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cardiac examination (hand examination (tar staining, peripheral cyanosis,…
cardiac examination
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patient optimally exposed (undressed to the waist) and positioned at 45 degrees angle -> happy with the exposure and position of the patient
equipment
surrounding the bed - O2 delivery, IV access, ECG monitor, catheter bag
mobility - walking frame, wheelchair
patient
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rapid/ laboured respiration - tachypnoea, dyspnoea
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obvious chest asymmetry, scars, pulsations - pectus carinatum, pectus excavatum
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clubbing - loss of angle between the nail and finger; fluctuations and softening of the nail bed; increased curvature of the nail
examine pulse: normal - 60-100 beats per minute; rhythm - regular or irregular (atrial fibrillation) ; character and volume; radial inequality - palpate both pulses together; radio femoral delay
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- face and neck examination
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neck
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JVP: visible, not palpable; occludable; fills from above; decreases with inspiration; increases with upward pressure of the liver - hepatojugular reflex; multi-wave form
hepatojugular reflux - abdominal compression increases venous return and pressure and facilities analysis of the JVP; apply firm sustained pressure over upper abdomen -> confirms venous nature of pulsation in the neck; upper right hand - liver; positive result > 4cm rise
- closer inspection of chest
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palpate for thrill - base of fingers; mitral: 5th ICS MCL; tricuspid: 5th ICS right sternal margin; pulmonary: 2nd ICS at left sternal margin; aortic: 2nd ICS at right sternal margin
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apex beat - most lateral, inferior point where pulse is felt; begin palpation in the axilla and move medially until apex beat is located; 2nd ICS lies below the jugular angle
heart sounds 1 and 2 were audible and normal; no murmurs present, no added sounds
manoeuvres: measure radial pulse at the same time, ask patient to take a deep breath in and out and hold
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areas: mitral (apex beat), tricuspid (5th ICS left), pulmonary (2nd ICS left of sternum), aortic (2nd ICS right)
mitral regurgitation: radiates to axilla, listen with diaphragm
aortic stenosis radiates to carotid arteries, listen with diaphragm or bell if patient small/thing
aortic regurgitation: lean patient forward in full expiration and listen at lower left sternal border with diaphragm
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