Cardiovascular clinical EXAMINATION.pptx

Cardiovascular examination

1. CVS EXAMINATION PREPARED BY: Dr.samiya A. (MD,assistant professor of internal medicine) Date-feb 26,2025

2. The CVS is made up of heart and blood vessels The clinical examination of CVS therefore involves examination of Examination of vascular sysytem Examination of precordium

3. Examination of Cardiovascular system General appearance Cardio pulmonary distress Distended neck vein Raised JVP Diaphoresis and cyanosis Hyperactive precordium Cyanosis Pallor Clubbing

4. Examination of vascular sysytem Arterial examination BP measurment Pulse examination Pulse Rate Rhythm Volume Character Radiofemoral delay Condition of the vessel wall

5. Wrap the cuff securely over the arm of patient with lower border of cuff to be 2.5 cm above the antecubital crease Place the bell of stethoscope lightly over the brachial artery Feel for radial artery with fingers of one hand and inflate the cuff until the radial pulse disappears and read the Pressure on the manometer and add 30mmhg to it Deflate slowly at a rate of 2-3 mmhg per second, and notice at manometer where the sound appear, muffled and disappear

6. Korotkoff sounds Phase1- the 1st appearance of the sounds marking systolic pressure Phase 2 and 3- increasing loud sounds Phase 4- abrupt muffling of the sounds Phase 5- disappearance of the sounds marking diastolic pressure

7. Reading assignment Definition & causes of orthostatic hypotension Hypertension with wide pulse pressure (difference b/n SBP and DBP 30-60 normally. If > 60 it is Wide pulse pressure and if <30 it is narrow pulse pressure) Wide pulse pressure → AR, Anaemia, thyrotoxicosis, AV malformation, Beriberi, pregnancy, Aging (Isolated systolic HTN is common in old age) Narrow pulse pressure → AS, Blood loss, cardiac tamponade

8. Arterial pulse (PR) The arterial pulses should be palpated for evaluation of rate, rhythm, character, volume and radio-femoral delay Feel for all peripheral arteries-carotid, brachial, radial, femoral, popliteal , posterior tibial and dorsalis pedis arteries in both upper and lower extremities

9. Rate and rhythm - Radial artery is commonly used to assess heart rate and rhythm Technique- Compress radial artery with pads of index and middle fingers and count pulse rate for one minute - N ormal PR = 60 – 100 BPM Determine the rhythm in radial artery Is the rhythm regular, regularly irregular or irregularly irregular ?

10. Volume abnormalities- N ormally full Feeble pulse (Hypokinetic) - Hypovolemia , left heart failure, constrictive pericarditis and mitral stenosis Absent (pulse is not palpable) - Shock Bounding/Hyperkinetic- AR, complete heart block, anemia, PDA, thyrotoxicosis and pregnancy

11. Character : palpate carotid pulse Slow rising pulse is in small volume with a late systolic peak – in aortic stenosis Collapsing pulse (water hammer pulse)- rapid upstroke and descent of the pulse – in aortic regurgitation Bisferience pulse: is a combination of slow rising and collapsing pulse – in aortic stenosis and regurgitation

12. Other characterstics of arterial examination Pulse deficit- Difference between heart beat rate and peripheral arterial rate-AF Pulses alternance : alternating weak and strong pulse in severely impaired left ventricular contraction (advanced systolic heart failure) NB- don’t confuse with pulses paradoxus Radio-femoral delay - Press both radial and femoral artery at the same time and notice for arterial pulse delay at femoral artery compared to radial artery, and usually observed in   coarctation of the aorta Symmetry : compare bilaterally

13. VENOUS EXAMINATION Distended neck vein JVP Hepatojugular reflex

14. Position the patient Elevate head of bed at 45 degree to maximize visibility of the jugular venous pulsation in the lower half of the neck Identify the highest point of pulsation of internal jugular vein Measure the vertical distance between the highest point of jugular pulsation and sternal angle with a metered ruler The normal upper limit is 3 cm vertically above sternal angle. This is about 8 cm above right atrium,

15. Raised JVP causes CHF Constrictive pericarditis SVC syndrome Cardiac tamponade Positive kussmauls sign - raised JVP during inspiration Constrictive pericarditis RCMP MI (right ventricular infarction)

16. Hepatojugular reflex An increase in JVP during firm, mid-abdominal compression for 10 seconds followed by a rapid drop in JVP of 4 cm on release of the compression Positive in congestive heart failure patients

17. Precordial examination INSPECTION Is there precordial bulging? Presence of precordial bulging indicates chronicity of the cardiac disease Activity Active precordium- normal Hyper active precordium- HCMP, CHF (cardiomegaly) Quite (silent) precordium- IHD, DCMP, massive pericardial effusion

18. Apical impulse Normally at 4th or 5th ICS,medial to left MCL Not visible - pericardial effusion, constrictive pericarditis, highly muscular individuals Displaced downwards and laterally - Cardiomegaly of different causes

19. Palpation Heart sounds Palpable P2 at pulmonary area- Pulmonary HTN Palpable S2 at aortic area- systemic HTN

20. Localize and characterize PMI (point of maximal intensity) I s it localized or diffuse? Diffuse PMI occupies >2.5 cm in diameter (palpable PMI between 2nd and 4th finger tips while off the 3rd finger tip from the precordial area) or occupies more than one interspace Is it sustained or non sustained? Sustained PMI occupies more than 2/3 of cardiac cycle Is it thrusting or tapping? Thrusting, sustained, high amplitude impulse suggests left ventricular hypertrophy due to pressure over load (hypertension, aortic stenosis) Tapping PMI occurs in mitral stenosis

21. Heave(parasternal or apical )- I ndicate cardiomegaly T e c h n i q u e -Put ulnar border of the hand over left sternal area and look for lift or heave Left parasternal lift - Left parasternal heave - RVH - Apical heave - LVH

22. Thrill - Palpable, low frequency, vibrations associated with heart murmurs Technique Palpate the apex, left upper and lower sternal border and right upper sternal border with palm of examining hand, and feel for thrill Timing - systolic or diastolic thrill

23. A uscultation D iaphragm - f o r h i g h p i t c h e d s o u n d - S 1 , S 2 , Ejection clicks , O S - H i g h p i t c h e d m u r m u r B e l l - f o r l o w p i t c h e d s o u n d s - S 3 , S 4 , l o w p i t c h e d m u r m u r

24. Heart sounds: S1 (Lub) and S2 (Dub) First heart sound (S1) corresponds to mitral and tricuspid valve closure at the onset of systole Second heart sound (S2) corresponds to aortic and pulmonary valve closure following ventricular ejection NB: Opening of any normal valve is not audible

25. Added heart sounds (S3 and S4) - Third (S3) and fourth (S4) heart sounds are low-frequency sounds, which occur early and late in diastole respectively - S3 occur due to rapid ventricular filling in early diastole, causing sudden stretching of cordea tendinea and papillary muscles - S4 occurs due to vigorous atrial contraction against a non- compliant ventricle in late diastole

26. S 3 c a n b e : - P h y s i o l o g i c i n y o u n g i n d i v i d u a l s - Pathologic in anemia, thyrotoxicosis and severe M R S4 is usually pathological and occurs in stiff non-compliant hypertrophied ventricle due to hypertensive heart disease, aortic stenosis and hypertrophic cardiomyopathy

27. Heart murmurs R esult from vibrations set up in the blood stream and the surrounding heart and great vessels as a result of turbulent blood flow Characterizing the heart murmur - Location of maximal intensity - Timing-systolic, diastolic or continous - Intensity/grading of the murmur - Pitch and quality

28. Grading of Intensity ( loudness ) of a murmur - Grade I - faint murmur, heard only with special efforts - Grade II -quiet but heard murmur - Grade III - Moderately loud murmur - Grade IV - Loud murmur accompanied by a thrill - Grade V - Very loud,heard with a stethoscope partly off the chest - Grade V I - Heard with the stethoscope entirely off the chest

29. P i t c h - l o w o r h i g h Q u a l i t y - b l o w i n g - H a r s h - R u m b l i n g - M u s i c a l - R a s p i n g

30. T i m i n g - S y s t o l i c , D i a s t o l i c , C o n t i n o u s m u r m u r S y s t o l i c m u r m u r M i d - s y s t o l i c M u r m u r - b e g i n a f t e r S 1 a n d s t o p s a f t e r S 2 - A S , P S , A S D L a t e s y s t o l i c m u r m u r - s t a r t s i n m i d s y s t o l e & p e r s i s t s u p t o S 2 - M V P P a n s y s t o l i c M u r m u r - s t a r t s w i t h S 1 & e n d s w i t h S 2 - M R , T R , V S D

31. D i a s t o l i c m u r m u r E a r l y d i a s t o l i c m u r m u r - s t a r t s w i t h S 2 a n d e n d s b e f o r e S 1 - A R , P R M i d d i a s t o l i c m u r m u r - s t a r t s a f t e r S 2 & e n d s w i t h S 1 - M S , A S D L a t e d i a s t o l i c m u r m u r - s t a r t s i n l a t e d i a s t o l e & e n d s w i t h S 2 - T S C o n t i n o u s m u r m u r - P D A

32. L o c a t i o n - s h o w s t h e o r i g i n o f m u r m u r - M R / M S - m i t r a l a r e a - T R / T S - L L S B - A R - E R B ' S p o i n t - A S - R i g h t s e c o n d I C S - P R , a c c e n t u a t e d P 2 - l e f t u p p e r s t e r n a l b o r d e r

33. R a d i a t i o n - d i r e c t i o n o f B l o o d f l o w - M R - l e f t o f a x i l l a - A S - t o t h e n e c k - T R - t o t h e e p i g a s t r i c r e g i o n

34. C o n f i g u r a t i o n - c r e s e n d o - p r e s y s t o l i c m u r m u r o f M S - c r e s e n d o - d e c r e s e n d o - m i d s y s t o l i c m u r m u r o f M S - D e c r e s e n d o - e a r l y d i a s t o l i c m u r m u r o f A R - P l a t e a u - p a n s y s t o l i c m u r m u r o f M R , T R

35. M a n o e u v e r R e s p i r a t i o n - l e f t s i d e d m u r m u r s i n c r e a s e w i t h e x p i r a t i o n ( M R , A R ) - R i g h t s i d e d m u r m u r s i n c r e a s e w i t h i n s p i r a t i o n ( T R , P R ) P o s i t i o n - f o r w a r d f o r A R - l e f t l a t e r a l f o r M S H a n d g r i p - M R , A R i n c V a l s a l v a m a n o e u v e r - s t a n d i n g - M R i n c , A S d e c - s q u a t t i n g - A S i n c , M R d e c

36. Other heart sounds Pericardial friction rub - High-pitched scratching sound audible at any part of cardiac cycle - H eard best at left lower sternal border in maintained expiration and patient leaning forward. - It is observed in acute pericarditis

37. Pericardial knock - Early diastolic knock sound caused by sudden halt in blood flow into the heart during diastolic filling It is observed in constrictive pericarditis Opening snap - High-pitched snapping sound heard in diastole, caused by sudden opening of non-calcified stenosed mitral valve

38. T h a n k y o u