Examination of the Abdomen for Nursing Students

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the abdomen.

Examination of the Abdomen Outline

  1. general considerations
  2. examining the hands
  3. examining the eyes
  4. examining the mouth
  5. palpating the cervical lymph nodes
  6. examining the patient’s chest
  7. examining the abdomen

1. General Considerations

  • ensure your hands are warm – patient comfort
  • during palpation check for signs of pain in patient’s face eg. grimacing
  • expose the abdomen including the inguinal regions (not the genitalia) while the patient is lying flat with one pillow
  • if patient has a nasogastric tube notice the aspirate
  • if patient has a urine catheter notice the urine bag
  • if patient has an IV line notice what is being administered
  • if patient has a drain following a laparoscopy check drain for massive amount of blood, urinary output, IV fluids, NG tube aspirate, and pain relief administration

2. EXAMINING THE HANDS

FINGER CLUBBING

  • check for finger clubbing caused by interstitial oedema and dilation of the arterioles and capillaries
  • assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
  • advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
  • finger clubbing causes may include gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage)
Finger Clubbing – Retrieved from https://en.wikipedia.org/wiki/Nail_clubbing on 21st March 2023

KOILONYCHIA

  • thin concave spoon-shaped nails commonly found in anaemia due to iron deficiency
Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMicm1802104 on 30th June 2023

LEUCONYCHIA

  • white discolouration of the nails (possibly totally opaque) commonly found in patients with a low serum albumin a.k.a. hypoalbuminaemia
Retrieved from https://www.huidziekten.nl/zakboek/dermatosen/ltxt/leukonychia.htm on 30th June 2023

BROWN LINES

Retrieved from https://www.huidziekten.nl/zakboek/dermatosen/ltxt/leukonychia.htm on 30th June 2023

PALLOR

  • pallor of the skin creases may be a sign of anaemia
  • thalassemia major (a severe recessive genetic disorder of hemoglobin structure with hemolysis or rapid breakdown of red blood cells resulting in anemia and iron overload in the heart, liver and other organs), sickle cell disease (red blood cells become hard and sticky and look like a C-shaped farm tool called a “sickle”), iron deficiency (due to malnutrition or heavy menstrual bleeding or IBD, celiac disease, Vitamin B12 deficiency, folic acid) and leukaemia (malignant progressive disease in which the bone marrow and other blood-forming organs produce increased numbers of immature or abnormal leucocytes which suppress the production of normal blood cells) may all lead to anaemia and consequentially pallor of the skin creases
Retrieved from https://twitter.com/Jcortesizaguirr/status/1281723663553908743 on 3rd April 2023

PALMAR ERYTHEMA

  • redness involving the heel of the palm, and occasionally the fingers; symptoms include non-itching, symmetrical, painless, and slight warmth in redness areas
  • common in patients with liver disease, thyrotoxicosis (a clinical state of inappropriately high levels of circulating thyroid hormones T3 and/or T4 in the body), rheumatoid arthritis (chronic inflammatory disorder), but also possible in pregnant women due to hormonal changes
Retrieved from https://dermnetnz.org/topics/palmar-erythema on 30th June 2023

DUPUYTREN’S CONTRACTURE

  • thickening of the palmar fascia which causes flexion contracture commonly affecting the ring and little finger
  • commonly found in patients with chronic liver disease
Retrieved from https://drdavidstewart.com/conditions/hand/dupuytrens-contracture on 30th June 2023

FLAPPING TREMOR

  • ask patient to outstretch arms with the wrists in extension; in this position, the downward intermittent flap of the hands is exaggerated
  • flapping tremor can be seen in patients with liver disease and chronic renal failure
Retrieved from https://medicinaonline.co/2019/09/02/asterissi-asterixis-in-neurologia-caratteristiche-significato-esecuzione/ on 3rd April 2023

3. EXAMINING THE EYES

PALLOR

  • pallor of the mucous membranes eg. the conjunctival mucosa (happens when the haemoglobin level is <9-10g/dl
Normal VS Conjunctival Pallor in Anaemia – Retrieved from https://www.grepmed.com/images/15116/conjunctival-anemia-clinical-physicalexam-pallor on 23rd March 2023

JAUNDICE

  • yellowish discolouration of the sclerae, mucous membranes and skin due to high concentration of Bilirubin in the blood; easily detected in daylight but may be missed in artificial lighting
Retrieved from https://www.verywellhealth.com/all-about-jaundice-1760104 on 30th June 2023

4. EXAMINING THE MOUTH

TONGUE

  • assess the patient’s tongue for dehydration (dry, coated tongue which looks white and furry)
  • pale and atrophic tongue can be seen in iron deficiency anaemia
  • beefy red and painful tongue can be seen when the patient is deficient in B12

BREATH SMELL

  • a ‘fishy’ breath smell indicates uaremia (raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys)
  • a ‘mousy’ breath smell indicates liver failure
  • a ‘fruity’ breath smell indicates presence of ketones in diabetic ketoacidosis
  • a ‘wine-like’ breath smell indicates renal failure
  • a ‘bad’ breath smell may also be caused by sleeping with an open mouth

5. PALPATING THE CERVICAL LYMPH NODES

  • Virchow’s node is an enlarged hard lymph node which can be found in the left supraclavicular fossa; it is indicative of abdominal neoplasm (abnormal growth that occurs within the abdomen)
Retrieved from https://casereports.bmj.com/content/2013/bcr-2013-200749 on 30th June 2023

6. EXAMINING THE PATIENT’S CHEST

SPIDER NAEVI

  • central spiral arteriole that supplies a radiating group of small blood vessels, which, if occluded by pressure, blanches
  • commonly found in the upper part of the body above the nipple line especially in areas exposed to sunlight
  • healthy people, including pregnant women and patients on oestrogen therapy may have one or two spider naevi, which is considered to be normal
  • a large number of spider naevi is commonly found in liver disease
examination of the abdomen
Retrieved from https://integrityskin.com.au/spider-naevi/ on 30th June 2023

PURPURA

  • purpura shows up when capillaries bleed into the skin
  • purpura commonly shows up in patients with a low platelet count caused by haematological malignancies or patients with chronic liver disease along with coagulation defects
Retrieved from https://www.physio-pedia.com/Purpura on 30th June 2023

GYNAECOMASTIA

  • gynaecomastia is enlargement of the breasts in males
  • can be discovered by feeling gently around the nipples
  • gynaecomastia may be caused by puberty, chronic liver disease, bronchial carcinoma, and drugs such as digoxin and spirinolactone
examination of the abdomen
Retrieved from https://gpnotebook.com/simplepage.cfm?ID=-1858797563 on 30th June 2023

7. examining the abdomen

ABDOMEN QUADRANTS

SWELLING

  • swelling may be caused by the 5 F’s in Abdo Distention, namely fluid, fat, flatus, faeces or foetus
  • swelling may also be a sign of hepatomegaly, incisional hernia, or abdominal mass

EPIGASTRIC PULSATIONS

  • epigastric pulsations can be due to aortic pulsations in a thin patient or an aortic aneurysm (a balloon-like bulge in the aorta – see further below for more information on palpating for aortic aneurysm)

DISTENDED SURFACE VEINS

  • commonly found in portal hypertension, usually radiating from the umbilicus (Caput Medusae) and in obstruction of the inferior vena cava
Retrieved from https://radiopaedia.org/articles/caput-medusae-sign-portal-hypertension-2?lang=us on 30th June 2023

SCARS

  • a midline scar may indicate a gastroduodenal, pancreatic or spleen surgery
  • a right subcostal scar may indicate a cholecystectomy or appendicectomy
  • a suprapubic scar a.k.a. Pfannensteil incision may indicate pelvic surgery or cesarean section
examination of the abdomen

STOMAS

  • an ileostomy can be found in the right iliac fossa as a spout of mucosa protruding from the abdominal wall with a continuous flow of effluent
  • a colostomy can be found in the left iliac fossa if permanent, or in the right hypochondrium or left iliac fossa if temporary; it is flat in appearance (mucosa is sutured to skin) with intermittent effluent
examination of the abdomen
Retrieved from https://twitter.com/drkeithsiau/status/1401279828121329673 on 1st July 2023

PERISTALSIS

examination of the abdomen
Retrieved from https://slideplayer.com/slide/10278930/ on 1st July 2023

PALPATION

  • ask patient if any abdominal discomfort is present, and if yes, where
  • ensure that your hands are warm
  • to palpate, use the flat surface of your fingers and keep your forearm at level with the abdominal wall
  • palpate the abdomen gently, leaving any painful areas for last; note any signs of pain on the patient’s face, rigidity, or tenderness
  • repeat palpation in a firmer deeper way, feeling for abnormal masses
  • if a mass is felt, note position, size, shape, surface (smooth or irregular), edge (clear or poorly defined), consistency, pulsatility, percussion note (dull or resonant), and presence of bowel sounds

PALPATION OF THE LIVER

examination of the abdomen
Retrieved from https://liver.org.au/your-liver/about-the-liver/ on 1st July 2023
  • to palpate the liver start in the right iliac fossa; when the patient breathes in and out, move your hand upwards bit by bit until you reach the costal margin
  • check for hepatomegaly (enlargement of the liver) and if present, note size in cm below the costal margin; hepatomegaly causes include metastases (eg. bowel carcinoma), congestive heart failure, cirrhosis (early stage), and infections (eg. viral hepatitis, infectious mononucleosis)
  • check liver edgesmooth edge may signify congestive heart failure; knobbly edge may signify metastases
  • check consistency – liver feels hard in the case of metastases
  • check for tenderness – happens when liver capsule is distended; indicates congestive heart failure, hepatitis or hepatocellular carcinoma
  • check for pulsatility – happens in the case of tricuspid regurgitation

PERCUSSION OF THE LIVER

  • start percussion of the liver further up from the fifth intercostal space and move down to the mid-clavicular line
  • the liver is dull to percussion
  • normal liver does not extend beyond 1 cm below the costal margin on deep inspiration

PALPATION OF THE SPLEEN

  • the spleen acts as a filter of the blood, filtering for bacteria, parasites, and fungi; the spleen has white blood cells to protect against septicaemia (infection of the blood)
  • start palpating the spleen from the right iliac fossa
  • as the patient breathes in and out, move your hand towards the tip of the tenth rib; on reaching the costal margin, place your left hand around the lower left rib cage and palpate with your right hand in the midaxillary line
  • a slightly enlarged spleen can best be felt if the patient half rolls over onto his right side
  • a large spleen would sound dull in percussion
  • MASSIVE splenomegaly can be caused by Myelofibrosis, Chronic graunlocytic leukaemia, and Malaria (parasitic infection)
  • MODERATE splenomegaly can be caused by Haemolytic anaemia, Chronic lymphocytic leukaemia, Lymphoma and Portal Hypertension
  • MILD splenomegaly can be caused by Infections such as glandular fever, hepatitis, brucellosis (from unpasteurised milk) and infective endocarditis, Pernicious anaemia, and Sarcoidosis
  • HEPATOSPLENOMEGALY is when both the liver and the spleen become enlarged; causes include Myelofibrosis, Portal Hypertension, Lymphoma, Leukaemia, and Infections

PALPATION OF THE KIDNEYS

examination of the abdomen
Retrieved from https://visualsonline.cancer.gov/details.cfm?imageid=12172 on 1st July 2023
  • the kidneys are usually not felt; only an enlarged kidney or enlarged spleen can be felt
  • palpate each kidney by positioning one hand behind the patient’s loin and the other just above the anterior superior iliac spine; instruct the patient to breathe deeply
  • normal kidneys usually give a tympanic sound when percussed
  • signs of renal swelling include: ballottable kidneys, vertical descent, moving down on inspiration, being resonant to percussion (due to overlying colon)
  • bilateral enlargement of the kidneys may happen due to polycystic kidney disease
  • unilateral enlargement of the kidneys may happen due to Hydronephrosis (kidney becomes stretched and swollen due to a build-up of urine inside them), simple renal cysts, or a tumour (renal cell carcinoma)
  • NOTE: thin patients may have a palpable right kidney lower pole

PALPATION FOR AORTIC ANEURYSM

examination of the abdomen
Retrieved from https://medlineplus.gov/ency/article/000162.htm on 30th June 2023
  • aortic aneurysm is a balloon-like bulge in the aorta that can dissect or rupture
  • palpate for aortic aneurysm by placing two hands along the midline, just above the umbillicus; aortic aneurysm may be present if an expansile pulsation can be felt

THE GALL BLADDER

Retrieved from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/gallbladder-scan on 1st July 2023
  • the gall bladder, which is situated just to the lateral side of the right rectus muscle adjacent to the 9th costal cartilage, is usually impalpable

PALPATING FOR OTHER MASSES

  • palpate for abnormal masses in the epigastric region which can be a sign of a gastric carcinoma or pancreatic cyst
  • palpate the suprapubic region for uterine fibroids
  • NOTE: in a normal patient, the descending colon is often palpable in the left iliac fossa

ASCITES EXAMINATIONonly necessary if the abdomen is distended!

examination of the abdomen
Retrieved from https://www.obesitydoctor.in/symptoms/Ascites on 1st July 2023
  • ascites is a condition in which fluid collects in spaces within the abdomen; it affects lungs, kidneys and other organs
  • check for shifting dullness by percussing over the abdomen, starting centrally and moving to the flanks; note change of percussion note from resonant to dull (dull = fluid); ask patient to roll over onto that side whilst holding your hand on that same position, then percuss the area and check if area of dullness has moved…if yes, this is a sign of shifting dullness
  • check for fluid thrill by asking a colleague to place the edge of his or her hand along the midline of the patient’s abdomen; flick one side while feeling the opposite side; if ascites is present, a wave-like sensation called fluid thrill may be felt hitting your hand
  • causes of ascites include: intra-abdominal neoplasms, liver cirrhosis with portal hypertension, carcinoma, and nephrotic syndrome

GROIN & EXTERNAL GENITALIA EXAMINATION

  • position your fingers over the inguinal and femoral orifices and feel for any masses at these sites; instruct the patient to cough and feel for a cough impulse and enlarged inguinal lymph nodes
  • causes of lumps in the groin include: inguinal or femoral hernia, vascular structures such as the saphena varix and femoral aneurysm, lymphadenopathy, ectopic testis in superficial inguinal pouch, undescended testis, lipoma or hydrocoele of the spermatic cord

AUSCULTATING THE ABDOMEN

  • auscultate for bowel sounds and assess pitch; bowel sounds may be absent or decreased if patient has peritonitis, or in post-operative ileus presence (temporary lack of normal muscle contractions of the intestines); bowel sounds may be increased with a tinkling pitch in the case of bowel obstruction
  • auscultate along the course of the aorta and iliac arteries, and in the renal areas for any bruits (audible vascular sound associated with turbulent blood flow)

URINE TESTING

  • examine the patient’s urine with a dipstix and check for protein, blood and glucose

DIGITAL RECTAL EXAMINATION

  • instruct the patient to turn in the left lateral position
  • reassure and explain that the procedure may be uncomfortable but painless
  • wear gloves and lubricate the index finger
  • examine the perianal skin for skin lesions, external haemorrhoids or fistulae
  • place the tip of the forefinger on the anal margin, steadily pressing on the sphincter whilst passing the finger gently through the anal canal into the rectum
  • assess tone of anal sphincter and palpate around the entire rectum; note for any abnormalities and examine any masses systematically
  • in a male patient, feel for the prostate gland anteriorly; a normal prostate is smooth with a firm consistency, and has two lateral lobes separated by a median groove
  • prostatic hyperplasia commonly produces a palpable symmetrical enlargement
  • a hard and irregular prostate with an undetectable median groove is usually a sign of prostatic carcinoma
  • after withdrawing your finger, examine stool colour and check for presence of blood and mucus
  • NOTE: 50% of rectal carcinomas may be detected through a rectal examination

Liver Issues can also arise from excessive alcohol consumption, drug reaction, hepatitis A (from food), gallstone obstruction in bile duct. An Examination of the Abdomen can help detect Liver Disease.

Summary


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Examination of the Respiratory System

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the respiratory system.

Examination of the RESPIRATORY System Outline

  1. looking out for sputum pots
  2. examining the hands
  3. examining the face
  4. examining the neck
  5. examining the chest wall

1. LOOKING OUT FOR SPUTUM POTS

  • look around for sputum pots at the patient’s bedside
  • if available, assess the quantity (large quantity may be a sign of bronchiestasis) and the character a.k.a. colour and consistency; haemoptysis (blood-streaked sputum) may be due to bronchial carcinoma, pneumonia, pulmonary infarction, bronchiestasis or tuberculosis; mucopurulent greenish-yellowish sputum may be due to a chest infection

2. EXAMINING THE HANDS

TAR STAINING

  • check for tar staining of the patient’s fingers – this would indicate that the patient is a smoker
Tar-Stained Fingers – Retrieved from https://escholarship.org/content/qt8ck911z0/qt8ck911z0.pdf on 21st March 2023

FINGER CLUBBING

  • check for finger clubbing caused by interstitial oedema and dilation of the arterioles and capillaries
  • assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
  • advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
  • finger clubbing causes may include cardiac issues such as cyanotic heart disease (heart disease that is caused by lack of oxygen) and infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart), respiratory issues such as bronchial carcinoma (a malignant cancerous tumour of the bronchi and the lung tissue), lung abscess (a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection), bronchiestasis (a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection), empyema (pus-filled pockets that develop in the pleural space), and fibrosing alveolitis (a disease involving the gas-exchanging portions of the lungs), and gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage)
Finger Clubbing – Retrieved from https://en.wikipedia.org/wiki/Nail_clubbing on 21st March 2023

PERIPHERAL CYANOSIS

  • can be physiological eg. due to a surrounding cold environment, reduced cardiac output eg. shock causes central cyanosis
  • featured through bluish discolouration of the nail beds
  • usually starts showing when patient is at <85% SPO2
Cyanosis – Retrieved from https://www.physio-pedia.com/Cyanosis on 21st March 2023

FLAPPING TREMOR

  • ask patient to outstretch arms with the wrists in extension; in this position, the downward intermittent flap of the hands is exaggerated
  • flapping tremor can be seen in patients with severe respiratory failure
Retrieved from https://medicinaonline.co/2019/09/02/asterissi-asterixis-in-neurologia-caratteristiche-significato-esecuzione/ on 3rd April 2023

HAND TEMPERATURE

  • warm hands signify vasodilation or carbon dioxide retention
  • cold hands signify vasoconstriction
  • note if hands are dry or moist
  • clammy hands may be a sign of anxiety or sympathetic activation
Clammy Skin – Retrieved from https://www.medicalnewstoday.com/articles/322446 on 21st March 2023

3. EXAMINING THE FACE

HORNER’S SYNDROME

  • if Horner’s Syndrome is present, the patient may have unilateral constriction of the pupil (miosis), partial drooping of the eyelid (ptosis), impaired sweating on the same size of the face, and enophthalmos (recession of the globe in the orbital fossa)
  • Horner’s Syndrome may be caused by an apical lung carcinoma infiltrating the sympathetic chain
Retrieved from https://www.drawittoknowit.com/course/neuroanatomy/glossary/physical-exam/horner-s-syndrome on 3rd April 2023

PALLOR

Retrieved from https://twitter.com/Jcortesizaguirr/status/1281723663553908743 on 3rd April 2023

CENTRAL CYANOSIS

  • can be easily noted when looking at the patient’s tongue
  • happens when the oxygen saturation of arterial blood falls below 80-85%; central cyanosis indicates lack of oxygen in the brain
  • may be a sign of congenital heart disease (conditions present at birth which affect the structure of the heart and the way it works) or chronic obstructive airways disease or COPD
examination of the respiratory system
Central Cyanosis – Retrieved from https://www.researchgate.net/figure/Clinical-photograph-showing-central-cyanosis-Note-also-clubbing-of-fingers_fig3_255685646 on 23rd March 2023

4. EXAMINING THE NECK

JUGULAR VENOUS PRESSURE (JVP)

  • assessing the right internal jugular vein is better since it is more proximal to the superior vena cava than the left; the right external jugular vein has venous valves between it and the superior vena cava, hence it is less preferred for assessment; ideal patient placement is at 45 degree angle, looking to his left
  • jugular venous pressure (JVP) can be noted as a double flicker above the clavicle parallel to the anterior border of the sternocleidomastoid muscle (remember that a venous pulse is never palpable)
  • note the height by measuring the vertical height in cm between the top of the jugular venous pulsation and the sternal angle
  • normal JVP height = <4cm
  • high JVP height is a sign of increased pressure in the right atrium, and so, may be a sign of congestive heart failure, fluid overload (which may be due to nephrotic syndrome) or superior vena cava obstruction (non-palsatile)
examination of the respiratory system
Jugular Venous Pressure Height – Retrieved from http://www.nataliescasebook.com/tag/jugular-venous-pressure on 24th March 2023

CAROTID PULSE

  • feel the carotid pulse – a bounding pulse indicates carbon dioxide retention
Carotid Pulse – Retrieved from https://3d4medical.com/blog/the-anatomy-behind-pulse-points on 24th March 2023

SUPRACLAVICULAR LYPMH NODES

  • feel the patient’s supraclavicular lymph nodes
  • if enlarged, they may indicate carcinoma, lymphoma, sarcoidosis or tuberculosis
examination of the respiratory system
Retrieved from https://ccij-online.org/storage/files/article/ccij-cfh8kkmrbug-771/ClinCancerInvestigJ_2018_7_6_231_250408.pdf on 3rd April 2023

TRACHEA

  • feel the patient’s trachea; normally, the upper 4-5cm of the trachea can be felt between the cricoid cartilage and the suprasternal notch; compare distance to each side
  • a displaced trachea may result from moving away from a lesion eg. due to a superior mediastinal mass such as lymphoma or carcinoma, massive pleural effusion, or retrosternal goitre, or moving towards a lesion eg. due to upper lobe collapse or fibrosis
examination of the respiratory system
Retrieved from https://ccij-online.org/storage/files/article/ccij-cfh8kkmrbug-771/ClinCancerInvestigJ_2018_7_6_231_250408.pdf on 3rd April 2023

5. EXAMINING THE CHEST WALL

CHEST SHAPE

  • barrel chest is caused by an increase in the anteroposterior diameter relative to the lateral diameter of the chest wall. While the normal ratio is usually 5:7, patients with emphysema present with both measurements approximate; barrel chest may also be a sign of thoracic kyphosis (excessive curvature in the thoracic spine that leads to a rounded upper back)
  • thoracic kyphoscoliosis – a patient with kyphosis presents with an excessive outward curvature of the spine, causing the back to hunch; a patient with scoliosis presents with lateral deviation of the backbone caused by congenital or acquired abnormalities of the vertebrae, muscles and nerves; a patient with kyphoscoliosis presents with abnormal curvature of the spine both forwards and sideways, in other words, a combination of both kyphosis and scoliosis
  • pectus carinatum a.k.a. pigeon chest presents as localised prominence of the sternum and adjacent costal cartilages, commonly accompanied by indrawing of the ribs to form symmetrical horizontal grooves (Harrison’s sulci) above the usually everted costal margins; the deformities are thought to result from lung hyperinflation with repeated strong contractions of the diaphragm while the bony thorax is still in a pliable state; pectus carinatum is common following chronic respiratory disease in childhood eg. severe asthma
  • pectus excavatum a.k.a. funnel chest is a developmental defect featuring either a localised depression of the lower end of the sternum, or depression of the whole length of the body of the sternum and of the costal cartilages attached to it; while this is usually asymptomatic, an increased degree of depression of the sternum may cause the heart to become displaced to the left, restricting the ventilatory capacity of the lungs
  • iatrogenic chest is the result of former treatment for pulmonary tuberculosis with thoracoplasty, which involves surgical removal of parts of the ribs, allowing the chest wall to fall in and collapse the affected lung

SKIN

  • look for scars from previous trauma, surgery, etc.
  • look for evidence of radiotherapy eg. ink marks and telangiectasia (small, widened blood vessels on the skin, sometimes spidery in appearance, which blanche on pressure)
  • look for subcutaneous nodules eg. metastases
examination of the respiratory system
Telangiectasia – Retrieved from https://dermnetnz.org/topics/telangiectasia on 6th April 2023
examination of the respiratory system
Subcutaneous Nodules – Retrieved from https://wellcomecollection.org/works/c5mvhyae on 6th April 2023

RESPIRATORY MOVEMENTS

  • rate of respiration is normally between 14-18 bpm; tachypnoea is noted in acute pulmonary infections (especially if accompanied by pleural pain), bronchial asthma, pulmonary embolism and acute pulmonary oedema
  • mode of breathing – when breathing, women tend to use the intercostal muscles more than the diaphragm, with their respiratory movements being predominantly thoracic; men tend to rely more on the diaphragm, with their respiratory movements being predominantly abdominal; lack of chest expansion may be caused by ankylosing spondylitis (an inflammatory disease that over time can cause some vertebrae to fuse), intercostal paralysis (causes reduced vital capacity, inability to cough, and high mortality) or pleural pain; breathlessness is usually accompanied by respiratory distress, increased respiratory frequency and abnormal respiratory movements
  • abnormal inspiratory movements – use of accessory muscles – sternomastoids, scaleni and trapezii, in-drawing of the suprasternal and supraclavicular fossae, intercostal spaces and epigastrium can be observed with each inspiration; paradoxical movements within the chest may indicate mobile fractures within the thoracic cage – these can cause serious issues such as respiratory distress and hypoxaemia due to interfering with pulmonary ventilation
  • abnormal expiratory movements – commonly caused if the elastic recoil of the lungs are insufficient in completing air expansion from the alveoli, as in emphysema or asthma; patients exhibiting these symptoms tend to prefer leaning slightly forward in an attempt to augment their expiratory efforts, at times exhaling through pursed lips
  • expansion of the chest wallunilateral reduction of chest wall movement may be caused by pleural effusion, pneumothorax, lung consolidation (as in pneumonia, tuberculosis, neoplasm or infarction), lung collapse / lobectomy or pneumonectomy, and fibrosis (as seen in pulmonary tuberculosis); generalised restriction of chest wall movement may be seen in emphysema, bilateral pleural effusion, and ankylosing spondylitis (an inflammatory disease that over time can cause some vertebrae to fuse)

MEDIASTINAL DISPLACEMENT

  • determine the position of the apex beat, which also reflects the position of the lower mediastinum; pleural effusion and pneumothorax may cause mediastinal displacement (pushed away); fibrosis, collapse, and pneumonectomy may cause mediastinal displacement (pulled towards)

TACTILE VOCAL FREMITUS

  • tactile vocal fremitus is the palpable vibration transmitted through the bronchiopulmonary system to the chest wall when the patient makes a deep vocal sound
  • fremitus is increased in consolidated areas within the lungs
  • fremitus is decreased when the bronchus is obstructed or the pleural space is filled by fluid, air or solid tissue eg. pleural effusion, pneumothorax or fibrosis

PERCUSSION

  • percussion is performed to compare the degree of resonance over equivalent areas on both sides of the chest, moving systematically from top to bottom
examination of the respiratory system
Retrieved from https://quizlet.com/220991698/ha-lab-physical-assessment-of-an-adult-respiratory-flash-cards/?src=set_page_ssr on 6th April 2023
examination of the respiratory system
Retrieved from https://www.paramedicpractice.com/features/article/respiratory-system on 6th April 2023
examination of the respiratory system
Retrieved from https://www.magonlinelibrary.com/doi/abs/10.12968/bjca.2011.6.2.63 on 6th April 2023

AUSCULTATION

  • auscultate over each lung segment whilst patient breathes in and out gently through mouth
  • note the character of the breath sound – diminished vesicular breath sounds may be caused by a generalised reduction in airflow eg. emphysema or tumour obstructing a bronchus, pleural effussion or pneumothorax; bronchial breath sounds in which both inspiration and expiration may sound as blowing in character, may be caused by consolidations, fibrosis or collapse
  • listen for added sounds such as rhonchi (wheezes – generalised: due to asthma, chronic bronchitis, emphysema, pulmonary congestion caused by left ventricular failure; localised: due to local bronchial obstruction due to carcinoma, lymph node or foreign body), crepitations (crackles – fine crackles due to lung fibrosis, pulmonary oedema or pneumonia; coarse crackles due to chronic bronchitis or bronchiectasis), pleural friction rub (creaking sound due to pneumonia and pulmonary infarct), and pneumothorax click (rhythmical sound synchronous with cardiac systole)
  • notice the character and intensity of vocal resonancediminished vocal resonance is heard in pleural effusion, pneumothorax and collapse; increased vocal resonance is heard as a louder and clearer transmission of sound, commonly indicative of consolidation; in whispering pectoriloquy, the whisper is heard clearly with a stethoscope if there is consolidation, but is not heard if there is no consolidation; egophony is tested by asking the patient to say EEE aloud…if EEE sounds more like an A, consolidation may be present
  • palpate for axillary lymphadenopathy which can be felt in patients with lymphoma and mestastases

Examination of the Respiratory System for Common Respiratory Problems

DiseaseMediastinal ShiftTactile Vocal Fremitus / Vocal ResonancePercussion NoteAuscultation
ConsolidationNoneIncreasedDullbronchial breath sounds, crackles, bronchosphony, egophony, whispered pectoriloquy
Chronic BronchitisNoneNormalResonantnormal to decreased breath sounds, wheezes
EmphysemaNoneDecreasedHyper-Resonantdecreased intensity of breath sounds usually with prolonged expiration
AsthmaNoneNormal to DecreasedResonant to Hyper-Resonantwheezes
Pleural EffusionAwayDiminishedStony Dulldecreased to absent breath sounds, bronchial breathing and bronchophony, egophony, whispering pectoriloquy above effusion over the area of compressed lung
PneumothoraxAwayDiminishedHyper-Resonantabsent breath sounds, possible click
FibrosisTowardsDiminishedDulllate inspiratory fine crackles
Pulmonary OedemaNoneNormalResonantcrackles at the bases of the lungs, possible wheezes

Summary

Step-by-step examination of the respiratory system:

  1. sputum sample examination – quantity & character
  2. examine hands for flapping tremor, temperature, sweat, pallor, peripheral cyanosis, finger clubbing, nail swing, tar staining
  3. check pulse
  4. check respiration rate
  5. check blood pressure
  6. examine eyes for horner syndrome
  7. observe face for signs of central cyanosis, pursed lip breathing, nose flaring
  8. observe neck for JVP height, enlarged supraclavicular lymph nodes, trachea displacement
  9. observe chest (lungs) for scars, evidence of radiotherapy, subcutaneous nodules, pectus excavatum, pectus carinatum, kyphosis, accessory muscle use for breathing
  10. check for chest expansion, determine position of apex beat, and perform tactile vocal fremitus (ninety-nine – note character and intensity of vocal resonance)
  11. percuss chest (lungs) over intercostal spaces and compare sides
  12. auscultate chest (lungs) and check for bronchial sounds, wheezing, crackles, pleural friction rub, or pneumothorax click
  13. repeat tactile vocal fremitus (ninety-nine – note character and intensity of vocal resonance), percussion and auscultation at the patient’s back
  14. perform whispering pectoriloquy (whispering ninety-nine) if suspecting consolidation
  15. assess under arms for enlarged lymph nodes in axilla

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Examination of the Cardiovascular System

In patient assessment, following the process of history-taking, we’ll be looking into performing a thorough examination of the cardiovascular system.

Examination of the Cardiovascular System Outline

  1. general considerations
  2. examining the hands
  3. examining the radial pulse, rhythm & rate
  4. measuring the blood pressure
  5. examining the face
  6. examining the neck
  7. examining the chest wall
  8. examining the bases of the lungs
  9. examining the abdomen
  10. examining the lower limbs

1. General Considerations

  1. If you haven’t done so already, introduce yourself and shake hands with your patient
  2. Note the patient’s age and general state
  3. Ensure that the examination room is quiet enough to perform auscultation
  4. The patient should be properly undressed for this examination
  5. The patient should be positioned adequately i.e. reclining at 45° with the head resting comfortably on pillows

2. Examining the Hands

FINGER CLUBBING

  • caused by interstitial oedema and dilation of the arterioles and capillaries
  • assess for finger clubbing by checking for the loss of the normal angle between the nail and the nail bed, and fluctuation of the nail bed
  • advanced finger clubbing may be featured through swelling of the subcutaneous tissues over the base of the nail causing the overlying skin to become tense, shiny and red, increase in the curvature of the nail especially in its long axis, and swelling of the pulp of the finger
  • finger clubbing causes may include cardiac issues such as cyanotic heart disease (heart disease that is caused by lack of oxygen) and infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart), respiratory issues such as bronchial carcinoma (a malignant cancerous tumour of the bronchi and the lung tissue), lung abscess (a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection), bronchiestasis (a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection), empyema (pus-filled pockets that develop in the pleural space), and fibrosing alveolitis (a disease involving the gas-exchanging portions of the lungs), and gastrointestinal issues such as inflammatory bowel disease (a term for two conditions – Crohn’s disease and ulcerative colitis, that are characterized by chronic inflammation of the GI tract), and liver cirrhosis (scarring of the liver caused by continuous, long-term liver damage).
examination of the cardiovascular system
Finger Clubbing – Retrieved from https://en.wikipedia.org/wiki/Nail_clubbing on 21st March 2023

PERIPHERAL CYANOSIS

  • can be physiological eg. due to a surrounding cold environment, reduced cardiac output eg. shock causes central cyanosis
  • featured through bluish discolouration of the nail beds
  • usually starts showing when patient is at <85% SPO2
examination of the cardiovascular system
Cyanosis – Retrieved from https://www.physio-pedia.com/Cyanosis on 21st March 2023

SPLINTER HAEMORRHAGES

  • featured as small dark subungual petechiae
  • may be symptoms of infective endocarditis (inflammation of the endocardium, the inner lining of the heart, as well as the valves that separate each of the four chambers within the heart) as well as trauma
examination of the cardiovascular system
Splinter Haemorrhages – Retrieved from https://www.health.com/mind-body/splinter-hemorrhage on 21st March 2023

TAR-STAINED FINGERS

  • caused by smoking – smoking accellerates build-up of atherosclerosis which leads to CVA and/or peripheral vascular disease and ischaemic heart disease. Complete occlusion by athersclerosis causes a Myocardial Infarction.
Tar-Stained Fingers – Retrieved from https://escholarship.org/content/qt8ck911z0/qt8ck911z0.pdf on 21st March 2023

TEMPERATURE

  • warm hands signify vasodilation
  • cold hands signify vasoconstriction
  • note if hands are dry or moist
  • clammy hands may be a sign of anxiety or sympathetic activation
examination of the cardiovascular system
Clammy Skin – Retrieved from https://www.medicalnewstoday.com/articles/322446 on 21st March 2023

3. Examining the Radial Pulse, Rhythm & Rate

ASSESSING THE RADIAL PULSE

  • the radial pulse can be located just lateral to the flexor carpi radialis
  • assess the rhythmsinus (normal – controlled by the sino-atrial node)? irregular (due to atrial or ventricular extrasystoles, atrial fibrillation or heart block)?
  • assess the rate – 60-100bpm at rest = normal; >100bpm = sinus tachycardia (due to fever, exercise, anxiety, heart failure); fast arrhythmias (due to atrial fibrillation, supraventricular tachycardia, or ventricular tachycardia); <60bpm = bradycardia (due to high vagal tone in athletes, sleep, or certain medication eg. beta blockers or calcium antagonists)
  • assess the condition of the vessel wall – if vessel wall feels stiff and tortuous, atherosclerosis is probably present
examination of the cardiovascular system
Locating the Radial Pulse – Retrieved from https://medlineplus.gov/ency/imagepages/19395.htm on 21st March 2023
examination of the cardiovascular system
ECG Waves – Retrieved from https://ib.bioninja.com.au/standard-level/topic-6-human-physiology/62-the-blood-system/electrocardiography.html on 21st March 2023

4. Measuring the Blood Pressure

TAKING THE PATIENT’S BLOOD PRESSURE

  • the patient should not eat, smoke, take caffeinated products, or perform vigorous exercise for 30 minutes prior to the examination
  • the room should be quiet and adequately prepared so that the patient is comfortable
  • the patient’s arm should be positioned in a way so that the antecubital fossa is level with the heart
  • the bladder of the cuff should be centered over the brachial artery about 2cm above the antecubital fossa; the bladder length should not be less than 80% of the patient’s arm circumference
  • patient’s arm should be slightly flexed at the elbow
  • palpate the radial pulse and inflate the cuff until the pulse cannot be palpated any more, take note of the number displayed and deflate the cuff
  • place the stethoscope over the brachial artery
  • inflate the cuff to 30mmHg over the estimated systolic pressure
  • release the pressure slowly at about 5mmHg/second
  • note the measurement where you start hearing the korotkoff sound as the systolic pressure
  • note the measurement where you stop hearing the korotkoff sound as the diastolic pressure
  • record the patient’s blood pressure as systolic over diastolic
  • retake blood pressure measurement by repeating the same process on the other arm if the patient is visiting for the first time; if there is a difference in blood pressure of more than 10mmHg in one arm, record the highest reading
CategorySystolicDiastolic
Normal<130<85
High Normal130-13985-89
Mild Hypertension140-15990-99
Moderate Hypertension160-179100-109
Severe Hypertension180-209110-119
Crisis Hypertension>210>120
Blood Pressure Classification in Adults

ASSESSING THE PULSE PRESSURE

  • pulse pressure is the difference between the systolic and diastolic blood pressure
  • a normal value of the pulse pressure falls somewhere between 30-40mmHg
  • a narrow pulse pressure may be a sign of reduced cardiac output such as in a haemorrhagic shock, as well as in severe aortic stenosis (prevents aortic valves from opening and closing properly, leading to stress on the heart to work harder to pump blood to the rest of your body), constrictive pericarditis (a condition in which granulation tissue formation in the pericardium results in loss of pericardial elasticity leading to restriction in the ventricular filling), and pericardial effusions (acute or chronic accumulation of fluid within the pericardial space)
  • a wide pulse pressure may be a sign of increased cardiac output and low vascular resistance, common in aortic insufficiency (heart valve disease where the aortic valve no longer functions adequately to control the flow of blood from the left ventricle into the aorta), anaemia (a condition in which the number of red blood cells or the haemoglobin concentration within them is lower than normal), and thyrotoxicosis (a clinical state of inappropriately high levels of circulating thyroid hormones T3 and/or T4 in the body)

PULSUS PARADOXUS

  • pulsus paradoxus is the difference between where the Korotkoff sounds are first heard on expiration only and where they are heard on both inspiration and expiration is normally 10mmHg
  • pulsus paradoxus is present when the difference exceeds 10mmHg
  • pulsus paradoxus is associated with pericardial effusion (acute or chronic accumulation of fluid within the pericardial space) and severe acute asthma

5. Examining the Face

CENTRAL CYANOSIS

  • can be easily noted when looking at the patient’s tongue
  • happens when the oxygen saturation of arterial blood falls below 80-85%; central cyanosis indicates lack of oxygen in the brain
  • may be a sign of congenital heart disease (conditions present at birth which affect the structure of the heart and the way it works) or chronic obstructive airways disease or COPD
Central Cyanosis – Retrieved from https://www.researchgate.net/figure/Clinical-photograph-showing-central-cyanosis-Note-also-clubbing-of-fingers_fig3_255685646 on 23rd March 2023

ANAEMIA

  • anaemia is characterised by a reduction of haemoglobin concentration in the blood, which usually are <13.5g/dl in adult males and <11.5g/dl in adult females
  • anaemia can be noticed as pallor of the mucous membranes eg. the conjunctival mucosa (happens when the haemoglobin level is <9-10g/dl
Normal VS Conjunctival Pallor in Anaemia – Retrieved from https://www.grepmed.com/images/15116/conjunctival-anemia-clinical-physicalexam-pallor on 23rd March 2023

CORNEAL ARCUS

  • corneal arcus is characterised by a greyish line in the periphery of the cornea, concentric with the edge but separated from it by a clear zone, consisting of cholesterol crystals
  • corneal arcus is typically seen in the elderly, but when seen in young people, it may be a sign of hypercholesterolaemia
Corneal Arcus – Retrieved from https://www.medical-actu.com/en/corneal-arcus/ on 23rd March 2023

XANTHELASMA

  • xanthelasma is characterised by intracutaneous yellow cholesterol deposits around the eyes
  • xanthelasma can be noted in normal people as well as in those with hypercholesterolaemia
examination of the cardiovascular system
Xanthelasma – Retrieved from https://torontodermatologycentre.com/xanthelasma/ on 23rd March 2023

MALAR FLUSH

  • malar flush is characterised by redness of the cheeks
  • malar flush is commonly seen in patients with mitral stenosis (narrowing of the valve between the two left heart chambers) as well as in normal individuals
Malar Flush – Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/malar-rash on 23rd March 2023

6. Examining the Neck

JUGULAR VENOUS PRESSURE (JVP)

  • the jugular veins, which are located adjacent to the superior vena cava, directly reflect right arterial pressure
  • assessing the right internal jugular vein is better since it is more proximal to the superior vena cava than the left; the right external jugular vein has venous valves between it and the superior vena cava, hence it is less preferred for assessment; ideal patient placement is at 45 degree angle, looking to his left
  • jugular venous pressure (JVP) can be noted as a double flicker above the clavicle parallel to the anterior border of the sternocleidomastoid muscle (remember that a venous pulse is never palpable)
  • note the height by measuring the vertical height in cm between the top of the jugular venous pulsation and the sternal angle
  • normal JVP height = <4cm
  • high JVP height is a sign of increased pressure in the right atrium, and so, may be a sign of congestive heart failure, fluid overload (which may be due to nephrotic syndrome) or superior vena cava obstruction
  • note the waveform: a wave signifies right atrial systole whilst an absent waveform may be due to atrial fibrillation; c wave, which is rarely noted, is due to tricuspid valve closure; x descent (systolic collapse) is a sign of atrial relaxation and downward displacement of the tricuspid valve towards the right ventricular apex in ventricular systole; v wave is due to right atrial filling; y descent (diastolic collapse) is a sign of a fall in right atrial pressure when the tricuspid valve opens
  • giant a waves happen when the right atrium is contracting against resistance as in tricuspid stenosis; cannon a waves happen when the right atrium is contracting against a closed tricuspid valve as in complete heart block
  • the hepatojugular reflux helps in re-checking an already raised jugular venous pressure; it is done by pressing with the flat of the hand over the liver and watching the rise of the JVP
Jugular Venous Pulse – Retrieved from https://sketchymedicine.com/2015/05/jugular-venous-pulse-jvp/ on 24th March 2023
examination of the cardiovascular system
Jugular Venous Pressure Height – Retrieved from http://www.nataliescasebook.com/tag/jugular-venous-pressure on 24th March 2023
examination of the cardiovascular system
Jugular Venous Pulse Waveform – Retrieved from https://www.youtube.com/watch?v=ZmgoMt-yj4k on 24th March 2023

THE CAROTID PULSE

  • the carotid pulse is the closest point to the heart where the arterial pulse can easily be felt
  • note the waveform of the pulse: slow rising pulse = moderate to severe aortic stenosis; collapsing pulse = aortic incompetence; double peak pulse a.k.a bisferiens = moderate aortic stenosis with severe incompetence
  • assess the pulse volume: small volume = low cardiac output; large volume = anaemia or thyrotoxicosis
Carotid Pulse – Retrieved from https://3d4medical.com/blog/the-anatomy-behind-pulse-points on 24th March 2023

7. Examining the Chest Wall

SCARS FROM PAST SURGERIES

  • left infra-mammary scar is a sign of past closed mitral valvotomy
  • central sternal scar is a sign of past open heart surgery

APEX BEAT

  • determine the position of the apex beat, which is the lowest and outermost point of definite cardiac pulsation; the apex is usually found in the 5th intercostal space within the mid-clavicular line
  • the apex beat may be impalpable in individuals with COPD and in patients with obesity
  • the apex may be displaced due to ventricular enlargement following cardiac failure, pneumothorax and scoliosis
  • assess the quality of the cardiac impulse: normal = brief outward movement at the onset of left ventricular ejection; abnormal = thrusting displaced apex beat in volume overload due to active large stroke volume ventricle caused by mitral or aortic incompetence, sustained apex beat in pressure overload due to aortic stenosis and gross hypertension with a normal or reduced stroke volume; or parasternal heave in central thrust or lift in the sternal region or 3rd or 4th intercostal space indicating right ventricular hypertrophy
  • assess for palpable murmurs a.k.a. thrills or palpable heart sounds at the apex and base of heart; systolic thrill at apex = due to a ventricular septal defect or mitral regurgitation; systolic thrill at base = due to aortic or pulmonary stenosis; diastolic thrill at the apex = mitral stenosis; diastolic thrill at the base = aortic regurgitation; palpable first heart sound (sounds like a tapping apex beat) = felt in mitral stenosis; palpable pulmonary sound = felt in pulmonary hypertension
examination of the cardiovascular system
Apex & Base of Heart – Retrieved from https://anatomyqa.com/heart-external-features/ on 29th March 2023
examination of the cardiovascular system
Normal VS Right Ventricular Hypertrophy – Retrieved from https://en.wikipedia.org/wiki/Right_ventricular_hypertrophy on 29th March 2023

PRAECORDIUM AUSCULTATION

  • prior to auscultation of the parecordium, ensure surrounding area is quiet
  • use the diaphragm of the stethoscope to filter out low pitched sounds and identify high pitched sounds eg. 2nd heart sound
  • use the bell of the stethoscope to listen to low-pitched sounds eg. mitral stenosis murmur
  • aortic valve = best heard at the right 2nd intercostal space close to the sternum; pulmonary valve = best heard at the left 2nd intercostal space close to the sternum; tricuspid valve = best heard at the left 3rd, 4th and 5th intercostal spaces close to the sternum; mitral valve = best heard at the apex
  • heart sound S1 = closing mitral and tricuspid valves + upstroke of carotid pulse; loud S1 = mitral stenosis; faint S1 = mitral regurgitation; intensity variation = atrial fibrillation
  • heart sound S2: loud S2 = systemic or pulmonary hypertension; soft S2 = calcified or immobile aortic or pulmonary valve; fixed splitting S2 = atrial septal defect; reversed splitting S2 on expiration = delayed aortic component follows pulmonary component; fixed splitting S2 on inspiration = aortic component superimposed on the normal pulmonary component, usually in left bundle branch block (delay in the activation of left ventricle)
  • extra heart sounds: S3 = low-pitched sound following S2 which happens in rapid ventricular filling in early diastole (physiologically heard in children, healthy young adults, athletes, and in pregnancy; pathologically heard in patients with large poorly contracting ventricle or with increased ventricular stroke volume due to a leaking heart valve)
  • extra heart sound: S4 = soft low-pitched sound occurring just before S1 in rapid emptying of a hypertrophied atrium, always abnormal, commonly associated with severe heart failure and/or hypertension
examination of the cardiovascular system
Auscultating Cardiac Valves – Retrieved from https://vula.uct.ac.za/access/content/group/9c29ba04-b1ee-49b9-8c85-9a468b556ce2/ClinicalSkills/cvs_08.html on 29th March 2023
examination of the cardiovascular system
Heart Sounds – Retrieved from https://rebelem.com/rebel-review/rebel-review-34-heart-sounds/heart-sounds/ on 29th March 2023

AUSCULTATING FOR MURMURS

  • heart murmurs are music-like sounds caused by turbulent blood flow in the heart; murmurs can result from normal blood volume passing through an abnormal valve, or from increased blood volume passing through a normal valve
  • assess murmur timing – is it systolic or diastolic? (you may compare with the carotid pulse, and if murmur accompanies the pulse would be systolic, while if it follows the pulse it would be diastolic)
  • ejection systolic murmurs start after the 1st heart sound, increase in amplitude to a peak around mid-systole, and quiet down towards the end of systole, stopping completely before the 2nd heart sound; causes include aortic stenosis, pulmonary stenosis (normal volume of blood flowing through a narrowed valve), and pregnancy (due to increased blood volume flowing through a normal valve)
  • pansystolic murmurs extend throughout systole to the 2nd heart sound; causes include mitral or tricuspid valve leakage, or a ventricular septal defect
  • late systolic murmurs are variants of the pansystolic murmurs, but these do not start right after the first heart sound but later on in systole; common in mitral valve prolapse
  • early diastolic murmurs start right after the 2nd heart sound and quiet down as diastole proceeds; causes include aortic and/or pulmonary regurgitation
  • mid-diastolic murmurs are low-pitched rumbling sounds best heard with the stethoscope bell at the apex of the heart while the patient is rolled onto the left hand side; occurs in mitral stenosis and rarely in tricuspid stenosis
  • continuous murmurs are heard during systole and diastole; occur in patients with ductus arteriosus (channel connecting the aorta and pulmonary artery, which normally closes after birth)
  • assess murmur intensity – murmur intensity is measured by grades…Grade 1 = heard by an expert in optimum conditions; Grade 2 = heard by a non-expert in optimum conditions; Grade 3 = easily heard, no thrill; Grade 4 = loud murmur with a thrill; Grade 5 = very loud, commonly heard over a wide area, with a thrill; Grade 6 = extremely loud, heard without a stethoscope
  • assess murmur site and radiationaortic stenosis = to the upper right sternal edge and neck; aortic rugurgitation = down the left sternal border and towards the apex; mitral stenosis = localised to the apex; pulmonary stenosis = to the upper left sternal border and beneath the left clavicle; pulmonary regurgitation = down the left sternal border; tricuspid stenosis = localised to the lower left sternal border; tricuspid regurgitation = lower left and right sternal border and epigastrium; ventricular septal defect = lower sternal edge
  • assess murmur pitch – high pitch = greater pressure gradient; aortic incompetence murmur is high pitched so it is best heard with the diaphragm of the stethoscope; mitral stenosis murmur is low pitched so it is best heard with the bell of the stethoscope

AUSCULTATING FOR ADDED SOUNDS

  • ejection click = opening sound caused by thickened aortic and pulmonary valves; happen right after first heart sound and before any ejection murmur
  • prosthetic heart valves = usually have a quiet opening sound and a louder closing sound, seemingly metallic in character
  • pericardial rub = friction sound common in acute pericarditis, usually heard by the diaphragm of the stethoscope left of the lower sternum with the patient breathing out, with intensity varying from hour to hour and with patient positioning
examination of the cardiovascular system
Murmurs & Extra Sounds – Retrieved from https://www.pinterest.com/pin/274297433526962442/ on 30th March 2023

8. Examining the Bases of the Lungs

  • crackes indicate pulmonary oedema, since they are produced by the explosive re-opening of collapsed airways

9. Examining the Abdomen

  • palpate for the liverenlarged liver is a sign of right heart failure; enlarged and pulsatile liver is a sign of tricuspid regurgitation
  • palpate for aortic aneurysm – felt as a pulsatile mass over the epigastrium; a bruit may also be heard over it

10. Examining the Lower Limbs

PALPATE FOR THE PERIPHERAL PULSES

  • femoral pulse = midway between the symphysis pubis and the anterior superior iliac spine
  • popliteal pulse = deep in the popliteal fossa
  • dorsalis pedis artery = along the cleft between the first two metatarsals
  • posterior tibial artery = half-way along a line between the medial malleolus and the prominence of the heel
  • NOTES: always compare left and right sides; always listen for bruits at all sites on both sides (heard over narrowed arteries); if peripheral pulses are impalpable, the problem may be peripheral vascular disease
Peripheral Pulses – Retrieved from https://www.brainkart.com/article/Assessment-of-Vascular-Disorders–Health-History-and-Clinical-Manifestations_31948/ on 30th March 2023

ASSESS FOR SACRAL & LOWER LIMB OEDEMA

  • oedema is the result of increased interstitial fluid that causes swelling of the tissues
  • subcutaneous oedema can be determined by pitting of the skin following firm pressure applied by a finger or a thumb for a few seconds

Examination of the Cardiovascular System

Summary

Step-by-step instructions on how to perform an examination of the cardiovascular system:

  1. assess hands for finger clubbing, peripheral cyanosis, tar staining
  2. assess face for yellow lesions close to the inner eyes, malar flush, central cyanosis
  3. assess neck: palpate the carotid artery & determine pulse rate, rhythm and volume; calculate CVP
  4. assess chest: determine apex beat placement
  5. auscultate for heart sounds and murmurs
  6. check pedal pulses and for pitting oedema

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