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Health History Subjective Questions

"Chest pain
Shortness of breath, dyspnea, orthopnea
Loss of consciousness (transient syncope)

Physical Examination

"1. Inspect precordium noting any visible apical impulse, heaves, or lifts
2. Palpate PMI during exhalation noting size and location (b/w 4th & 5th ICS at or medial to MCL 1cm x 2cm)
3. Palpate across precordium using palmar aspect to note any pulsations or thrills
4. Auscultate each precordial landmark first w/ diaphragm then bell

Auscultation Sites

"APE To Man
Aortic valve area: 2nd ICS, RSB
Pulmonic valve area: 2nd ICS, LSB
Erb's point: 3rd ICS, LSB
Tricuspid valve area: 5th ICS, LSB
Mitral valve area: 5th ICS, MCL

Auscultation of Precordial Landmarks

"Note rate and rhythm
Identify S1 and S2
Assess S1 and S2 separately
Listen for extra heart sounds
Listen for murmurs

Auscultation of Murmurs

"Listen supine
Have client roll to his left side and listen w/bell
Have client sit up leaning slightly forward during exhalation and listen with diaphragm firmly pressed at base


"1st heart sound (lub)
Coincides w/carotid artery pulse
Occurs with closure of AV valves and signals beginning of systole
Loudest at apex


"2nd heart sound (dub)
Occurs with closure of semilunar valves and signals end of systole
Loudest at base


"3rd heart sound
Usual cause is myocardial failure
Occurs immediately after S2 (early diastole)
Heard best at apex with bell
Low pitch


"4th heart sound
Occurs when ventricles are resistant to filling
Occurs just before S1 (late diastole/ early systole)
Heard best at apex with bell
Low pitch

Pericardial Friction Rub

"Grating sound
May obscure heart sound


"Caused by turbulent blood flow and collision currents during diastole and systole
Heard around area of sound transmission
Gentle, blowing, swooshing sound
Causes: Increased velocity of blood from exercise, pregnancy, thyrotoxicosis, decreased viscosity from anemia, structural defects in valves or unusual openings in chambers

Murmur Grading

"i: barely audible, heard only in quietroom
ii: clearly audible but faint
iii: moderately loud, easy to hear
iv: loud, associated with a thrill palpable on the chest wall
v: very loud, heard with one corner of stethoscope lifted off the chest wall
vi: loudest, still heard with entire stethoscope lifted just off chest wall

Physical Examination of Neck

"1. Palpate carotid pulse noting rate, rhythm and amplitude. Palpate gently, one at a time. DO NOT MASSAGE
2. Auscultate for bruit using bell
3. Visually inspect jugular veins
4. Assess for neck vein distension (NVD, JVD)

Jugular Vein

"1. Internal jugular vein reflects the central venous pressure
2. This shows thehearts efficiency as a pump
3. Position patient from 30 to 45 degrees
4. Turn head slightly to opposite side
5. Direct light on neck
6. Use angle of Louis as a reference point
7. Compare angle to highest level of venous pulsation

Hepatojugular Reflex

"1. Position patient supine
2. Patient breathes quietly through an open mouth
3. Examiner takes right hand on right upper quadrant of patient's abdomen just below rib cage
4. Watch level of jugular pulsation as examiner pushes hand in. Firm sustained pressure for 30 sex. is to be maintained
Normal= jugular veins rise for a few secs and recede
Abnormal= jugular veins elevate and remain elevated as long as examiner pushes abdomen which indicates heart failure

The Older Adult

"Stiffening of the arteries and calcification cause an increase in systolic BP
Increased pusle pressure since the systolic increases and diastolic does not change significantly
Increased thickness of the wall of the left ventricle
Ectopic beats are more common and may compromise cardiac output

Heart Failure

"Occurs when heart fails as a pump and the circulation becomes backed up and congested
Symptoms: Orthopnea, JVD, pale or cyanotic skin, fatigue

Myocardial Infaction

Heart attack

Low Sodium, Low Cholesterol Diets

"Dietary Approaches to Stop Hypertension (DASH)
Increase vegetables and fruits
Limit saturated fat
Yes to poly and mono unsaturated fats
No to trans fats

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