B

CARDIOVASCULAR SYSTEM EXAMINATION

THE HEART

For it is the heart by whose virtue and pulse the blood is moved, perfected, made apt to nourish and is preserved from corruption and coagulation. It is indeed the fountain of life, the source of all action. William Harvey 1578-1657
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Outline
Introduction General examination Examination of vessels
Arterial system Venous system

Precordial examination
Inspection Palpation Auscultation and Percussion??

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Introduction of Normal Anatomy

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Different Valves of the Heart and Normal Blood Flow

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General examination
Examination of the hands Cyanosis (central and peripheral) Look for any malformation Examination of eye Examination of lower extremities

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Examination - Hands
Clubbing Splinter hemorrhages (infective endocarditis) Oslers nodes (tender) Janeway lesions (non-tender) Xanthomata (Hyperlipidemia)

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CLUBBING
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Oslers node

Janeway lesions

Splinter Haemorrhages

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General examination cont

Cyanosis (central) Peripheral cyanosis

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Examination of the eyes

Xanthelasma

Subconjuctival petechae

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High arched palate

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Examination of the Arterial System

Rate (normal = 60-100)
Bradycardia (<60) Tachycardia (>100)

Rhythm
Regular Irregular

Rate and rhythm are checked in the radial artery Character and volume assessed from carotid artery Radio-femoral delay (Coarctation of the aorta)-comparing radial and femoral pulse Peripherally accessible arterial pulses
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Cont

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Technique for brachial artery palpation

Technique for palpation of the femoral arteries

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Technique for timing the femoral and radial pulses.

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Technique for palpation of the popliteal artery

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Peripheral Pulses

Dorsalis pedis pulse

Posterior tibial pulse

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Venous System Examination

Jugular venous pressure measurement Lower extremity venous system examination
NB: The latter would be discussed in future clinical year attachments.

Jugular Venous Pressure (JVP)

JVP reflects pressure in the right atrium Assessed from pulsations in the right internal jugular vein. It shouldnt be done in children < 12 yrs Estimate CVP maximal 3-4cm from sternal angle + 5cm from atrium (Right atrial pressure)

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Cont

Steps
Position patient 30/45 Tangential light Identify internal jugular venous pulsation (right) Extend a long rectangular object or card horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right angle. Measure the vertical distance in centimeters
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Causes for rise in JVP are

Congestive heart failure Cor pulmonale Pulmonary embolism Right ventricular infarction Tricuspid valve disease Cardiac tamponade Constrictive pericarditis Superior vene cava obstruction Hypertrophic / Restrictive cardiomyopathy Fluid overload

Examination of Heart/ Precordium

Inspection Palpation Auscultation Percussion ???

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PRECORDIUM - INSPECTION

Scars Chest deformity

Pectus excavatum Pectus carinatum Bulged precordium

Apex beat: lowest and most lateral beat;

Lt. 5th ICS MCL
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Precordium - Palpation
Point of maximal impulse (PMI)
Location Character
Heaving Thrusting Tapping localized/diffuse

Left parasternal heave Thrills (palpable murmurs)

Systolic Diastolic

Palpable P2 (pulmonary hypertension) Pacemaker box

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Auscultation
Proper auscultation requires Quiet area. Avoid extraneous noise from radios, televisions, .. The earpieces of the stethoscope are directed anteriorly or parallel to the direction of the external auditory canal

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Precordium Auscultation Heart Sounds

Bell low pitched sounds Diaphragm high pitched sounds Mitral Tricuspid Pulmonary Aortic areas S1 (first heart sound) S2 (2nd heart sound) Lub-dub-lub-dub

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Sounds to be heard in auscultation

First and second heart sound S and S sounds Murmur Splitting of the heart sounds Opening snap Pericardial knock/friction rub
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Precordium Auscultation Murmurs

Timing of murmur
Systolic Diastolic Continuous

Pitch Radiation Dynamic maneuvers

Respiration
Left-sided on exp. Right-sided on insp.

Site of maximal intensity Loudness

Grades I-VI Thrill

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Heart Murmurs
Systolic
Pansystolic
Mitral regurgitation Tricuspid regurgitation Ventricular septal defect

Diastolic
Early diastolic
Aortic regurgitation Pulmonary regurgitation

Mid-diastolic
Mitral stenosis Tricuspid stenosis Atrial myxoma

Ejection systolic
Aortic stenosis Pulmonary stenosis HOCM Atrial septal defect

Continuous
Patent ductus arteriosus Arteriovenous fistula

Late systolic
Mitral valve prolapse

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Cont
Grading of Murmurs
1. 2. 3. 4. 5. Very faint, heard only with special effort Quiet, but readily detected Moderately loud Loud, usually accompanied by a thrill Very loud, with thrill, heard when the stethoscope is partly off the chest 6. Very loud, with thrill, heard when the stethoscope is entirely off the chest

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THANKS