Examination of CVS PDF

Examination of the Cardiovascular System Prof. Dr. Beste Özben Sadıç 1 1. BP 6. JVP 2. Pulses – Height and waveform – Rate and rhythm 7. Carotids 3. Inspection – Palpate and – Form...

Examination of the Cardiovascular System Prof. Dr. Beste Özben Sadıç 1 1. BP 6. JVP 2. Pulses – Height and waveform – Rate and rhythm 7. Carotids 3. Inspection – Palpate and – Form clinical auscultate impressions 8. Peripheral pulses – Disease likelihood – Palpate and listen for 4. Palpation bruits – Precordium and apex 9. Examine extremities – Location, size, – Arterial/venous abnormal impulses insufficiency/trophic 5. Auscultation changes – Precordium and apex 2  Vital signs Heart rate Respiratory rate Blood pressure Oxygen saturation Temperature  Blood Pressure Assessment: Patient preparation and posture Standardized technique: Posture The patient should be calmly seated for at least 5 minutes, with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed. The patient should be instructed not to talk prior and during the procedure. 4  Blood Pressure Assessment: Patient preparation and posture 5  Blood Pressure Assessment: Patient preparation and posture Standardized technique: Patient 1. No caffeine in the preceding hour. 2. No smoking or nicotine in the preceding 15-30 minutes. 3. No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops). 4. Bladder and bowel comfortable. 5. Quiet environment. Comfortable room temperature. 6. No tight clothing on arm or forearm. 7. No acute anxiety, stress or pain. 8. Patient should stay silent prior and during the procedure. 6 Recommended Technique for Measuring Blood Pressure Select a cuff with the appropriate size 7 Recommended Technique for Measuring Blood Pressure – Locate brachial and radial pulse – Position cuff at the heart level – Arm should be supported 8 Recommended Technique for Measuring Blood Pressure – To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 20-30 mmHg above level of disappearance of radial pulse – Place stethoscope over the brachial artery 9 Recommended Technique for Measuring Blood Pressure – Drop pressure by 2 mmHg / sec Appearance of sound (phase I Korotkoff) = systolic pressure – Record measurement – Drop pressure by 2 mmHg / beat Disappearance of sound (phase V Korotkoff) = diastolic pressure – Record measurement – Take 2 blood pressure measurements, 1 minute apart 10 Recommended Technique for Measuring Blood Pressure Korotkoff sounds 200 No sound 180 Systolic BP Clear sound Phase 1 160 Muffling Phase 2 Auscultato 140 No sound ry gap 120 Muffled sound Phase 3 100 Muffled sound Phase 4 80 Diastolic BP 60 No sound Phase 5 Possible readings: 40 184 / 100 136 / 100 20 184 / 86 = correct 0 136 / 86 mm Hg 11 12 13 14 15 What are the indications for checking BP in the lower extremities? – Hypertensive patient under 40 years of age. – Elderly patient with suspected peripheral arterial disease How do you do it? – Thigh cuff-auscultate over popliteal artery – Large arm cuff around calf (bladder posterior) - palpate tibialis posterior or dorsalis pedis Which is normally higher- arm or leg BP? 16  Ankle-Brachial Index Resting and post exercise Systolic Blood Pressure in ankle and arm. – Normal ABI > 1 – ABI < 0.9 has 95% sensitivity for angiographic PVD – ABI 0.5- 0.84 correlates with claudication – ABI < 0.5 indicates advanced ischaemia 17 Pulse 18  Retinal Carotids Brachial Ulnar Radial Femoral Popliteal Posterior Tibial Dorsal Pedis 19 Checking Pulse (Cranial to caudal)  Feel & Describe the Pulse Rate Normal sinus 60-100 bpm Sinus bradycardia < 60 bpm Sinus tachycardia > 100 bpm Regularity Sinus arrhythmia- varies with respiration Intermittent irregularity –ectopic beats Continuously irregular (irregularly irregular – atrial fibrillation) 21 Feel Pulse Volume & Contour Palpate at large vessels: Forearm/Brachial/Carotid/Femoral Describe: Volume: Normal/increased/decreased Slow rising +/- brachial-radial delay (aortic stenosis -AS) Collapsing or water hammer pulse - (aortic regurgitation -AR) Bifid (bisferiens –AS/AR or HCM) – Pulsus paradoxus Tamponade COPD – Pulsus alternans LV dysfunction 22 Type of pulse Pulse characteristics Most likely cause Regularly irregular – 2nd-degree heart block, ventricular bigeminy Irregularly irregular – Atrial fibrillation, frequent ventricular ectopics Slow rising Low gradient upstroke Aortic stenosis Waterhammer, collapsing Steep up and down stroke Aortic regurgitation, patent (lift arm so that wrist is ductus arteriosus above heart height) Bisferiens A double-peaked pulse – the Aortic regurgitation, second peak can be smaller, hypertrophic cardiomyopathy larger, or the same size as the first Pulsus paradoxus !!!!!!! An exaggerated fall in pulse Cardiac tamponade, acute volume on inspiration (>10 mm asthma Hg on sphygmomanometry) Bounding Large volume Anemia, hepatic failure, type 2 respiratory failure (high CO2) Pulsus alternans Alternating large and small Bigeminy, left heart failure 23 volume pulses – small pulse with a slow upstroke (pulsus tardus): aortic stenosis – bounding, rapidly rising and collapsing pulse (reffered to a waterhammer pulse or Corrigans pulse: result of aortic regurgitation – pulsus alternans: alterning strong and weak pulses at regular intervals: it frequently reflects LVF – pulsus bigeminus: alterning strong and weak pulses at irregular intervals: consequence of extrasystolic bigeminia – pulsus paradoxus: smaller pulse amplitude during inspirium: - it is the consequence of exaggerated fall in systolic BP of greater than 10 mmHg during inspiration – it is present in heart tamponade and constrictive pericarditis  Inspection Cyanosis Clubbing Xanthoma and xanthelasma Arcus senilis Stigmata of endocarditis Pectus excavatum/body habitus Anemia, jaundice 25  Cyanosis Blue or blue-gray discoloration of a mucosa and/or skin due to an abnormal amount of deoxygenated Hb or metHb in capillary vascular bed – 5g and more of deoxygenated Hb per 1dl of blood in small superficial vessels leads to cyanosis – Development of cyanosis is less probable in people suffering from anemia and more probable in people with polycythemia – Cyanosis can be caused by different mechanisms: - decreased oxygenation of blood in the lungs - increased consumption of O2 by tissue - decreased speed of blood flow - drug overdose-nitrates, nitrites - due to deposition of melanin stimulated by silver iodide  Cyanosis Central cyanosis: poor gaseous exchange in the lungs -pulmonary disease, pulmonary edema, right to left shunt CHD Peripheral cyanosis: vasoconstriction  Cyanosis/Clubbing Cyanosis Clubbing 30 Differential Diagnosis of Clubbing  Cyanotic congenital heart disease  Lung disease  Cystic fibrosis  Interstitial fibrosis  Malignancy  Sarcoidosis  Bronchiectasis  Hyperthyroidism  GIS (Ulcerative colitis, Chron’s disease, 31 32 Peripheral signs associated with infective endocarditis Peripheral sign Description Cardiac association Clubbing Broadening or thickening Infective endocarditis, of the tips of the fingers cyanotic congenital heart (and toes) with increased disease lengthwise curvature of the nail and a decrease in the angle normally seen between the cuticle and the fingernail Splinter hemorrhages Streak hemorrhages in Infective endocarditis nailbeds Janeway lesions Macules on the back of the Infective endocarditis hand Osler's nodes Tender nodules in Infective endocarditis fingertips 33 34 35 36 37  Facial signs associated with cardiac conditions Possible cardiac Facial sign Description association Malar flush Redness around the cheeks Mitral stenosis Xanthomata Yellowish deposits of lipid Hyperlipidemia around the eyes, palms, or tendons Corneal arcus A ring around the cornea Age, hyperlipidemia Proptosis Forward projection or Atrial fibrillation displacement of the eyeball; occurs in patients with Graves' disease 38 Malar flush 39 40  Arcus senilis (juvenilis) Arcus juvenilis. This ring is associated with premature atherosclerosis 41 Pigmentation due to amiodarone 42  Marfan Syndrome Body Habitus Tall/thin/long facies Long fingers Ligamentous laxity Scoliosis/kyphosis Pectus excavatum/carinatum Ectopia lentis Narrow long facies High arched palate 43  Cardiac manifestations of genetic disorders Genetic disorder Associated cardiac manifestation Marfan's syndrome Aortic regurgitation (aortic dissection) Down's syndrome ASD, VSD Turner's syndrome Coarctation of the aorta Spondyloarthritides, eg, ankylosing spondylitis Aortic regurgitation ASD: atrial septal defect; VSD: ventricular septal defect. 44  Precordial Palpation Parasternal: Lift: RV enlargement or severe MR Thrill: VSD, HOCM Palpable P2 (ULSB): pulmonary hypertension Apex Location Size 45 Precordial movements – sign of ventricular hypertrophy and increased myocardial contractility Pathomechanism: – LV hypertrophy the apical impulse is more sustained, more forceful, and larger point of maximal impulse done by LV is displaced laterally to the left and down-ward – RV hypertrophy produces substernal heave or a systolic lift of the sternum Sequence of Precordial Palpation Sequence same as for Auscultation: Upper right sternal border -2ICS (intercostal space) Upper left sternal border - 2ICS Parasternal (left sternal border 3rd - 5th ICS) Apex Apex left decubitus (patient rolled over halfway) Apex upright leaning forward 47 48  Palpation - Apex  Apex:  Palpable in 1 of 5 adults < age 40  Best felt with fingertips or finger pads (NOT palms)  Maximal point of impulse is the lowermost lateral point a pulsation is felt.  Supine, torso at 450  Normal location: midclavicular line at the 5th intercostal space  No more than 10 cm from mid-sternal line in the supine position  Left decubitus position not reliable for apical location (Left lateral decubitus position enhance the pulse sensation)  Early systolic over an are a of a coin  No larger than 3 cm (about 2 finger width) 49  Apex-Dynamic Qualities LV impulse moves outward like a ping pong ball protruding between the ribs In severe aortic regurgitation ,a typically high and conical pulsation can be palpated. It is called as ‘’choc en dome’’ Apex moves outward for the first third of systole and falls away rapidly Lasts for no more than 2/3 of systole Sustained apex: – > 2/3 systole - hangs out to S2 – correlates with LV pressure overload – Aortic stenosis, Left Ventricular Hypertrophy or Left Ventricular systolic dysfunction 50  Apex–Dynamic Abnormalities Hyperdynamic Apex: correlates with volume overload AR/MR Palpable S4 (atrial kick) – stiff LV – Loss of LV compliance – LVH 2o Hypertension – Aortic Stenosis – Hypertrophic Cardiomyopathy Palpable S1 (Mitral stenosis) Palpable non-ejection click (Mitral Valve Prolapsus) 51  Palpation Thrill Thrill are palpable murmurs some what similar to the sensation on the throat a purring cat. Thrills are actually palpable fine vibrations, most commonly produced by blood from one chamber of the heart to another through a restricted or narrowed orifice, it may occur in systole, diastole, presystole and at times may be continuous. 53  Palpation Any thrill should be described as to its location, its time in cardiac cycle, and its mode of extension or transmission. The intensity of the thrill varies according to the velocity of the blood, the degree of narrowing of the orifice and which it is produced and difference in pressure between the two chambers of the heart. 54  Palpation Quality of a thrill depends on the frequency of vibration producing it, rapid vibrations result in fine thrills whereas slower vibrations produce coarser thrill. 55  Palpation Restricted or narrowed orifice produces thrill according blood velocity Intensity degree of narrowing varies to gradient between two chambers 56 Auscultation 57  Auscultation- Approach The patient should be in a supine with torso elevated to 45°. Ask the patient to refrain from speaking while the heart sounds are being assessed. The radial pulse should be palpated while auscultation is performed. If heart sounds are weakly audible, ask the patient to hold their breath after exhaling. Assess the following: Location, timing, changes in intensity, and splitting of heart sounds Abnormal heart sounds Murmurs  Auscultation Use the diaphragm for high pitched sounds and murmurs – Use firm pressure to bring out high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs – Use light pressure to bring out low pitched sounds and murmurs If using tunable diaphragm – Firm pressure for high pitched sounds – Light pressure for low pitched sounds 59  Sequence of Auscultation Upper right sternal border (URSB) with diaphragm Upper left sternal border (ULSB) with diaphragm Lower left sternal border (LLSB) with diaphragm Apex with diaphragm and then bell Apex - left lateral decubitus position with bell Lower left sternal border (LLSB)- sitting, leaning forward, held expiration with diaphragm 60 61  Basic Auscultation 1.Listen with the diaphragm at the right 2nd interspace near the sternum (aortic area). 2.Listen with the diaphragm at the left 2nd interspace near the sternum (pulmonic area). 3.Listen with the diaphragm at the left 3rd, 4th, and 5th interspaces near the sternum (tricuspid area). 4.Listen with the diaphragm at the apex (PMI) (mitral area). 5.Listen with the bell at the apex. 6.Listen with the bell at the left 4th and 5th interspace near the sternum.  Mesocardiac area (Erb’s point) This area is placed at the left sternal border of the 3rd and 4th intercostal space.It is also called as Erb’s point. It can be determined as the middle part of the line connecting the aortic and mitral area.Usually this point is at the cross-section of the left sternal border and 3rd and 4th intercostal space. Especially the murmurs of aortic regurgitation and pulmonary insufficiency are heard in this area and can be confused with each other. The murmurs of aortic regurgitation increases with expiration. But on the contrary, pulmonary regurgitation murmur increases only with inspiration.These murmurs can be differentiated with this respiratory finding. 63 Heart sounds – First heart sound – Second heart sound – Third heart sound – develops during fast filling of ventricle in early phase of diastole (normal in children, after 40 think of systolic heart failure) – Fourth heart sound – it is present at the end of ventricular diastole due to pushing the blood from atrium by its contraction (diastolic heart failure, AS, acute MR) – Clicks – Prosthetic valve sounds – Pericardial rub  Identify Heart Sounds S1 – closure of mitral and tricuspid valves S2 – closure of aortic (A2) and pulmonary valves (P2) S3 – early diastolic filling of volume overloaded ventricle – Low pitched, bell, apex S4 – pre-systolic sound – atrial contraction filling non-compliant ventricle – Low pitched, bell, apex 66 Normal First & Second Sounds 68 69 70  Reversed splitting Reversed splitting of S2 (i.e., splitting of S2 is heard during expiration and no splitting is heard during inspiration) is associated with obstruction of aortic outflow as in subaortic hypertrophic cardiomyopathy. In this instance, aortic valve closure is delayed during expiration because of outflow obstruction and closes after the pulmonic valve (i.e., P2 comes before A2 during expiration). During inspiration P2 is somewhat delayed and A2 comes somewhat earlier as in the normal situation and S2 is no longer split. 71 72  Fixed splitting Fixed splitting of S2 (i.e., splitting of S2 into A2 and P2 components is heard both during expiration and inspiration) is pathognomonic of atrial septal defect with a left to right shunt. 73 74  A-Normal B-Wide C-Fixed D-Paradoxical Splits  Abnormal sounds-1 The low-pitch third heart sound S3 that occurs early in diastole is normal in young and fit healthy subjects but indicates abnormal ventricular filling in patients with heart disease. The equally low-pitch fourth heart sound S4 occurs later in diastole and is due to atrial contraction pumping blood into a stiff left ventricle. It is always abnormal. (S4, being dependent on atrial contraction, is absent if the heart is not in sinus rhythm.) A high-pitch opening snap can be heard at the beginning of diastole in some patients with mistral stenos is. 78 Third Heart Sound S3 80 Fourth Heart Sound S4 Gallop 81  Listen for Extra Sounds Systolic extra sounds Diastolic extra sounds Ejection click Wide split S2 – Bicuspid aortic valve Pericardial knock – Aortic root Opening snap of mitral Non Ejection click stenosis – Mitral valve prolapse 82  Abnormal sounds-2 A high-pitch ejection click, occurring early in systole following S1, is sometimes heard over the aortic or pulmonic valve when these valves are diseased. A mid-systolic click is commonly associated with mitral valve prolapse. Murmurs should be described according to their timing within the cardiac cycle (systole or diastole). Terms commonly used are: systolic, pansystolic (holosystolic), early diasolic, mid- diastolic, presystolic (late in diastole and just before S1), continuous. 83  Pericardial rub(frotman) Pericardial rub is heard in acute pericarditis. It is a friction rub that sounds like rubbing sand papers together and heard both in systole and diastole. Pericardial friction rub is a to-and-fro grating sensation, which is usually present during both phases of cardiac cycle, often rubs are more readily palpated with the patient sitting erect and leaning forward during the end period of deep inspiration In the presence of pericardial effusion the rub will usually disappear because of the separation of visceral and parietal layers by the accumulated fluid. 84 86  Relative positions of heart sounds and added sounds in auscultation. Sounds in red are high pitched. A2: aortic component of second heart sound; EC: ejection click; MSC: mid systolic click; OS: opening snap; P2: pulmonary component of second heart sound; S1–S4: heart sounds 1–4. 87  Listen for Murmurs What is a murmur? A sound/vibration made by blood flowing through a normal valve or an abnormal valve. A sound made by blood flowing backwards through a leaking valve – Murmurs may be functional or pathologic 88  Identify Murmurs and Timing Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1 89  Murmurs Murmurs should also be described by their acoustic characteristics. Examples are the crescendo-decrescendo or diamond shape (intensity rising to a peak and then falling off) ejection murmur of aortic stenos is and the diastolic rumble of mistral stenosis with pre- systolic accentuation. 90 Pansystolic(holosystolic) murmur 91 A systolic ejection (crescendo-decrescendo or diamond shape) murmur 92 Late systolic murmur 93 An early diastolic murmur 94 A mid-diastolic murmur 95 A late diastolic (presystolic) murmur 96 97  What are the types of murmurs? Systolic Diastolic Ejection quality Early diastolic Early, mid or late regurgitant quality e.g. systolic aortic or pulmonary Pan-systolic e.g mitral regurgitation or tricuspid Diastolic rumble e.g. regurgitation mitral stenosis =/- presystolic accentuation. 98  duration location disease systole second right ICS AS second left ICS PS third fourth left ICS VSD diastole apical area MS continuous 2nd left ICS PDA  Murmurs Murmurs should also be described by their direction of radiation. The ejection systolic murmur of aortic stenos is radiates to the neck; that of pulmonary stenos is to the left shoulder; and the systolic murmur of mitral regurgitation into the left axilla and the lower left chest at the back. Systolic murmur is heard in the back between the scapulae and alongside the lower dorsal spine. 101  Grading of murmurs Murmur should be graded according to their loudness: Grade 1 – just audible when the room is quiet and the patient holding his breath; Grade 2 – audible but faint or quiet; Grade 3 – readily audible but not accompanied by a thrill; Grade 4 – easily audible and accompanied by a thrill; (thrill may not be easily palpable in a heavy set or obese patient); Grade 5 – very loud; audible with the stethoscope partially off the chest Grade 6 – loud enough to be heard without a stethoscope; the examiner only has to put his ear close to, but not on, the patient’s chest. 102  Functional Murmurs Common in Asymptomatic Adults Characterized by – Grade I – II @ LSB – Systolic ejection pattern - no  with Valsalva S1 S2 – Normal precordium, apex, S1 – Normal intensity & splitting of second sound (S2) – No other abnormal sounds or murmurs – No evidence of LVH 103  Characteristic of Pathologic Murmurs Diastolic murmur Loud murmur - grade 4 or above Regurgitant murmur Murmurs associated with a click Murmurs associated with other signs or symptoms e.g. cyanosis Abnormal 2nd heart sound – fixed split, paradoxical split or single 104  Special Maneuvers Have the patient roll on their left side. Listen with the bell at the apex. This position brings out S3 and mitral murmurs. Have the patient sit up, lean forward, and hold their breath in exhalation. Listen with the diaphragm at the left 3rd and 4th interspace near the sternum. This position brings out aortic murmurs. Copyright 2000 by the University of Florida 105 106 107 108 109  Valsalva maneuver The valsalva maneuver is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one’s mouth, pinching one’s nose shut while pressing out as if blowing up a balloon. To do the Valsalva maneuver, follow these steps: 1 -Inhale deeply and then hold your breath. 2 -Imagine that the chest and stomach muscles are very tight and bear down as though straining to initiate a bowel movement. 3 -Hold this position for a short time, usually about 10 seconds. 4 -Breathe out forcibly to release the breath rapidly. 5 -Resume normal breathing. 110 111  Handgrip maneuver It is performed by clenching one’s fist forcefully for a sustained time until fatigued.Variations include squeezing an item such as a rolled up washcloth. 112 113 > Murmurs and Extra Sounds Systolic Click Systolic Ejection Pansystolic Late Systolic Innocent/Physiologic Mitral/Tricusp Regurgitation Mitral Valve Prolapse Aortic/Pulmonic Stenosis Opening Snap Early Diastolic Mid Diastolic Diastolic Rumble Aortic Regurgitation Mitral/Tricusp Stenosis Mitral Stenosis Ejection Sound S3 S4 Aortic Valve Disease Normal in Children Physiologic Heart Failure Various Diseases Copyright 2000 by the University of Florida  Auscultation-Murmurs Murmurs are blowing or whooshing sounds that occur as a result of turbulent flow They are described according to  location  radiation  timing  intensity  configuration  frequency,  response to dynamic maneuvers. Grading of murmur intensity Functional vs Pathological Murmur Timing of Murmur  Configuration and Frequency of Murmurs Uniform: unchanging intensity Crescendo: increasing intensity Decrescendo: decreasing The frequency of a murmur is intensity determined by the velocity Crescendo-decrescendo: initial of turbulent flow, which is in increase followed by a turn affected by the pressure decrease in intensity gradient. High pitch: high- pressure gradient and high- velocity flow (VSD) Low pitch: low- pressure gradient and low- velocity flow (mitral stenosis) Maneuvers Abnormal heart sounds JVP Inspection 123  The jugular veins. The patient is lying at a 45° angle, thus revealing the surface markings of the neck. 125  Jugular Venous Pressure To assess the volume status of the circulation Level Waveform Differentiate from carotid – Multiple wave forms – Compressible – Varies with inspiration and abdominal pressure 126  Jugular Venous Pressure Sternal angle is the reference point for JVP Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION. JVP is measured in ANY position in which top of the column is seen easily. Usually JVP is less than 8 cm water < 3 cm column above level of sternal angle. 127 128  Jugular venous pressure Since the sternal angle is 5 cm above the right atrium in an adult – irrespective of whether he/she is supine, reclining, or sitting upright – the hydrostatic pressure in the right atrium (in cm of H2O) is equal to the vertical height (in cm) of the column of blood above the sternal angle plus 5 cm. In a normal subject, the head of the jugular venous pulse is commonly seen at the level of the clavicle when he/she is reclining at an angle of 45o. To put it in another way, a JVP more than 5 cm above the sternal angle is elevated 129  Waveforms of the jugular venous pressure The "c" wave represents right ventricular contraction "pushing" the tricuspid valve back into the right atrium. 131 Jugular Venous Pressure Systole Diastole a a c c a-wave v  Rise in JVP due to atrial contraction c-wave  Transmitted carotid pulse at onset of systole y x v-wave  Rise in RA due to filling against a closed tricuspid valve x descent  RA relaxation followed by descent of TV in systole y descent  Pressure drop as TV opens at start of diastole 132 Pulsation in internal jugular vein - Norm – up to 7 cm over - Pathologic – more than 10 cm Record of Int jug art pressure a - right atrium contraction c - transmission from right ventricular pressure during its isometric contraction x - TK in atrium during its relaxation and shift of fibrous anulus downword v – end of atrium filling y - atrium empties  Jugular Venous Pressure Rapid y descent – Myocardial dysfunction and Abnormal JVP increased CVP – ASD Large a-wave  RVH – Constrictive pericarditis  TS Kussmaul’s sign Cannon waves – Rise of JVP on inspiration  Atrial contraction against Constirctive pericarditis a closed valve Tamponade  Junctional rhythm  Complete heart block Fixed, raised JVP Large v-wave – SVC Obstruction  TR 134 135  Hepato-Jugular reflux and Kussmaul’s sign Hepato-jugular reflux JVP normally falls with (abdomino-jugular) inspiration – sustained rise 1 cm for Kussmaul’s sign 30 sec. – inspiratory  in JVP –  venous tone & SVR – constriction –  RV compliance – rarely tamponade Positive HJR correlates – RV infarction with LVEDP > 15 136  Hepatojugular reflux In right heart failure all systemic organs are congested because the right ventricle fails to eject the venous blood being returned to it. A sign of venous congestion in the liver is hepatojugular reflux. By applying pressure to the epigastrium and indirectly to the liver, more venous return is pushed out of the liver towards the heart. A failing right heart cannot cope with the increased venous return and JVP rises. In the presence of right heart failure, the vertical height of the JVP will increase by more than 1 cm and remain elevated for as long as pressure is applied to the epigastrium 137  Venous pressure and pulsation Jugular venous pressure and pulsation reflect the function of the right side of the heart: – pressure in the internal jugular vein (IJV) is taken as the central venous pressure(CVP) – CVP is increased when pulsation in IJA is present higher than 3 cm over the sternal angle: it is the consequence of right side heart failure – paradoxic increase in CVP during inspiration (Kussmauls sign): consequence of venous return impediment to the right heart – it is present in severe right heart failure – positive hepatojugular reflux: result of right HF Carotid Palpation 139  Carotid Examination Carotid upstroke – Brisk, normal or delayed – Volume: normal, increased or decreased – Anacrotic pulse: one in which the ascending limb of the tracing shows a transient drop in amplitude, or a notch -Bisferiens pulse: A pulse with a double peak. This is suggestive of a narrowing and leakage of the aortic valve – Carotid auscultation – Bruit – Transmitted murmur 140 Carotid Pulse Contour 141  Carotid Pulse Contours A. Hyperkinetic (corrigan- water- hammer) – Aortic regurgitation B. Bifid – AS/AR C. Bifid typical of – HCM D. Hypokinetic – LV dysfunction E. Parvus et Tardus – Aortic stenosis http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=II.bxml 142  Retinal Carotids Brachial Ulnar Renal Radial Femoral Popliteal Posterior Tibial Dorsal Pedis 143  Examination of Pulses Grading: – Normal/Increased/Decreased/Absent – 2+/3+/1+/0 – Allen’s test Trophic changes/Ulceration Pulse deficit Perfusion – Pallor on elevation – Rubor on dependency – Venous refill with dependency (should be less than 30 seconds) Bruits 144  Trophic Changes Shiny, hairless skin, dystrophic nail changes and dependent rubor associated with peripheral arterial occlusive disease of the patient's right foot 145 Digital Ischaemia Gangrene 146  A Practical Guide to Clinical Medicine - UCSD Acute Arterial Chronic Arterial Insufficiency: Insufficiency Mottled Appearance of with Ulcers Skin http://medicine.ucsd.edu/clinicalmed/extremities.htm 147  Measurement of the Ankle-Brachial Index (ABI) Hiatt W. N Engl J Med 148 2001;344:1608-1621 Venous Abnormalities Varices 149 Spider Veins 150 Venous Insufficiency 151 Stasis Dermatitis/Ulceration 152 Edema 153 154  Inspection-Appearance-Lower Limbs Peripheral Edema: Abnormal fluid in interstitium due to imbalance in fluid hemostasis. Pitting vs non-pitting Congestive heart failure Kidney failure Liver cirrhosis, nephrotic syndrome Portal hypertension Hypothyroidism Pregnancy Deep vein thrombosis (unilateral) Compromised lymphatic system  Inspection- Appearance- Lower Limbs- Edema Inspection-Appearance-Lower Limbs- Venous Insufficiency: Spectrum of disorders caused by venous dysfunction including edema, skin changes, and venous ulceration Varicose veins: a type of CVD characterized by cylindrical dilation (diameter > 3 mm) and tortuosity of superfici al vein  Cellulitis vs DVT Cellulitis Right Deep Venous Thrombosis 160 162  Signs and Symptoms of Heart Failure Symptoms Signs Investigations Shortness of breath Tachycardia Chest X-ray Swelling of feet & leg Increased JVP Echocardiogram Fatigue Oedema Ambulatory ECG Orthopnoea Rales Exercise treadmill PND (Paroxysmal Hepatomegaly Cardiac catheter nocturnal dyspnoea) Nocturia Ascites Elevated natriuretic Anorexia Cardiomegaly peptides Weight loss 163