Cardiovascular+Exam.pdf

Cardiovascular System Exam Dr. Rakesh Calton Professor and Assistant Chair DCF Director of Medical Simulation [email protected]  The Heart Bates -Ch. 9 CVS (pg. 333-344 and 361-385 & Review 391-403) - UpToDate - Scholar Rx - [email protected] Simulation Lab, First f...

Cardiovascular System Exam Dr. Rakesh Calton Professor and Assistant Chair DCF Director of Medical Simulation [email protected]  The Heart Bates -Ch. 9 CVS (pg. 333-344 and 361-385 & Review 391-403) - UpToDate - Scholar Rx - [email protected] Simulation Lab, First floor LESC In Person or online. 2024-05-13 2 References/Resources 2024-05-13 3 Braunwald’s HEART DISEASE 9th Edition “Declining physical examination skills have raised great concerns. Only a minority of internal medicine and family practice residents recognize classic cardiac findings. Performance does NOT predictably improve with experience. Lessened bedside skills have increased the unnecessary use of noninvasive imaging.” 2024-05-13 4 Learning Objectives At the end of this enhancement session, the learners will be able to: LO1: Understanding Cardiovascular Physiology Integrate clinical findings with the underlying physiological mechanisms that result in normal cardiovascular examination findings. Explain the pathophysiological changes leading to abnormal cardiovascular findings, such as variations in carotid and peripheral pulses, blood pressure, altered jugular venous pulse, precordial palpation, and auscultatory changes including heart sounds (S1, S2, S3, S4), murmurs, opening sounds, clicks, and rubs. Discuss Dynamic Auscultation LO 2: Clinical Application and Interpretation Apply knowledge of cardiovascular physiology to recognize abnormal findings during cardiovascular examination, using Inspection, Palpation and Auscultation. Interpret the significance of abnormal cardiovascular findings within a clinical vignette or in a clinical setting while examining a patient, integrating their knowledge of cardiac anatomy, physiology, and pathophysiology to form a clinical judgment. LO 3: Diagnostic Anticipation Predict and identify expected cardiovascular examination abnormalities in a patient based on a given diagnosis. Evaluate the relationship between a patient's diagnosis and their cardiovascular examination findings, to anticipate clinical manifestations. Overview Review CVS Physiology – in relation to the following physical exam findings General Survey pertaining to CVS Pulse: normal, bisferiens and alternans BP JVP Precordium Inspection Palpation – apical impulse, parasternal heave/lift, thrills Auscultation -S1 (split), S2 (split), S3, S4 -valves: ejection sounds, murmurs (systolic/diastolic/continuous), clicks -rubs 2024-05-13 6  HARVEY Use HARVEY Programs included in this presentation to see, feel and hear the CVS exam abnormalities!! 2024-05-13 7 Harvey Programs EXAM FINDING HARVEY PROGRAM Jugular Venous Distention #13, 17 Palpation #11, 17, 36, 42 S1 #46, 5 Split S2 (variable vs. fixed) #46, 23 S3 #46, 6, 42 S4 #36, 13 Ejection Sounds #13, 9 Opening Snap #4 Innocent Murmur #22 Early-Systolic Murmur #49, 13 Holosystolic Murmur #7 Late-Systolic Murmur #9 Diastolic Murmur #4, 17 Continuous Murmur #28 2024-05-13 8 General Survey Relevant to Cardiovascular System Check for skin color (pale vs. pink) Pull down the eyelids looking for pallor. Have the patient open their mouth, and look for angular stomatitis, glossitis, cheilosis, and dental hygiene (evidence of nutritional deficiency). Check for Cyanosis: central (blue mucous membranes) vs. peripheral (blue fingers/toes) Look for rash, petechiae, splinter hemorrhages, xanthomata, Osler’s nodes and Janeway lesions. Note any tobacco staining. Perform Schamroth’s window test checking for clubbing (bringing two fingernails together) Respiratory distress: tachypnea, accessory muscle use, intercostal indrawing, position. Assess the temperature of both arms. Check the capillary refill time of the middle finger (less than 2 seconds is normal) Presence of edema in lower limbs.  Examination of Peripheral Pulse Rate Rhythm Grade Amplitude Description Regular / Irregular/ Irregularly Irregular 0 Absent No Pulse Volume 1+ Faint A Faint but detectable pulse Character Grade 2+ Diminished A slightly diminished pulse then normal Radio - Radial Delay 3+ Normal Normal Pulse Radio - Femoral 4+ Bounding A Bounding pulse Delay All peripheral Pulses Examination of Carotids Auscultate the carotid artery, (checking for bruits) and have the patient hold their breath while you listen. Be sure to tell the patient they can resume breathing once you have finished listening. Do not auscultate for more than 15 seconds. Palpate the carotid pulse ONE AT A TIME, if no bruits are noted. Note the character and volume of the carotid pulse.  Arterial Pulses -Volume – pressure of the pulse (full/weak) -Contour – ejection speed (brisk/delayed) -Mono vs biphasic -Rhythm – regular vs irregular A – Normal –full, brisk, monophasic, regular B – Aortic Stenosis –weak, delayed, monophasic (pulsus parvus et tardus) C – Aortic Regurgitation –sharp upstroke, rapid downstroke, may be biphasic (may be difficult to palpate biphasic nature) 2024-05-13 14 Pulsus Paradoxus and Alternans Pulsus Alternans -beat-to-beat variability in amplitude -Left Ventricular Failure -mechanism unknown Pulsus Paradoxus - >10 mmHg drop in BP with inspiration - Pericardial Tamponade (blood in pericardial sac) - Inspiration = RV EDV (blood prevents RV dilation) interventricular septum pushed into LV 2024-05-13 decreased LV EDV/SV = BP 15 A 45-year-old man has severe valvular aortic stenosis. On palpation it is noted that the carotid pulse rises very slowly. The mechanism is 1. Low cardiac output 2. Shortened diastole 3. Decreased flow velocity 4. Increased peripheral vascular resistance 5. Decreased compliance 2024-05-13 16 A 45-year-old man has severe valvular aortic stenosis. On palpation it is noted that the carotid pulse rises very slowly. The mechanism is 1. Low cardiac output 2. Shortened diastole 3. Decreased flow velocity 4. Increased peripheral vascular resistance 5. Decreased compliance 2024-05-13 17 Blood Pressure Measurement Review BP Measurement Semester 1 AND 2 JNC 8 Criteria Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr, Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Jr, Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr, Williamson, J. D., … Wright, J. T., Jr (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension (Dallas, Tex. : 1979), 71(6), 1269–1324. https://doi.org/10.1161/HYP.0000000000000066 Examination of the JVP Jugular Venous Pulse (JVP) & Right Atrial Pressure 2024-05-13 20 JVD Images https://www.youtube.com/watch?v=lBPvJpaQWC4 2024-05-13 21 Jugular Venous Pulse (JVP) JVP = ~Right Atrial Pressure ****jugular vein is open to the RA àLook at Right Internal Jugular Vein A wave – atrial contraction (Tricuspid Valve open - diastole) X descent – atrial relaxation (Tricuspid Valve closed - systole) V wave – slow atrial filling (Tricuspid Valve closed - systole) Y descent – passive flow into RV (Tricuspid Valve open - diastole) 2024-05-13 22 A 38-year-old female is diagnosed with severe pulmonary hypertension secondary to frequent pulmonary emboli. On examination, the JVP demonstrates a very prominent “a” wave. This finding is caused by which of the following? 1. Short diastolic filling period 2. Increased LV preload 3. Decreased right ventricular compliance 4. Increased right ventricular compliance 2024-05-13 23 A 38-year-old female is diagnosed with severe pulmonary hypertension secondary to frequent pulmonary emboli. On examination, the JVP demonstrates a very prominent “a” wave. Please explain the physiological explanation for this finding. This finding is caused by which of the following? 1. Short diastolic filling period 2. Increased LV preload 3. Decreased right ventricular compliance – this is a chronic condition, what do you think will happen to the right ventricle over time? Why would this result in a prominent a wave? 4. Increased 2024-05-13 right ventricular compliance 24 Differences between JVP and carotid pulsations Hepatojugular/Abdominojugular Reflux (HJR) Ask the patient if they have any abdominal pain. If not, check for hepatojugular reflux (a positive result is a sustained rise of greater than or equal to 4cm). o Position the patient so that the top of the JVP is visible. o Place the right hand over the liver in the right upper quadrant or anywhere in the abdomen. o Apply moderate pressure {25-30 mmHg) and maintain compression for 10 s. o The JVP may rise or remain unchanged; a sustained elevation of the JVP height (>4 cm) after 2 spontaneous breaths (to ensure the patient is not having a Valsalva maneuver) is pathological. Abnormalities of the JVP Elevated JVP suggests increased pressure in the right atrium. b. Complete atrioventricular (AV) block Elevated "a" wave c. Ventricular tachycardia Resistance to right atrial emptying may occur at or beyond the Absent "a" wave tricuspid valve. No atrial contraction, common to atrial fibrillation. Examples include: Elevated "v" wave Pulmonary Hypertension Tricuspid regurgitation is the most common cause (Lancisi Rheumatic tricuspid stenosis sign). a. The ventricle contracts and if the tricuspid valve does Right atrial mass or thrombus not close well, a jet of blood shoots into the right atrium. Cannon "a" wave b. Tricuspid regurgitation, if significant, will be Large positive venous pulse during "a" wave. It occurs when accompanied by a pulsatile liver (feel over the lower an atrium contracts against a closed tricuspid valve during costal margin). AV dissociation. c. A murmur of tricuspid regurgitation—a pan-systolic Examples include: murmur that increases during deep inspiration. a. Premature atrial/junctional/ventricular beats Kussmaul's Sign The rising of JVP with inspiration (paradoxical) suggests that the blood Constrictive Restrictive Pericardial flow into the right heart is impaired. pericarditis cardiomyopathy tamponade This could result from: Kussmaul’s Yes Yes No o Constrictive pericarditis sign o Right heart failure o SVC obstruction Pulsus Yes Yes Yes o Tricuspid stenosis paradoxus o Restrictive cardiomyopathy Pre-cordial Examination (Integration with Harvey) Follow: Inspection, Palpation and Auscultation. Palpation findings in all four cardiac areas: Area Abnormal Possible Pathology Findings A Systolic impulse Systemic HTN Dilated aortic aneurysm P Systolic impulse Pulmonary HTN Heave, thrill RV enlargement (2° to T pulmonary HTN or left- sided AA = Aortic Area, heart disease) PA = Pulmonic Area, M Thrill Mitral regurgitation (MR) TA = Tricuspid Area MA = Mitral Area Palpation Parasternal Heave/Lift -Abnormal Right Ventricular Hypertrophy Thrill – palpable murmur (grade 4-6) Apical Impulse - LV contraction -size -