Cardiovascular Examination DAWIT AYELE (MD) INTERNIST

Dyspnea Dyspnea an abnormally uncomfortable awareness of breathing that is easily differentiated from normal, quiet, unnoticed breathing heart failure, pulmonary edema, obstructive airway disease, and pulmonary embolism. Onset, precipitating factors, paroxysmal nature

Orthopnea Dyspnea that occurs when the patient is lying down and improves upon sitting. It is quantified according to the number of pillows on which the patient sleeps

Paroxysmal Nocturnal Dyspnea Describes episodes of sudden dyspnea and orthopnea that awakens the patient from sleep, usually 1 or 2 hours after going to bed. The patient typically sits up, or goes to a window for air. Wheezing and coughing may be associated

Chest pain and discomfort Nature of the pain: squeezing, crushing etc. Location Radiation: to the jaw, left arm, hand etc. Exacerbating and Alleviating Factors

Palpitations An unpleasant awareness of the heart beats. Patients report it as: skipping beat, bounding beat, racing beat, stopping of the heart. It may result from: irregularities, tachycardia, forceful beat, bradycardia, extra beats.

Edema Accumulation of excessive fluid in the body An ascending type of body swelling is characteristic to cardiac problems.

Examination of the venous system CVP Extremity veins

CVP, central venous pressure Pressure of the right atrium Measured in cm of water Use a column of blood in the jugular veins We use blood to estimate this pressure

Jugular Venous pressure The internal jugular communicates directly with the right atrium No venous or cardiac valves intervene Act as a manometer of right atrial pressure The external jugular vein is usually more readily visible as it passes over the sternomastoid muscle towards the mid-clavicle. It is easily kinked as it passes through the fascia of the neck and may give a false impression of right atrial pressure.

Distinguishing the internal jugular from the carotid artery pulsation JVP No pulsations palpable Pulsations obliterated by pressure above the clavicle Level of pulse wave decreased on inspiration; increased on expiration. Pulsation of the jugular vein will vary with position Usually two pulsations per systole (x and y descents). Prominent descents Pulsations sometimes more prominent with abdominal pressure. Carotid Palpable pulsations Pulsations not obliterated by pressure above the clavicle. No effects of respiration on pulse. No effect of position One pulsation per systole Descents not prominent. No effect of abdominal pressure on pulsations.

Technique for examination for CVP Position the patient reclining at an angle of 45° Turn the head to the left, Neck should not be sharply flexed Observe neck with a light falling obliquely across the neck Identify the external jugular veins on each side Then find the pulsations of the internal jugular veins Observe for a double-complex waveform

..technique Identify the highest point of pulsation With a centimeter ruler measure the vertical distance between this point and the sternal angle. Measurements greater than 3 is abnormal

JVP pulsations

Examination of the arterial system Pulse Blood pressure The vessel itself

Arterial Pulses The presence and the volume of each pulse should be compared with the other side Detected by gently compressing the vessel against firm structures, usually bones The main peripheral arterial pulses that should be felt include: radial, brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis.

Arterial Pulses Heart rate: use the radial artery, count for 60 seconds, if the rhythm is irregular, auscultate Rhythm: regular Vs irregular If irregular: regularly irregular, irregularly irregular Character: form of the wave (speed of upstroke and downstroke and summit)

..pulse, character Parvus et tarsus Collapsing pulse (water hammer) Pulsus paradoxus Volume (amplitude): rough guide to pulse pressure and stroke volume Delay: radio-femoral delay in coarctation of the aorta.

..character Pulsus alternans—suspect acute or chronic reduction in left ventricular ejection fraction Anacrotic pulse, delayed upstroke, —suspect aortic valve stenosis Pulsus paradoxus—suspect tamponade, emphysema

Blood pressure measurement Patient should avoid smoking and caffeine for 30 min Rest for at least 5 minutes The arm should be resting and free of clothing Position the hand so that the brachial artery is at the level of the heart

..BP measurement Inflatable bladder over the arm. The lower border of the cuff should be 2.5cm above the antecubital crease Inflate the cuff 30mmHg above the point at which radial pulse disappears Put your stethoscope over the antecubital fossa and deflate the cuff slowly at a rate of 2-3 mmHg/sec

…BP measurement The level at which the Korotkoff are heard is the systolic pressure The disappearance point is the diastolic pressure Wait 2 or more minutes and repeat. Average your readings.

Examination of the vessel Assess the rigidity and elasticity of the arteries The thickness and firmness of the arterial walls are examined by rolling the vessel, usually the radial artery Osler’s maneuver: elevate the cuff pressure to obliterate the radial pulse; if, after obliteration of the pulse, the radial artery is easily palpable and appears rigid then it is a positive Osler’s sign

Precordium-surface projections

INSPECTION Stand on patient’s right Better if patient is supine upper body 30o Look for visible scar , vessel Look at precordium active/quiet Look for apical impulse:+/-visible-characterize Look for extraprecordial pulsation(epigastric..)

PALPATION Palpate heart sounds(valves):-press ball of the hand firmly on the chest S1-Mitral-apex -Tricuspid-left parasternal 4th INTERCOSTAL S2-Aortic-rt parasternal 2nd INTERCOSTAL -Pulmonic-lt parasternal 2nd INTERCOSTAL Characterize apical impulse- may use finger tips& positioning- Location , diameter,amplitude , duration Check for thrill(palpable m)/heave(hypertrophy)

AUSCULTATION Start at apex or base: Rt 2nd,lt 2nd 3rd,4th,5th Use diaphragm-for high pitched S1 & S2(MR,AR),pericardial friction rub Use bell-for low pitched-S3,S4,MS-(apex & along the lower sternal border)-apply it lightly You may use maneuvers-sit pt. up, standing , squatting,exercise,lean forward, exhale completely, stop breathing or inhale deeply..

Characterize added sounds: Murmur-Timing-systole/diastole/early, late, holo -Shape-crescendo , decrescendo, plateau -Location -Radiation -Transmission -Intensity-grade 1-6 -Pitch-high,medium,low -Quality-blowin,harsh,rumblin,musical

Gallop-S3,S4 Split sounds-S1,S2 Extrasystole/Irregularities/Pulse deficit…