Cardiovascular and JVP
Examination
M. Platero, RN, MD, FPCP
January 2023
Physiology
S
Y
S
T
O
L
E
D
I
A
S
T
O
L
E
Common or Concerning Symptoms
▪ Chest pain
▪ Palpitation
▪ Shortness of breath: dyspnea, orthopnea, paroxysmal nocturnal
dyspnea
▪ Swelling (edema)
▪ Syncope (fainting)
Chest pain
▪ one of the most serious of all patient complaints
▪ most common symptom of coronary heart disease (CHD)
▪ always consider life-threatening diagnoses such as:
– MI (unstable angina, STEMI, non-STEMI)
– dissecting aortic aneurysm
– pulmonary embolus
▪ Cardiac vs Pulmonary vs Gastro
▪ women, particularly those over age 65, are more likely to report
atypical symptoms that may go unrecognized
Palpitations
▪ unpleasant awareness of the heartbeat
▪ terms to describe palpitations such as skipping, racing, uttering,
pounding, or stopping of the heart
▪ Palpitations do not necessarily mean heart disease
Shortness of breath
▪ Shortness of breath is a common patient concern that can represent
dyspnea, orthopnea, or PND
– PND occurs with heart failure
– Lying down increases volume of intrathoracic blood, and the weakened heart
cannot accommodate the increased load. Typically, the person awaken after 2
hours of sleep with the perception of needing fresh air
Cough
▪ Do you have cough?
▪ Duration: how long have you had it?
▪ Frequency: is it related to time of day?
▪ Type: dry, hacking, barky, or congested?
▪ Do you cough up mucus? Color? Any odor? Blood tinged?
▪ Associated with: activity, position (lying down)?
▪ Does activity make it better or worse?
▪ Relieved by rest or medication?
Fatigue
▪ Do you seem to tire easily? Able to keep up with your family and co-
workers?
▪ Onset: when did fatigue start? Sudden or gradual? Has any recent
change occurred in energy level?
Cyanosis or pallor
▪ Ever noted your facial skin turns blue or ashen?
– Cyanosis or pallor occurs with myocardial infarction or low cardiac output states
as a result of decreased tissue perfusion
Edema (swelling)
▪ refers to the accumulation of excessive fluid in the extravascular
interstitial space
▪ systemic vs local
▪ Do your shoes get tight? Are the rings tight on your fingers? Are your
eyelids puffy or swollen in the morning? Have you had to let out your
belt? Have your clothes gotten tight around the middle?”
▪ Bilateral or unilateral?
▪ Cause of bilateral edema?
Nocturia
▪ Do you awaken at night with an urgent need to urinate? How long
has it been occurring? Any recent change?
– Nocturia – recumbency at night promotes fluid reabsorption and excretion; this
occurs with heart failure in the person who is ambulatory during the day
Fainting (syncope)
▪ is a transient loss of consciousness followed by recovery
▪ the most common cause is neurocardiogenic (also called neutrally
mediated vasodepressor syncope or vasovagal syncope)
▪ cardiac origin from arrhythmias
Cardiac History
▪ Any past history of: hypertension, elevated cholesterol or
triglycerides, valvular heart disease, congenital heart disease,
rheumatic fever or unexplained joint pains as child or youth,
recurrent tonsillitis, anemia?
▪ Last ECG, stress ECG, serum cholesterol measurement, other heart
tests?
Family Cardiac History
▪ Any family history of: hypertension, obesity, diabetes, CAD, sudden
death at younger age?
Personal Habits (cardiac risk factors)
▪ Nutrition: please describe your usual diet. What is your usual weight? Has
there been any recent change?
▪ Smoking: do you smoke cigarettes or other tobacco? At what age did you
start? How many packs per day? For how many years haveyou smoked this
amount? Have you ever tried to quit? If so, how did this go?
▪ Alcohol: do you drink alcohol? What type? How much alcohol do you
usually drink each week or each day? When was your last drink? What was
the number of drinks during that episode?
▪ Exercise: what is your usual amount of exercise each day or week? What
type of exercise? Light, moderate or heavy?
▪ Drugs: do you take any antihypertensives, BB, CCB, ARB, digoxin, diuretics,
antiplatelets/anticoagulants, OTC or street drugs?
Physical Examination
Jugular Venous Pressure
▪ closely parallels pressure in the right atrium,
or central venous pressure, related primarily
to volume in the venous system
▪ best assessed from pulsations in the right
internal jugular vein, which is directly in line
with the superior vena cava and right atrium
▪ JVP falls with loss of blood or decreased
venous vascular tone
▪ increases with right or left heart failure,
pulmonary hypertension, tricuspid stenosis,
AV dissociation, increased venous vascular
tone, and pericardial compression or
tamponade
▪ JVP measured at >3 cm above the sternal angle, or >8 cm above the right
atrium, is considered elevated or abnormal.
JVP Examination
1. Makes the patient lie in supine position comfortable
2. Raises the head slightly on a pillow to relax the sternocleidomastoid muscle
3. Raise the head of the examining table to about 30 degrees
4. Turn the patients head away from the side to be examined
5. Use tangential lighting and examine both sides of the head
6. Identify the external jugular vein on each side
7. Finds the right internal jugular vein (jugular vein VS carotid artery)
8. Look for the pulsations
9. Identifies the highest pulsation
10. Extends a long rectangular object or card horizontally from this point and a
centimeter ruler vertically from the sternal angle
11. Measures correctly the JVP
Hepatojugular reflux
Assessment of the Carotid Pulse
1. Inspects the carotid for pulsation
2. Points correctly the proper position of the
carotid pulse (medial to the sternocleidomastoid
muscle)
3. Place the right index finger and the middle
finger on the right carotid artery in the lower
third of the neck and feel for pulsation
4. Presses the medial border of the SCM at the
level of the cricoid cartilage by slowly increasing
the pressure until you feel the maximal pulsation
Assessment of the Carotid Pulse
▪ Avoid excessive pressure on the carotid area higher in the neck.
WHY?
▪ Palpate only one carotid artery at a time. WHY?
▪ Auscultate the carotid artery at 3 levels (base, middle, upper) using
the bell
– Bruit – a blowing, swishing sound indicating turbulence due to a local vascular
cause, such as atherosclerotic narrowing
– If positive, ½ to 2/3 of the lumen is occluded
Cardiac Examination
Cardiac Inspection and Palpation
1. Carefully inspect the anterior
chest and noting for the PMI
2. Shine a tangential light across
the chest wall to appreciate
the apex
3. If the apex is identified,
palpate the PMI to confirm its
characteristic
4. Check for heaves, thrills, and
know how to differentiate
them
Cardiac Inspection and Palpation
1. Carefully inspect the anterior
chest and noting for the PMI
2. Shine a tangential light across
the chest wall to appreciate
the apex
3. If the apex is identified,
palpate the PMI to confirm its
characteristic
4. Check for heaves, thrills, and
know how to differentiate
them
Cardiac Inspection and Palpation
1. Carefully inspect the anterior
chest and noting for the PMI
2. Shine a tangential light across
the chest wall to appreciate
the apex
3. If the apex is identified,
palpate the PMI to confirm its
characteristic
4. Check for heaves, thrills, and
know how to differentiate
them
Cardiac Inspection and Palpation
1. Carefully inspect the anterior
chest and noting for the PMI
2. Shine a tangential light across
the chest wall to appreciate
the apex
3. If the apex is identified,
palpate the PMI to confirm its
characteristic
4. Check for heaves, thrills, and
know how to differentiate
them
Cardiac Inspection and Palpation
1. Carefully inspect the anterior
chest and noting for the PMI
2. Shine a tangential light across
the chest wall to appreciate
the apex
3. If the apex is identified,
palpate the PMI to confirm its
characteristic
4. Check for heaves, thrills, and
know how to differentiate
them
Case scenario:
▪ A 50-year-old male, chronic hypertensive, and diabetic
patient
▪ CC: chest pain
▪ PMI at 12 cm left-lateral from the midsternal line at the 6th
ICS measuring 3-4cm, all through-out systole
Cardiac Percussion
1. Starting with the left side of the chest, percusses from resonance
toward cardiac dullness, in the 3rd, 4th, 5th, and possible the 6th
interspace
Cardiac Auscultation
1. Position the patient properly
2. Uses the diaphragm of the stethoscope
3. Auscultates in the right position
• left lateral decubitus position - this
brings the ventricular apex closer to the
chest wall
• sit up, lean forward, and exhale - to
bring the left ventricular out ow tract
closer to the chest wall and improve
detection of aortic regurgitation
Cardiac Auscultation
1. Position the patient properly
2. Uses the diaphragm of the stethoscope
3. Auscultates in the right position
Cardiac Auscultation
Patterns of Auscultation
▪ Apex → base
▪ Base → apex
Cardiac Auscultation
1. Note the rate and
rhythm
2. Identify S1 and S2
3. Assess S1 and S2
separately
4. Listen for extra
heart sounds
5. Listen for murmurs
Cardiac Auscultation
▪ 60 to 100 beats per minute
1. Note the rate and
rhythm
▪ Regular pattern
2. Identify S1 and S2
3. Assess S1 and S2
▪ Sinus arrhythmia – normal in young adults
separately and children
4. Listen for extra – Increases during inspiration
heart sounds – Decreased during expiration
5. Listen for murmurs
Cardiac Auscultation
▪ This is important because S1 is the start of
1. Note the rate and systole and thus serves as the reference
rhythm
point for the timing of all other cardiac
2. Identify S1 and S2 sounds
3. Assess S1 and S2 ▪ Usually, you can identify S1 instantly
separately
because you hear a pair of sounds close
4. Listen for extra together (lub-dup), and S1 is the first pair
heart sounds
5. Listen for murmurs ▪ S1 is louder than S2 at the apex (LUB-dup)
▪ S1 coincides with the carotid artery pulse.
The sound you hear as you feel each pulse
is S1
▪ S1 coincides with the R wave if the person
is on an ECG monitor
Cardiac Auscultation
S1
1. Note the rate and
rhythm
▪ First heart sound
2. Identify S1 and S2
3. Assess S1 and S2
▪ Caused by closure of the AV valves
separately
▪ Signals the beginning of systole
4. Listen for extra
heart sounds
▪ Loudest at the apex (LUB-dup)
5. Listen for murmurs
Cardiac Auscultation
S2
1. Note the rate and
rhythm ▪ Second heart sound
2. Identify S1 and S2
▪ Associated with closure of the semilunar
3. Assess S1 and S2
separately valves
4. Listen for extra
heart sounds
▪ Loudest at the base (lub-DUP)
5. Listen for murmurs
Cardiac Auscultation
Splitting of S2
1. Note the rate and
rhythm ▪ A normal phenomenon that occurs toward
2. Identify S1 and S2 the end of inspiration
3. Assess S1 and S2
separately ▪ MORE TO THE RIGHT, LESS TO THE LEFT
4. Listen for extra
heart sounds
▪ Closure of aortic and pulmonic valves is
nearly synchronous, and inspiration
5. Listen for murmurs separates the timing of the closure of the
two valves
▪ Aortic valve closes before the pulmonic
valve
▪ Lub-T-DUP
Cardiac Auscultation
S3
1. Note the rate and
rhythm ▪ Third heart sound
2. Identify S1 and S2
▪ Normally, diastole is a silent event
3. Assess S1 and S2
separately
▪ In some conditions, ventricular filling
4. Listen for extra
heart sounds
creates vibrations that can be heard → S3
5. Listen for murmurs ▪ Occurs when the ventricles are resistant
to filling during the early rapid filling
phase
▪ Occurs immediately after S2, when AV
valves open and atrial blood pours into
the ventricles
Cardiac Auscultation
S4
1. Note the rate and
rhythm ▪ Fourth heart sound
2. Identify S1 and S2
▪ Occurs at the end of diastole, at
3. Assess S1 and S2
separately presystole, when the ventricle is resistant
to filling
4. Listen for extra
heart sounds
▪ The atria contract and push blood into a
5. Listen for murmurs noncompliant ventricle creating
vibrations → S4
▪ Occurs just before S1
Cardiac Auscultation
A murmur is a blowing, swooshing sound
1. Note the rate and that occurs with turbulent blood flow in the
rhythm
heart or great vessels.
2. Identify S1 and S2
3. Assess S1 and S2 Causes:
separately
▪ Velocity of blood increases (e.g. exercise,
4. Listen for extra
heart sounds thyrotoxicosis)
5. Listen for murmurs ▪ Viscosity of blood decreases (e.g.
anemia)
▪ Structural defects in the valves (narrowed
valve, incompetent valve) or unusual
openings in the chambers (dilated
chamber, wall defect)
Cardiac Auscultation
Note for the following characteristics:
1. Note the rate and
rhythm ▪ Timing
2. Identify S1 and S2
▪ Loudness
3. Assess S1 and S2
separately
▪ Pitch
4. Listen for extra
heart sounds ▪ Pattern
5. Listen for murmurs
▪ Quality
▪ Location
▪ Radiation
▪ Posture
Cardiac Auscultation
Note for the following characteristics:
1. Note the rate and
rhythm ▪ Timing (systole, diastole, all throughout)
2. Identify S1 and S2
▪ Loudness (grade I to VI)
3. Assess S1 and S2
separately
▪ Pitch (high, medium or low)
4. Listen for extra
heart sounds ▪ Pattern (crescendo, decrescendo)
5. Listen for murmurs
▪ Quality (musical, blowing, rumbling)
▪ Location ( where beast heard)
▪ Radiation (transmission of the murmur)
▪ Posture
https://www.youtube.com/channel/UCtMfWirs0KsHyAo1lveRCWw
