Exam 3

Position and Landmarks

The heart is located in the mediastinum, between the lungs, behind the sternum, and slightly tilted left.

Heart Chambers/Valves

The heart consists of four chambers: right atrium, right ventricle, left atrium, left ventricle, and four valves: tricuspid, pulmonic, mitral, and aortic.

Blood Flow Through Heart

Blood flows in sequence: vena cava → right atrium → tricuspid valve → right ventricle → pulmonic valve → pulmonary artery → lungs → pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta → body.

Neck Vessels: Carotid/Jugular Venous Pulse

Carotid arteries deliver oxygenated blood to the brain; jugular veins reflect right atrial pressure and provide information on heart function.

Subjective vs Objective Data

Subjective data involves symptoms reported by the patient; objective data includes observable signs measured by the clinician.

Risk Factors

Major risk factors for heart disease include smoking, hypertension, diabetes, high cholesterol, obesity, and a sedentary lifestyle.

Heart Auscultation (A-PET-M)

Aortic: 2nd RICS; Pulmonic: 2nd LICS; Erb's Point: 3rd LICS; Tricuspid: 4th LICS; Mitral: 5th ICS, MCL.

Murmur Description

Murmurs are graded I-VI by loudness, described by pitch, location, and timing in the cardiac cycle.

Apical Impulse

Palpated at the 5th ICS, midclavicular line, corresponding to the apex of the heart.

Thrill

A palpable vibration on the chest wall, indicating turbulent blood flow, often associated with loud murmurs.

Hypertension

Persistent BP ≥140/90 mmHg; increases the risk of stroke, heart attack, and kidney damage.

S1-Which Is Louder Where

S1 is louder at the apex (mitral and tricuspid valve closure).

S2-Which Is Louder Where

S2 is louder at the base (aortic and pulmonic valve closure).

Splitting S2

Physiologic splitting occurs during inspiration, with delayed pulmonic valve closure.

Bruits

Abnormal swishing sounds heard over arteries, indicating turbulent blood flow due to stenosis or aneurysm.

Neck Vessels: Inspection

Inspect jugular venous pulse with patient supine; observe for distention, height, and wave pattern.

Neck Vessels: Palpation

Palpate carotid arteries one at a time to assess amplitude, symmetry, and rhythm.

Neck Vessels: Auscultation

Auscultate carotid arteries with the bell for bruits, with the patient holding their breath briefly.

Precordium: Inspection

Inspect the chest for visible pulsations or abnormal movements, indicating cardiac enlargement or dysfunction.

Precordium: Palpation

Palpate for thrills, heaves, or lifts to assess abnormal cardiac activity.

Precordium: Auscultation

Auscultate heart sounds systematically in the A-PET-M pattern.

Developmental/Cultural/Genetic Consideration

Children often have physiologic murmurs; elderly may have stiff arteries or valve issues; cultural practices affect health risks and management.

Peripheral Vascular: Main Pulse Sites

Assess radial, brachial, carotid, femoral, popliteal, posterior tibial, and dorsalis pedis arteries for rhythm, strength, and equality.

Edema Types and Scoring

Pitting edema graded 1+ (mild) to 4+ (severe); non-pitting indicates lymphatic or thyroid issues.

Doppler

A handheld device used to amplify weak peripheral pulses or detect fetal heart tones.

Health Promotion and Patient Teaching

Encourage exercise, healthy diet, smoking cessation, and routine screenings for cardiovascular health.

Inspection of PV System

Inspect extremities for color, swelling, hair distribution, and venous patterns.

Developmental Considerations

Elderly may have weakened pulses and arterial insufficiency; children may show bounding pulses in fever.

Breast: Education

Women should perform BSE 5-7 days after menstruation; men should report any lumps or abnormalities.

Abnormal Findings: Breast

Concerning findings include irregular nodules, nipple discharge, peau d’orange, deviation, or retraction.

Tanner Staging

Helps assess pubertal development to identify delays or precocious puberty in adolescents.

Developmental Considerations: Breast

Newborns may have breast buds; adolescents undergo growth stages; older adults have atrophic tissue.

Therapeutic Communication

Use empathy and reassurance when discussing concerns about breast abnormalities.

Gynecomastia

Benign enlargement of male breast tissue, often due to hormonal changes, medications, or systemic conditions.

Supernumerary Nipple

A small extra nipple along the "milk line," often harmless, but associated with renal anomalies in rare cases.

Inspection of the Breast

Normal: Symmetrical, no dimpling, uniform texture. Abnormal: Lumps, retraction, skin changes.

BSE Techniques

Use the pads of fingers in a circular motion, applying light, medium, and firm pressure; follow a systematic pattern (e.g., spiral, wedge, or linear).