Alright, so today we're going to go through both the sitting and two-point position of the cardiovascular exam, as well as measuring JVP, how to go about measuring JVPs, and then evaluating peripheral pulses, peripheral vessels. This will follow the pulmonary. So if you notice that pulmonary stopped at 18 with the special tests, your patient will already be in that sitting position. So I've just done egophony or bronchophony, whatever I've done. And then I'm gonna go right into.
the sitting position exam. The first article is auscultating the carotids. So we need to auscultate the carotids and remember that it's done with the bail. First, I want to kind of get a position, so if you'll put your chin up for me. Right?
So, gently palpate until we evaluate for rubies. Gently palpate the carotid artery. Now, I'm going to have my patient take a deep breath in and hold it, and I'm going to listen.
Okay, good. Once again, take a deep breath in. Hold it.
Good. So I'm listening for a bruit, so I'm going to tell you that this, I said please hold your breath while I'm listening for a carotid bruise. There are no carotid bruises here.
Okay? Now, auscultation. of the heart.
We've talked about it in lecture, but now let's take a look at the topical anatomy, right? In regards to like doing inspection, we always talk about doing inspection first. That's been completed previously in the, just before the pulmonary. right?
So we're moving right through. Let's talk about the topography of the chest. We know that we have the sternal notch. Below the sternal notch is the manubrium and the sternal angle, or the angle of Lewy.
At the angle of Lewy, we have the second rib that attaches at the angle of Lewy, and just below that second rib is the second intercostal space. That's going to be important for our auscultation, so we need to know second intercostal space, our third. There's our third rib, so our third intercostal space.
Fourth rib, fourth intercostal space. Our fifth rib, fifth intercostal. The other thing we need to know is the midclavicular line that's on our patient as well. Okay? So we're going to go through with the diaphragm.
We're going to listen to all four valvular positions, and we're going to look at the left third intercostal space, which is termed Erb's point. Okay? So we're going to name the valves as we go through.
I like going through with the diaphragm first. So my second intercostal space on the right side is my aortic. Straight over is my pulmonic.
Third interspace, herbs. Fifth intercostal space along the left sternal border is my tricuspid. And then just lateral in the midclavicular line, fifth intercostal space, mitral valve. I leave my stethoscope on, I change to the bell, and I just go in reverse. Fifth intercostal space, midclavicular line, mitral.
Fifth intercostal space, left sternal border, tricuspid. Third intercostal space, left sternal border, curves. Second intercostal space, left sternal border, pulmonic. Second intercostal space, right sternal border, aortic.
So I say at this point, it's just a matter of naming as I go through. That's your key indicator of performance there, okay? Now, I'm going to ask a take with inspiration here.
And remember, we were talking about the physiologic split of S2. Some will have you take a deep breath and hold it, but taking a deep breath and listening will split the S2. We did a little audio in the classroom. It's a very quick split. It's not like an S3 that has a longer duration between the two sounds.
It's a very quick split. So I'm listening with my diaphragm, second intercostal space, third intercostal space. First thing I do is I want to listen to the heart sound.
The most important thing here, like I was saying before, you close your eyes and you start getting into the music of the heart, so to speak. So the heart's loved up, loved up, loved up. Once I get... That in and I'm hearing it. I understand.
I'm really listening to it close. I want you to take a deep breath. Take another deep breath. I definitely heard it the second time. Right?
So he does have a physiologic split. It's very close. But you've got to train your ears first.
You've got to find out what is S1 and S2. And then once you figure out what S1 and S2 is, and you get the beat in your head, then have them take a deep breath, it might be the second or third inspiration, the third kind of taking a deep one, that you'll actually start hearing the split. Okay?
So, I'm listening for a physiologic split of S2, or you can say there is a physiologic split of S2. Now, we're going to auscultate with the diaphragm in the third intercostal space. Again, over at Erb's, but this time we're going to do it with an expired breath. And what we're listening for is the murmur of aortic regurgitation. So, back to Erb's point we go.
Again, lugged up. Take a big breath in and hold it. Okay, go ahead and breathe. And I will try it one more time if I didn't hear it.
Another big breath in. Hold it. Very good.
So there is no murmur of aortic regurgitation. The important thing there is the deep breath. It's an expired air, and then the patient leans forward at the same time, right?
Expired and moved forward. Now we're going to do the bowel salivary maneuver. And over here we're looking for that hypertrophic obstructive cardiomyopathy, right, the hokums.
In hokums, we're going to have them stay upright. And then we're going to have them bear down, like if you're moving your bowel, okay? So I'm going to tell you to bear down, if you'll just bear down for me. Again, in herbs point.
You know you can actually, you don't have a murmur, that's good, but I'll tell you that you can actually hear the intensity of the heartbeat as it goes, right? So as we bring on that preloader, we engorge that ventricle, you can actually hear, even if there's no hope. So we're going to bring our bed up, right to 30 degrees.
About 30 degrees. I'm going to stand on the right side. I'm going to bring out the leg.
Alright, on this exam... I'm going to have my patient turn their head to the left because I want to measure the right jugular, the right jugular, right internal. Remember we had talked about the sternocleidomastoid. We have the clavicular head lies on one side, and then the sternal head lies medial.
If I'm having a hard time actually seeing those heads to get my landmarks, I can actually take my finger just to his chin and have him turn to my chin. And you can actually see the sternocleidomastoid. collado-mastoid heads actually accentuate right with resistance so gentle pressure so I kind of know my landmark so at this point at 30 degrees I'm going to actually start inspecting for any pulsations along that pathway remember that the internal jugular follows this pathway right to the angle of the jaw So at this time, I'm going to look. I don't really see much at all, and I don't expect to see much in a healthy patient, right? I really don't because I'm, what am I evaluating here?
I'm evaluating the right atrium, right? Or the right ventricle, I'm sorry, the right ventricle to make sure that the right ventricle... functioning properly. So for him it looks fine.
Let's pretend that we had a pulse that comes just below this mark on his neck, right? That would be my meniscus and it would be a pulse waveform that travels up with an oscillation each time it travels up. So once I find that waveform, I come to the angle of Louis, right?
I'm going to actually use my centimeter side facing my patient. I place that on my angle of Lewy and at the top of the oscillation with a straight edge is where I'll measure my jugular venous pressure and our number would have been two centimeters right two centimeters that tells me that his right The ventricle is not congested and it's performing appropriately because the cutoff is 3. 3 and less is a normal JVP. Higher than 3 suggests congestion. If he had congestion... Blood backup, because the muscles aren't working so well, they would have something called jugular venous distension.
JVD, it's a visible thing. There's a PowerPoint slide with a picture, and it's just this huge internal jugular vein that's kind of popping out of his neck. Right? At the top of that big congested vessel is an oscillatory move. The oscillation, you'll see the top of that oscillation.
That's where it's moving. Remember that it has two waveforms, not one like a carotid artery. but two waveforms.
So that's why I was saying let's pretend that it actually goes to the top. Right here, this little mark on his neck, let's pretend that this is where we see the top of that oscillation. He has obvious JVD that I can see. He has peripheral edema. shorter breath and he has some chest pain.
Those things suggest we have right-sided failure, probably maybe even left-sided failure, but definitely right-sided. So at this point, I see the oscillation. I want to go to the sternal angle, right?
The sternal angle on his chest. Once I go to the sternal angle, I'm going to put my measuring device, whatever it is, but it should be in centimeters, right on the sternal angle. Once I have it placed on the sternal angle, I'm looking at the top of the oscillation.
and I'm going to take my straight edge, it's not so straight anymore, but I will take my straight edge and I place my straight edge straight to the top of the oscillation and to my measuring device and yours is now 2.5 centimeters. He's still within normal limits, even though I've moved him up. I'll expect that oscillatory thing as I move them up.
Already I've third spaced a lot of volume. I might have to move him up a little higher, right? Or excuse me, if he's volume overloaded, I would have to move him up a little higher if he's volume overloaded, right, to move that oscillation. As I move him down, what would happen to my meniscus?
Starting to settle back into the chest, yes? So it's important that we describe the angle that we have our patient. Is he at 30 degrees?
JVP, measure 2 centimeters above the startle angle at 30 degrees, 60 degrees, 90 degrees. So we have to report what angle we have our patient at local measure. So after we measure JVP, we're going to inspect the precordium at this point.
And we're inspecting for precordial heaves at points of maximal impulse that we can actually see. We're going to palpate the precordium and we're going to locate the PMI. So when I palpate the precordium, it's with the balls of my hand just like so.
I want to hit the valvular areas, Erb's point, tricuspid, mitral. Now, I'm also going to try to find the PMI. Where am I going to find the PMI? Do you remember?
It's the fifth intercostal space. It's the fifth intercostal space, and where in the fifth intercostal? Midclavicular, it could be medial or just anterior or lateral to it, but not by much. So to find it, I'm going to place my hand on his chest. Let's pretend that I found it right in the midclavicular line.
I would march these fingers to that point. It's still under those two fingers. And then I'm going to use my index finger to calculate the size. Remember that the size should be less than a quarter, the size of a quarter. Right?
You can also use this maneuver to try to find the PMI. I'm going to have you lean on the left side. It's called a lateral, left outer decubitus.
Right? So the same thing. If I wanted to bring the apex of the heart a little closer to the wall, I'm going to lean you way over. palpate, found it, palpate it and then to one quarter size. Okay, lay back over.
So there are no lifts, heaves or drills and the PMI is non-displaced. was displaced, it would be lateral. It could also, you can actually find PMIs in the xiphoid region, right, towards that right atrium, the heart, especially when the heart tilts.
Typically, you can find that in like very thin or COPD fascias. You can find it here, right? His is non-displaced.
Now, we're going to auscultate the heart with the diaphragm at those four valvular positions again, in this position. So, second intercostal space. Second intercostal space on the right. Aortic. Second intercostal space on the left, pulmonic.
Third intercostal space is Erb's point. Fourth, or excuse me, fifth intercostal space is the tricuspid. Fifth intercostal space on the left.
Mitral. Backwards now with the bell. Fifth intercostal space on the left, midclavicular.
Mitral. Fifth intercostal left sternal border, tricuspid. Third interspace on the left sternal border, herbs.
Second intercostal. Hormonic, right, second intercostal, aortic. So at that point, I just went through and mentioned what I did. I went through and named my valves, my valvular areas, and there's 0.4 gallops.
We're listening for those gallops. So I'm going to put him in his left lateral decubitus position one more time. Break.
I'm taking a listen. It's midclavicular. Back in supine position.
There are no gallops. There are no gallops or S3 or S4 hurt. Okay?
So that's important that it's bell and it's left lateral decubitus. Once I finish with my exam, like when I finished that, just like we did did with people's equal round reactive to light and accommodation we had this little saying here that we would say that the rate and rhythm are regular without murmurs gallops or ruffs after we evaluate for gallops correct all right We've pretty much done the cardiac portion of the cardiovascular, but now we still have the peripheral vascular portion of the exam. So we're going to palpate the peripheral arteries or the pulses. We've already done the carotids, right? But the brachials, like I was saying before, they can be done symmetrically together.
So my brachials... Pericular arteries, radials. We would mention the femorals, but we don't need to examine the femorals. We would mention femorals, they're important. We'll take both legs off.
The popliteal. Then there's the posterior tibialis. You can see my hand position, right?
This lies behind the medial ameliolus. Then I can have my patient flex his big toe and relax. This is my dorsalis pedis, checking for pulses. And then I would report. Pulses are full and equal bilaterally.
And then I'm going to check the nail beds and fingers and toes for cyanosis and clubbing. Right? Cap refill is less than two seconds.
There's no peripheral cyanosis or clubbing noted. And then I'm going to check the lower vessels, right? Peripheral vessels. We're going to check those by inspecting and palpating the legs. We're looking for edema, hair distribution, skin condition, temperature, and variscosities.
And we use the back of our hands to compare the temperature of legs. So I would say I'm inspecting for edema, hair distribution, skin condition, temperature, and variscosities. So when I go through first, I really want to look at his legs. I really want to take a look and see if I can find some edema or any tender spots, variscosities for sure, no edema. And then I'm looking at the hair distribution of his legs.
Remember we talked about toes, circulation, great circulation. And then the back of my hands is how I want to feel temperature. I want to make sure that there's no fever or anything to the feet.