II.

Eyes

Opthalmoscopic examination for hypertensive retinopathy (usually already done if

HEENT exam is performed)

III. Neck

Inspect for JVD

o Have patient turn neck to the left
o Have patient neck be elevated to 30
o Measure centimeters of elevation comparing to sternum level
o Normal level should be > or = to 3 cm

If patient is elderly, auscultate for bruits prior to palpation

Palpate carotids, separately

IV. Chest

Inspection
o Stand on right side of patient, examine precordial area
o Vizualize PMI, heaves

Identify cardiac areas of palpation and auscultation

o Aortic: 2nd right intercostal space along sternal border
o Pulmonary: 2nd left intercostal space along sternal border
o Tricuspid: 4th or 5th left intercostal space along sternal border
o Mitral: 4th or 5th left intercostal space along midclavicular line

Palpation
o Thrills using metacarpal phalangeal joints
o PMI (point of maximal impulse) with pad of finger

Note ICS and vertical location of PMI

Auscultation
o Note rate and rhythm
o Note character of first (S1) and second (S2) heart sounds

S1: closure of AV valves - onset of systole

S2: closure of semilunar valves - onset of diastole

o Assess splitting of S2 (right side slightly delayed with decreased pressures)

Have patient exhale and hold to assure splitting is only physiologic and
not pathologic

Extra Sounds
o Ejection click: early systole

Diseased aortic valve

o Opening snap: early diastole

Mitral disease

o S3: rapid deceleration of blood

o S4: atrial kick

Murmurs
o Timing (systolic, diastolic) and duration (early, middle, late)
o Shape

Crescendo/decrescendo - aortic stenosis

Plateau - mitral regurg, tricuspid regurg, ventriculoseptal defect

Decrescendo - aortic regurgitation

o Location
o Radiation
o Pitch (low, medium, high)
o Quality (musical, rumbling, blowing, harsh)
o Intensity - Graded on a 1-6 scale

Grade 1: very faint, not heard in all positions

Grade 2: easily heard but faint

Grade 3: moderate

Grade 4: loud with palpable thrill

Grade 5: heart with stethoscope partially off chest wall

Grade 6: heart with stethoscope off chest wall

Special Positions
o Left lateral decubitus: if mitral stenosis, S3, or S4 suspected
o Sitting, leaning forward, breath out and hold: if aortic murmur is suspected
o Standing, squatting, valsalva: if MVP or aortic stenosis is suspected

V. Abdomen

Auscultation for bruits

o Aorta
o Renal aa
o Iliac aa
o Femoral aa

Palpation
o Hepatojugular reflex for JVP
o Aortic size - should be < 3 cm

VI. Extremeties

Inspection
o Edema - Scale 0-4

0: no edema

1: swelling of ankle

2: swelling to tibia

3: swelling to femur

4: swelling to sacrum

o Varicosities
o Hair loss - peripheral artery disease
o Nail beds - splinter hemorrhages
o Stasis dermatitis

Palpation
o Compare bilaterally

Brachial aa

Radial aa

Femoral aa

Popliteal aa

Dorsalis pedis aa

Posterior tibialis aa

o Capillary refill
o Signs of phlebitis - venous tenderness, warmth, cords

Allen Test - competency of radial and ulnar aa

o Palm up
o Patient clenches fist
o Compress radial and ulnar aa
o Patient relaxes hand
o Observe pale palm
o Release ulnar a
o Findings

Normal - pink in 3-5 seconds

Abnormal - repeat test releasing radial a