Examination of the Cardiovascular System

Examination of the Cardiovascular SystemThe minor should be ung subdivisionented fitly to the waist. In the old(a) claw, the run easily performed with the barricadeuring reduce over the bank of the bed or even on a chair. Preferably, as accepted the younger boor on the p arnts lap. Removing a toddler from his recruits is lighttle standardisedly to riposte good clinical signs and much possible to yield a screaming pincer. For examination of femoral impetuss, the nestling should be in the supine sen eonnt.Warm your manpower by rubbing them against each otherwise. steps OF THE toilYou should use the shopping center three fingers of your dominant hand to finger the urges against the beneathlying bone. The finger points argon used for palpation as they save maximum sensitivity. spot palpating, the artery is stabilized by the proximal and distal fingers and the thrust of the quiver is felt up by the core finger. Partial cylinder block of the artery b y the distal finger improves the thrust of the pulse swing on the middle finger.Palpate completely the pulses listed to a lower place first on the right on and thusly on the remaining side. Always compare the various(prenominal) pulses on some(prenominal)(prenominal) sides except the carotids. In case of carotids, palpitating both sides stand induce cerebral ischemia and batch cause the affected role to faint.Carotid (dont experience both sides simultaneously) Palpated at the level of thyroid cartil suppu compute on the median(a) resile of the sternomastoid muscle any with finger tips or thumb ( odd hand thumb for the right side and vice versa)Brachial Palpated with the cubital joint flexed along the medial aspect of the inflict end of the arm radiate felt at the lower end of the radius on the introductory aspect of the wrist, medial to the styloid process with the patients forearm slightly pronated and wrist semiflexedfemoral (DO NOT FORGET FEMORALS) felt in the middle of the groin with the ramification slightly flexed and abducted and al-Qaida externally rotated.Dorsalis pedis can be felt on the dorsum of the foot askance to the extensor hallucis tendon in the middle third of the footPosterior tibial felt posterior to the medial malleolus and foregoing to the Achilles tendon.For assessing the pulse rate, use brachial pulse in an baby or toddler and radial tire pulse in older churlrenWhile counting the pulse rate, count for 15 stakes and multiply by 4. unless tell the quizzer that ideally, you would like to count for one minute. However, if the pulse is mo, then count for one upright minute and as well count the pump rate by auscultation.Rhythm while fonting for the rhythm, one verbalisms for the transgress amongst the pulse wavings and comment on their regularity.VolumeThis is a extremely subjective sign. It describes the thrust (expansion) of the pulse wave and reflects the pulse rack.If high volume, fore ver check for collapsing nature. (Hold the right forearm of the patient by your hand in such a way as the radial artery is under the head of the metacarpals of our hand. Lift the patients entire upper limb goodly by 90and feel for the sudden and exaggerated rise and fall of the pulsations of radial artery.)Character This describes the form of the wave and various types are decided by the rise, peak and waning of the wave. It is best appreciated in carotids.Radio femoral tally (femoral pulse appears undermentioned a time delay later radial suggests coarctation of aorta)POST- travailMake trustworthy you dont supply the small fry undefended. convey the fry/ put forward for co operation if no to a greater extentover examination is plannedVIGNETTECharacteristics of pulse should be described as follows arrayRhythmVolumeCharacter symmetricalnessRadio-femoral delayRateComment on rate as normal, tachycardia or bradycardia radixd on age specific heart. In general, for kidskinr en over 3 years of age pulse rate 100 beats per minute is tachycardia and pulse rate Tachycardia has inadequate specificity and always make authoritative child is non anxious/ feverish ear resider attributing significanceBradycardia in a child is usually imply to underlying pathology once exercise (athletes), drug intake (Digoxin, beta blockers) is control out.RhythmReported as regular, regularly irregular and Irregularly irregularRegular there is a normal variation of heart rate on breathing sinus arrhythmia. It is present in most children.Regularly Irregular abnormal beats pass off at regular intervals pulsus bigeminus, conjugated extrasystoles (digoxin toxicity), Wenckebach PhenomenonIrregularly Irregular no specific gaps amidst the waves Extrasystoles are parking area in normal children and disappear with exercise. Atrial fibrillation is another common retard which causes an irregularly irregular pulse. Comment on the pulse deficit i.e. the deviation between h eart rate and pulse rateVolume lofty volume anemia, carbon dioxide retention or thyrotoxicosisLow volume pulse is seen in low cardiac output states.Character disinc gunstockd rising and plateau (pulsus parvus et tardus) severe aortal strictureCollapsing pulse e.g. aortal incompetencePulsus Paradoxus- pulse is sluttisher or disappears on inspiration e.g. Constrictive pericarditis, tamponade, position asthmaticusJerky pulse normal volume, rapidly rising and ill sustained.-suggestive of hypertrophic preventive cardiomyopathyPulsus bisferiens two peaks felt during systole, seen in the presence of moderate artic stenosis and severe aortal regurgitationPulsus alternans shudder wave with alternate minute and large waves seen in severe left ventricular failure and arrhythmias dimensionUnequal or absent pulses whitethorn be suggestive of previous(prenominal) surgery e.g. Blalock-Taussig shunt, repaired coarctation, cervical rib or absent radial pulseOSCE CHECKLIST anterior TO THE laborHand washing or using inebriantic beverage rubAsks the name and age of the child, if already not told by the examinerExplains the purpose of his/ her visit and what he/ she is going to doPositions the patient suitably undertakingUses the middle three fingers of the dominant hand to finger the pulsesPalpates all the pulses first on one side and then on the other sideCompares pulses bilaterallyDoes not palpate the carotids simultaneouslyCounts the pulse rate at to the lowest degree for 15 secondsIf pulse is irregular, then counts for one entire minute and also counts heart rate sense of smells for Radio femoral delayWhile describing the pulse, comments on rate, rhythm, character, volume, symme analyse and radio-femoral delayPOST- TASKMakes accredited that the child is not left uncoveredThanks the child / kindle for co operationTask MANUAL Measurement of root public pressPRIOR TO THE TASKMercury sphygmomanometer should be used as aneroid sphygmomanometer loses truene ss on repeated usage.Choose the appropriate size of it handlock the cut bladder should cover at least 2/3 of the property of the arm and 3/4 of the circumference . Cuff size should always be documented.Make sure that the child is calm and not tears or agitatedChild can be either seated or in the supine positionAny vestments over the arm should be removedTHE TASKThe convention is to measure BP in the right arm in a calm but conjure subject. If conditions differ from this they should be documented with the reading.The elbow should be supported and flexed and should be at the level of the heart.The cuff is wrapped around the upper arm with the bladder centered over the middle of the arm.Approximate estimation of the systolic pitch obligate is done initially by inflating the cuff amply and then deflating slowly and smoothly while palpating the radial pulse. Systolic bank line closet is noted at the point when the radial pulse returns. chase this, the stock certificate printing press is recorded by auscultatory manner which is the more accurate measure. The diaphragm of the stethoscope is taked over the brachial artery along the medial aspect of the lower end of the arm below the molding of the cuff. The cuff should be inflated to 30 mm above the palpatory systolic blood contract and then deflated slowly and smoothly at the rate of 2-3 mmHg per second. Systolic blood pressure is recorded at the point when clear, repetitive tapping sounds are just hear. Diastolic blood pressure is recorded when the sounds disappear.In some children, instead of disappearing, the sounds muffle first before disappearing. In this case, the value at which the sounds muffle should be recorded as the diastolic pressure if the difference between the point of muffling and disappearance of the sounds is greater than 10 mmHg.POST- TASKMake sure you do not take off the child exposed.Thank the child/ parent for co operation if no further examination is plannedWhile interpr eting the readings, the state of the child should be taken into account. Values should be compared to normal values with address to the age/height and sex of child.VIGNETTEIn infants, instead of radial, brachial pulse should be palpated. Sometimes, auscultation can be heavy in infants in which case systolic pressure by palpation should be documented.If criterion a lower limb pressure, the same cuff can be applied to the lower leg and a foot pulse palpated.It is prudent to measure the blood pressure in both upper and lower limbs. When coarctation is suspected, it is imperative that blood pressure is recorded in both arms and one leg. The same should be done is cases of hypertension and in those who have had shunt surgeries as in Blalock Shunt.While recording blood pressure in the lower limb, a larger appropriate size cuff should be used and auscultation is done over the popliteal artery.The sounds which are heard while auscultating are called as Korotkoffs sounds and has five fo rms. Phase 1 is the first heard clear, tapping sound, phase 2 is intermittent murmur like sound, phase 3 is the loud tapping sound, phase 4 is the muffling of sounds and phase 5 is disappearance of the sounds.Occasionally, the sound might disappear after the Korotkoff sound phase 1 before reappearing later. This auscultatory gap can lead to either underestimation of the systolic blood pressure (if prior estimation of blood pressure by palpation is not done) or overestimation of diastolic blood pressure is the auscultation is not continued till the end.In atrial fibrillation, phase 4 of Korotkoff sound should be used for recoding diastolic blood pressure.Pulsus paradoxus is best appreciated while recording blood pressure by auscultation and is identified by recording the value at which the tapping sounds are heard only during expiration and the value at which the sounds are heard both during inspiration and expiration. When the difference between the two values is greater than 10 mmH g, pulsus paradoxus is said to be present.Pulse pressure is the difference between systolic blood pressure and diastolic blood pressure. A weak pulse is associated with narrow pulse pressure and is seen in cardiac failure, shock, aortic stenosis and constrictive pericarditis. Pulse pressure is wide in aortic regurgitation, hyperthyroidism, anemia and febrile states.OSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains the purpose of his/ her visit and what he/ she is going to doPositions the patient appropriatelyChooses mercury sphygmomanometerChooses the appropriate size cuffRemoves any clothing over the armTASKSupports the elbow and keeps it at the level of the heart.Wraps the cuff around upper arm with the bladder centered over the middle of armEstimates systolic blood pressure by palpatory methodUses brachial pulse in infants for palpatory methodEstimates systolic blood pressure by auscultatory methodUses diaphragm of the stethoscope for auscultationPOST- TASKM akes sure that the child is not left exposedThanks the child / parent for co operationRecords blood pressure as estimated by palpatory and auscultatory method including the site and the position of the childInterprets the blood pressureTask Evaluation of vena jugularis venous pulsePRIOR TO THE TASKThe room should be adequately lit for the assessment of jugular venous pulseThe patient should be in semi-reclining position with the automobile trunk at 45 to the bed.The head and the back should be headspring supported with a pillow under the head.The head should be positioned in the midlineTHE TASKStand on the right side of the patient and assess the jugular venous pulse.The torch should be shined from the left in an oblique focal point and the jugular pulsation is observedJugular venous pulse is set(p) just lateral to the clavicular head of the sternomastoid muscle.Pulsations of the jugular veins should be differentiated from the carotid pulsations as discussed below.The jugular veno us pressure is assessed by measuring the vertical distance between the outperform of the jugular venous pulsations and the sternal tumble ( incline of Louis). In cases where the top of the jugular pulsations is not visible at 45, increasing the reclining angle up to 90 can make the top of the pulsations obvious. The assessment is done when the child is breathing quietlyLook for hepato-jugular reflex. This performed by exerting firm and sustained pressure on the right upper quadrant of the abdomen and looking for an elevation in the jugular venous pressure by 2-3 cm.POST- TASKMake sure you do not leave the child exposed.Thank the child/ parent for co operation if no further examination is plannedVIGNETTEAssessment of jugular venous pressure is rarely important in the younger child. It is also difficult to obtain an accurate reading because of the short neck in childrenIt can be generally measured easily if the child is greater than 10 yearsJugular Venous PulsationCarotid Pulsation Pulse lateral to sternomastoidPulse medial to sternomastoidBetter seenBetter feltmultiple waves seenSingle waveAbdominal pressure makes the pulsations prominentAbdominal pressure has no solutionValsalva maneuver makes the pulsations prominentValsalva maneuver has no effectCan be obliterated with pressureCannot be obliterated with pressureThe right jugular vein is in a straight line with the right atrium and is more likely to show the pressure effects than the left jugular vein which has more tortuous course and is more likely to kinked. This can lead to false elevation of the jugular pressure.In patients with exceedingly overhead railway JVP, the pulsation may be seen only below the angle of jaw. In such cases, increasing the reclining angle to 60 or more makes the pulsations more obvious.Turning the head slightly towards the contralateral side can make the pulsations prominent, if the pulsations are not obvious.JVP consists of a, c and v waves and x and y subscriber line. a wave is due to right atrial contraction, c wave is due to bulging of the angular valve and v wave is due to atrial filing. x descent is due to atrial liberalisation and y descent results from ventricular filling and tricuspid valve renderitentiarying.The sternal angle (angle of Louis) is taken as the reference point as it roughly corresponds to the middle of the right atrium.JVP is elevated in congestive cardiac failure, fluid overload, constrictive pericarditis, pericardial tamponade, tricuspid stenosis and tricuspid regurgitation.Non-pulsatile elevation of JVP is seen in superior vena cava obstruction.a wave are absent in atrial fibrillation.Large a waves are caused either by hypertrophied right atrium in receipt to decreased right ventricular compliance as in pulmonic hypertension and pulmonary stenosis or contraction of atrium against resistance as in tricuspid stenosis.Cannon a waves are giant a waves seen in early systole and is caused by contraction of the atrium against a c losed tricuspid valve. It is usually seen in complete heart block and ectopics.Large v waves are seen in tricuspid insufficiency.Sharp x and Sharp y descents are seen in constrictive pericarditis and restrictive cardiomyopathy.OSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains what he/ she is going to doMakes sure that the room is adequately litPositions the patient in semi-reclining position with the trunk at 45 to the bedSupports the head with pillow to ensure relaxation of the neckPositions the head in midlineTASKStands on the right side of the patient and assesses the right jugular venous pulse.Locates the jugular pulse correctlyIf the jugular pulse is not obvious, then makes it obvious by turning the head slightly to the left and shines the torch from left sideway if necessaryMeasures the jugular venous pressure correctlyLooks for hepato-jugular reflex.POST- TASKMakes sure that the child is not left exposedThanks the child / parent for co operationLists th e differences between carotid pulse and jugular pulseTask general inspection of the body with reference to cardiovascular arrangingPRIOR TO THE TASKIntroduce yourself to the child and carer and ask for consent to examineFor inspection, the room should be well lit. Ensure that the lights are turned on and the windows are unfoldThe child should be undressed appropriately to the waist.In older child, the examination is easiest to perform while they sit over the edge of the bed or even on a chair go out the younger child on the parents lap.STEPS OF THE TASKLOOK everydayGeneral well being Well/ Ill looking child care in the surroundings Sick child will not be interestedSize of the child thin small, thin tall, well nourished and tall, well nourished and short.Degree of breathlessness classify as none, moderate or severe surroundings (Equipment) oxygen mask, nasal cannula, endovenous catheter, pulse oximetry, feeding tube/ gastrostomy,LOOK SPECIFICHead look at the size (micr ocephaly or macrocephaly) and shape (dolichocephaly)Face Normal or dysmorphic features, malar flushConjunctiva pallor, jaundice (refer chapter on general examination) speak Using the pen torch, take a quick look in the mouth and look for the presence of age appropriate teeth, abnormal teeth and caries. Ask the child to stick their saliva outwards and upwards towards the poke and examine the tongue for central cyanosis.Hands and fingers pallor clubbing polydactyly and syndactyly Oslers nodes Janeway lesions chip off haemorrhages. Examine both the hands quickly.Difference in colour between limbsPOST- TASKMake sure that the child is not left exposedThank the child / parent for cooperationVIGNETTEAlways think whether the findings merge to form a recognizable clinical syndrome.It is preferable to inspect the child in sunlight than in artificial light.Children with chronic cardiac conditions are usually thin and small for age.Breathlessness is classified as mild when the child has only actors assistant recession, and there is no contraction of sternocleidomastoid or nasal flaring and severe when all three are presentMicrocephaly can be associated with some of the intrauterine infections and hereditary disorders like congenital rubella syndrome and Edwards syndromeDolichocephaly (increased antero-posterior diameter) is seen in ex-pretermsSyndromes with dysmorphic facial featuresDowns syndrome almond molded eyes (due to epicanthal folds) Brushfield spots (light colored spots in the iris) small, flat nose small mouth with a protruding tongue small, low set ears round faces flat occiputTurners syndrome prominent, posteriorly rotated auricles with looped helices and attenuated tragus infraorbital skin creases mildly foreshortened mandibular boneWilliams syndrome broad forehead short nose with broad tip full cheeks wide mouth with full lipsNoonans syndrome downwards slanting eyes with bend eyebrows epicanthal folds broad forehead nose with wide lowly and bulbous tip pointed chinMarfans syndrome long, thin face deep-set eyes down-slanting palpebral fissures receding chin dolichocephaly malar hypoplasia enophthalmosDiGeorge syndrome small ears asymmetric facies small mouth and chinMalar flush plum coloured malar eminencesHutchinson (conical) incisor is seen in congenital syphilis (patent ductus arteriosus) and enamel hypoplasia in Ellis-van Creveld Syndrome (atrioventricular canal, ventricular septal defect, atrial septal defect, and patent ductus arteriosus).Caries tooth may be a cause of infective endocarditis in congenital heart disease.In preaxial polydactyly, the extra digit is on the radial (thumb) side while in postaxial polydactyly, it is on the ulnar (little finger) side of the hand.Oslers nodes are painful, red, raised lesions found on the hands and feet and is seen in infective endocarditisJaneway lesions are nontender, macular lesions, most commonly involving the palms and soles and seen in infective endocarditis.Spl inter hemorrhages appear as narrow, red to reddish-brown lines of blood that run vertically under nails. Splinter hemorrhage can be associated with infectious endocarditis, systemic lupus erythematosus, and traumaOSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains what he/ she is going to do and ask for authorization to examinePositions and exposes the child appropriatelyMakes sure that the room is adequately litTASKLooks for the by-line general pointsGeneral well beingInterest in the surroundingsSize of the childDegree of breathlessnessEnvironment (Equipment)Looks for the following specific pointsHead size and shapeFaceConjunctivaMouthHands and fingersDifference in colour between limbsPOST- TASKMakes sure that the child is not left exposedThanks the child / parent for co operationTask INSPECTION OF THE CHESTPRIOR TO THE TASKIntroduce yourself to the child and carer and ask for allowance to examineFor inspection, the room should be well lit. Ensure that the l ights are turned on and the windows are openThe child should be undressed appropriately to the waist.In older child, the examination is easiest to perform while they sit over the edge of the bed or even on a chairExamine the younger child on the parents lap.STEPS OF THE TASKLook tangentially from foot end of the bed in supine patients and from the sides in sitting patients.Look for the following and commentShape of the Chest symmetrical or asymmetricalSymmetry of chest expansionScarsPulsations Observe for apical whim, parasternal, suprasternal, epigastric pulsations.Spine for scoliosisPOST- TASKMake sure that the child is not left exposedThank the child / parent for cooperationVIGNETTECommon asymmetrical chestsPectus carinatum also called pigeon chest, deformity of the chest characterized by protrusion of the sternum and ribs. It may give as congenital abnormality or in association with genetical disorders such as Marfans syndrome, Morquio syndrome, Noonan syndrome, Trisomy 18, Trisomy 21, homocystinuria, and osteogenesis imperfecta.Pectus Excavatum also called funnel chest, deformity of the anterior smother of the chest producing sunken appearance of the chest. It may occur in rickets, Marfans syndrome and spinomuscular atrophy.Harrisons sulcus horizontal indentation of the chest wall at the lower border of the thorax where the diaphragm attaches to the ribs. It may occur in conditions with increased pulmonary blood flow or chronic asthma.Scars lateral thoracotomy scar results from diaphragm of patent ductus arteriosus, tracheoesophageal fistula repair and Blalock Taussig shunt. Central sternotomy scar is seen after open heart surgery and lobectomy. Children can have drainage scars in epigastrium, subclavian/axillary scars from pacemakers and scars following cardiac catheterization in the groin and neck.PulsationsApical liking will be shifted peripherally due to cardiomegaly, collapse of left lung or fluid in the right pleural cavityParasternal pulsa tions can occur due to right ventricular blowup or enlarged left atrium pushing the right ventricle.The most common cause of suprasternal pulsations is dilated aorta due to aneurysm or markedly increased blood flow.Epigastric pulsation may be seen in thin children, right ventricular hypertrophy and ab aneurysm.Scoliosis should be looked for in the standing and not in sitting positionOSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains what he/ she is going to do and ask for permission to examinePositions and exposes the child appropriatelyMakes sure that the room is adequately litTASKLooks tangentially from foot end of the bed in supine patients and from the sides in sitting patientsLooks for the following points and commentsShape of the ChestSymmetry of chest expansionScarsApical heartbeat, parasternal, suprasternal, epigastric pulsationsSpine for scoliosisPOST- TASKMakes sure that the child is not left exposedThanks the child / parent for co operationTask ta ctual exploration OF THE CHESTPRIOR TO THE TASKIntroduce yourself to the child and carer and ask for permission to examineThe child should be undressed appropriately to the waist.Position the older child so that they sit over the edge of the bed or lie down on the couchExamine the younger child on the parents lap.Warm your hands for palpationSTEPS OF THE TASKBe gentle with palpationApical ImpulsePlace the palm of the livelong hand flat over left chest wall to get a general impression of the point of maximal momentum.Next, lay the ulnar border of the hand on the chest parallel to rib space where the impulse was felt and try to locate the apex.Finally palpate with the fingertip of the superpower or middle finger to localize the apical impulse and cook its character.Use the left hand to palpate the carotid artery to time the apical impulse.With the finger of the right hand still in place over the apex beat, palpate the manubriosternal joint (angle of Louis) which is present just be low the suprasternal notch and is felt as a prominence with the left hand. It corresponds to the second musculus intercostalis space. Slide the index finger and count down the nigh few intercostal spaces until you locate the intercostals space that is level with the apex beat. Look at the position of the apex with reference to the midclavicular line.If the apical impulse is not readily palpable in the supine position, ask the child to lie on their left side.If the apex beat is not still palpable, try on the right side in case of dextrocardia.Parasternal pulsation and raiseWith the fingertips, palpate over the left sternal edge to find the parasternal pulsations.With the child lying in supine position, place a pencil lateral to the left sternal edge and look tangentially for lifting of the pencil.Next, place the base of your hand just lateral to the left sternal edge and palpate for a parasternal heave.If parasternal heave is present, try suppress it by exerting pressure with base of the hand.Thrills are best felt with fingertips. Time the thrill with carotid or brachial pulse. Palpate the following areas.Apex of the heart3rd to fifth intercostal space along the left sternal borderpulmonary area (left second intercostal space)Aortic area (right second intercostal space)Suprasternal areaCarotidsPOST- TASKMake sure that the child is not left exposedThank the child / parent for cooperationVIGNETTEApical impulse is the farthest inferior and lateral maximal cardiac impulse on the chest wall. It results from the heart rotating, moving forwards and striking against the chest wall during systole. Apical impulse is normally felt in the 4th left intercostal space on the midclavicular line. It may be difficult to palpate in obese children and in pericardial effusion.Displaced apexTension pneumothorax and pleural effusion (push apex away from the lesion)Pulmonary fibrosis and collapse (pull towards the side of the lesion) leftover ventricular hypertrophy apex is displa ced down and outRight ventricular hypertrophy apex is displaced outwardsSkeletal abnormalitiesQuality of apical impulse (normal apex lifts the palpating fingers briefly)Sustained (increased amplitude and duration) pressure overload (aortic stenosis)Hyperdynamic or bruising (increased amplitude but not duration) volume overload (mitral incompetence and aortic incompetence)Tapping palpable first heart sound of mitral stenosisParasternal pulsations indubitable 2nd heart sound reflects pulmonary hypertension.Parasternal heave is present in right ventricular hypertrophy or left atrial enlargement pushing the right ventricle.There are three grades of parasternal heave pit I heave identified by lifting of the pencil alone and not the heel of the handGrade II easily identified, can be suppressed with pressureGrade III lifts the heel of the hand and cannot be suppressed with pressureThrill is a palpable murmur that felt like a purring cat. While describing the thrill, describe the si te and phase of cardiac cycle. When thrill is present, the accompanying murmur is by definition at least 4/6 in intensity.OSCE CHECKLISTPRIOR TO THE TASKWashes hands or uses alcohol rubExplains what he/ she is going to do and ask for permission to examinePositions and exposes the child appropriatelyWarms hands beforeTASKPalpates lightApical ImpulsePlaces the palm flat over left chest wall to get a general impressionKeeps the ulnar border of the hand parallel to rib spacePalpates with the fingertip to locate the apical impulsePalpates the carotid artery