© Continuing Medical Implementation …...bridging the care gap How to Examine the Heart and Blood Vessels Joel Niznick MD FRCPC

© Continuing Medical Implementation …...bridging the care gap

Look at the patient Sick/well Comfortable/in distress Cyanosed/plethoric Wet/dry Young/old Male/Female Establish probabilities of disease –History will have told you what to suspect

© Continuing Medical Implementation …...bridging the care gap Common Clinical Scenarios Younger people –Functional murmur vs MVP vs bicuspid AV Older people –Aortic sclerosis vs aortic stenosis

© Continuing Medical Implementation …...bridging the care gap Probabilities Males more commonly have aortic valve disease –Young – BAV –Elderly - Degenerative Females more commonly have mitral valve disease MVP > rheumatic heart disease

© Continuing Medical Implementation …...bridging the care gap Inspect Facies/body habitus –Cyanosis –Xanthelasma –Arcus senilis –Conjunctival hemorrhages Syndromes –Marfan’s –Down’s

© Continuing Medical Implementation …...bridging the care gap Hands Clubbing Capillary return Digital ischaemia Splinter hemorrhages Osler’s nodes Janeway lesions

© Continuing Medical Implementation …...bridging the care gap Blood pressure At rest 5” Both arms Legs if young hypertensive

© Continuing Medical Implementation …...bridging the care gap Look at the Fundi OSU Interactive Physical Exam Guide

© Continuing Medical Implementation …...bridging the care gap Look at the Fundi Disc Vessel Hemorrhages Exudates

© Continuing Medical Implementation …...bridging the care gap Pulses Rate Rhythm Volume –Quincke’s –Water hammer –Brachio-radial delay

© Continuing Medical Implementation …...bridging the care gap Carotid Upstroke-normal/brisk/delayed/anacrotic Volume-normal/increased/decreased Auscultate: –Bruit –Murmur –S2 audible ? Over carotid?

© Continuing Medical Implementation …...bridging the care gap Carotid Tutorial

© Continuing Medical Implementation …...bridging the care gap JVP Height Waveform Specific patterns Response to maneuvers –Inspiration –HJR

© Continuing Medical Implementation …...bridging the care gap JVP Inspection

© Continuing Medical Implementation …...bridging the care gap

JVP Summary Confirm it’s the JVP you are seeing –Compressibility –Waveform –Manoeuvers Identify the height – start at 30 o Identify the waveform

© Continuing Medical Implementation …...bridging the care gap If unable to see JVP-lie patient flat If still unable to see JVP-sit patient upright

© Continuing Medical Implementation …...bridging the care gap Use the hand made ruler

© Continuing Medical Implementation …...bridging the care gap Normal JVP Waveform a cv x x y

© Continuing Medical Implementation …...bridging the care gap JVP Inspection Look for descents not waves Descents are easier to see due to greater amplitude and frequency Time deepest descent with systole. This is the X’ descent

© Continuing Medical Implementation …...bridging the care gap Specific JVP patterns ConditionPattern Normal waveformX' deeper than Y Post CABGX' shallower, now = Y Atrial fibrillationCV wave Tricuspid regurgitationCV wave Complete heart blockIrregular cannon A waves Tamponade  JVP brisk X' > Y Constriction  JVP brisk X' & Y descents X' less exaggerated than Y RV infarction  JVP –low amplitude

© Continuing Medical Implementation …...bridging the care gap Precordium Palpate: Aortic → Pulmonary → LSB → Apex → Left decubitus Thrills Palpable HS Lifts Apex: size/position/motion

© Continuing Medical Implementation …...bridging the care gap Auscultation Follow same sequence Aortic → Pulmonary → LSB → Apex → Left decubitus → Upright lening forward Diaphragm except for apex (use both here) Identify HS, then extra sounds, them murmurs Dynamic maneuvers

© Continuing Medical Implementation …...bridging the care gap Palpation - Precordium Parasternal: Palpable P 2 -pulmonary HTN Thrill –VSD/HCM RV lift –RVH –Severe MR

© Continuing Medical Implementation …...bridging the care gap 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)

© Continuing Medical Implementation …...bridging the care gap Sustained Apex: correlates with pressure overload or LVF ( > 2/3 systole-hangs out to S2) AS, LVH or LV systolic dysfunction Hyperdynamic Apex: correlates with volume overload AR/MR palpable S4 (atrial kick) palpable S1 (MS) palpable non-ejection click (MVP) Apex–Dynamic Abnormalities

© Continuing Medical Implementation …...bridging the care gap Apex–Dynamic Abnormalities Atrial kick: Palpable S4 –Loss of LV compliance –LVH 2 o Hypertension –Aortic Stenosis –Hypertrophic Cardiomyopathy

© Continuing Medical Implementation …...bridging the care gap Auscultation

© Continuing Medical Implementation …...bridging the care gap What are we listening for?

Normal First & Second Sounds

Normal First & Second Sounds 2

Splitting of the Second Sound

Timing of Cardiac Sounds

Fourth Heart Sound S4 Gallop

Third Heart Sound S3

Systolic Murmurs

Diastolic Murmurs

© Continuing Medical Implementation …...bridging the care gap Common Murmurs Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

© Continuing Medical Implementation …...bridging the care gap Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side Auscultation

© Continuing Medical Implementation …...bridging the care gap Characteristics of a “functional” murmur Short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for any hemodynamic abnormality

© Continuing Medical Implementation …...bridging the care gap Functional (Innocent) Murmurs Common in asymptomatic adults Characterized by –Grade I – LSB –Systolic ejection pattern - no  with Valsalva/  upright –Normal precordium, apex, S1 –Normal intensity & splitting of second sound (S2) –No other abnormal sounds or murmurs –No evidence of LVH S1 S2

© Continuing Medical Implementation …...bridging the care gap Characteristic of the NOT Innocent Murmur Diastolic murmur Loud murmur - grade IV or above Regurgitant murmur Murmurs associated with a click Murmurs associated with other signs or symptoms e.g. cyanosis Abnormal 2 nd heart sound – fixed split, paradoxical split or single

© Continuing Medical Implementation …...bridging the care gap Integrating Pulse with HS and Murmurs

© Continuing Medical Implementation …...bridging the care gap Examining the Peripheral Pulses

Femoral Popliteal Posterior Tibial Dorsal Pedis Radial Ulnar Brachial Retinal Carotids Renal

© Continuing Medical Implementation …...bridging the care gap 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

© Continuing Medical Implementation …...bridging the care gap Trophic Changes Shiny, hairless skin, dystrophic nail changes and dependent rubor associated with peripheral arterial occlusive disease of the patient's right foot

© Continuing Medical Implementation …...bridging the care gap Pallor on elevation Rubor on dependency

© Continuing Medical Implementation …...bridging the care gap Digital Ischaemia Gangrene

© Continuing Medical Implementation …...bridging the care gap A Practical Guide to Clinical Medicine - UCSD Acute Arterial Insufficiency: Mottled Appearance of Skin Chronic Arterial Insufficiency with Ulcers

© Continuing Medical Implementation …...bridging the care gap Hiatt W. N Engl J Med 2001;344: Measurement of the Ankle-Brachial Index (ABI)

© Continuing Medical Implementation …...bridging the care gap Venous Abnormalities Varices

© Continuing Medical Implementation …...bridging the care gap Spider Veins

© Continuing Medical Implementation …...bridging the care gap Venous Insufficiency

© Continuing Medical Implementation …...bridging the care gap Stasis Dermatitis/Ulceration

© Continuing Medical Implementation …...bridging the care gap Edema

© Continuing Medical Implementation …...bridging the care gap Cellulitis vs DVT Right Deep Venous ThrombosisCellulitis

© Continuing Medical Implementation …...bridging the care gap

© Continuing Medical Implementation …...bridging the care gap