As you begin the cardiovascular examination, review the blood pressure and heart rate recorded during the General Survey and Vital Signs at the start of the physical examination. If you need to repeat these measurements, or if they have not already been done, take the time to measure the blood pressure and heart rate using optimal technique (see Chapter 3, Beginning the Physical Examination: General Survey and Vital Signs, especially pp. __-__).

In brief, for blood pressure, after letting the patient rest for at least 5 minutes in a quiet setting, choose a correctly sized cuff and position the patient's arm at heart level, either resting on a table if seated or supported at midchest level if standing. Make sure the bladder of the cuff is centered over the brachial artery. Inflate the cuff about 30 mm Hg above the pressure at which the radial pulse disappears. As you deflate the cuff, listen first for the sounds of at least two consecutive heartbeats—these mark the systolic pressure. Then listen for the disappearance point of the heartbeats, which marks the diastolic pressure. For heart rate, measure the radial pulse using the pads of your index and middle fingers, or assess the apical pulse using your stethoscope (see pp. - ).

Now you are ready to systematically assess the components of the cardiovascular system:

■ The jugular venous pressure

■ The carotid upstrokes and presence or absence of bruits

■ The point of maximal impulse (PMI) and any heaves, lifts, or thrills

■ The first and second heart sounds, S1 and S2

■ Presence or absence of extra heart sounds such as S3 or S4

■ Presence or absence of any cardiac murmurs.

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