1. Cardiovascular Examination
DAWIT AYELE (MD) INTERNIST

2. 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

3. 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

4. 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

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

6. 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.

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

8. Examination of the venous system
CVP
Extremity veins

9. 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

10. 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.

12. 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.

13. 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

14. ..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

17. JVP pulsations

19. Examination of the arterial system
Pulse
Blood pressure
The vessel itself

20. 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.

22. 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)

23. ..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.

25. ..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

26. 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

27. ..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

28. …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.

30. 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

31. Precordium-surface projections

32. 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..)

33. 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)

34. 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..

35. 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

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