Midterms (Canvas)

• Assessment of the Head


  • Inspect skull size, shape and configuration
  • Palpate head for consistency (nodules or masses & depression)
  • Inspect symmetry of facial movements
  • Inspect facial features
  • Inspect eyes for edema and hollowness
  • Palpate for temporomandibular joint range of motion (TMJ ROM)
• Role of the cardiovascular system

  • Delivers oxygenated blood, removes waste products
• Pulsations may occur to the right of the sternum, in the epigastric area, and in the sternoclavicular areas as deviations from normal
• AORTIC ANEURYSM


  Apical pulsation displaced toward axillary line due to left ventricular hypertrophy
• Carotid Artery Palpation


  1. Lightly palpate each carotid separately

  2. Note rate, rhythm, amplitude, contour, symmetry, elasticity, and thrills
• Jugular Vein Palpation


  1. Palpate jugular veins and check direction of fill

  2. Occlude under the jaw to see flattening and more prominent wave form

  3. Occlude above the clavicle to see jugular distension and diminished wave
• Abdominojugular (Hepatojugular) Reflux Test

  1. Position patient at 45-degree angle, place hands over the midabdominal area and apply 20 to 30 mm Hg of pressure for 15 to 30 sec

  2. Look at the jugular veins while applying pressure and note increase vein distension and return to normal upon release of pressure
• Deviations from normal cardiac rate

  • Sinus tachycardia
  • Supraventricular tachycardia (SVT)
  • Paroxsymal tachycardia (PAT)
  • Uncontrolled atrial fibrillation
  • Ventricular tachycardia
• Causes of tachycardia


  • CHF drugs (atropine, nitrates, epinephrine, isoproterenol)
  • Nicotine and caffeine
  • HYPERCALCEMIA
• Deviations from normal cardiac rate

  • Sinus bradycardia
  • Heart block
• Causes of bradycardia


  • MI drugs (digoxin, quinidine, procainamide, beta-adrenergic inhibitors)
  • HYPERKALEMIA
• Irregular rhythm


  Arrhythmia, abnormal pulses, unequal pulses
• Causes of irregular rhythm

  • Obstruction or occlusion (stiff, cordlike arteries)
  • Right-sided CHF
  • Tricuspid regurgitation
  • Tricuspid stenosis
  • Constrictive pericarditis
  • Cardiac tamponade
  • Inferior vena cava obstruction
  • HYPERVOLEMIA
• Normal precordium


  • Apex (left ventricular area): PMI 1–2 cm, negative thrills, amplitude may be increased in high-output states
  • LLSB (tricuspid area): May not be palpable, negative thrills
  • Base left (pulmonic area): 2nd ICS, left sternal border
  • Base right (aortic area): 2nd ICS, right sternal border
  • Epigastric area: Positive slight pulsation may be normal, no diffusion, palpations not palpable except in thin patients
• Abnormal precordium


  • Enlargement and displacement of PMI to left midaxillary line (ventricular hypertrophy with dilation)
  • Apical impulse located on right side of precordium (DEXTROCARDIA, heart located on right side, often with congenital heart disease)
  • Enlarged apical pulsation without displacement >2–2.5 cm supine or >3 cm left lateral (ventricular enlargement, HTN, aortic stenosis)
  • Sustained pulsation (hypertrophy, HTN, overload, CMP)
• Deviations from normal precordium

  • Thrills (cause: murmur)
  • Palpable lifts or heaves (cause: right ventricular hypertrophy)
  • Pulsations felt on the fingertips (may come from the right ventricle, indicating right ventricular hypertrophy)
  • Large diffuse epigastric pulsation (cause: abdominal aortic aneurysm)
  • Accentuated pulsation in pulmonic area (cause: pulmonary HTN)
  • Accentuated pulsation in aortic area (cause: HTN or aneurysm)
• Percussion findings

  • Dullness at 3rd, 4th, and 5th ICS to left of sternum at MCL
  • Left sternal border extends to midaxillary lines in an enlarged, dilated heart
• Auscultation of the neck

  1. Have client hold breath

  2. Auscultate the carotid with the bell portion of the stethoscope for bruits

  3. Auscultate the jugulars with the bell portion of the stethoscope for venous hums
• Normal neck auscultation findings

  • Positive carotid bruit may be normal in children and is associated with high-output states
  • Negative venous hum
  • Positive venous hum may be normal in children
• Abnormal neck auscultation findings

  • Bruit suggests carotid stenosis
  • Murmurs can also radiate up to the neck from the heart, as in aortic stenosis
• Precordium auscultation


  1. Auscultate at apex, LLSB, Erb's point, base left and base right

  2. Note rate, rhythm, extra sounds, or murmurs

  3. Listen at each site with both the bell and the diaphragm

  4. The diaphragm is best for high-pitched sounds, the bell is best for low-pitched sounds
• Normal apex (mitral) auscultation

  • Rate depends on age, regular rhythm, S1 S2, high-pitched systolic murmur of short duration, no extra sounds
  • Physiological S3 and S4 may be heard in children and young adults without heart disease
• Deviations from normal apex (mitral) auscultation

  • Bradycardia rates 60 BPM or tachycardia rates 100 BPM
  • Irregular rhythm: Arrhythmia
  • Quadruple rhythm, S3 S4 with fast rate (summation gallop)
• Angina Pectoris


  • Chest pain resulting from myocardial ischemia, anxiety, pale/diaphoretic/cool/clammy skin, dyspnea, tachycardia, pulsus alternans, arrhythmias, S4, S3, nausea, belching, weakness, paresthesias
• Congestive Heart Failure


  • Right-sided: Fatigue, weight gain, confusion, pale/cool skin, neck vein distension, tachycardia, right ventricular heaves, murmurs, S3, right-sided pleural effusion, anorexia, bloating, RUQ tenderness, hepatomegaly, ascites, edema, diminished hair growth
  • Left-sided: Fatigue, confusion, pale/dusky/cyanotic/cool skin, left ventricular heaves, pulsus alternans, increased heart rate, displaced PMI, S3, S4, dyspnea, crackles, orthopnea, dry/hacking cough, PND, nocturia
• Coronary Artery Disease


  • Anxiety, dizziness, chest pain, fatigue, pale/ashen/cool/diaphoretic/feverish skin, neck vein distension, dyspnea, tachypnea, crackles, tachycardia or bradycardia, arrhythmias, elevated BP initially, S3, S4, murmur, rubs, diminished heart sounds, nausea, vomiting, low urinary output, cool/pale/decreased pulses, chest pain aggravated by inspiration/coughing/movement, fever, friction rub at LLSB
• Pericarditis


  • Inflammation of the pericardium, resulting in cardiac compression, decreased ventricular filling and emptying, and cardiac failure, often occurs 2 to 3 days after MI
• Normal findings for head assessment


  • Round and is of normal size or head circumference
  • Normocephalic
  • In proportion w/ gross body structure
  • Frontal, parietal and occipital prominences
  • Smooth skull contour
  • Smooth, uniform consistency; absence of nodules or masses
  • Symmetric facial movements
  • Symmetric facial features
  • No edema
  • Eyes not sunken
  • No edema
  • Eyes not sunken
• Deviations from normal head assessment

  • Disproportionate
  • Asymmetric parietal and temporal prominences; with more prominent nose and forehead; longer mandible
  • Increased head circumference
  • Square – head
  • Bulging / depressed bone
  • Abnormal increase in head size in young child: may indicate hydrocephalus
  • Inconsistently large head size in adolescent or adult: may indicate acromegaly
  • Sebaceous cysts
  • Local deformities from trauma
  • Masses
  • Nodules
  • Asymmetric facial movements
  • Drooping of lower eyelid and mouth
  • Involuntary facial movement
  • Asymmetric features
  • Increased facial hair; thinning of eyebrows; exopthalmos; moon face
  • Periorbital edema
  • Sunken eyes, cheeks and temples (indicative of dehydration, starvation, and illness)
  • Abnormal
  • Swelling
  • Tenderness
  • Crepitation
• Assessment of the Neck

  • Inspecting the neck from the neutral position
  • Inspecting the neck when hyperextended
  • Use light palpation and check for masses or areas of tenderness
• Normal findings for neck assessment

  • Neck erect, midline, no lumps, bulges, or masses
  • Thyroid not visible. No masses, swelling, or hypertrophy in mid to lower half of anterior neck
  • Supple, nontender, no masses
• Deviations from normal neck assessment

  • Enlargements
  • Lymphadenopathy, lymphoma, or other malignancy
  • Torticollis
  • deviation of neck to one side caused by spasmodic contraction of neck muscles
  • Enlarged, visible thyroid
  • Goiter or malignant mass
  • Masses: Lymphadenopathy, malignancies, thyroid masses
• Cervical Lymph Nodes


  • Occipital nodes
  • Post - auricular nodes
  • Pre - auricular nodes
  • Tonsillar nodes
  • Submandibular nodes
  • Submental nodes
  • Superficial cervical nodes
  • Posterior cervical nodes
  • Deep cervical nodes
  • Supraclavicular nodes
  • Infraclavicular nodes
• Normal findings for lymph node palpation


  • Lymph nodes normally not palpable especially the deep and clavicular nodes
  • If a node is palpable, normal characteristics include small, 1 cm, mobile, soft, nontender, and usually superficial
• Deviations from normal lymph node palpation

  Palpable nodes (1 cm or greater): Malignancy, inflammatory, or infectious process of glands or area they drain
• Palpating the Thyroid


  • Locate the thyroid isthmus below the cricoid cartilage
  • Anterior approach
  • Posterior approach
• Normal findings for thyroid palpation


  Generally nonpalpable. If some tissue is palpable , consistency is firm, smooth, and meaty, with no nodularity, enlargement, or tenderness
• Deviations from normal thyroid palpation

  • Enlarged thyroid
  • Nodular thyroid tissue
  • Tender thyroid
• Auscultation of the Thyroid

  If thyroid gland is palpable, have patient hold breath and then listen over the thyroid gland with the bell portion of the stethoscope for bruits
• Normal findings for thyroid auscultation


  No sounds detected