NURS 356 INTRODUCTION TO PHYSICAL EXAMINATION - COMPONENTS OF GENERAL SURVEY

NURS 356 INTRODUCTION TO PHYSICAL EXAMINATION - COMPONENTS OF GENERAL SURVEY ▪ General appearance - Are they dressed appropriately? Do they have an odor? Are they walking normal? ▪ Height and weight ▪ Description o Apparent state of health - Acute or chronically ill, frail o Level of consciousness - Awake, alert, responsive or lethargic, obtunded, comatose o Signs of distress - Cardiac or respiratory; pain; anxiety/depression o Skin color and obvious lesions o Dress, grooming, and personal hygiene - Appropriate to weather and temperature. Clean, properly buttoned/zipped o Facial expression - Eye contact, appropriate changes in facial expression. Odors of body and breath o Posture, gait, and motor activity o Does the pt look acute or chronically ill? Are they in extreme pain? Can they ambulate? Transfer by self? o You have to be able to picture the patient walking up. Motor activity: ROM, how they walk in the room o Chronic: COPD look: ashen color, wet cough, frail o S/S of distress? BP, HR, red face, crying, o Choose words carefully with advice o Facial expression: very important with neurological disorders ▪ Height and Weight o Height ▪ Measure in stocking feet ▪ Short or tall ▪ Build: slender and lanky, muscular, or stocky ▪ Body symmetry ▪ Note general body proportions and any deformities o Weight ▪ Emaciated, slender, plump, obese ▪ If obese, is fat distributed evenly or concentrated over trunk, upper torso, or around the hips? ▪ Measure in kg o Calculating the body mass index (BMI) ▪ Know classifications  always on boards ▪ If BMI 35, check waist circumference just above the hips. Risk for DM, HTN, cardiovascular disease increase significantly if waist circumference is or =35 inches in women and or =40 inches in men ▪ BMI: important for treatment of HTN and heart disease ▪ Hugh effect on CV risk ▪ Helps with risk assessments HEALTH HISTORY ▪ Changes in weight o Rapid or gradual - Rapid changes over a few days suggest changes in fluid, not tissue o Weight gain: nutrition vs. medical causes o Weight loss: medical vs. psychosocial causes ▪ Fatigue and weakness o Fatigue: a sense of weariness or loss of energy o Weakness: a demonstrable loss of muscle power o Medical vs. psychosocial causes ▪ Fever, chills, and night sweats o Ask about exposure to illness or any recent travel o Some medications may cause elevated temperature ▪ Need to know about changes in weight. Gradual loss of 20 lbs with no abd s/s: thinking some type of carcinoma ▪ Any time pt comes c/o abdominal pain always ask about weight loss ▪ Changes in weight acutely are r/t fluids. Weight loss: think about endocrine ▪ Fatigue: How bad is the fatigue? “I cant get out bed”. Weakness: muscle tone ▪ Fever/night sweats: migrant workers, travelers, VITAL SIGNS ▪ Blood pressure; Heart rate and rhythm; Respiratory rate and rhythm; Temperature (Use back of hand for temp.) ▪ Pain: Have to ask how often; Characteristics; Radiates? Ask about typical s/s BLOOD PRESSURE – OPTIMAL CONDITIONS ▪ Avoid smoking or drinking caffeinated beverages 30 minutes prior to measurement. Smoking raises BP. ▪ If pt comes with high BP, take 5 min later. ▪ Ensure that the room is quiet and comfortably warm ▪ Patient should be seated quietly in a chair with feet on the floor for at least 5 minutes ▪ Patient’s arm should be FREE of clothing ▪ Palpate the brachial artery – antecubital fossa (know location) ▪ Position the arm so that the brachial artery is at heart level ▪ Rest the arm on a table a little above the patient’s waist, or support the patient’s arm with your own at his mid-chest level ▪ Wait 15 mins after coffee; 15-30 mins after cigarette ▪ Blood pressure – cuff size and position o Width: 40% of upper arm circumference o Length: 80% of upper arm circumference • If too big abnormally lower BP on small arm, and high on large arm • If too small abnormally high ▪ Measurement of Blood Pressure o Center the inflatable cuff over the brachial artery with the lower border 2.5 cm above the antecubital crease o Secure the cuff snugly, not tightly, and position the patient’s arm so that it is slightly flexed at the elbow o With the fingers of your opposite hand, palpate the radial artery and inflate the cuff until the radial pulse disappears; add 30 mm Hg to this pressure o Deflate the cuff promptly and completely and wait 15-30 seconds o Place the bell of the stethoscope lightly over the brachial artery o Inflate the cuff to the sum pressure previously determined and deflate slowly ▪ The point at which you hear the first two consecutive beats is the systolic pressure ▪ The disappearance point is the diastolic pressure ▪ Normally, maximal left ventricular pressure corresponds to systolic blood pressure ▪ If the brachial artery is 7-8cm below heart level, the BP will read aprox. 6cm higher; if the brachial artery is 6-7cm higher, the BP will read 5cm lower ▪ To determine how high to raise the cuff pressure, estimate systolic pressure by palpation. Fell radial artery with finger and inflate the cuff, when pulse disappears read this pressure and add 30mm HG to it. Use this sum as a target for subsequent inflations. Deflate cuff, wait 30 seconds ▪ Pressure difference of more than 10-15 mm Hg occurs in subclavian steal syndrome, aortic dissection ▪ Auscultatory gap o A silent interval that may be present between the systolic and diastolic blood pressures; i.e., the sound disappears for a while, then reappears – may lead to serious underestimation of systolic pressure or overestimation of diastolic pressure o It’s associated with arterial stiffness and atherosclerotic disease o If you find an auscultatory gap, record your findings completely. Ex: 200/98 with an auscultatory gap from 170-150 ▪ Orthostatic blood pressure o Measure blood pressure and heart rate with the patient supine; wait 3 minutes, then have the patient stand up; now repeat the measurements ▪ Normal: systolic BP drops slightly or remains unchanged; diastolic BP rises slightly ▪ Orthostasis: systolic BP drops 20 mm Hg or diastolic BP drops 10 mm Hg • orthostatics: indication of overall fluid status ▪ Orthostatic hypotension  140/60 to 110/55 ▪ Causes may be drugs, blood loss, prolonged bed rest, and diseases of the autonomic nervous system ▪ Normal and Abnormal Blood Pressure o Normal (adults older than 18 years) ▪ Systolic: 120 mm Hg ▪ Diastolic: 80 mm Hg o If blood pressure is elevated: ▪ Repeat blood pressure and verify in the contralateral arm ▪ Consider “White Coat Hypertension” - Occurs in 10%–20% of all patients • Try to relax the patient and retake BP later in the visit o Starting treatment usually around 130 WITH risk factors or changes o Coarctation of aorta and occlusive aortic disease are distinguished by HTN in the upper extremities and low BP in the legs, and diminished or delayed femoral pulses ▪ Heart Rate and Rhythm o Radial pulse is commonly used to measure the heart rate o Use the pads of the index and middle fingers o If the rate seems normal (50–90 bpm) and the rhythm is regular, count the rate for 30 seconds and multiple by 2. o If the rate is fast or slow and/or the rhythm is irregular, count for a full 60 seconds. (if any doubt count the full minute) ▪ Respiratory Rate o Observe rate, rhythm, depth, and effort of breathing ▪ Normal rate: ~20 breaths/minute - Count for 60 seconds o Observe rhythm: regular, irregular o Observe depth: shallow, gasping o Observe effort: normal, labored - Look for accessory muscles (prolonged expiration is common in COPD) ▪ Temperature o Average oral temperature: 37°C or 98.6°F o Diurnal variation: 35.8°C (96.4°F) to 37.3°C (99.1°F) ▪ Diurnal variation: how temp fluctuates during the day ▪ Rectal is higher than oral and that’s higher than axillary (0.5 C Oral temp) ▪ Axillary temp is 0.5 LESS than Oral temp. ▪ Chief cause for hypothermia is exposure to cold. Other causes: reduced movement as in paralysis, sepsis, excess alcohol, starvation, hypothyroidism and hypoglycemia. Older adults are more susceptible. ▪ Pain o Assess location, severity, associated features, attempted treatments/medications, related illnesses, impact on daily activities o Types of pain ▪ Nociceptive or somatic – related to tissue damage • Cut/laceration ▪ Neuropathic – resulting from direct trauma to the peripheral or central nervous system ▪ Psychogenic – relates to factors that influence the patient’s report of pain • Psychiatric conditions • Personality and coping style • Cultural norms • Social support systems ▪ Idiopathic – no identifiable etiology MENTAL STATUS AND BEHAVIOR HISTORY TAKING ▪ Unlike most organ systems, mental status and behavior are not areas you can inspect, percuss, or palpate ▪ As you talk to a patient, you will quickly begin to discern the patient’s level of alertness, mood, orientation, attention, and memory ▪ As you continue talking with a patient in depth, you will begin to learn about his insight, judgment, and any thought disorder or disorder of perception ▪ To appreciate the differences in mental status and behavior, you must learn the terminology o Level of consciousness: how aware the person is of his environment o Attention: the ability to focus or concentrate ▪ Alert: the patient is awake and aware ▪ Lethargic: you must speak to the patient in a loud forceful manner to get a response ▪ Obtunded: you must shake a patient to get a response ▪ Stuporous: the patient is unarousable except by painful stimuli (sternal rub) ▪ Coma: the patient is completely unarousable ▪ Memory: the process of recording and retrieving information o Short-term memory covers events or memories that occurred minutes to days before o Long-term memory covers events or memories that occurred months to years before ▪ Orientation: aware of person (who they are), place (where they are), and time (when is it); this requires memory and attention ▪ Elderly: starts to make things up to fill the gaps of what they forget ▪ Have them repeat three words  indicates attention ▪ Perceptions: awareness of the objects in the environment to the five senses and their interrelationships ▪ Thought processes: the logic, coherence, and relevance of a patient’s thoughts as they lead to thoughts and goals; HOW people think ▪ Insight: awareness that thought, symptoms, or behaviors are normal or abnormal; e.g., distinguishing that a daydream or hallucination is not real ▪ Judgment: process of comparing and evaluating different possible courses of action ▪ Affect: the observable mood of a person expressed through facial expression, body movements, and voice ▪ Mood: the sustained emotion of the patient o Euthymic: normal o Dysthymic: depressed o Manic: elated ▪ Language: the complex symbolic system for expressing written and verbal thoughts, emotion, attention, and memory o Dysarthria refers to defective articulation o Aphasia refers to a disorder of language (difficulty talking or understanding others). Two common kinds of aphasia Wernicke’s and Broca’s ▪ Higher cognitive functions: level of intelligence assessed by vocabulary, knowledge base, calculations, and abstract thinking o Flat affect: with anything that block dopamine… Like Parkinson’s o Blunted: minimized affect o Normal o Labile: up and down MENTAL STATUS EXAMINATION ▪ Consists of the following components: o Appearance and behavior o Speech and language o Mood o Thoughts and perceptions o Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability ▪ Assess the level of consciousness o Is the patient awake and alert? o Does the patient understand your questions? o Does the patient respond appropriately and reasonably quickly or lose track of the topic and fall silent or even asleep? ▪ If the patient does not respond to your questions, escalate the stimulus in steps: o Speak to the patient by name and in a loud voice o Gently shake the patient ▪ Posture and motor behavior o Does the patient lie in bed or prefer to walk around? o Is the patient sitting or lying comfortably? o Is the patient agitated with repetitive movements? ▪ Assess the patient’s dress, grooming, and personal hygiene o Generally, grooming and hygiene deteriorate in depression or schizophrenia ▪ Assess the patient’s facial expressions o A flat affect (lack of facial movement) can be seen due to a physical reason such as Parkinson’s disease or a psychological reason such as profound depression ▪ Assess the patient’s manner, affect, and relationship to people and things o Does the affect reflect the mood? o Is the affect stable or labile (mood changing from happiness to tears and back quickly)? o Does the patient seem to see or hear things you do not? ▪ SPEECH AND LANGUAGE o Quantity: Is the patient talkative or silent? o Rate: Is the speech fast or slow? o Loud: Is speech loud or soft? o Articulation of words: Does the patient speak clearly and distinctly? Is there nasal quality to the speech? o Fluency: involves the rate, flow, and melody of speech ▪ Hesitancies in speech (as seen in patients with aphasia from strokes) ▪ Monotone inflections (schizophrenia or severe depression) ▪ Circumlocutions: words or phrases are substituted for the word a person cannot remember; e.g., “the thing you block out your writing with” for an eraser ▪ Paraphasias: words are malformed (“I write with a den”), wrong (“I write with a branch”), or invented (“I write with a dar”) ▪ Assessing Moods o Use open-ended questions ▪ “How do you feel about that?” ▪ “How are you feeling?” o How long has the patient’s mood been this way o How good or bad has the patient felt o Sometimes you have to ask friends or family of the patient to help you assess the patient’s mood Do not be afraid to ask the patient about thoughts of self-harm or suicide ▪ Thought and Perceptions: ▪ Thought Processes o Assess thought processes: logic, relevance, organization, and coherence o Abnormalities in the thought process ▪ Circumstantiality: speech characterized by indirection and delay due to the patient’s excessive use of details that have no connection to the point ▪ Derailment: speech in which a person shifts topics with no apparent relation between the topics ▪ Flight of ideas: accelerated change of topics in a very fast but generally coherent manner ▪ Neologisms: invented or distorted words ▪ Incoherence: speech that is incomprehensible because it is illogical ▪ Blocking: sudden interruption of speech, before the completion of an idea, occurs in normal people ▪ Confabulation: fabrication of facts to hide memory impairment. Seen in Korsakoff’s syndrome from alcoholism ▪ Perseveration: persistent repetition of words or ideas ▪ Echolalia: repetition of the words or phrases of others ▪ Clanging: choosing a word on the basis of sound rather than meaning ▪ Thought Content o Assess thought content during the interview by following appropriate leads as they occur o Abnormalities of thought content ▪ Compulsions: repetitive behaviors that a person feels driven to perform to prevent or produce some future state of affairs ▪ Obsessions: recurrent, uncontrollable thoughts, images, or impulses that a patient considers unacceptable ▪ Phobias: persistent fear of a stimuli the patient feels is irrational (spiders, snakes, the dark) ▪ Anxiety: apprehension or fear that may be focused (phobia) or free floating (general sense of dread) o Abnormal thought content continued ▪ Delusions: false, fixed beliefs that are not shared by other members of the person’s culture • Delusion of persecution, grandeur, or jealousy • Delusion of reference: a person believes an outside event or object has an unusual personal reference to them; i.e., a comet passing earth means the patient should buy a car • Delusion of being controlled by outside forces • Somatic delusion: believing one has a disease or defect that he does not • Systematized delusion: a single delusion with many elaborations around a single theme all systematized into a complex network; i.e., the KGB is after the patient ▪ Perceptions o Inquire about false perceptions ▪ Do you hear voices other people don’t hear? ▪ Do you see things other people don’t see? ▪ Do you know things other people don’t know? o Abnormalities of perception ▪ Illusions: misinterpretations of real stimuli; e.g., the postman leaves mail, therefore there is a plot to poison the patient ▪ Hallucinations: a subjective external stimuli the patient hears or sees that others do not hear or see and that the patient may not recognize as false; these can be auditory, visual, olfactory, gustatory, or tactile • Abe Lincoln speaks to the patient from the back of a penny • Do not include false perceptions associated with dreaming/falling asleep ▪ Olfactory and gustatory hallucinations are not common with psych have to follow up with b/c it can be r/t neuro ▪ Insight and Judgment o Ask the patient about the reasons behind his clinic or hospital visit; patients with psychological disorders often lack insight into their disease o You can usually assess judgment by noting the patients’ responses to stressors on their relationships, job, and finances ▪ Cognitive Functions o Assess orientation to person, place, and time o Assess attention ▪ Digital span: give the patient a string of numbers to recite back to you ▪ Serial 7s: ask the patient to subtract serial “7s” from 100 - and keep subtracting. Normally a pt can complete in 1 ½ min with fewer than 4 errors ▪ Spelling backward: ask the patient to spell W-O-R-L-D backwards ▪ Poor performance may result from delirium, the late stage of dementia, mental retardation, loss of calculating ability, anxiety, or depression. Also consider the possibility of limited education o Assess remote memory by asking about past historical events o Assess recent memory by asking about something recent (weather, national event, etc.) o Assess new learning ability by giving the patient three or four words to remember; then ask him to repeat the words after several minutes ▪ Higher Cognitive Functions – may be helpful for distinguishing mentally retarded adults (whose information and vocabulary are limited) from those with dementia (whose information and vocabulary are fairly well preserved) o Through your conversation, you can often assess the patient’s higher cognitive functions o Information and vocabulary o Calculating ability: ask the patient to perform more difficult calculations such as making change (e.g., if you had a dollar’s worth of nickels and someone needed 65 cents how many nickels would you have left?) – poor performance may be a useful sign of dementia or may accompany aphasia, but it must be assessed in terms of the pt’s intelligence and education o Abstract thinking ▪ Interpreting proverbs: “A stitch in time saves nine” ▪ Similarity exercises: What do a ball and an orange have in common? o Constructional ability ▪ Ask a patient to copy a geometric figure onto a sheet of paper ▪ Ask a patient to draw a clock face indicating 5:00 ▪ If vision and motor ability are intact, poor constructional ability suggests dementia or parietal lobe damage. Mental retardation may also impair performance ▪ Something on here will be on the exam, that chart with the circle and clock and figures will be on there CARDIOVASCULAR SYSTEM: EXAMINING THE HEART AND BLOOD VESSELS ▪ Boards: ask a lot about s3/s4. When is abnormal/normal and where you hear it. What disease process would you expect with this ▪ Know when murmurs happen during diastole or systole and effect on these places ▪ Helps: knowing location it narrows down what kind of murmur ▪ Myocardium is the affected layer for people with sustained HTN/ hypertrophy of one of the ventricles. Order 2D-echo (look at wall motion abnormalities, ejection fraction, look at valves), EKG only tells you what side of the heart the ischemia/infarction occurs. ▪ Left side of heart is most affected and it’s the worse place to get an infarction because the left ventricle is the largest part and it’s the part responsible for pumping blood out to our body. ▪ Structure of the Heart o Pericardium o Epicardium: thin outer layer that covers the heart o Myocardium: responsible for pumping. Thick muscle o Endocardium: covers valves. Inner layer. Lining of chambers and covering valves ▪ Anatomy of the Heart o Main function: circulate blood to body and lungs o Located in mediastinum – importance: If you have an MVA, you have to know where heart is supposed to be located and where heart sounds are supposed to be o Right and left atria – thin wall chambers. Primary reservoir of blood o Right and left ventricle – thick wall chambers, pump blood thru the lungs and throughout the body o Septum: divides ventricles o Abnormalities: ▪ VSD • Hole in ventricle. Have to know what location the shunt, right to left or left to right – importance: left to right shunt moves oxygenated blood to right ▪ PFO ▪ Heart Valves side = no problem; right to left shunt is a problem because deoxygenated blood is pumped to rest of body • Foramen ovale doesn’t close • Connected to atrium • Relevant to adults because a lot of times thy are asymptomatic in young women and they have a stroke (d/t birth control pills) • Considerations: don’t close PFO unless someone had a stroke • Risk outweighs benefits because increased risk for thrombus • If you have young female, what kind of birth control should they use? Advise not to smoke, might suggest IUD or implant but not oral contraceptives o Valves permit flow of blood in ONE direction - FORWARD FLOW o Sound you hear is the closure of the valves o AV valves: tricuspid, mitral o Semilunar: pulmonic and aortic o Who closes together? Tricuspid and mitral close together and pulmonic and aortic close together o Usually when we place central line we go on right side b/c its easier o If you have central line on right side where would you get infection? Mitral valve. Example: ▪ Pt had central line infection - Have to get blood cultures and get results for Abs ▪ Right over the wire exchange - Breaks off fibrin sheaths with bacteria and it goes into lungs and seeds on mitral valve ▪ This pt had mitral regurgitation and anemia (not feeling well) THE HEART AND GREAT VESSELS: ANATOMY ▪ POSITION: o In mediastinum o Left of midline o Above diaphragm o Between medial/lower borders of lungs o Behind sternum o 3rd to 6th intercostal cartilage In an MVA where pt has multiple fractured ribs - Can puncture lung or heart - Rip off shirt and look at chest (symmetry, abnormalities, depression within the chest wall???) CARDIAC CYCLE ▪ Diastole - Blood flows from the veins into the heart chambers – Mitral and tricuspid valve opens. Blood goes from the atria to the ventricles. Sometimes you have a 3rd heart sound (S3) ▪ Systole (ventricles contract) - Blood is ejected from left ventricle to the aorta and from the right ventricle into the pulmonic artery. The mitral and tricuspid valve closes (1st heart sound). Pressure continues to rise. The aortic and pulmonic valves open, blood ejects into the arteries and then the pressure falls. The aortic and pulmonic valves close (2nd heart sound). o Sometimes there is a split between aortic and pulmonic valve: split s2 heard on inspiration • The atria briefly contract and fill the ventricles with blood ▪ Then the ventricles contract and propel blood out o First heart sound: mitral and tricuspid valves close** which are the AV Valves o Second heart sound: Aortic and pulmonic valves close*** which are the semilunar valves o S3: normal variant adults all the way up to 40 - Abnormal in pregnant women and heart failure… d/t volume overload. Any pregnant women with heart abnormalities for an echo!!! o 3rd Heart sound disease is found in Heart Failure Non-compliant venricle** o S3- normal in young adults and athletes, abnormal in elderly – indicative of CHF ▪ Low pitched, use BELL of stethescope o S4: usually in aging adult. Sclerosis in arterial... Almost everyone will end up with S4. S4 with HTN o S3 heart sound: All of the above. Normal in young healthy adults, sign of heart failure, sound of rapid ventricular filling in early diastole.** o S4 produced by an increase in stiffness of the left ventricle due to scar tissue formation ▪ Manifestation of coronary heart disease ▪ 40yr the diastolic sounds of S3 and S4 are pathologic, and are highly correlated with HF and acute myocardial ischemia. ▪ S3 corresponds to a abrupt deceleration of inflow across the mitral valve • Indicates a pathological change in ventricular compliance ▪ S4 to increased left ventricular and diastolic stiffness • Marks atrial contraction. Also reflects pathological change in ventricular compliance ▪ During systole, the aortic valve is open allowing ejection of blood from left ventricle into aorta. The mitral valve is closed, preventing blood from regurgitating back into left atrium. ▪ In diastole, the aortic valve is closed, preventing regurgitation of blood from the aorta back into left ventricle. The mitral valve is open, allowing blood to flow from the left atrium into the relaxed ventricle. Electrical system of the heart - Starts in SA node in right atrium  Release impulse simultaneously to both atriums AV node  to bundle of his  to purkingie fibers o During the cardiac cycle o Intrinsic: enables heart to contract by itself o Sequential rhythmic form. Coordinates the sequence of the muscular contraction that happens throughout the heart during a cardiac cycle o Starts in SA node in the Right Atrium, release impulse simultaneously to both atriums o AV node, bundle of his, purking fibers o EKG: graphic recording of cardiac cycle ASSESSMENT ▪ Inspect the precordium for the following: Apical impulse, Pulsations, Heaves or lifts o Palpate the precordium to detect the following: Apical Impulse; Thrills, heaves, or lifts ▪ Percussion to estimate the heart size (optional) ▪ Heaves/lifts: you can feel them ▪ Get palm where PMI and you feel a lift ▪ Diameter of PMI should be 2.5 cm • If larger – pt has underlying disease process • 0.5 inch will tell you differential of what process is going on ▪ Apex=PMI – 5th intercostal, Mid clavicular line • If larger PMI worry about enlarged heart where the heart has shifted • Hard to get PMI with COPD or Emphysema. Larger AP diameter – pt have to lean forward for assessment. • If you have hard time auscultating heart sounds you ask them to hold breath o Apical impulse – PMI – found in the cardiac “apex”. Normal PMI is 1 to 2.5cm. Found in 5th intercoastal space 7-9cm lateral to the midsternal line o A PMI 2.5cm is evidence of left ventricular hypertrophy (LVH), or enlargement, seen in HTN and aortic stenosis o Displacement of the PMI lateral to the midclavicular line or greater than 10cm lateral to the midsternal line also suggests LVH o In COPD pt’s the PMI may be in the xiphoid or epigastric area as a result of right ventricular hypertrophy. ▪ Percussion: tells you borders of heart doesn’t tell much else (only tells you location) ▪ To find out where murmurs are you need to know when its during diastole or systole ▪ Auscultate while feeling carotid pulse – this way you will know when S1 is ▪ May hear splitting – splitting S2 may be heard in 2nd and 3rd left interspaces close to the sternum ▪ Murmur - Know duration, pitch, location (where best do you hear it). Does it radiate anywhere? Aortic sometimes will radiate to neck ▪ Murmur can radiate to neck, axilla, or apex KNOW YOUR SURFACE LANDMARKS ▪ Count interspaces. Identify your ... ▪ Midsternal line ▪ Midclavicular line ▪ Anterior axillary line ▪ Midaxillary line ▪ Variance - Dextrocardia: heart is positioned in the right. Either rotated or displaced. Mirrored to the left o Sometimes the other organs (liver, stomach and heart) are displaced Called Situs Inversus ▪ If you have 8-10 ribs you have a good radiograph o Sharp angles o Blunting – angles where you see some cloudiness o Look at the shape/size of heart o The heart should be about 50% of a lung o If larger start thinking of cardiomegaly VISUALIZE THE CHAMBERS OF THE HEART AND IMPORTANT GREAT VESSELS ▪ KNOW CIRCULATION OF HEART AND VALVES ▪ Visualize the circulation through the: o Superior and inferior vena cava o Right atrium and the right ventricle o Pulmonary arteries o Left atrium and left ventricle o Aorta and the aortic arch THE HEART AS A PUMP: KEY POINTS FOR EXAMINING THE HEART ▪ Note the heart chambers and valves and the forward flow of blood from the right side of the heart through the pulmonary arteries and veins to the left side of the heart. Combine this knowledge with careful examination and systematic clinical reasoning o This will lead you to correct identification of valvular and heart disease ▪ In ICU, for heart failure you give beta-blockers and diuretics. Have to know if it’s a volume issue (give diuretics) for structural issue (ACE) ▪ ▪ Important concepts o Preload  volume overload – the load that stretches the cardiac muscle before contraction. o The volume of blood in the right ventricle at the end of diastolic constitutes its preload for the next beat. o Cause of decrease right ventricular preload include: exhalation. Decrease LV output, and pooling of blood in the capillary bed or the venous system o Contractility: ventricles contract during systole o Afterload pressure overload – degree of vascular resistance to ventricular contraction o Cardiac output: stroke volume x heart rate o Blood pressure: cardiac output x systemic vascular resistance Pt goes from sitting to standing up: Systemic Vascular Resistance decreases b/c you pull blood back form the heart. It will increase if you go into squatting Pathologic increases in preload and afterload, called volume overload and pressure overload, produce changes in the ventricular function that may be clinically detectable. These changes include alterations in ventricular impulses, detectable by palpation, and in normal heart sounds. Pathologic heart sounds and murmurs may also develop. The term heart failure is now preferred over “congestive heart failure” because not all patients have volume overload on initial presentation. BLOOD PRESSURE ▪ Systolic blood pressure o Pressure generated by the left ventricle (LV) during systole, when the LV ejects blood into the aorta and the arterial tree. Pressure waves in the arteries create pulses ▪ Diastolic blood pressure - Pressure generated by blood remaining in the arterial tree during diastole, when the ventricles are relaxed o Systole: ventricles contract (aortic and pulmonic valve opens) o Diastole: ventricles relax (mitral and tricuspid valve opens) ▪ Pulse pressure = difference between systolic and diastolic pressures ▪ Factors influencing arterial pressure  Left ventricular stroke volume; distensibility of the aorta and the large arteries; peripheral vascular resistance, particularly at the arteriolar level; volume of blood in the arterial system ▪ After ejection of blood into aorta, the ensuing pressure wave moves rapidly through the arterial system, where it is felt as the arterial pulse. Although the pressure wave travels quickly, many times faster than the blood itself, a palpable delay between ventricular contraction and peripheral pulses makes the pulses in the arms and legs suitable for timing events in the cardiac cycle. VITAL SIGNS - First observe the patient, and then begin assessing the vital signs ▪ Blood pressure o Select the proper size cuff o Position the patient properly o Make sure there is a brachial pulse o Apply the cuff correctly o Assess blood pressure for hypertension o Have to have the right size of cuff. Have to think of factors that could affect BP. BP differs throughout the day ▪ Know JNC VIII for BP ▪ Heart rate: radial vs. apical ▪ Jugular Venous Pressure Assessment o JVP reflects right atrial pressure, which in turn equals central venous pressure and right ventricular end-diastolic pressure. It’s best estimated from the right internal jugular vein o Increased JVP is highly correlated with acute/chronic Right & Left HF. It has also seen in tricuspid stenosis, chronic pulmonary HTN, superior vena cava obstruction, and pericardial disease (tamponade, constrictive pericarditis) o Elevated JVP is 98% specific for an increased left ventricular end diastolic pressure and low left ventricular ejection fraction, and increases risk of death from HF o Local kinking or obstruction is the usual cause of unilateral distention of the external jugular vein o Oscilation in the internal jugular vein, and often in the external jugular vein, reflects changing pressure in the right atrium o Ideal way to assess cardiac pressure is at 30 degree angle o Factors to consider o At 30 degree, sternal notch is 5 cm above right ventricle. You get the maximum pulsation, internal and external o Have to have jugular and carotid o Carotid is just medial to cricoid process o Depends on how pt is positioned ▪ If 30 degrees, you add 5 cm to number b/c the sternal notch is 5 cm above the right ventricle ▪ Hypovolemic, you measure them supine b/c they are volume depleted (JVP – low) ▪ Volume overloaded sitting up 30 or 90 degrees ▪ If measures supine, you do not add the 5 cm o Abnormal is 8 to 9, need to add 5 to measured value, why do we add 5? - distance to right atrium ▪ JVD reflects the atrial pressure on the right side o If having trouble, you put pressure on liver (right side) and it will cause congestion ▪ Assessing the Carotid Pulse o Keep the patient’s head elevated to 30° o Place your index and middle fingers on the right then the left carotid arteries, and palpate the carotid upstroke o Never palpate right and left carotid arteries simultaneously (decreases blood flow to brain and causes syncope) o The upstroke may be: ▪ Brisk – normal ▪ Delayed – suggests aortic stenosis ▪ Bounding – suggests aortic insufficiency o Listen with the stethoscope for any bruits o Normal upstroke occurs in systole - follows S1 and precedes S2 o Weak/thready: cardiogenic shock or cardiac problems o Bounding: pt is overloaded o Auscultate and feel carotid upstroke o Risk factors: auscultate for bruit/ Feel for thrill o Carotid bruit: only time to intervene when greater than 70% stenosis. Listen for in older pt and pt’s with suspected cerebrovascular disease o Bruits can also arise from aortic stenosis, the hypervascularity of hyperthyroidism o Why do we auscultate the carotid artery – b/c it tells you risk factors for TIA, stroke or atherosclerosis o Atherosclerotic narrowing or occlusion causes decreased pulsations o Carotide pulse is useful for detecting stenosis or insufficiency of the aortic valve ▪ Palpating the Chest Wall o Using the finger pads, palpate for heaves or lifts from abnormal ventricular movements o Using the ball of the hand, palpate for thrills, or turbulence transmitted to the chest wall surface by a damaged heart valve (place pt leaning forward) o Palpate the chest wall in the aortic, pulmonic, left parasternal, and apical areas ▪ Ball of hand for thrills ▪ Finger pads for lifts o Palpable S2 suggests systemic HTN o Successful palpation is less likely in patients with a thickened chest wall or increased anteroposterior diameter ▪ Assessing the Point of Maximal Impulse (PMI) o Inspect the left anterior chest for a visible PMI o Using your finger pads, palpate at the apex for the PMI o The PMI may be: ▪ Tapping — normal ▪ Sustained — suggests LV hypertrophy from hypertension or aortic stenosis ▪ Diffuse — suggests a dilated ventricle from congestive heart failure or cardiomyopathy o Locate the PMI by interspace and distance in centimeters from the midsternal line o Assess location, amplitude, duration, and diameter o S4 is heard with years of sustained HTN also long standing anemia d/t left ventricular hypertrophy o Cardiomegaly: shifts the heart and PMI o Pregnancy may displace PMI upward and to the left o Normal PMI diameter is 2.5cm, 3 = left ventricular enlargement o Increased amplitude may indicate hyperthyroidism, severe anemia, pressure overload of left ventricle (as in aortic stenosis), or volume overload of left ventricle (as in mitral regurgitation) o Apical impulse should be visible at the 5th left intercoastal space, mid clavicular line. In some pt’s is visible in the 4th intercoastal space, it should not be visible in more than one space if the heart is healthy. Obese, big boobs, muscular: variances ▪ Book o Pregnancy or a high left diaphragm may displace the apical impulse upward and to the left o Lateral displacement from cardiac enlargement is seen in heart failure, cardiomyopathy, and ischemic heart disease. Displacement also occurs from deformities of the thorax and mediastinal shift. o Lateral displacement outside the midclavicular line makes cardiac enlargement and a low left ventricular ejection fraction 3-4 and 10 times more likely, respectively. o In the left lateral decubitus position, a diffuse PMI with diameter greater than 3 cm indicates LV enlargement. o If PMI is greater than 4 cm or 5 cm when the patient is supine, LV overload is almost five times more likely. o Increased amplitude may also reflect hyperthyroidism, severe anemia, pressure overload of the left ventricle (as in aortic stenosis), or volume overload of the LV (as in mitral regurgitation). o A sustained, high-amplitude impulse that is normally located suggests LVH from pressure overload (as in HTN). If such an impulse is displaced laterally, consider volume overload. o A sustained low-amplitude (hypokinetic) impulse is seen in dilated cardiomyopathy o A brief mid-diastolic impulse indicates S3; an impulse just before the systolic apical beat itself indicates S4. o An impulse with increased amplitude and duration occurs with pressure overload of the right ventricle, as in pulmonic stenosis or pulmonary hypertension. o In obstructive pulmonary disease, hyperinflated lungs may prevent palpation of an enlarged right ventricle in the left parasternal area. The impulse is felt easily, however, high in the epigastrium where heart sounds are also more audible. ▪ LISTENING TO THE HEART – AUSCULTATION ▪ S1 = closure of mitral valve (louder at apex), S2 = closure of aortic valve (louder at base). ▪ Listen in all 6 listening areas for S1 and S2 using the diaphragm of the stethoscope ▪ Then listen at the apex with the bell ▪ Best place to auscultate the aorta – 2nd intercostal, midsternal border right side ▪ The diaphragm and the bell o The diaphragm is best for detecting high-pitched sounds like S1, S2, and also S4 and most murmurs (useful for carotid bruit) o The bell is best for detecting low-pitched sounds like S3 and the rumble of mitral stenosis (good for S3, S4) ▪ HEART SOUNDS ▪ S3 o Pathognomic for CHF (CHF or heart failure). o Occurs during early diastole (also called a “ventricular gallop” or an “S3 gallop”). o Sounds like “Kentucky.” ▪ S4 MURMURS o Physiological: Always considered abnormal if it occurs after the age of 35-40. o This may be a normal variant in some children or young adults if there are no signs or symptoms of heart or valvular disease. o Caused by increased resistance due to a stiff left ventricle; usually indicates LVH; o Considered a normal finding in some elderly (slight thickening of left ventricle). o S4 occurs during late diastole (also called an “atrial gallop” or “atrial kick”). o Sounds like “Tennessee.” o Best heard at the apex or apical area (mitral area) using the bell of the stethoscope. o Book ▪ S1 is diminished in first-degree heart block ▪ S2 is diminished in aortic steonsis ▪ Systolic murmurs – coincides with carotid upstroke. May indicate valvular disease but often occur when heart valves are normal o Midsystolic murmur – begin after S1 and stops before S2. Arise from blood flow across semilunar valves o Pansystolic murmur – starts with S1 and stop at S2. Usually occur with regurgitant (backward) flow across atrioventricular valves o Late systolic murmur – starts mid or late systole and persists up to S2. It’s the murmur of mitral valve prolapse o Aortic Stenosis-2nd intercostal space (IC) right sternum, with patient sitting and leaning forward ▪ Crescendo-decrescendo. First rises in intensity, then falls* o Mitral Regurgitation- 5th ICS – a plateau murmur. Same intensity throughout o Mitral Valve Prolapse ▪ Picture showing apical impulse, what murmur would you hear? – Mitral Valve Prolapse* ▪ “Mid-systolic click” ▪ Diastolic murmurs – occur after carotid upstroke. o Often heard best with bell of stethoscope o Very hard to hear, will not be as loud o Mitral Stenosis- - 5th ICS ▪ Heard more with pt in left lateral decubitus position; also with exercise o Aortic Regurgitation- (early diastolic murmur) ▪ 2nd intercostal space (IC) heard at RSB with patient leaning forward and listening with diaphragm pressed firmly on the chest o Murmurs during ventricular systole – aortic stenosis and tricuspid regurgitation** Murmurs arising from the pulmonic valve are usually herd in the 2nd and 3rd left interspaces close to the sternum, but may also be heard at higher or lower levels Murmurs originating from the aortic valve may be heard anywhere from the right 2nd interspace to the apex Pt sitting, leaning forward, after full exhalation – listen at right sternal border for tricuspid murmurs and sounds with the bell Mitral Stenosis – low pitched S3 Aortic Insufficiency – soft decrescendo higher-pitched diastolic murmur ▪ Describing Heart Murmurs: Timing and Duration o Identify and describe any murmurs o Timing and Duration: are the murmurs systolic or diastolic? ▪ Tip: palpate the carotid upstroke (occurs in systole) as you listen ▪ If the murmur coincides with the carotid upstroke, it is systolic ▪ Early / mid / or late systolic ▪ Early / mid / or late diastolic o Location (where is it that you hear) o Radiation o Variation with respiratory phase – abnormal in expiration o Normal carotid upstroke = BRISK o Shape/ Intensity ▪ Crescendo, decrescendo, or both (sometimes called diamond-shaped) • Example, crescendo-decrescendo systolic murmur of aortic stenosis ▪ Shape • Plateau ... machinery • Example, holosystolic murmur of mitral regurgitation ▪ Intensity: grade the murmur on a scale of 1 to 6 • Grades 4 through 6 must have accompanying thrill • Continuous polo systolic o Quality - Apply terms like harsh, musical, soft, blowing, or rumbling o Pitch - Apply terms like high, medium, or low-pitched o Examples ▪ Harsh 2/6 medium-pitched holosystolic murmur best heard at the apex describes ▪ Soft, blowing 3/6 decrescendo diastolic murmur best heard at the lower left sternal border describes ▪ Medium-pitched, grade 2/6, blowing decrescendo diastolic murmur, heard best in the 4th left interspace, with radiation to the apex describes ▪ Mitral regurgitation murmur usually radiates to axilla ▪ Aortic stenosis murmur often radiates to the neck, specially right side Listening landmarks for auscultation ▪ Aortic Valve area – right 2nd intercoastal space ▪ Pulmonic area – left 2nd intercoastal space ▪ Tricuspid – lower left sternal border, 4th intercoastal space ▪ Mitral area - TYPES OF MURMURS ▪ ▪ INFANTS AND CHILDREN ▪ Heart assumes adult function early in fetal life. ▪ Changes at birth: o Ductus arteriosus and interatrial foramen ovale close (close when the baby takes 1st breath). o Right ventricle assumes pulmonary circulation. o Left ventricle assumes systemic circulation. ▪ Ventricle muscle mass increases over first year. ▪ Heart lies more horizontally and apex higher. o Adult heart position reached by age of 7 years. ▪ Examine newborn at birth or at 2 to 3 days for circulation transition signs. ▪ Heart function examination includes skin, lungs, and liver. ▪ Inspect color of skin and mucous membranes. Skin changes: tells you oxygenation - Lips, mucosal, nail beds ▪ Look for enlargement of heart and position if dyspneic. - S/S of when infant is dyspneic,: Nasal flaring; Retraction (abdominal breathing); Accessory: more in pediatrics ▪ Heart sounds are difficult to assess; vigor and quality are indicators of heart function. ▪ Heart rates vary with eating, sleeping, and waking. ▪ Murmurs are common until 48 hours of age. CHILDREN ▪ Bulging precordium if longstanding heart enlargement ▪ Sinus arrhythmia a physiologic event of childhood ▪ Do not ignore these have to work up with children ▪ Other arrhythmias usually ectopic in origin and rarely require investigation ▪ Supraventricular and ventricular ectopic beats ▪ Heart rates more variable than in adult ▪ Expected heart rates variable with child’s age - Heart rates for children - 4-5 yr: 100-120 ▪ Organic murmurs usually indicative of congenital heart disease ▪ Some murmurs are innocent, caused by the vigorous expulsion of blood from the left ventricle into the aorta; it increases in intensity with activity and diminishes when the child is quiet (still murmur). ▪ Child with known heart disease: o Weight gain or loss o Developmental delays d/t poor oxygenation o Cyanosis o Clubbing of fingers or toes - Don’t forget to look at the feet!!! PREGNANT WOMEN ▪ Maternal blood volume increases 40% to 50% over pre-pregnancy level. ▪ Heart works harder to accommodate the increased heart rate and stroke volume required for the expanded blood volume. ▪ Left ventricle increases in both wall thickness and mass. ▪ Heart shifts to more horizontal position. o Uterus enlarges and the diaphragm moves upward. ▪ S3 with pregnancy d/t Overload ▪ Heart rate gradually increases during pregnancy. ▪ Pulse is 10% to 30% faster by end of third trimester. ▪ Heart position shifts as size and position of uterus changes. ▪ Apical impulse shifts up and laterally. ▪ Heart sounds change with increased blood volume: o Audible splitting of S1 and S2 o S1 has 2 components: mitral (louder - heard best at apex), tricuspid (softer - heard best at left sternal border – this is where you may hear a splitting in S1) o Splitting is normally heard late in inspiration o Expiratory splitting suggests abnormality o Persistent splitting results from delayed closure of pulmonic valves or early closure of aortic valve o S3 may be readily heard after 20 weeks of gestation. (3rd trimester d/t change in volume) o Systolic ejection murmurs (SEMs) may be heard over the pulmonic area in 90% of pregnant women ▪ No significant change in the ECG. OLDER ADULTS ▪ Heart size may decrease. ▪ Left ventricular wall thickens. ▪ Valves fibrose and calcify. ▪ Heart rate slows. ▪ Stroke volume decreases. ▪ Cardiac output during exercise declines by 30% to 40%. Recommend walking 5 times a week for 30 minutes at a time o 220 – age times a percentage = HR during exercise (60% of that for the elderly) ▪ Endocardium thickens. ▪ Myocardium becomes less elastic. ▪ Electrical irritability may be enhanced. ▪ KNOW FOR TEST!!! o When screening for BP : age 20 o Heart disease: start identifying risk factors as early as possible o African American females highest risk o Women in general treated less o Woman at higher risk d/t hormones o Know screenings and different methods to evaluate o Preventative measures o Metabolic syndrome – must meet 3 or more of 5 ▪ Waist circumference men 102cm, women88cm ▪ Fasting plasma glucose 100mg/Dl ▪ HDL men 40, women50mg/Dl ▪ Triglycerides 150mg/Dl ▪ BP 130/85 o Cardiac risk score: up to a 20% - SEE TEXTBOOK!!! o Cardiac risk score for women of 10% is high o Common arrhythmia: afib - Risk factors for older adults: smoking, age, alcohol use, medications. May want to introduce aspirin to patientr ▪ ECG tracing changes - Don’t have to memorize o First-degree atrioventricular block o Bundle branch blocks o ST-T wave abnormalities o Premature systole (atrial and ventricular) o Left anterior hemiblock o Left ventricular hypertrophy o Atrial fibrillation ▪ Slow down pace of examination; cardiac response may be slowed by demands of positional changes. ▪ Heart rate is variable: o Slower if increased vagal tone o Range from low 40s to 100+ beats per minute o Ectopic beats common ▪ Apical impulse is harder to find with increased anteroposterior chest diameter. ▪ Diaphragm is raised and heart is transverse in obese adults. ▪ Exercise may delay age-related changes. ▪ S4 heart sound is more common. o May indicate decreased left ventricular compliance ▪ Physiologic murmurs are caused by o Aortic lengthening o Sclerotic changes ▪ Obesity: greatest risk factor for DM  criteria for diagnosing DM: fasting plasma glucose or =126mg/Dl, Ha1c or =6.5mg/Dl, random glucose or = 200mg/Dl ABNORMALITIES ▪ Mitral stenosis – orthopnea occurs ▪ Aortic stenosis ▪ Subaortic stenosis ▪ Pulmonic stenosis ▪ Tricuspid stenosis ▪ Mitral regurgitation ▪ Mitral valve prolapse ▪ Aortic regurgitation ▪ Pulmonic regurgitation ▪ Tricuspid regurgitation CARDIAC DISORDERS ▪ Bacterial endocarditis - Bacterial infection of the endothelial layer of the heart and valves. American heart association does not recommend prophylactic antibiotics for dentist ▪ Congestive heart failure - Heart fails to propel blood forward with its usual force, resulting in congestion in the pulmonary or systemic circulation - orthopnea and paroxysmal nocturnal dyspnea are seen in left ventricular HF ▪ Cardiac tamponade - Excessive accumulation of effused fluids or blood between the pericardium ▪ Friction rub with cardiac tamponade ▪ Hydralazine overtime can cause cardiac tamponade ▪ Pericarditis - Sudden inflammation of the pericardium ▪ Cor pulmonale - Enlargement of the right ventricle secondary to pulmonary malfunction ▪ Myocardial infarction - Ischemic myocardial necrosis caused by abrupt decrease in coronary blood flow to a segment of the myocardium ▪ Myocarditis - Focal or diffuse inflammation of the myocardium. May occur d/t viral infection ▪ Heart and kidneys most affected by strep infections ABNORMALITIES IN HEART RATES AND RHYTHMS ▪ Conduction disturbances o Atrial flutter o Sinus bradycardia o Atrial fibrillation o Heart block o Atrial tachycardia o Ventricular tachycardia o Ventricular fibrillation - Ventricular arrhythmias are the most lethal ▪ Sick sinus syndrome - Arrhythmias caused by a malfunction of the sinus node INFANTS AND CHILDREN ▪ Tetralogy of Fallot o Ventricular septal defect o Pulmonic stenosis o Dextroposition of the aorta o Right ventricular hypertrophy ▪ Ventricular septal defect - Opening between the left and right ventricles ▪ Patent ductus arteriosus - Failure of the ductus arteriosus to close after birth ▪ Atrial septal defect - Congenital defect in the septum dividing the left and right atria ▪ Acute rheumatic fever - Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection o Skin infections can cause rheumatic diseases ▪ Kawasaki disease - Condition causing inflammation in walls of small and medium-sized arteries throughout the body, including coronary arteries o Kawasaki: Asian 2-5 yo o Autoimmune - Virus that attacks immune o Inflammation o Can affect the adult o Dx= gamaglobulin, high dose of ASA for pedi OLDER ADULTS ▪ Atherosclerotic heart disease - Caused by deposition of cholesterol, other lipids, and by a complex inflammatory process ▪ Mitral insufficiency/Regurgitation - Abnormal leaking of blood through the mitral valve, from left ventricle into left atrium ▪ Angina - Pain caused by myocardial ischemia o Women have atypical s/s of angina ▪ Senile cardiac amyloidosis - Amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in the heart ▪ Aortic sclerosis - Thickening and calcification of aortic valves THE PERIPHERAL VASCULAR SYSTEM ANATOMY AND PHYSIOLOGY - ARTERIES ▪ Arteries must respond to the variations that cardiac systole and diastole generate in cardiac output ▪ Anatomy and size vary according to their distance from the heart ▪ Arterial pulses are palpable when artery lies close to body surface ▪ Arms o Brachial: at bend of elbow just medial to biceps tendon o Radial: lateral flexor surface at wrist o Ulnar: medial flexor surface (overlying tissues may obscure) ▪ Legs o Femoral: below inguinal ligament o Popliteal: passes medially behind the femur; palpable behind knee o Dorsalis pedis: dorsum of foot; lateral to extensor tendon of big toe o Posterior tibial: behind medial malleolus of ankle ▪ Know how to assess all the pulses o Book ▪ Injury to vascular endothelial cells provokes thrombus formation, atheromas, and the vascular lesions of HTN ▪ An atheroma begins in the intima as lipid-filled foam cells and then becomes fatty streaks. ▪ Complex atheromas are thickened asymmetric plaques that narrow the lumen, reducing blood flow, and weaken the underlying media. They have soft lipid core and fibrous cap of smooth muscle cells and a collagen-rich matrix. Plaque rupture may precede thrombosis. ▪ Because of their weaker wall structure, the leg veins are susceptible to irregular dilatation, compression, ulceration, and invasion by tumors, and warrant special attention. o ANATOMY AND PHYSIOLOGY – VEINS ▪ Veins are thin-walled and highly distensible ▪ Deep veins - Carry ~90% venous return from lower extremities and are well-supported by surrounding tissues ▪ Superficial veins o Subcutaneous with poor tissue support ▪ Include great saphenous and small saphenous veins ▪ Anastomotic veins connect two saphenous veins ▪ Perforating veins connect superficial (saphenous) system with deep system ▪ Deep, superficial, and perforating veins have one-way valves o Propel blood toward heart, preventing pooling, venous stasis, and backward flow ▪ Lymphatic system runs along the veins and arteries. Lymphatic picks up all the fluid… Filtering system ▪ Epitrochlear lymph node missed a lot  after trauma ▪ Streaking seen in the skin (with skin infections) Book – Deep veins of legs carry approximately 90% of venous return from the lower extremities ANATOMY AND PHYSIOLOGY – LYMPHATIC SYSTEM ▪ Extensive vascular network that drains lymph from body tissues and returns it to venous circulation ▪ Lymph nodes o Round, oval, or bean-shaped structures o Vary in size according to location ▪ Important role in body’s immune system o Cells in lymph nodes engulf cellular debris/bacteria and produce antibodies ▪ Only superficial lymph nodes accessible to physical examination ▪ Parenchymal infection: with getting nails and Dog/cat bites: assess epitrochelar Book – Lymphatic dysfunction or disturbances in hydrostatic or osmotic forces can all disrupt this equilibrium, resulting in accumulation of interstitial fluid termed edema HEALTH HISTORY ▪ Common or concerning symptoms o Pain in arms/legs o Intermittent claudication (cramping) o Cold, numbness, pallor in legs, hair loss (specially over anterior tibia = decreased arterial perfusion) o Swelling in calves, legs, or feet o Color change in fingertips or toes in cold weather ▪ Red/rubor = arterial – dry or brown-black ulcers from gangrene may ensue ▪ Brown pigmentation = venus ▪ Cold legs = arterial o Swelling with redness or tenderness o Claudication: cramping o Vascular: pain in legs resolves when stop walking o Neurogenic: originates lower back or spine - indicative of spinal stenosis… Not cramping but extreme pain or tiredness. Symptoms decreased by sitting down or lying on stomach ▪ Peripheral arterial disease (PAD) o Intermittent claudication – d/t decreased oxygen ▪ Ask patients, “Have you ever had any pain or cramping in the legs when walking or with exercise?” “Does the pain get better with rest?” o Arterial spasm: fingers and toes ▪ Ask patients, “Do your fingertips or toes ever change color in cold weather or when you handle cold objects?” o Venous peripheral vascular disease ▪ Swelling of feet and legs - Ask about ulcers on lower legs, often near ankles HEALTH PROMOTION AND COUNSELING ▪ Most patients with peripheral arterial disease (PAD) have no symptoms or non-specific symptoms o Triad of exercise-induced calf pain that causes patient to stop exercise and experience relief of pain in 10 minutes is present in only 10% of affected patients ▪ Screen for subclinical PAD (peripheral arterial disease) ▪ Aggressive risk factor intervention (risk factors: 50yr, or younger if DM or atherosclerosis risk factor ofsmoking, dyslipidemia, HTN, or hyperhomocysteinemia; 50-69yr and Hx. of smoking or DM; 70yr or older; leg symptoms with exertion or ischemic rest pain; abnormal lower extremity pulses; known atherosclerotic coronary, carotid, or renal artery disease) ANKLE-BRACHIAL INDEX (ABI) – screening for PVD. KNOW FOR TEST!!! ▪ Detects stenosis of 50% or more in major vessels of legs ▪ Measure systolic blood pressure (with Doppler ultrasonography) in each arm and in pedal pulses ▪ Calculate reading for right and left o Divide the highest ankle systolic pressure with the highest brachial pressure for the index ▪ Numerator: ankle ▪ Denominator: brachial o ABI 0.90-1.30: normal o ABI 0.41-.90: mild to moderate disease** o ABI 0.00-0.40: severe disease with critical stenosis ▪ Diagnostics for PVD is US TECHNIQUES OF EXAMINATION ▪ Palpate the arterial pulses in distal extremities, comparing characteristics bilaterally. ▪ Important areas of examination o Arms ▪ Size, symmetry, skin color ▪ Radial pulse, brachial pulse ▪ Epitrochlear lymph nodes ▪ Skin texture (coarse, smooth, shiny), and nail changes (angle of nail) ▪ Presence of hair ▪ Muscular atrophy ▪ Edema or swelling ▪ Varicose veins o Legs ▪ Size, symmetry, skin color ▪ Femoral pulse and inguinal lymph nodes ▪ Popliteal, dorsalis pedis, and posterior tibial pulses ▪ Peripheral edema ▪ Shiny skin is not normal o Auscultate the carotid, abdominal aorta, renal, iliac, and femoral arteries for bruits. o Arms ▪ Inspect both arms from fingertips to shoulders • Note the following: o Size, symmetry, and any swelling o Venous pattern o Color of skin and nail beds; texture of skin ▪ Palpate radial pulse • Use finger pads on flexor surface of wrist • Partially flex patient’s wrist • Compare pulse in both arms ▪ Palpate brachial pulse • Flex elbow slightly • Palpate artery medial to biceps tendon in antecubital crease ▪ Epitrochlear nodes • Flex elbow 90° • Support forearm • Feel in groove between biceps and triceps muscle, 3 cm above medial epicondyle ▪ Book • Measure blood pressure in both arms o Asymmetric blood pressures as seen in coarctation of the aorta and dissecting aortic aneurysm. • Lymphedema of the arm and hand may follow axillary node dissection and radiation therapy • Prominent veins in an edematous arm suggest venous obstruction. • Note that if an artery is widely dilated, it is aneurysmal. • Bounding carotid, radial, and femoral pulses are present in aortic insufficiency; asymmetric diminished pulses occur in arterial occlusion from atherosclerosis or embolism. • An enlarged epitrochlear node may arise from local or distal infection, or may be associated with generalized lymphadenopathy. o Legs ▪ Patient should lay down, draped so external genitalia is covered and legs are fully exposed ▪ MUST remove patient’s stockings or socks ▪ Inspect both legs from groin and buttocks to feet ▪ Note the following: • Size, symmetry, and any swelling • Venous pattern/venous enlargement • Pigmentation, rashes, scars, or ulcers • Color and texture of skin, color of nail beds, distribution of hair on lower legs, feet, and toes • Book – warmth and redness over calf signal cellulitis ▪ Palpate superficial inguinal nodes • Horizontal/vertical groups • Note size, consistency, and discreteness and tenderness • Nontender, discrete nodes up to 1-2 cm are palpable in normal people o Document if pt has tenderness; Infection of leg/cellulitis; Tender, hard node, non- moveable is NOT normal – may be cancer o Palpate pulses ▪ Femoral pulse - Press deeply below inguinal ligament, midway between anterior superior iliac spine and symphysis pubis – exaggerated widened femoral pulse suggests femoral aneurysm ▪ Popliteal pulse - Flex knee some, leg relaxed. Place fingertips of both hands to meet midline behind knee and press deeply into popliteal fossa – exaggerated widened popliteal pulse suggests aneurysm of the popliteal artery ▪ Dorsalis pedis pulse - Feel dorsum of foot, lateral to extensor tendon of great toe ▪ Posterior tibial pulse - Curve fingers behind and slightly below medial malleolus of ankle ▪ Book • A diminished or absent pulse makes partial or complete proximal occlusion 10 times more likely. • If the occlusion is at the aortic or iliac level, all pulses DISTAL to the occlusion are typically affected. • An exaggerated, widened femoral pulse suggests a femoral pulse suggests a femoral aneurysm, a pathologic dilatation of the artery. • An exaggerated, widened popliteal pulse suggests an aneurysms of the popliteal artery. o They are usually caused by atherosclerosis and occur primarily in men older than 50. • In atherosclerosis, most commonly obstructs arterial circulation in the thigh. The femoral pulse is normal, the popliteal is decreased or absent. • Absent pedal pulses with normal femoral and popliteal pulses make atherosclerotic disease in the lower popliteal pulses make atherosclerotic disease in the lower popliteal artery or its branches 14 times more likely. Seen in diabetes mellitus. • Sudden arterial occlusion from embolism or thrombosis causes pain and numbness or tingling. The limb distal to the occlusion becomes cold, pale, and pulseless. EMERGENCY TREATMENT IS REQUIRED! • Coldness, especially when unilateral or associated with other signs, suggests inadequate arterial perfusion. ▪ ▪ o Atherosclerosis most commonly obstructs arterial circulation in thigh. The femoral pulse is normal, the popliteal decreased or abscent o Grading amplitude of arterial pulses ▪ 3+ Bounding ▪ 2+ Brisk, expected (normal) ▪ 1+ Diminished, weaker than expected ▪ 0 Absent, unable to palpate • Have to see if they’re the same on the both sides ▪ EDEMA o Compare one foot and leg with the other ▪ Note relative size and prominence of veins, tendons, and bones o Check for pitting edema ▪ Press firmly with thumb for 5 seconds over dorsum of each foot, behind medial malleolus and shins o Severity of edema graded on four-point scale ▪ (Slight to very marked) o Pt’s with cardiac, renal, or liver problems - edema in the orbital area o After over 10% of body weight you see in extremities o If edema is present, look for causes ▪ Recent deep venous thrombosis ▪ Chronic venous insufficiency ▪ Lymphedema o Note color of skin ▪ Local area of redness ▪ Brownish areas near ankles ▪ Ulcers and where ▪ Thickness of skin o Edema could be s/s of infection o Describe ulcerations – brown discoloration or ulcers just above the malleolus suggest chronic venous insufficiency o In DVT, location of edema suggest location of occlusion; if lower leg or ankle is swollen  popliteal vein; entire leg is swollen  iliofemoral veins o Painful, pale swollen leg, together with tenderness in the groin over femoral vein sug