Cardiovascular Examination PDF

CARDIOVASCULAR EXAMINIATION Dr. Saed A. Ibrahim, MD Frantz Fanon University (FFU), Hargeisa, Somaliland @Nov, 2023 Anatomy History taking In cardiovascular system, you start with history taking. Finding the chief complain is the key. Always focus on what you are aske...

CARDIOVASCULAR EXAMINIATION Dr. Saed A. Ibrahim, MD Frantz Fanon University (FFU), Hargeisa, Somaliland @Nov, 2023 Anatomy History taking In cardiovascular system, you start with history taking. Finding the chief complain is the key. Always focus on what you are asked to do as a medical student. History Chest pain Dyspnoea Palpitations Oedema Syncope or presyncope Dyspnea and chest pain are cardial sysmptoms of cardiovascular disease.  Dyspnoea Onset Severity Related to effort Orthopnoea Paroxysmal nocturnal dyspnoea  Chest pain Site and radiation Character Severity Onset and Frequency Duration Aggravating factors Relieving factors Associated features Chest pain Six life threatening causes: 1. Myocardial infarction (MI) 2. Unstable angina pectoris (USAP) 3. Aortic dissection 4. Pulmonary embolus 5. Tension pneumothorax 6. Oesophageal rupture Other Differentials Costochondritis Herpes Zoster Musculoskeletal Pancreatitis Anxiety Other Differentials Cardiac Angina Pericarditis Respiratory Pneumothorax Pneumonia GI Reflux Oesophageal spasm Cholecystitis pancreatitis  Other symptoms Cough (dry or productive, Haemoptysis) Tiredness Nausea and vomiting Bowel upset Oliguria Visual loss  Other aspects of history Past medical history Drug history Family history Social history Occupational history  Physical examination When you are asked to examine system of a patient, always start with general physical examination except when examiner asks you to omit it. 1. WIPE 2. Examination of pulse 3. Measurement of blood pressure 4. Examination of Neck veins 5. Examination of precordium by: a. Inspection b. Palpation c. Percussion d. Auscultation Look around Initial impression Distress Breathlessness Audible cough O2 TPR  General Appearance Marfan Syndrome Tall, long extremities Duchenne type Associated with: aortic root muscular dystrophy dilitation, MV prolapse Pseudohypertrophy of Acromegaly the calves Large stature, coarse facial Cardiomyopathy features, “spade” hands Associated with: Cardiac hypertrophy Turner Syndrome Web neck, hypertelorism, short stature Associated with: Aortic coarctation, pulmonary stenosis Pickwickian Syndrome Severe obesity, somnolence Associated with: Pulmonary General Appearance- 2 “Spade” hands in acromegaly HANDS/ARMS Look at both hands for: Perfusion and refill Clubbing Palpate radial pulse Splinter Check for a haemorrhages Janeway lesions collapsing pulse Osler's nodes Radio-radial delay Cyanosis Mention blood Nicotine staining pressure tendon xanthomata Clubbing cyanos Nicotine staining is Pulse A pulse can be felt where accessible artery is pressed against under lying bone. Commonly felt pulses are: 1. Radial pulse 2. Brachial pulse 3. Carotid pulse 4. Femoral pulse 5. Popliteal pulse 6. Posterior tibial pulse 7. Dorsalis pedis pulse  Pulses are impalpable in systolic pressure below 50mmHg. Radial pulse – is the most easily accessible and the most commonly felt pulse. The pateints hand should be slightly flexed, and pronated. Press the radial artery against the head of radius.  Popliteal pulse Patients should lie on a firm comfortable surface so they can relax their muscles. Flex the patient's knee to 30°. With your thumbs in front of the knee and your fingers behind, press firmly in the midline over the popliteal artery. It is sometimes difficult to feel. By sliding your fingers 2-3 cm below the knee crease it may be possible to compress the artery against the back of the tibia as it passes under the soleal arch making it easier to feel. If the popliteal artery is especially easy to feel, consider the possibility of an aneurysm and request an ultrasound scan. Posterior tibial pulse Feel 2 cm below and 2 cm behind the medial malleolus, using the pads of your index and middle fingers. Dorsalis pedis pulse Feel in the middle of the dorsum of the foot just lateral to the tendon of extensor hallucis longus Pulse and BP Radial pulse rate rhythm volume and character Comparison with other pulses Condition of the vessel wall Central pulse BP consider BP in both arms Pulse Rate: Normal average PR is 72 Tachycardia PR is more than 100 b/m Bradycardia PR is less than 60 b/m Relative bradycardia: PR is slower than expected for the body temperature. (pulse rises 10 bpm in every 1 F increase of body temperature). Pulse Rhythm Regular Sinus arrhythmia – respiratory rate is faster during inspiration and slower during expiration. This is normal phenomenon. And it is more pronounced in certain individuals. Occasional irregularity – it is due to premature beats. Premature beat occurs earlier than expected normal beat, is weak and it is followed by a longer pause. Common in healthy individuals.  Regularly irregular pulse – premature beats occur in fixed intervals. After one normal beat (bigeminy) or two normal beats (trigeminy). Digoxin toxicity is most common cause.  Irregularly irregular pulse – there is no pattern and beats occur irregularly.  Pulse deficit ( PR & HR) – the pulse rate is slower than heart rate counted by auscultation. Occurs in atrial fibrillation. Pulse Volume of pulse Normal volume – learnt with experience High volume – occurs in fever, Aortic regurgitation, thyrotoxicosis, severe anemia etc. Low volume – occurs in heart failure and hypovolemic shock Comparison with other pulses Radio-radial delay Radio-femoral delay Pulse Character Slow raising pulse Collapsing pulse Pulsus paradoxus Pulsus alternans Causes of tachycardia Exercise Anxiety Fever Anaemia Heart failure Thyrotoxicosis hypotension Causes of bradycardia Athletes Raised ICP hypothyroidism Drugs Complete heart block Relative bradycardia Enteric fever Viral infections  RECOMMENDED BLOOD PRESSURE MEASUREMENT TECHNIQUE: The patient should be relaxed and the arm must be supported. Ensure no tight clothing constricts the Thearm. cuff must be level with heart. If arm circumference exceeds 33 cm, a large cuff must be used. Place stethoscope diaphragm over brachial artery The column of mercury must be vertical. Selecting a cuff appropriate cuff size. CUFF Limb size in CM Infant 9-14 child 13-19.5 Small adult 19 - 27 Adult 23-40 Large adult 34 -50 Thigh 40-66  RECOMMENDED BLOOD PRESSURE MEASUREMENT TECHNIQUE: Inflate to occlude the pulse. Deflate at 2 to 3 mm/s. Measure systolic (first sound) and diastolic (disappearance) to nearest 2 mm Hg Select a cuff with the appropriate size  Recommended Technique for Measuring Blood Pressure (cont.) – Locate brachial and radial pulse – The Armseated shouldblood be supported pressure is used to determine and monitor treatment decisions. The standing blood pressure is used to test for postural hypotension: elderly, diabetics, diuretics. A fall in systolic BP > 10 mm Hg is significant  Recommended Technique for Measuring Blood Pressure (cont.) – 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  Face Malar flush Xanthelasma Corneal arcus Central cyanosis Anaemia Teeth – endocarditis  FACE Look at the eyes Conjunctival pallor Xanthelasma Corneal arcus Look at the Face Malar flush Conjunctival petechiae Dentitcian - endocarditis Cyanosis Cyanosis  JVP JVP = right atrial pressure Falls during inspiration High in fluid overload e.g. right heart failure Fixed in SVCO Low in dehydration and fluid depletion Jugular Venous Pressure 45o – supine Inspect from side Internal jugular Sternomastoid Height Waveforms  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. Examination of the Internal Jugular vein: Wave Pattern a-wave : produced due to right atrial contraction and is the largest positive wave It preceds the carotid pulsation C-wave Small in size and brief in duration Rarely seen normally Produced by buldging of TV during the isovolumetric contraction of RV and by the neighboring carorid Examination of the Internal Jugular vein: Wave Pattern X-descent Negative wave due to atrial relaxation and descent of the TV plane during RV contraction V-wave Positive wave Produced when the right atrium is filled from venous return when the TV closed Y-descent Negative wave inscribed as the TV opens allowing the rapid inflow of blood in to RV  Differences: JVP and Carotid JVP Carotid Character Double pulsation Single pulse Obliteration Can be obliterated Cannot Position JVP falls if sit up No effect Respiration JVP falls No effect Reflex Hepatojugular No effect Palpable pulse No Palpable  The Heart Inspection Palpation (Percussion) Auscultation  Inspection Skeletal abnormalities( chest deformity) Bulging of precordium Prominent veins Scars Pulsations Pacemaker Respiratory rate  Palpation 1. Apex beat 2. Parasternal heave( left parasternal heave) 3. Thrills (palpable murmur) 4. Palpable heart sounds 5. Palpable pericardial rub Apex beat: The lower most and outer most point of precordium where a definite cardiac impulses is felt.  Apex beat Furthest point downwards and outwards Normally 5th interspace in mid- clavicular line Right hand placed on left chest wall Middle finger over approx site Once located count down the rib spaces Displacement suggests cardiac enlargement May be impalpable Character of apex beat: Normal, tapping, and heaving tapping – forceful but palpating finger is not lifted Heaving – palpating finger is lifted. Apical Impulse absent Normal individuals Obese or thick chest wall Large breasts Hyperinflated chest Pericardial effusion Dilated cardiomyopathy Dextrocardia: apical impulse in right chest  PALPATION OF THE PRECORDIUM Thrill and Heave Thrill is a palpable vibratory sensation related to the presence of murmur. Detectable when murmur of grade of >=4 intensity. Use the ball of the palms or the lateral edge of the hand. Determine timing of occurrence: systolic vs diastolic  PALPATION OF THE PRECORDIUM Systolic thrill Occurrence coincides with the apical and carotid pulses Occurs during the outward movement of the apex Location of thrill Cause R-2ICS Aoric Stenosis L-2ICS Pul Stenosis Apex Mitral regurgitation LL sternal border VSD, TR  PALPATION OF THE PRECORDIUM Diastolic thrill Occurs during the retraction of the apex and precede the apical impulse Apical area Diastolic thrill: miral stenosis Continuous thrill in left upper chest: PDA Heave: palpable force of contraction Apply ulnar side of hand parallel to the LL sternal border and appreciate for lifting ( parasternal heave) Right ventricular hypertrophy Enlargement ( plus rotation) of Left atrium  PALPATION Palpable heart sounds OF THE PRECORDIUM 1. First heart sound (s1) - in apical area miral stenosis 2. Sec heart sound (P2) - in L-2ICS Pul HTN 3. Sec Heart sound (A2) - in R-2ICS Systemic HTN 4. S3, S4: apex LV dysfunction  Auscultation Diaphragm – high pitched sounds Bell – low pitched sounds Heart sounds Added sounds  Heart sounds 1st & 2nd heart sounds usually audible at apex “lub-dup” Time with carotid pulse Systole occurs between the heart sounds Heart Sounds 1st heart sound – “Lub” Closure of Mitral & Tricuspid Valves 2nd heart sound – “Dub” Closure of Aortic & Pulmonary Valves 3rd heart sound (S3) – “Lub Dub De” Early Diastolic - Rapid filling of ventricles 4th heart sound (S4) – “Le Lub Dub” Late Diastolic - Atrial contraction filling a stiff left ventricle  Listening Entire precordium Apex (mitral) Lower left sternal edge (tricuspid) Upper left sternal edge (pulmonary) Upper right sternal edge (aortic) Identify S1 and S2 Identify any murmurs  Auscultation Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs Sequence of auscultation 1. – Upper right sternal border (URSB) with diaphragm 2. – Upper left sternal border (ULSB) with diaphragm 3. – Lower left sternal border (LLSB) with diaphragm 4. – Apex with diaphragm and then bell 5. – Apex - left lateral decubitus position with bell 6. – Lower left sternal border (LLSB)- sitting, leaning forward, held expiration with diaphragm Listening  Listening Note features of murmurs (Carotids and axilla) Roll to the left (MS) Sit forward (AR) o Posterior lung base auscultation is carried out. o Sacral odema  First heart sound Mitral valve closure (end of atrial systole) Tricuspid valve usually quiet “lub” in lub-dup Immediately precedes apical pulse Immediately precedes carotid wave pulse Apex with bell or diaphragm Causes of loud S1: MS, tachycardia, short PR interval. When would it be soft: MR, PR long  Second heart sound Closure of aortic and pulmonary valves at end of ventricular systole “dup” in lub-dup Immediately follows apical impulse Immediately follows carotid wave pulse Upper left sternal edge with diaphragm  Second heart sound Physiological splitting. Delayed closure of pulmonary valve due to increased venous return on deep inspiration Exaggerated splitting e.g. RV dilatation in pul stenosis Fixed splitting in ASD Reverse splitting in delayed left ventricular ejection e.g. HOCM S3 Early Diastolic. Physiological causes: young adults, athletes, pregnancy, and fever Pathological causes: large, poorly contracting LV (eg CCF, restrictive pericarditis), MR S4 Late Diastolic Sound – Always Abnormal Causes – LVH, HCM, LV ischaemia  Heart sounds Rate Rhythm Sinus arrhythmia Ectopic beats – premature Intermittent heart block – dropped beats Atrial fibrillation Murmur Definition of Heart murmurs: Are sounds caused by turbulence of blood flow due to flow through narrow orifices, abnormal orifices/direction, rapid blood flow, low blood viscosity or combination. Murmurs are classified according to their quality, frequency (pitch), intensity (loudness), duration, configuration and placement of cardiac cycle, site and radiation. Quality of murmur is subjective but terms such as harsh, blowing, musical, rumbling etc is used. Murmurs are described according to its grade of intensity and has a grade of 1-6. SCORED – 1-6 (Above 3 = Palpable Thrill)  Murmurs Turbulent flow across valves Leaking or narrowed valve Timing in cardiac cycle, murmur could be systolic, diastolic, or continues murmur. Intensity Grade 1 – very quiet... Grade 6 – audible without stethoscope Type of murmur cause Pan systolic Mitral/tricuspid regurgitation, VSD Ejection systolic Aortic/Pulmonary stenosis, HOCM and Pregnancy Early diastolic Aortic and pulmonary Regurgitation Mid-diastolic Mitral/tricuspid stenosis Continuous murmur PDA “machinery like’’ Grading the Intensity of Cardiac Murmurs Grade 1 Murmur heard with stethoscope, but not at first Grade 2 Faint murmur heard with stethoscope on chest wall Grade 3 Murmur hears with stethoscope on chest wall, louder than grade 2 but without a thrill Grade 4 Murmur associated with a thrill Grade 5 Murmur heard with just the rim held against the chest Grade 6 Murmur heard with the stethoscope held away and in from the chest wall Cardiac Murmurs Most mid systolic murmurs of grade 2/6 intensity or less are benign Associated with physiologic increases in blood velocity: Pregnancy Elderly In contrast, the following murmurs are usually pathologic: Systolic murmurs grade 3/6 or greater in intensity Continuous murmurs Any diastolic murmur  Systolic murmurs Heard between 1st & 2nd heart sounds Pan-systolic Ejection systolic  Pan systolic murmurs Start with S1 Mid systolic accentuation Extend through systole & continue to S2 Mitral regurgitation – apex, low pitched Triscuspid regurgitation- left sternal edge to apex VSD – rough, tearing with thrill Mitral Regurgitation Plateau-like, Pan-Systolic, Quiet S1, Blowing, High-Pitched, Heard at Apex, Radiates to Axilla,  Ejection systolic murmurs Turbulent flow across narrowed valve Onset after SI - distinct and separate Intensity increases towards mid systole Aortic stenosis – aortic area (carotid) Pulmonary stenosis – pulmonary area Aortic Stenosis Crescendo-Decrescendo, Ejection systolic, Loud, Rough, Medium Pitched, Heard over Aortic Area, Radiates to Carotids  Diastolic murmurs Heard between 2nd & 1st heart sounds Aortic regurgitation Mitral stenosis Mitral Stenosis Plateau-like, Diastolic, Rumbling, Low- Pitched, Heard over Apex Aortic Regurgitation Tapering, Early-Diastolic, Low-pitched, Heard over Apex.  Listen for Extra Sounds Systolic extra sounds Ejection click – Bicuspid aortic valve – Aortic root Non Ejection click Mitral valve prolapse Diastolic extra sounds Wide split of S2 Pericardial knock Opening snap. Clicks Early Systolic Aortic Ejection Aortic Stenosis (with or without bicuspid valve) Pulmonary Ejection Pulmonary Stenosis Mid-Systolic Mitral Valve Prolapse Opening Snap Mitral Stenosis Early Diastolic, sound of mitral valve opening Closeness to S2 = Severity Becomes absent in late disease when mitral cusps are immobile (calcification)  Other findings Carotid bruits Pitting oedema (ankles & sacrum) Chest auscultation Abdominal examination Peripheral pulses Urinalysis Questions/Comments. 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