Transcript CV exam.2016

THE CARDIOVASCULAR EXAM
PSD
Nadine Gauthier, MD, Med, FRCPC
Division of Cardiology
SPECIFIC OBJECTIVES
12077 - Describe a basic approach to the physical
examination of the cardiovascular system
including inspection, palpation and
auscultation.
12078 - Explain the basic heart sounds.
12079 - Describe how to perform a blood pressure.
GENERAL OBJECTIVES
• Demonstrate the basic
use of the stethoscope.
• Approach to Vital Signs
– Demonstrate how to
properly measure the heart
rate, and respiratory rate.
• Blood Pressure
Measurement
– Demonstrate how to take
an office blood pressure as
per the Canadian
Hypertension Program
(CHEP).
• Approach to CVS
Exam
– Explain a basic approach
to the physical examination
of cardiovascular system
including inspection,
palpation and auscultation.
– Demonstrate the normal
location of the apical
impulse.
– Demonstrate manoeuvres
to elicit the apical impulse
and auscultation of the
heart.
WHERE TO START
• Must first understand the process and
develop a systematic approach.
• Need to be able to recognize normal to
diagnose abnormal.
• Head to toe approach.
EXAMINING THE HEART AND CIRCULATION
•
Inspection
•
– General inspection
– Specific to CV
•
•
•
Pulses
– Precordium and apex
– Location, size,
abnormal impulses
– Rate and rhythm
•
BP
JVP
•
Carotids
– Palpate and auscultate
Auscultation
– Precordium and apex
Peripheral pulses
– Palpate and listen for
bruits
– Height and waveform
•
Palpation
•
Examine extremities
– Arterial/venous
insufficiency/atrophic
changes
IS THE PATIENT STABLE?
Acute Evaluation
• A - Airway –
patent/obstructed
• B - Breathing –
rate/pattern
• C - Circulation –
HR/BP
• D - Describe the
patient
Elective Evaluation
• Comfortable/distresse
d
• Dyspneic/fatigued
• Pale/cyanosed
• Diaphoretic
• Dehydrated/volume
depleted
• Congested/edematou
s/ volume overloaded
INSPECTION
•
•
•
•
•
Cyanosis
Clubbing
Xanthoma and xanthelasma
Stigmata of endocarditis
Pectus excavatum/body habitus
CYANOSIS
CLUBBING
DIFFERENTIAL DIAGNOSIS OF
CLUBBING
• Cyanotic congenital
heart disease
• Lung disease
–
–
–
–
–
Cystic fibrosis
Interstitial fibrosis
Malignancy
Sarcoidosis
Bronchiectasis
• Hyperthyroidism
MARFAN’S SYNDROME
Body Habitus
• Tall/thin/long facies
• Long fingers
– Thumb sign
– Wrist sign
• Ligamentous laxity
• Scoliosis/kyphosis
• Pectus
excavatum/carinatum
• Ectopia lentis
• Narrow long facies
• High arched palate
PULSE
RADIAL PULSE
• Most common site to measure heart rate
• Palpate radial artery with index and middle
finger for 15s then multiply x 4.
• If rate too rapid, slow or irregular rhythm palpate
for full 60s.
Normal rate: 60-100 ppm
Tachycardia: ≥ 100 ppm
Bradycardia: ≤ 60 ppm
RADIAL PULSE
• Cardiac rhythm
–
–
–
–
–
If the rhythm is irregular, auscultation should be used
Regular
Irregularly irregular
Regularly irregular
Respiratory variability
• Carotid pulse is also very reliable to determine
rhythm
– Carotid upstroke: volume and contour
– Reduced in aortic stenosis
– Increased in aortic regurgitation
REGULAR RHYTHM
Normal Sinus Rhythm
IRREGULARLY IRREGULAR
Atrial Fibrillation
REGURLARLY IRREGURLAR
Ventricular Bigeminy
CAROTID PALPATION
CAROTID EXAMINATION
• Carotid upstroke
– Brisk, normal or delayed
– Volume: normal, increased or decreased
– Anacrotic or Bisferiens
• Carotid auscultation
– Bruit
– Transmitted murmur
– A2 audible in neck?
• Presence excludes severe AS
PULSE VOLUME & CONTOUR
• Palpate
– Forearm/Brachial/Carotid/Femoral
• Describe:
– Volume: normal/increased/decreased
– Slow rising +/- brachial-radial delay (aortic stenosis
-AS)
– Collapsing or water hammer pulse - (aortic
regurgitation -AR)
– Bifid (bisferiens –AS/AR or IHSS)
– Pulsus paradoxus
• Tamponade
• COPD
– Pulsus alternans
• LV dysfunction
BLOOD PRESSURE ASSESSMENT:
PATIENT PREPARATION
Standardized technique:
Posture
The patient should be calmly seated for
at least 5 minutes, with his or her back
well supported and arm supported at
the level of the heart. His or her feet
should touch the floor and legs should
not be crossed.
The patient should be instructed not to
talk prior and during the procedure.
RECOMMENDED TECHNIQUE
FOR MEASURING BLOOD PRESSURE
– Locate brachial and
radial pulse
– Position cuff at the
heart level
– Arm should be
supported
RECOMMENDED TECHNIQUE
–
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
RECOMMENDED TECHNIQUE
Standardized technique:
• For initial readings, take
the blood pressure in both
arms and subsequently
measure it in the arm with
the highest reading.
• Thereafter, take two
measurements on the side
where BP is highest.
RECOMMENDED TECHNIQUE
The seated blood 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
BP TREATMENT
TARGETS
160/100
CONDITION
Treatment threshold if no risk factors
< 140/90
Normal office BP
Treatment target for office BP
measurement
< 135/85
Normal Home BP
Treatment target for for ABP or HBP
measurement
< 130/80
Treatment target for for Type 2 diabetics
or non-diabetic nephropathy or CAD
(AHA)
JUGULAR VENOUS PRESSURE
• Measured JVP height correlates with the central
venous pressure
• Measurement of pressure in the right atrium
– Height of JVP in cm + 5 cm H2O = RA pressure
• External jugular is more visible than the internal
jugular
• Reference point is the angle of Louis (2nd ICS)
• Requires 2 rulers, measure horizontal distance
to reference point and then vertical height.
MORE ON JVP
• Patient position is key for proper assessment
• Patient at 30-45°degrees
• Head in slight extension, turn to the left
– Tangential lighting
– Right side of neck exposed
• Technique
– Look for double pulsation medial to external jugular
vein
– Between the two heads of the SCM
– Above the clavicle
ABNORMAL JVP
• Normal JVP
– 3-4 cm above angle of Louis
• Identification of the height of the column
• If JVP is not visible
– Pressure too high: elevate the head of the
bed to 90 degrees (column should drop with
gravity)
– Pressure too low: lower the head of the bed
(supine)
Proper
positionning
is key!
External Jugular Vein
HAND MAND RULER
NORMAL JVP WAVEFORM
• 3 positive waves
–a
–c
–v
• 3 descents
–x
– x'(x prime)
–y
NORMAL JVP WAVEFORM
"A" wave: atrial contraction (ABSENT in atrial fibrillation)
"C" wave: ventricular contraction (tricuspid bulges). YOU WON'T SEE
THIS
"X" descent: atrial relaxation
"V" wave: atrial venous filling (occurs at same of time of ventricular
contraction)
"Y" descent: ventricular filling (tricuspid opens)
JVP VS. CAROTID
Pulsation of the JVP
Pulsation of the Carotid Pulse
Rarely palpable
Palpable
Two waves, two descents
Weak pulsation
Strong upstroke, one descent
Strong pulsation
Compressible
Non-compressible
Height of column varies with
patient positionning
Position does not affect the
height of the pulsation
Abdominal-jugular reflux
N/A
Respiratory variation
No respiratory variation
HEPATO-JUGULAR REFLUX AND
KUSSMAUL’S SIGN
• Abdomino-jugular
reflux
(various definitions)
– sustained rise to 4 cm
for 10 sec.
–  RV compliance
• Positive HJR
correlates with
LVEDP > 15
• JVP normally falls
with inspiration
• Kussmaul’s sign
–
–
–
–
inspiratory  in JVP
constriction
rarely tamponade
RV infarction
CAUSES OF ABNORMAL JVP
• Heart failure
– Right or left
•
•
•
•
Pericardial effusion
Pericardial constriction
Tricuspid stenosis
Hypervolemia
– Hyperthyroidism
– Fistula
– Pregnancy
• SVC obstruction
SVC
RA
RV
Pericardium
CARDIAC EXAM
• Inspection
–
–
–
–
Scars
Chest wall deformities: pectus excavatum
Visible apical impulse
Ventricular lifts (parasternal borders)
• Palpation
–
–
–
–
–
Four zones
Thrills: palpable murmurs
Lifts: ventricular displacement due to dilatation
Palpable P2 (pulmonary artery)
Palpable S3, S4
PRECORDIAL PALPATION
Sequence of auscultation:
• Upper right sternal border -2ICS (intercostal
space)
• Upper left sternal border - 2ICS
• Parasternal (left sternal border 3rd - 5th ICS)
• Apex
• Apex left decubitus (patient rolled over halfway)
• Apex upright leaning forward
1
2
3
4
PRECORDIAL PALPATION
• Parasternal:
– Lift: RV enlargement or severe MR
– Thrill: VSD, HOCM (IHSS)
– Palpable P2 (ULSB): pulmonary hypertension
• Apex
– Location
– Size
PALPATION - APEX
• Apex
– Palpable in 1 of 5 adults < age 40
– Best felt with fingertips or finger pads
• Normal Location
– No more than 10 cm from mid-sternal line in the
supine position
– Left decubitus position not reliable for apical
location
• Normal Size
– No larger than 3 cm (about 2 finger breadths)
APEX-DYNAMIC QUALITIES
• LV impulse moves outward like a ping pong ball
protruding between the ribs
• Apex moves outward for the first third of systole
and falls away rapidly
• Lasts for no more than 2/3 of systole
• Sustained apex:
– > 2/3 systole - hangs out to S2
– correlates with LV pressure overload
– AS, LVH or LV systolic dysfunction
AUSCULTATION
AUSCULTATION
• Use the diaphragm for high pitched sounds
and murmurs
– Use firm pressure to bring out high pitched sounds
and murmurs
• Use the bell for low pitched sounds and
murmurs
– Use light pressure to bring out low pitched sounds
and murmurs
• If using tunable diaphragm (Masters)
– Firm pressure for high pitched sounds
– Light pressure for low pitched sounds
AUSCULTATION
• Stethoscope diaphragm
– High pitch heart sounds
• S1, S2, murmurs of AS or regurgitant jets
• Pericardial rub
• Stethoscope bell
– Low pitch heart sounds
• S3, S4, mitral stenosis
Aortic valve: Right upper sternal border– 2nd ICS
Pulmonic valve: Left upper sternal border – 2nd ICS
Tricuspid valve: Right lower sternal border – 4th ICS
Mitral valve: Midclavicular line – 5th ICS
Pulmonic
Aortic
Mitral
Tricuspid
1
2
3
4
FIRST HEART SOUND
• S1 (M1, T1)
• Louder at the apex
– Mitral valve closure
• Loud S1
– Mitral stenosis
– Tricuspid stenosis (rare)
– Tachycardia, exercise, anemia
• Soft S1
– Mitral and tricuspid regurgitation
– Left ventricular dilatation
– Decreased heart sounds (obesity, COPD)
SECOND HEART SOUND
•
•
•
•
S2 (A2, P2)
Loudest at the base, RUSB, 2nd ICS
A2 > P2
Physiological split
– With inspiration, P2 closes later, A2-P2 widens
– With expiration, A2-P2 narrows again
• Wide split: pulmonic valve closes late (RBBB)
• Fixed split: ASD (more flow RA-RV)
• Paradoxal: P2-A2 wide in expiration (LBBB)
THIRD HEART SOUND S3
• Physiologic or pathological
• Pathological: > 40 years old
– Volume overload
• Heart Failure
• Mitral regurgitation
• Positioning
– Left lateral decubitus, 5th ICS – LV
– Right parasternal border, 4th ICS – RV
– “MONTREAL”
S3
FOURTH HEART SOUND S4
• Physiological or pathological
• Pathological
– Pressure overload
– Resistance of ventricular filling due to the increase
ventricular wall tension
– Decreased compliance
•
•
•
•
Myocardial infarction
Cardiomyopathy
Hypertension
Aortic stenosis
• “Toronto”
• Gallop
– S4, S1, S2, S3
S4
LISTEN FOR MURMURS
• What is a murmur?
– A sound/vibration made by blood flowing
through a normal valve or an abnormal valve.
– A sound made by blood flowing backwards
through a leaking valve
– Murmurs may be functional or pathologic
HEART MURMURS
• Approach to murmur description
– Timing of cardiac cycle (systole, diastole)
– Shape (Crescendo, decrescendo, holo or
pansystolic)
– Loudest in specific cardiac zone depending
on valve
– Radiation (jet direction)
– Intensity (Grade I-VI)
– Tone (high or low pitch)
– Quality (musical, harsh, blowing)
MURMUR INTENSITY
•
•
•
•
•
I : very weak, barely audible
II : audible but discrete
III: loud murmur, audible for most
IV: loud murmur with a thrill
V: very loud, murmur audible with
stethoscope partially applied to skin
• VI: audible with stethoscope not on chest
wall
FUNCTIONAL MURMURS
COMMON IN ASYMPTOMATIC ADULTS
• Characterized by
– Grade I – II @ LSB
– Systolic ejection pattern - no  with Valsalva
–
–
–
–
S1
S2
Normal precordium, apex, S1
Normal intensity & splitting of second sound (S2)
No other abnormal sounds or murmurs
No evidence of LVH
PATHOLOGIC MURMURS
•
•
•
•
•
Diastolic murmur
Loud murmur - grade 4 or above
Regurgitant murmur
Murmurs associated with a click
Murmurs associated with other signs or
symptoms e.g. cyanosis
• Abnormal 2nd heart sound – fixed split,
paradoxical split or single
SYSTOLIC MURMURS
• Crescendo-Decrescendo
– B1 and B2 audibles
– Aortic or pulmonic stenosis
• Pansystolic
– Starts with B1 and finishes
on B2
– Tricuspid and mitral
regurgitation
• Late systolic
– Starts in mid-systole and
extends to S2
– Mitral valve prolapse
• Non-ejection click
B1
B2
B1
B2
B1
B2
B1
B2
B1
B2
B1
B2
AORTIC STENOSIS
• Carotid pulse
– Decrease volume and
contour (with  severity)
• Palpation
– Sustained apex
– LV hypertrophy
• Ausculatation
B4
– Soft S2
– S4
– Crescendo-decrescendo
murmur RUSB, 2nd ICS
– Radiates to carotid and
apex
– Murmur peaks later in
systole with  severity
B1
B2
B1
B2
MITRAL INSUFFICIENCY
• Carotid pulse
– Low volume
– Hyperdynamic contour
• Palpation
– Enlarged apex
• Auscultation
– Soft S1
– S3
– Holosystolic murmur
at the apex radiates to
axilla or RLSB
B1
B2
B3
B1
B2
DIASTOLIC MURMURS
• Early decrescendo
– Starts with S2,
finished mid-diastole
– Aortic or pulmonic
regurgitation
• Mid diastolic
– Turbulent flow across
AV valves
– Volume overload
– Diastolic rumble, MS
B1
B2
B1
B2
B1
B2
B1
B2
CHEST EXAMINATION
• Part of a complete cardiovascular examination
• Respiratory distress
– Use of accessory muscles
• Identify presence of heart failure
– Fine crackles at the base
– Crackles throughout with respiratory distress =
pulmonary edema
• Wheezing can also be seen with CHF
– Bronchospasm
ABDOMINAL EXAM
• Inspection
– Jaundice
– Ascites
– Pulsatile liver or mass
• Ausculatation
– Abdominal bruits
• Palpation
– Pulsatile liver: right CHF, fluid overload
– AAA
LOWER PERIPHERAL EXAM
• Peripheral pulses
• Peripheral edema
– Pitting – right CHF, bilateral
– Non-pitting – venous insufficiency – bilateral
– Unilateral – not cardiac
EXAMINATION OF PULSES
• Grading:
– Normal/Increased/Decreased/Absent
– 2+/3+/1+/0
– Allen’s test
• Trophic changes/Ulceration
• Perfusion
– Pallor on elevation
– Rubor on dependency
– Venous refill with dependency (should be less
than 30 seconds)
• Bruits
PALLOR ON ELEVATION
RUBOR ON DEPENDENCY
VENOUS INSUFFICIENCY
VENOUS ABNORMALITIES
VARICES AND SPIDER VEINS
TYPES OF EDEMA
CELLULITIS VS DVT
Cellulitis
Right Deep Venous Thrombosis
IMPORTANT RESOURCES