sistem cardiovasculer 7

8/11/2019 Sistem Cardiovasculer 7

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Cardiovascular Examination


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The Normal Heart - Coronary Artery Anatomy

Left Main CA

Circumflex

Left Anterior Descending CA

Right CA

Marginal Branch

Layers of the Arterial Wall

PENDAHULUAN.

Anatomi arteria coronarria dan jantung normal


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Pengertian volume ventrikel kiri

End Systolic Volume (ESV)

Volume akir sistol

(akir kontraksi ventrikel)

Stroke Volume (SV) = EDV - ESV

Ejection Fraction (EF) = SV

EDV

Normal darah yg dipompoventrikel kiri: 62%

Hambatan pompa jantung

adalah indikator terbaik dari

kemampuan kerja jantung dan

prognosa kondisi jantung.

End Diastolic Volume EDV)

Volume akir diastol

(volume akir pengisian ventrikel)


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1. Cardiac Output (COP) = Heart Rate X Strooke Volumes

2. Cardiac Index= COPbody surface area

3. Preload:Volume darah yang masuk ventrikel saat diastole (End

Diastole Volume= reflects stretch of the cardiac muscle cells)

4. Afterload: Tahanan ventricular selama systole (Kemampuanotot ventrikel untuk mendorong darah ke aorta)

5. Frank Starling Law of the Heart - Kemampuan kontraksi otot

ventrikel terbesar mulai pre load secara bertahap.

6. Myocardial Contractility

Kekuatan kontraksi otot jantung danperkembangannya sampai preload.

7. Regulated by:

1. sympathetic nerve activity (most influential)

2. catecholamines (epinephrine norepinephrine)

3. amount of contractile mass4. drugs

Pengertian


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Starlings Law of the Heart and Contractility

SV

leftventricular

performance

preload (venous return)

ucontractility

normal

contractility

d contractility

(heart failure)


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0

120

dP/dt dP/dt

Normal

Heart Failure

(lemah jantung)

dP/dt = change in pressure per unit of time

Gambaran

peningkatan saatdan akhir tekanan

diastol

Curves saat tekanan ventrikel

indikasi kemampuan kontraksi

Dan fungsi jantung.

Perubahan tekanan per tahap

Pada jantung normal SV= 60-80 CC Jantung terlatih SV= 90-250 CC

Jantung sakit SV = 40-50 CC


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Kemampuan kontraksi

dipengaruhi oleh

1. Kekuatan otot jantung.

2. Fleksibilitas otot jantung.

3. Tahanan perifer (aorta, jaringan, vena

4. Peningkatan max selisih preload danafterload (dP/dt from LV pressure curve)

5. Pengaruh Positive/negative iontropic.

6. Ejection fraction (EF = SV/EDV) used in

clinical practice7. Hormonal (epineprin atau norepineprin)

increase contractility assumed with

increase EF with Ca, NE, digitalis,

exercise;with [K]o, [Na]o


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Contractility related to :

1. sympathetic adrenergic nerves

a. catecholamines: epinephrine

norepinephrine

b. Obat: digitalis

sympathomimetics

anesthetics, barbiturates

2. Hilangnya kemampuan kontraksi otot

misalnya MCI, cardiomyopathy.


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1. Perbedaan tekanan oksigen antara darah arteri dan vena.

Arteriovenous Oxygen Difference (AVO2D)

PENGUKURAN DALAM ml % - ml O2/ 100 ml blood

2. Oxygen Consumption (VO2)Jumlah oksigen yang

dibutuhkan darah untuk metabilism dalam menghasilkan

energi/

1. absolute measures: L / min , ml / min2. relative measures: ml / kg body wt. / min

3. Fick equation: VO2= COP X Selisih O2 arteridan vena

3. Maximum Oxygen Consumption (VO2max)Jumlah oksigenyang mampu disediakan secara maksimal per menit untuk

metabolism dalam menghasikan energi

1. Tak langsung 220-usia = 60-80 % VO2 maks.

2. Spirometri .

Definisi


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4. Myocardial Oxygen ConsumptionVO2of

the heart muscle (myocardium)"estimated" by RPP: HR X Sistole BP.

5. Functional Aerobic Impairment:

predicted VO2max - attained VO2max

predicted VO2max

mild 27% - 40%

moderate 41% - 54%

marked 55% - 68%severe > 69%

Definisi


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1. Systolic Blood Pressure (SBP)pressure measured in brachial

artery during systole (ventricular emptying and ventricular

contraction period)

2. Diastolic Blood Pressure (DBP)pressure measured in brachial

artery during diastole (ventricular filling and ventricular

relaxation)

3. Mean Arterial Pressure (MAP)"average" pressure throughoutthe cardiac cycle against the walls of the proximal systemic

arteries (aorta)

1. estimated as: .33(SBP - DBP) + DBP

4. Total Peripheral Resistance (TPR) - the sum of all forces that

oppose blood flow

1. length of vasculature (L)

2. blood viscosity (V)

3. hydrostatic pressure (P)

4. vessel radius (r)

Definitions

TPR = ( 8 ) ( V ) ( L )

(p) ( r4 )


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Perform a patient introduction
http://www.osceskills.com/resources/1intro.jpg


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2. Firstly, you should start by observing the

patient from the end of the bed. You should

note whether the patient looks comfortable.

Are they cyanosed or flushed? Is their

respiration rate normal? Are there any clues

around the bed such as PCA machines, GTN

sprays or an oxygen mask? You shouldcomment on each of the areas to the

examiner.


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Observe the patient from the end of the bed
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3. Next you should look at the patients hands.

Initially note how warm they feel as this gives

an indication of how well perfused they are.

Particular signs which you should be looking

for are nail clubbing, splinter haemorrhages,

palmar erythema and nicotine staining.


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Look at the patients hands
http://www.osceskills.com/resources/3hands.jpg


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4. Now is a good time to take the radial pulse. It isnot a suitable pulse for describing the characterof the pulsation, but can be used to assess therate and rhythm. At this point you should also

check for a collapsing pulsea sign of aorticincompetence. Remembering to check that thepatient doesnt have any problems with theirshoulder, locate the radial pulse and place your

palm over it, then raise the arm above thepatients head. A collapsing pulse will present asa knocking on your palm.


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Locate the radial pulse and place your palm

over it
http://www.osceskills.com/resources/4-1pulse.jpg


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Raise the arm above the patients head
http://www.osceskills.com/resources/4-2collapsing.jpg


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5. Examine the extensor aspect of the elbow forany evidence of xanthomata.

6. At this point you should say to the examiner thatyou would like to take the blood pressure. Theywill usually tell you not to and give you thevalue.

7. Next you should move up to the face. Look inthe eyes for any signs of jaundice (particularly

beneath the upper eyelid), anaemia (beneaththe lower eyelid) and corneal arcus. You shouldalso look around the eye for any xanthelasma.


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Look in the eyes for any signs of jaundice,

anaemia, and corneal arcus
http://www.osceskills.com/resources/5eyes.jpg


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8. Whilst looking at the face, check for any

malar facies, look in the mouth for any signs

of anaemia such as glossitis, check the colour

of the tongue for any cyanosis, and around

the mouth for any angular stomatitis

another sign of anaemia.


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Exam around the patient's face
http://www.osceskills.com/resources/6tongue.jpg


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9. Next, move to the patients neck to assess theirjugular venous pressure (JVP). Ask them to turn theirhead to look away from you. Look across the neckbetween the two heads of sternocleidomastoid for a

pulsation. If you do see a pulsation you need todetermine whether it is the JVPif it is then thepulsation is non-palpable, obliterable by compressingdistal to it and will be exaggerated by performing thehepatojugular reflex. Having warned the patient that

it may cause some discomfort, press down on theliver. This will cause the JVP to rise further. If youdecide the pulsation is due to the JVP, note its verticalheight above the sternal angle.


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Assess the patient's jugular venous pressure

(JVP)
http://www.osceskills.com/resources/7jvp.jpg


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10. It is now time to move the examination to the chest,or praecordium. Start by inspecting the area,particularly looking for any obvious pulsations,abnormalities or scars, remembering to check the

axillae as wel11. Palpation of the praecordium starts by trying to locatethe apex beat. Start by doing this with your entirehand and gradually become more specific until it isfelt under one finger and describe its location

anatomically. The normal location is in the 5thintercostals space in the mid-clavicular line. However,it is not uncommon to not feel the apex beat at all.


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Try to locate the apex beat
http://www.osceskills.com/resources/8apex.jpg


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12.Next you should palpate for any heaves or

thrills. A thrill is a palpable murmur whereas

a heave is a sign of left ventricular

hypertrophy. A thrill feels like a vibration anda heave feels like an abnormally large beating

of the heart. Feel for these all over the

praecordium.


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Palpate for any heaves or thrill
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13. Palpate for any heaves or thrill

14. You now move onto auscultation. This is done for all four valves of the heart inthe following areas:

Mitral valvewhere the apex beat was felt.

Tricuspid valveon the left edge of the sternum in the 4th intercostal space.

Pulmonary valveon the left edge of the sternum in the 2nd intercostal space.

Aortic valveon the right edge of the sternum in the 2nd intercostal space.

15. You should listen initially with the diaphragm noting how many heart sounds youcan hearare there any extra to the two normal sounds? Are there anymurmurs? Are the heart sounds normal in character? Can you hear any rub? Ifyou hear any abnormal sounds you should describe them by when they occurand the type of sound they are producing. Feeling the radial pulse at the sametime can give good indication as to when the sound occursthe pulse occurs atsystole. Furthermore, if you suspect a murmur, check if it radiates. Mitralmurmurs typically radiate to the left axilla whereas aortic murmurs are heardover the left carotid artery.


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16.You may also wish to listen with the bell of

your stethoscope for any low pitched

murmurs.

Mitral valve location
http://www.osceskills.com/resources/10-1mitral.jpg


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Tricuspid valve location
http://www.osceskills.com/resources/10-2tricuspid.jpg


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Pulmonary valve location
http://www.osceskills.com/resources/10-3pulmonary.jpg


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Aortic valve location
http://www.osceskills.com/resources/10-4aortic.jpg


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17.To further check for mitral stenosis you can

lay the patient on their left side, ask them to

breathe in, then out and hold it out and

listen over the apex and axilla with the bell ofthe stethoscope.

Further check for Mitral Stenosis
http://www.osceskills.com/resources/11mitral2.jpg


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18.Aortic incompetence can be assessed in a

similar way but ask the patient to sit forward,

repeat the breathe in, out and hold exercise

and listen over the aortic area with thediaphragm.

Assess for Aortic incompetence
http://www.osceskills.com/resources/12aortic2.jpghttp://www.osceskills.com/resources/12aortic2.jpg


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19.Finally you should assess for any oedema.

Whilst the patient is sat forward, feel the

sacrum for oedema and also assess the

ankles for the same.

Assess for any oedema
http://www.osceskills.com/resources/13oedema.jpghttp://www.osceskills.com/resources/13oedema.jpg

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