PCSIII_Adv_Cardiac_Skills_ILA_Scott_Aubrey Scott.pdf

Advanced Cardiovascular Skills PCSIII ILA Lee Scott, MD Objectives 1. Recognize and describe retinal changes of hypertensive vascular disease. 2. Describe how to perform a peripheral vascular exam (grading findings included). 3. Describe the expected findings of a peripheral...

Advanced Cardiovascular Skills PCSIII ILA Lee Scott, MD Objectives 1. Recognize and describe retinal changes of hypertensive vascular disease. 2. Describe how to perform a peripheral vascular exam (grading findings included). 3. Describe the expected findings of a peripheral vascular exam. 4. Document the findings of a peripheral vascular exam. 5. Describe the steps involved in setting up an EKG. The Peripheral Vascular Exam Eyes Neck Abdomen Extremities The Eyes The retinal exam allows you to visualize blood vessels!!! Hypertension causes progressively increasing retinal microvascular changes. You can also see microvascular changes from chronic diseases such as diabetes.(covered in Endo) Hypertensive Retinopathy Mild – Retinal arteriolar narrowing related to vasospasm, arteriolar wall thickening or opacification (copper wiring), and arteriovenous nicking Moderate – Hemorrhages, either flame or dot-shaped, cotton-wool spots, hard exudates, and microaneurysms Severe – Some or all of the above, plus optic disc edema (papilledema) From: Downie LE, Hodgson LA, Dsylva C, et al. Hypertensive retinopathy: Comparing the Keith-Wagener- Barker to a simplified classification. J Hypertens 2013; 31:960. DOI: 10.1097/HJH.0b013e32835efea3. Copyright © 2013. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Hypertensive Retinopathy Copper Wiring: Retinal arterioles appear orange or yellow instead of red Silver Wiring: Retinal arterioles look white if they have become occluded  Cotton Wool Spots: caused by microinfarction AV Nicking: Retinal arterioles indent retinal veins as they cross each other Retinal Hemorrhages Hard Exudates UpToDate The Neck Able to examine External Internal Carotid arteries and veins! Carotid Artery Artery Internal Jugular Vein Common Carotid Artery The Carotids (a review) 1. Inspect the neck for carotid pulsations, often visible just medial to the SCMs. @stritch.luc.edu 2. Auscultate then 3. Palpate the Carotids. See Review Lab Guide if needed. 10 Jugular Venous Pressure The JVP closely parallels pressure in the right atrium, or central venous pressure. Careful observation of the fluctuations of the JVP yields clues about volume status, right and left ventricular function, patency of the tricuspid and pulmonary valves, pressures in the pericardium, and arrhythmias caused by junctional rhythms and AV blocks. For example, JVP falls with loss of blood or decreased venous vascular tone and increases with right or left heart failure, pulmonary hypertension, tricuspid stenosis, AV dissociation, increased venous vascular tone, and pericardial compression or tamponade. To check the JVP: Position the patient supine, reclined at 45°, with the head on a pillow to relax the sternocleidomastoid muscles. Look across the patient's neck from the right side. Use oblique lighting if the external jugular vein is difficult to see. Identify the jugular vein pulsation in the suprasternal notch or behind the sternocleidomastoid muscle. Use the abdomino-jugular test or occlusion to confirm it is the jugular vein. You can also press firmly over the liver (hepatojugular reflex) or have them Valsalva. Identify the timing and waveform of the pulsation and note any abnormality. You can identify some JVD in most people. If it is present when sitting upright, there is much greater concern. JVD is a sign of increased central venous pressure. 11 Jugular Venous Pressure 12 Jugular Venous Pressure https://www.yo utube.com/wat ch?v=AWxbAg0 E3E4 13 The Abdomen Listen with the bell. Aorta Renals Iliacs Femorals The Extremities Overview Inspect for color changes, ulcers, scars, hair loss, swelling, etc. Palpate for temperature changes. Assess capillary refill. Check pulses. Check for edema. Special tests Allen Test ABI Inspection Inspection is always first! Palpation - Temperature Assess the temperature of the feet and legs with the backs of your fingers. Compare one side with the other. Bilateral coldness is usually caused by a cold environment or anxiety. 17 Palpation- Capillary Refill