Download - Skills in CV1 1
-
8/4/2019 Skills in CV1 1
1/8
Physical Examination Inspection
Anatomical landmarks incardiovascular examination
Body habitus Stature Skin exam Cachectic? Obese? Gait abnormalities
Palpation Percussion Arterial pulses Jugular venous pressure
Congenital problems associated withCV disordersMarfanSyndrome
Aortic aneurysm Aortic regurgitation: classic for
Marfans Mitral regurgitation: can coexist
with AR Pt. tends to be male, tall, with
significant aortic regurgitation
Klinefelter Syndrome Tall stature, long extremities,
eunuchoid Congenital heart diseases
Ventricular septal defect Patent ductusarteriosus Tetralogy of Fallot
Gait AbnormalitiesSeen in:
Cardioembolic strokes Hypertensive CV disease Shy Drager syndrome
Degenerative disease of theautonomic nervous system
Parkinsonian gait
Body Habitus Obesity
Part of metabolic syndrome,which also has hypertension,hypercholesterolemia, diabetes.Can lead to strokes and heartattacks.
Cardiac cachexia, seen in: CHF, especially those with
chronic low output states
Respiration
CHF Orthopnea: patient needs to be
elevated with pillows whilesleeping
Cheyne Stokes respirationwith sleep apnea
COPD The blue bloater of chronic
bronchitis and pink pufferwith emphysema
Cyanosis Peripheral detected in exposed
skin (lips, nose, earlobes, andextremities)
Central cyanosis seen in thetongue, uvula, and buccalmucus membrane Intrapulmonary or
intracardiac right to leftshunting
Edema Generalized edema
Nephrotic syndrome and sepsis Heart problem or vascular
disease Dependent edema
Right heart failure Ascites in the absence of edema of
the lower extremities Liver disease, ie, cirrhosis or
hepatitis
Skin CHF
Slate or bronze pigmentation ofthe skin (hemochromatosis)
Mild jaundice Hypercholesterolemia
Arcus: white rim around iris Xanthelasma
Acute rheumatic fever Erythema marginatum (pink
rings on the trunk and innersurfaces of the arms and legs)
Subject:Physical DiagnosisTopic: Skills in CVS1Lecturer:Dr. TironaDate of Lecture:September 7, 2011
Transcriptionist: Original SinEditor:deray loverPages: 7
SY2011-2012
-
8/4/2019 Skills in CV1 1
2/8
Rheumatic nodules Bacterial endocarditis
Conjunctival hemorrhages,purpuric skin rash, petechiallesions, and splinterhemorrhages
Osler nodes (palms, soles of thefeet and pads of the fingers and
toes, tender and result frommicroemboli Janeway lesions (non tender,
raised hemorrhagic nodules onthe palms of the hands andsoles of the feet.
Funduscopy Hypertensive retinopathy
Grade I Minimal irregularity of the
arterial lumen and narrowing
with increased light reflex Grade II AV nicking with more
marked narrowing andirregularity of the arteriolesand distention of veins
Grade III Flame shaped hemorrhages
and fluffly cotton woolexudates
Grade IV Papilledema with another
changes from grades Ithrough III
Below: Grade II
Below: Grade III
Below: Grade IV
Inspection (see diagram on lastpage)
Anatomical landmarks Midsternal line Parasternal borders Midclavicular line Anterior axillary line Midaxillary line Posterior axillary line Suprasternal notch: visible
aortic pulsations and aortic
aneurysms may be visible here Subxiphoid area: enlargement
of left ventricle can beappreciated upon palpation
Aortic area: 2nd ICS,midclavicular line
Pulmonic area Mitral area: 5th ICS,
midclavicular line Tricuspid area: 3rd and 4th ICS
left parasternal border Point of Maximal Impulse (PMI)
5th ICS left midclavicular line In 50% of individuals, it may
not be visible. In whichcase, palpate for apex beat(next)
Apex beat Determined by palpation 5th ICS LMCL
Parasternal borders Midclavicular line
Palpation Pulsations of the heart and great
arteries are transmitted to thechest wall
Precordial movements should betimed with simultaneously palpatedcarotid pulse or auscultated heartsounds
Examination carried out with thechest completely exposed andelevated to 30 degrees
Examination of precordial pulsations Best performed in patients insupine position with head andtrunk elevated 45 degrees
Examiner positioned in the rightside of the supine patient
Rotating the patient in the leftlateral decubitus position with theleft arm elevated over the headcauses the heart to move laterally
-
8/4/2019 Skills in CV1 1
3/8
and increases the palpability ofboth normal and pathologicalthrusts of the left ventricle
Above: Structures that can be palpated Short arrow: aortic arc Arched arrow: pulmonary artery Straight and long arrow: left atrial
appendage Open arrows: area of left ventricle
Palpation The left ventricular impulse
Apex beat normally producedby left ventricular contractionand is the lowest and mostlateral point on the chest atwhich the cardiac impulse isappreciated
5th ICS, LMCL (left midclavicularline)
May not be palpable in thesupine position in as many ashalf of all normal subjects, apexbeat is palpable in the leftlateral decubitus position.
Abnormal Precordial Pulsations Pronounced epigastric or
subxiphoid pulsation Right ventricular failure Abdominal aortic aneurysm
A visible pulsation over the right 2nd
ICS or right sternoclavicular joint Aneursym of the ascending
aorta Suprasternal pulsation
Aneurysm of the arch of theaorta
A visible pulsation over the left 2nd
or 3rd ICS Dilated pulmonary artery
Palpation Right ventricle
Subxiphoid area Pulmonary artery
2nd ICS, LMCL (left midclavicularline)
Thrills The flat of the hand or the
fingertips usually bestappreciate thrills which arevibratory sensations that arepalpable manifestations of loudharsh murmurs having low tomedium frequency componentsseen in stenotic valves.
Percussion Palpation is far more helpful than is
percussion in determining cardiacsize
Useful in the absence of apicalsystolic beat Pericardial effusion Dilated cardiomyopathy Heart failure Marked displacement of the
hypokinetic apical beat Percussion carried out from mid to
lateral or vice versa within theintercostals spaces
Normal cardiac area of dullness iswithin 10 cm from midsternal lineto the lowest most lateral border ofthe heart
Examination of the arterial pulse Arterial pulses
Carotid: do one at a time
please lest the patient shouldfaint or stroke
Brachial, radial, and ulnar Femoral, popliteal,
posterialtibial, and dorsalispedis(absent 40% of the time)
Assess Rigidity and elasticity of the
arteries Done by rolling the vessel under
underlying tissue The more rigid the artery,
the less compressible
Arterial pulses rate and rhythm Arrhythmias
Sinus bradycardia, junctionalrhythm, complete AV block
Ventricular premature beats Bigeminies
Atrial fibrillation Irregularly irregular pulses
Arterial pulses: variations in thecharacter of the pulse
Pulsusalterans Alternating strong and weak
pulses in the presence of aregular pulse
Commonly caused by leftventricular systolic failure
Other causes: Aortic stenosis
-
8/4/2019 Skills in CV1 1
4/8
Hypertrophic obstructivecardiomyopathy
Ischemia Pulsusparadoxus
Substantial reduction in theamplitude of the pulse duringinspiration
Inspiratory decrease in arterialpressure exceeding 12 to 15mmHg
Causes: Cardiac tamponade COPD Rarely in PE, pregnancy,
marked obesity, partialobstruction of the SVC.
Above:A: Normal. Brisk and rapid upstroke thatoccurs at systole.Dicrotic notchrepresents aortic valve closure.B: Aortic stenosis. Because the aorticvalve does not open up all the way, thereis a delay in the upstroke and theamplitude of the stroke is diminished.
They pulse is delayed and weak, hence,pulsustardus.C: Aortic regurgitation:pulsusbisferiens. There are 2 systolicpeaks.D: Hypertrophic cardiomyopathy: Alsoexhibiting pulsusbisferiens duringsystole, but lower in amplitude than withAR.E: Chronic heart failure: 2 peaks, one insystole and one in diastole.
Above: Pulsusalternans: Alternating
strong and weak pulses. Pulsusparadoxus: substantial
reduction in the amplitude of thepulse during inspiration. It iselicited using asphygmomanometer. Take not ofthe 1stKorotkoff sound. Thereshouldnt be an inspiratorydecrease of >10 mmHg. If there is>10mmHg decrease during normalrespiration that is a (+)pulsusparadoxus. Seen in cardiactamponade, severe COPD,sometimes pulmonary embolismand pregnancy or partialobstruction of SVC.
Arterial Pulses Changes in Contour Pulsustardus
Delayed upstroke in theascending limb of the carotidpulse
Aortic stenosis
-
8/4/2019 Skills in CV1 1
5/8
Pulsusparvus Aortic stenosis Small amplitude pulse
Pulsusbisferiens Presence of 2 positive impulses
near the peak of the arterialpulse Aortic regurgitation
Altered Characteristic of the ArterialPulse and their Clinical Significance
Pulsusalternans Suspect acute or chronic
reduction in left ventricularsystolic function
Pulsustardus Suspect fixed left ventricular
outflow tract obstruction suchas valvular aortic stenosis
Pulsusbisferiens Suspect aortic regurgitation,
large PDA, HOCM, completeheart block, hyperkinetic heart
syndrome Pulsusparadoxus
Suspect tamponade,emphysema
Dicrotic pulse Suspect low output syndrome
with increased systemicvascular resistance
Commonly seen in patients withsevere heart failure.
Sign characteristic of severe aortic
regurgitation Corrigan or Water hammer pulse
Abrupt upstroke followed byrapid collapse
Traube sign Pistol shot sounds heard over
the femoral artery when thestethoscope is placed on it
Duroziez sign
Systolic murmur heard over thefemoral artery when the arteryis compressed proximally; adiastolic murmur heard whenthe artery is compresseddistally
Quincke sign Phasic blanching of the nailbeds
Hill sign Systolic pressure in the lower
extremity exceed that in thearms by more than 20 mm Hg
Becker sign Visible pulsations of the retinal
arterioles Mueller sign
Pulsating uvula
Examination of the Jugular venouspulse and pressure
Essential to assess hemodynamicchanges in the right side of theheart
Done with the patient in a 45degree semirecumbent position
IJV pulse located medial to themandibular portion of thesternocleidomastoid muscle
IJV is valveless so is morerepresentative of right atrialpressure than EJV, which has avalve.
Difference between venous andcarotid artery pulsation
Venous pulse Sharp inward movement Double undulation character
during sinus rhythm Gentle compression obliterates
the venous pulse Venous pulse amplitude
decreases on inspiration Carotid arterial pulse
Sharp outward movement Arterial pulse remain visible on
gentle compression Arterial pulse amplitude does
not change on respiration
JVP Normal right atrial pressure is 9 cm
of water
Jugular venous pulse waverecordings
Take note of the uppermost visiblepulsation of the jugular vein and thelandmark used is the sternal angle ofLouis. The measurement that is obtainedwill have 5 cm added to it. (eg,measurement obtained is 3 cm3cm +5cm = 8cm).
Positive waves A wave
-
8/4/2019 Skills in CV1 1
6/8
Caused by transmitted rightatrial pressure to the jugularveins during right atrialsystole
Cannon waves seen incomplete heart block
C wave Recognized with the onset of
right ventricular systole andoccurs from bulging of thetricuspid valve into the rightatrium
V wave Caused by the rise of in right
atrial and jugular venouspressure due to continuedinflow of blood to the venoussystem during rightventricular systole when thetricuspid valve is still closed
Tricuspid regurgitation Negative waves X descent Results from right atrial
relaxation Prominent in patients with
cardiac tamponade Y descent Caused by opening of the
tricuspid valve and the rapidflow of blood from the rightatrium to the right ventricle
Rapid and deep in patientswith constrictive pericarditis Kussmaul sign Increase in JVP during
inspiration Seen in: Constrictive pericarditis Right ventricular
infarction Severe right heart failure
Hepatojugular Reflux Test With the patient breathing
normally in the semirecumbentposition, firm pressure is applied
with the palm of the hand to theRUQ of the abdomen for at least 10seconds
Normal patients exhibit slightincrease in JVP with rapid return tobaseline in less than 10 seconds
The abnormal hepatojugular refluxis defined when there is a rapidincrease in JVP that remainselevated by 4 cm or more untilabdominal compression isreleased.
Abnormalities of the venous pressureand pulse and their clinicalsignificance
Positive hepatojugular reflex Suspect CHF, particularly left
ventricular dysfunction Elevated systemic venous pressure
without obvious X or Y descent andquiet precordium andpulsusparadoxus Suspect cardiac tamponade
Elevated systemic venous pressurewith sharp Y descent, Kussmaulsign, and quiet precordium Suspect constrictive pericarditis
because right ventricle is so stiffso it gives rise to a sharp Ydescent.
A prominent A wave with orwithout elevation of mean systemicvenous pressure Exclude tricuspid stenosis, right
ventricular hypertrophy due topulmonary stenosis, andpulmonary hypertension
A prominent V wave with a sharp Y
descent Suspect tricuspid regurgitation Sometimes in severe tricuspid
regurgitation there will bemerging of the C and V wavesto create a CV wave.
-
8/4/2019 Skills in CV1 1
7/8
-
8/4/2019 Skills in CV1 1
8/8
Above: Landmarks__________________________________________________________________________________
End of transcription