• Inspect the skin on arms and legs for:

cyanosis, erythema, or pallor

decreased hair growth

muscle atrophy

edema

varicosities

• Inspect and estimate the Jugular Venous Pulse (JVP) -- jugular veins reflect the activity of the right side of the heart and can be used to estimate right heart pressure

• Position patient in supine position at ~ 45 degrees so the external jugular pulsation can be seen
• Measure the distance between the Angle of Louis (top of sternum) and the top of the pulsation, then add 5 cm
• You can also measure the distance between the Midaxillary line and the top of the pulsation, but don't add 5 cm this time
• If JVP > 9 cm, + JVD
• Indicates right side volume, such as pulmonary edema

• Hepatojugular Reflux
• Palpate for pulses
• Palpate the capillary refill
• Palpate the lower extremities for temperature and edema

• Place patient in supine position
• Gently but firmly press on the RUQ of abdomen, just below the rib cage for 30-60 sec
• JVP will elevate in all patients, but normally returns to original JVP within 10 sec
• If HJR remains elevated after 10 sec, it may suggest HF

0 = absent

1+ = weak, thready

2+ = normal

3+ = increased

4+ = bounding

• Extend patient's hands near heart level
• Squeeze nail bed of each finger
• Release and note time of color return (1-2 sec is normal)

• Weak or absent pulses
• Loss of body warmth at affected area
• Leg muscle atrophy and hair loss
• Cyanosis or pallor of LE
• Ulcer or gangrene of LE
• Pain or weakness with exertion and relieved with rest
• Numbness in toes or feet

• Constant pain
• Positive Homan's Sign
• Erythema and/or cyanosis
• Unilateral leg swelling

• A blowing, murmur-like sound of vascular origin, which may suggest narrowing or partial occlusion of lumen (atherosclerosis)
• Lightly place bell of stethoscope over the carotid artery
• Ask the patient to hold breath
• Listen for presence of bruit
• Other sites to listen for bruit include temporal, subclavian, abdominal aorta, renal, iliac, and femoral arteries

Isovolumetric Ventricular Contraction

• Ventricles start to contract and pressure in ventricles increase, leading to AV valve closure
• All valves are now closed
• Pressure and tension continue to build up

• Once ventricular pressure drops below aortic or pulmonary artery pressure, the semilunar valves close

• Can be seen in the 5th (sometimes 4th) intercostal left space at the midclavicular line

• A fine, palpable (over base), rushing vibration (palpable murmur) which indicates disruption of the expected blood flow
• Indicates valvular or septal defects

• Produced by closure of AV valves
• Signals the beginning of systole
• Loudest over the apex of the heart

• Produced by closure of SL valves
• Signals the end of systole
• Loudest over the base of the heart

• Normal in children and young adults
• Represents HF in > 30 yo

• Normal in children and young adults
• > 30 yo, indicates resistance of filling secondary to noncompliant ventricle (aortic stenosis)