Transcript Chapter V Thorax

Chapter V Thorax
D. Heart and blood vessels
Blood Vessel
by Dr. Zhuo-ren Lu
1. Inspection
(1) Venous blood pressure
l
When the venous pressure is elevated, an
engorged external jugular vein can be seen above
the lower one third of the distance between super
clavicle and the angle of the jaw with patient sitting
erect, and above the lower two third of the distance
between super clavicle and the angle of the jaw at
supine position.
l It often indicates the elevated pressure in the right
atrium and is an important sign of congestive heart
failure, pericardial constriction, and pericardial
effusion.
(2) The visible pulsation in the neck veins

It indicates the regurgitation of tricuspid valve
and the visible pulsation of carotid artery occurs
in aortic regurgitation.

The level of visible pulsation in the neck veins
descends on normal inspiration and rises on
expiration.

The pulsation of jugular vein looks diffuse, but
the point of carotid artery pulse is limited.

It requires much greater pressure to eliminate the
carotid artery pulse with a distinct pulse feeling.
(3) Hepatojugular reflux
Compression of the right upper abdominal
quadrant for 30 to 45 seconds will result in more
prominent distension of external jugular vein.
l
It usually is an important sign of right
ventricular failure or pericardial effusion or
constriction, because blood is being transmitted
from the liver to the superior vena cave without
returning back to right atrium more.
It is usually used to distinguish hepotohemia from
hepatitis, hepotoma, hepatocirrhosis.
(4) Capillary pulsation
Check capillary pulsation by pressing on nails
or lips with a clear glass and looking at the
change of color from pink to white. Capillary
pulsation occurs in aortic regurgitation and
other abnormalities associated with wide pulse
pressure.
2. Palpation
(1) Examiner place fingers over the radial artery and
can feel the strong artery pulsating. It is still a
bounding pulse when elevating the patient’s arm
over his head. It is called as water-hammer pulse
and often occurs in aortic regurgitation and other
abnormalities associated with wide pulse pressure.
(2) Pulsus paradoxus (paradoxical pulse) is an
important sign of cardiac tamponade with tense
pericardial effusion and less frequently with
chronic constrictive pericarditis. The term refers
to weakening of the pulse during deep inspiration.
( 3 ) Pulsus alternans is characterized by a
regularly alternating pulse, in which every other
beat is weaker than the preceding beat. It is
valuable indication of left ventricular failure.
(4) Check the symmetry of pulses. Thrombosis or
embolism involving one subclavian, axillary, or
brachial artery usually results in an absent
radial pulse on the affected side. Thus one must
palpate over both sides of the radial, brachial,
dorsalis pedis, popliteal, femoral arteries pulse
simultaneously.
3. Auscultation
(1) Auscultate both sides of carotid bruit.
(2) Put the bell head on the femoral artery
or brachial artery to auscultate for a
pistal-shot sound like “Ta-Ta” and over
the femoral artery to hear the to and fro
bruit called Duroziez sign. Both of the
sounds are associated with increased
pulse pressure.
4. Arterial blood pressure
(1) Measure blood pressure (Bp) on right arm.
l The point in which Bp is to be measured should
be at the level of the heart.
l Place cuff in correct location 23cm above the
elbow joint and make one finger admitted under
the cuff.
l The mercury column on the manometer should
be properly calibrated with the pointer at “0”
before the cuff is inflated.
l The stethoscope is placed firmly over the brachial
artery.
l
The examiner inflated the cuff slowly but
steadily until the brachial artery pulse disappears
and 2030mmHg higher. Deflate the cuff slowly
at the rate of about 2mmHg/min.
l The number where the examiner hears the first
pulse is the systolic pressure. The number where
the pulse sound disappears is the diastolic pressure.
If the difference between weakening of the sound
and its disappearance is 20mmHg or greater, these
two numbers should be recorded.
l One minute later, the same procedure may be
followed for a second measurement of Bp. The
lowest pressure is recorded as the patient’s Bp.
(2) Under the normal circumstances there is little
or no significant difference in Bp (510mmHg)
in the two upper extremities.
The systemic pressure is slightly higher,
2040mmHg in the lower extremities by placing
the cuff around the lower third of the thigh and
the stethoscope over the popliteal artery than in
the upper.
It is important to mearsur Bp in the low
extremities when the femoral and popliteal
pulses are either weak or absent and in order
to rule out coarctation of the aorta.
Definitions and classification of blood pressure
levels (mmHg) by WHO/ISH 1999
Category
Systolic
Optimal
< 120
Normal
<130
High normal
130-139
Grade 1 hypertension (mild)
140-159
Subgroup: borderline
140-149
Grade 2 hypertension(moderate) 160-179
Grade 3 hypertension (severe)
180
Isolated systolic hypertension
subgroup:borderline
 140
140-149
Diastolic
< 80
< 85
85-89
90-99
90-94
100-109
 110
< 90
< 90
l
Some serious causes of low Bp include acute
myocardial infarction, hemorrhage, and shock.
l
Increased pulse pressure happens frequently in
hyperthyroidism, aortic valve regurgitation, etc.
l
In elderly persons the most common cause for an
elevated SP and normal DP is aortic
atherosclerosis or arteriosclerosis.

The decreased pulse pressure may be resulted
from pericardial effusion, constrictive pericarditis,
aortic stenosis, mitral stenosis, and heart failure.