palpate both carotid arteries at the same time or press too firmly. If you do, the patient may faint or become bradycardiac
• epitrochlear lymph nodes (ELN) are the main peripheral nodal station of the upper limb, receiving lymphatic drainage from the ulnar-side-of the hand and forearm
• Ankle- Brachial Pressure Index (ABPI) or AnkleBrachial Index (ABI) is the ratio of the blood pressure at the ankle to the blood pressure in the upper arm (brachium).
• lower blood pressure in the leg suggests blocked arteries due to peripheral artery disease (PAD).
• If no wave felt with the lower hand, the patient have Competent valves. If wave was felt, incompetent Valves
• Retrograde filling (Brodi- Trendelenburg test) occurs when valves are incompetent, leading to varicose veins. to assess valvular competency in both communicating veins and saphenous system
• negative test- with the tourniquet in place the veins fill within a period of 30 seconds, and upon removal of the tourniquet an increased rate of filling is observed. There is no retrograde flow taking place through the saphenofemoral junction, and the filling occurs due to incompetency of the communicating veins
• If the test is positive. While the patient stands with a tourniquet is placed, the varicosities will remain collapsed throughout the 30second period. Once the tourniquet is removed the internal saphenous vein rapidly fills with blood from above. This indicates that the valves of the saphenous vein at the saphenofemoral junction are incompetent, but the valves of the communicating veins are still
• Doubly positive. If the veins rapidly fill on standing and again as the tourniquet is removed is there is further distension of the veins. This indicates incompetency of the valves of both the saphenous and communicating systems of veins.
• Nil - the tourniquet is applied and even after removal there is only slow filling of the veins from below. This indicates that both the saphenous veins and the communicating veins are competent.
• The carotid artery should have a brisk, localized pulsation.