Clinical Examination - Heart and Blood Vessels PDF

BASICS IN CLINICAL PRACTICE Prof.dr.Gordana Kamceva Mihailova SPECIAL PHYSICAL EXAMINATION HEART AND BLOOD VESSELS CARDIOVASCULAR SYSTEM  INSPECTION 1. BODY POSITION: active, passive, forced, actively forced position (higher upper part of the body in bed to upright) 2. VISIBLE PULSATIONS A...

BASICS IN CLINICAL PRACTICE Prof.dr.Gordana Kamceva Mihailova SPECIAL PHYSICAL EXAMINATION HEART AND BLOOD VESSELS CARDIOVASCULAR SYSTEM  INSPECTION 1. BODY POSITION: active, passive, forced, actively forced position (higher upper part of the body in bed to upright) 2. VISIBLE PULSATIONS AT HEART (ictus cordis) normally located in the IV/V intercostal space on the left, by 1-2 cm. inside from the medio-clavicular line, with an area of 2-3 cm2. Pulsation in the epigastrium is encountered with an enlarged right ventricle. 3. VISIBLE CHANGES: Rhythmic nodding of the head synchronous with heart action (Musset's sign) in aortic regurgitation; Reddish-livid discoloration of the lips and around the cheeks (facies mitralis – Courvoasier) - with mitral stenosis; Swollen, congested and pulsating neck (jugular) veins, Pulsation of carotid arteries in aortic regurgitation.  PALPATION It is performed over the topographic projections of the heart valves 1. HEART PEAK (TOP): localization, size, strength, rise time; 2. FREMEN CATER/TRILL (topographic localization, phase of heart action in which it occurs, quality, intensity – is always a pathologic finding) 3. PALPATION OF PERIPHERAL ARTERIES - arterial pulse wave Arterial pulse wave assessment of pulse quality, which is normally rhythmic, with a frequency of 6o-100/min, well filled, with a fast and strong rise, a short plateau and a slow descent. Assessment of the presence and intensity of a pulse wave (a sign of peripheral arterial disease and/or occlusion) Pulse quality - pathological types of pulse curves a.radialis a.brachialis a.carotis aorta abdominalis a.poplitea a.dorsalis pedis a. femoralis a.tibialis posterior  PERCUSSION As a method of cardiology examination, it has lost most of its everyday meaning. • It is performed with quiet, fine percussion along the intercostal spaces (from III to V), from the periphery to the heart on both sides. • The right border - starts from the dullness of the liver below, and moves up to the lower edge of the 3rd rib, parallel to the right edge of the sternum and at a distance of 0.5 to 1 cm: • The left border - moves from the lower edge of the 3rd rib to the left about 2 cm from the left edge of the sternum and is gradually directed down and to the left to the ictus in the Vth intercostal space. • These are the limits of the so-called RELATIVE HEART DULLNESS. AUSCULTATION It involves auscultation of: heart sounds (normally audible two heart sounds S1 and S2 rhythmic with a frequency of 60-100/min, not accompanied by pathological murmurs) heart murmurs (rarely present as a normal finding, so-called physiological noises, more common in childhood or during physical exertion, elevated body temperature, pregnancy ) auscultation of arterial blood vessels (on the peripheral arteries available for auscultation (those listed above available for palpation), but also on Ao – abdominal, renal, iliac arteries. Normally no noises are heard. An audible systolic murmur over an artery is always a pathological finding. In cases of arterio-venous fistulas, continuous murmurs are heard TRADITIONAL AUSCULTATORY AREAS a) at the apex of the heart in the fifth left intercostal space at the midclavicular line (mitral area); b) fourth left intercostal space along the lower left sternal border (tricuspid area) c) second right intercostal space at the right sternal border (aortic valve area) e) second left intercostal space at the left sternal border (pulmonic valve area) f) ERB point - third left intercostal space at the left sternal border (ventricular septum) HEART SOUNDS - Basic Heart Sounds: First heart sound (S1) indicates the beginning of systole (closing of MV and TV) The second heart sound (S2) indicates the beginning of diastole (closing of AV and PV), the interval between them is the time of systole, and the interval between S2 and the next S1 is the time of diastole. Extra Heart Sounds (audible in pathological but also in normal situations), the state of audibility of the third heart sound is a gallop rhythm Third (S3) (at the beginning of diastole after the second heart sound, it is not of organic origin - a consequence of the rapid flow from the atria to the ventricles at the beginning of diastole) Fourth heart sound (S4) (at the end of diastole before the first heart sound - a consequence of atrial contraction) S3 S4 HEART MURMURS MECHANISM OF EVENT Created blood turbulence in the heart due to: a) fast flow through intact valves; b) anterograde leakage through pathologically changed valves or large arteries (stenosis); c) retrograde blood flow through pathologically changed valves that are not narrowed, but do not close completely (insufficiencyregurgitation) d) blood flow through abnormal communications between the atria, ventricles and great vessels. HEART MURMURS CHARACTERISTICS OF HEART MURMURS: 1. intensity (audibility)* 2. frequency (tonality) 3. configuration (shape) 4. quality (color) 5. duration 6. direction of propagation 7. the time of occurrence in the cardiac cycle * Classification in six degrees S.A. Levin, 1933 is recommended) TYPES OF HEART MURMURS - IN RELATION TO THE HEART CYCLE 1) Systolic - after S1 to before S2 heart sound (holosystolic, protosystolic, mesosystolic, telesystolic); 2) Diastolic (after S2 to the next S1 sound) and are: holodiastolic, protodiastolic, mesodiastolic, telediastolic or presystolic and are practically always pathological, 3) Continuous, when the murmur begins with systole and ends at the end of diastole, 4) Systolic-diastolic, where there is a clear border between the two components, separated by sounds. TYPES OF HEART MURMURS - ACCORDING TO ETIOLOGY 1. CARDIAL murmurs a) ORGANIC in case of damage to: the valves (valvular), damage to the myocardium with dilatation of the ventricles and/or atria and valvular fibrous rings, and when only the papillary muscles are involved (myocardial). b) INORGANIC (functional) in the absence of valvular and myocardial structures. Origin: increased blood viscosity, tumors and deformities in the chest, anemia, thyrotoxicosis, etc. Most common in children up to 15 years old, pregnant women, during tachycardias, and disappear when they calm down. 2. PERICARDIAL murmurs - pericardial friction, heard best at the base of the heart. The rub is usually not intense, it is heard in both systole and diastole and has the same characteristics. They change over time and may disappear in a few hours. CARDIOVASCULAR SYSTEM - NORMAL FINDING • Heart tip (ictus cordis) is palpated with normal size and localization, without palpatory thrill (freme/thrill), auscultatory, rhythmic heart action, with normal sounds not accompanied by pathological murmurs. • CP: 120/80mmHg; Pulse: 75/min • Peripheral vascular system: palpable peripheral arterial pulsations are present with normal strength, without signs of arterial and venous insufficiency. LINKS • https://www.youtube.com/watch?v=XU_xeUMJ3Zc • https://www.youtube.com/watch?v=6beOTEKx1ek • https://www.youtube.com/watch?v=FtXNnmifbhE • https://www.youtube.com/watch?v=SZcAJVcbHaY • https://www.youtube.com/watch?v=dBwr2GZCmQM • https://www.youtube.com/watch?v=baxNxWIWdK8 THANK YOU