EXAMINATION OF CARDIO VASCULAR SYSTEM Dr G SWARNALATHA

EXAMINATION OF CARDIO VASCULAR SYSTEM Dr. G. SWARNALATHA DEVI M. D PROFESSOR OF MEDICINE

HISTORY § Chest pain—site, radiation, nature, duration of pain, aggravating & releiving factors, associated symptoms § Breathlessness—duration, grade, progression, PND, ORTHOPNEA, § Palpitations, --continuous or intermittent § How they are releived § Syncope—postural , seizures

§ Cough , expectoration, heamoptysis, § Cyanotic spells § Swelling of feet , distension of abdomen, pain abdomen, § Urinary symptoms—oliguria, anuria § Loss of § appetite, loss of weight § Squatting § Stokes-adams attacks

§ Past history-----rheumatic fever, hypertension, diabetes, ischemic heart disease, tuberculosis, drugs, asthma § Personal history—smoking, alcohol, drug addictions, sleep § In female-menstrual history, obstetric history. § Treatment history-rheumatic fever prophylaxis.

GENERAL EXAMINATION § Built, nourishment, pallor, jaundice, cyanosis, clubbing, koilynochia, pedal edema, lymphadenopathy, § Marfanoid features, other congenital anomalies. § High arched palate, low set ears, § Down syndrome features, § poly or syn dactyly, ear lobe crease, § Rheumatic nodules, osler’s janeway nodules § Xanthomas, thyromegaly, § Nicotine stains over fingers

§ VITALS- pulse-Rate, Rhythm-if irregular pulse deficit Volume—high volume or low volume Character— Vessel wall thickening Other peripheral vessels, radio –femoral , radio-radial delay Blood pressure- upper &lower limbs Temparature Respirations –rate, type of breathing

Examination of arterial pulse in clinical medicine

Pulse § The blood forced into aorta during systole not only moves the blood in the vessels forward but also sets up a pressure wave that travels along arteries. The pressure wave expands the arterial wall as it travels , and the expansion is palpable as the pulse.

Normal Pulse

Evaluation § § § § Rate Rhythm Volume Character Vessel wall thickness Radio- femoral delay , radio- radial delay Peripheral pulses Pulse deficit

Rate § § Count the pulse for 1 min / at least 30 sec Normal : 60 – 100 /min Tachycardia : >100 /min Bradycardia : <60 /min

Sinus Tachycardia § Physiological : infants children anxiety , emotion § Pathological : Tachyarrhythmia- SVT, VT High output states § Drugs – atropine nifedipine caffiene, nicotine

High Output States § § § § Anaemia Pyrexia Beri beri Thyrotoxicosis Pheochromocytoma AV fistula cardiogenic shock, cardiac failure Hypovolemia, hypotension

Sinus Bradycardia § Physiological : atheletes, sleep § Pathological : severe hypoxia hypothermia sick sinus syndrome myxoedema obs. jaundice ac. inf wall MI raised ICT § Drugs : beta blockers, verapamil, diltiazem

Relative Bradycardia § § § Typhoid Pt on beta blocker CNS infection with raised ICT

Rhythm § § § Assessed by palpating radial artery Normally – regular Irregular – ectopics Regularly irregular – ventricular bigemini Irregularly irregular – AF, multiple ectopics

Diff b/w heart block & ectopic § Rhythm : § Irregularity changes with exertion – extrasystole / ectopic § Irregularity doesn’t change with exertion – Heart block

Volume § Assessed by palpating – carotid artery § Pulse pressure – accurate measure of pulse volume ( N – 30 – 60 mm Hg ) § Correlates with stroke volume § High volume – high output states anxiety emotional excitability

Volume § Low vol ( pulsus parvus ) – shock myocardial ds Aortic stenosis pericardial ds cardiac failure

Character § Best assessed by palpating – carotid artery § Normal / Abnormal

Vessel Wall Thickness § Assess the state of medium sized arteries which are palpable. § Method: palpate radial artery with middle 3 fingers. Occlude proximally & with index finger empty artery by pressing out blood distally. Applying pressure on either side – roll the artery over underlying bone using middle finger.

Radio – femoral Delay § Usually 2 radial pulses come simultaneously & femoral comes 5 msec before ipsilateral radial pulse. § Delay in femoral pulse – obstruction of aorta – coarctation

Peripheral Pulses Radial pulse § At wrist , lateral to flexor carpi radialis tendon , place your three middle fingers over the radial pulse

Carotid Pulse § Palpate carotid pulse with the pt lying on a bed / couch § Never compress both carotid arteries simultaneously. § Use your left thumb for right carotid pulse & vice versa. § Place tip of thumb b/w larynx & ant. border of sternocleidomastoid.

Brachial pulse § Use your thumb ( rt thumb for rt. arm & vice versa ) with your fingers cupped round the back of the elbow. § Brachial pulse – felt in front of the elbow just medial to tendon of biceps.

Femoral Pulse § Is felt at groin just below inguinal ligament midway b/w ant. sup. iliac. spine & symphysis pubis.

Popliteal pulse § Knee to be flexed 40 deg. Heel resting on bed § Place fingers over lower part of popliteal fossa & fingers are moved sideways to feel pulsation of Popliteal. A against post. aspect of tibial condyles.

Posterior Tibial Pulse § Felt just behind medial malleolus , midway b/w medial malleolus & tendo achillis.

Dorsalis Pedis Pulse § Felt just lateral to tendon of ext. hallucis longus.

Pulse Apex Deficit § Diff b/w heart rate & pulse rate , when counted simultaneously for one minute. § Diff b/w AF & Ectopics Features Pulse deficit On exertion rhythm Atrial fibrillation > 10 / min Persists/increas e Irregularly irregular Ectopics < 10 / min Decrease Regularly irregular

Hypokinetic & Hyperkinetic Pulses § Hypokinetic pulse – small volume, narrow pulse pressure § Eg: cardiac failure, MS, AS, Shock § Hyperkinetic pulse: large volume pulse with high stroke vol, wide pulse pressure § Eg : high output states , MR, VSD

Collapsing Pulse § Corrigan’s pulse / water hammer pulse § Large vol pulse with rapid upstroke ( high sys. pressure ) & rapid downstroke ( low diastolic pressure ) § Rapid upstroke – increased stroke vol § Rapid downstroke – diastolic runoff into Lt. Ven & decreased PR & rapid runoff to periphery. § AR

Pulsus Alternans § Alternating strong & weak pulse. § Palpation of radial, femoral, brachial pulses § Palpation by light pressure, breath held in mid expiration § Better – recording BP, when sys. pressure alternates by >20 mm

Pulsus Alternans § A sign of severe LV dysfunction.

Pulsus Paradoxus § Exaggerated reduction in strength of arterial pulse during normal inspiration due to exaggerated insp fall in sys. pressure (> 10 mm) § >20 mm Hg – detected by palpating brachial artery § Milder fall – measuring BP

Pulsus Paradoxus § Cardiac tamponade, constrictive pericarditis, § severe airway obstruction , § SVC obstruction

Recording Of BP § Pulsus paradoxus : inflate bp cuff to suprasystolic level & deflate slowly @ 2 mm/heart beat. § Note - Peak sys. pressure during expiration § Now deflate more slowly – note pressure when korotkoff sound – audible throughout resp. cycle § If diff > 10 mm Hg - pulsus pardoxus +

Pulsus Tardus § Delayed systolic peak resulting from obstruction of lt. ven. ejection § Fixed LV obstruction – Valvular AS

Pulsus Parvus et Tardus § Small vol pulse with delayed systolic peak § Severe AS

Bisferiens Pulse § 2 systolic peaks , the percussion & tidal waves separated by distinct midsystolic dip. § Detected more rapidly by palpating carotid artery. § AS+AR

Dicrotic Pulse § 2 peaks. § 2 nd peak is in diastole after S 2. § Normally a small wave that follows aortic valve closure ( dicrotic notch ) is exaggerated § Due to very low stroke vol & per. Resistance. § LVF

CARDIO VASCULAR SYSTEM § INSPECTION—JVP , column , waves , change with inspiration and expiration § Hepato JUGULAR REFLUX § TRACHEA § CHEST DEFORMITY § ENGORGED VEINS, § VISIBLE PULSATIONS § PRE CORDIAL BULGE § APEX BEAT

PALPATION § § § § TRACHEAL POSITION APEX BEAT-- POSITION, NATURE, THRILLS, PALPABLE SOUNDS, RUB LEFT PARA STERNAL HEAVE-- GRADE

PERCUSSION § § RIGHT& LEFT BORDERS RETRO STERNAL DULLNESS LIVER DULLNESS LEFT SECOND SPACE

AUSCULTATION § MITRAL , TRICUSPID , AORTIC , PULMONARY AREAS— § HEART SOUNDS- INTENSITY SOFT OR LOUD , CHANGING INTENSITY § 1 , 2 , 3 , 4 SOUNDS § SPLITTING OF SECOND SOUND § OPENING SNAP

AUSCULTATION § MURMURS—SITE § , TIMING, § SELECTIVE CONDUCTION, § QUALITY, § PITCH § , HEARD WITH BELL OR DIAPHRAGM § , EFFECT OF EXERCISE, § CHANGE WITH RESPIRATION § CLICKS § PERICARDIAL RUB

§ § § § § PERIPHERAL SIGNS OF AORTIC REGURGITATIONCOLLAPSING PULSE , HILL’S SIGN , PISTOL SHOT SOUNDS, DUROZIEZ’S MURMUR, ALFRED DEMUSSET’S SIGN, QUINCKY’S SIGN, HEPATIC, SPLENIC PULSATIONS SIGNS OF INFECTIVE ENDOCARDITIS EXAMINATION OF OTHER SYSTEMS

§ THANK YOU