3. Cardiovascular Examination
• Lighting
• Lying and comfortable
• Stripped to the waist
• General inspection
– General features
– Eyes
– Face
– Praecordium
– Ankles
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6. Cardiovascular Examination
• Jugular venous pressure (JVP)
•JVP reflects central
venous or right atrial
pressure.
•Normally 9cmH2O
•Sternal angle approx 5cm
above right atrium.
•Normal JVP should be
about 4cm above this
angle when patient is at
45 degrees
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9. Cardiovascular Examination
• Systematic
– Time what you hear with the patients pulse.
– First heart sound (precedes peripheral pulse)
– Second heart sound (after pulse is felt)
– Murmers during systole
– The absence of silence during diastole
– Any extra sounds.
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11. Cardiovascular Examination
• The Precordium
This is the area on the front of the chest that relates
to the surface anatomy of the heart.
Inspect the precordium with the
patient sitting at 45 degree angle
with shoulders horizontal.
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13. Cardiovascular Examination
• Heave
– A palpable impulse that lifts your hand noticeably
• Right ventricular hypertrophy
• Thrills
– Feel like a ringing phone or a fly trapped in ones
hand
• Aortic stenosis
• Palpable first heart sounds
– Mitral stenosis.
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15. Cardiovascular Examination
• Abnormal Heart Sounds
– Aortic Stenosis
•Timing- ejection systolic murmur
•Location- loudest over 2nd right
intercostal space
•Character- harsh, saw like.
•Thrill- often present.
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16. Cardiovascular Examination
• Abnormal heart sounds
– Aortic Regurgitation
•Timing- early diastolic
•Location- left or right 2-4th
intercostal space
•Character- quiet, blowing
•Use diaphragm with patient
leaning forward.
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17. Cardiovascular Examination
• Abnormal heart sounds
– Mitral stenosis
•Timing- mid diastolic. May
be preceded by opening
snap.
•Location- apex
•Character- low pitched
rumbling
•Listen for mitral stenosis
with lightly applied bell
and patient in left lateral
position
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18. Cardiovascular Examination
• Abnormal heart sounds
– Mitral regurgitation
•Timing- pansystolic
•Location- loudest at the apex
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21. Cardiovascular Examination
• Common Cardiovascular problems
– Breathlessness
• Common with some degree of heart failure
• Orthopnoea
– Dyspnoea when lying flat
– Sign of advanced heart failure
• Paroxysmal nocturnal dyspnoea
– Sudden breathless which wakes the patient from sleep
choking or gasping for air.
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22. Cardiovascular Examination
• Common Cardiovascular problems
– Palpitations
• An unexpected awareness of the heart beating
• Most patients do not have a sustained arrhythmia
• Those that do often do not experience palpitations.
• Ask about
– Onset and termination
– Precipitating factors
– Frequency and duration of episodes
– Character of the rhythm
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23. Cardiovascular Examination
• Common Cardiovascular problems
– Syncope and dizziness
• Postural hypotension
• Neurocardiogenic syncope
• Arrhythmias
• Mechanical obstruction to cardiac output.
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26. Cardiovascular Examination
Chest Pain
Watching the patient describing the character of
the pain is helpful
•A clenched fist on the chest is worrying
•A single pointed finger is less worrying
Take time to tease out the history
•Chest pain causes anxiety in patients and this may
cloud genuine/significant pathology
•Do not increase anxiety by performing unnecessary
investigations.
If in doubt:
MONA.
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Notas del editor
Cardiovascular system
Chest pain
Characteristics of the pain
Where exactly
Does it radiate
Nature of pain....burning, stabbing, crushing, gripping?
Precipitating factors
Time course and relieving factors
Associated features....nausea, vomiting, sweating, SOB....
Breathlessness
Lying flat (orthopnoea)...how many pillows do they use...LVF
Paroxysmal nocturnal dyspnoea......Do they ever wake at night fighting for breath....LVF
On minimal exertion....how far can they walk...and what stops them....pain, breathlessness
Ankle swelling...RVF
Duration
Degree
Ascites
Nausea and poor appetite due to bowel oedema
Right upper quadrant discomfort due to hepatic congestion.
Fatigue
Lighting
Seated and comfortable
Stripped to the waist
General Inspection
General features
Age, sex, general health
Obese or skinny
Breathless
Position in bed....do they seem to need to sit up?
Eyes
Jaundiced
Xanthalasma...hyperlipidemia
Face
Cyanosis
Teeth....poor dental hygiene?
Praecordium
Any obvious deformity
Visible collateral veins
Presence of scars.
Ankles.
Swelling/oedema.
Pulse
Presence and symmetry
Check both radial pulses together for asynchrony (aortic dissection, vasculitis)
Rate
Rhythm
Irregularly irregular?
Volume
Bounding pulse CO2 retention/LVF
Small volume shock.
Pulsus paradoxus
Detectable increase in pulse volume is felt during expiration (cardiac tamponade or severe asthma)
Pulsus alternans
Alternate pulses are felt as strong or weak due to presence of bigeminy
Character
Requires considerable practice to feel waveforms!!
Due to anatomy of innominate veins best seen on right hand side
Elevated in fluid overload
Heart Failure
Pulmonary embolism
Pericardial effusion
SVC obstruction
COPD
Position patient so that he is reclining comfortably until the waveform is clearly visible.
Rest the patients head on a pillow to ensure that the neck muscles are relaxed
Look across the neck from the right side of the patient. (due to anatomy of innominate veins)
Identify the jugular vein pulsation
Abdomino-jugular reflux- gently press over the abdomen for ten seconds. This increases venous return to the right side of the heart and the JVP normally rises
Occlusion: the JVP waveform is obliterated by gently occluding the vein at the base of the neck with your fingers
Can be raised in:
Fluid overload- characteristically in heart failure
Primarily a sign of right sided heart failure.
Acute pulmonary embolism
COPD
Systole starts at the point of closure of the mitral valve and tricuspid valve(FIRST HEART SOUND) as the pressure in the left ventricle exceeds that in the left atrium.
Contraction occurs before the pressure in the left ventricle exceeds that in the aorta....
At which point the aortic valve opens and blood starts to flow into the aorta.
Left ventricle relaxes....
Aortic pressure exceeds that in the left ventricle and the aortic valve closes (SECOND HEART SOUND) and pulmonary valves
The ventricle continues to relax until the pressure falls below that in the filled left atrium..
The mitral valve opens to allow blood to flow into the left ventricle.
S1- ‘lub’ caused by closure of the mitral and tricuspid valves at the onset of ventricular systole and is best heard at the apex.
S2- ‘dup’ caused by closure of the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge.
Physiological splitting may occur at inspiration
S3- ‘dum’ best heard with the bell. Normal in children, young adults and during pregnancy. Pathological after 40. common causes LVF and mitral regurg
Locate the apex beat
Normally in the 5th left intercostal space, at or medial to the mid-clavicular line
Normally briefly lifts the palpating fingers
Palpate for thrills at the apex and both sides of the sternum
Maybe absent in overweight or muscular people
Maybe absent due to hyper-inflated chest as in asthma or emphysema.
If you cannot feel it ask the patient to lay on his left side.
LISTEN TO ALL WITH DIAPHRAGM AND BELL.
Aortic – second right intercostal space
Pulmonary- Second left intercostal space
Aortic regurgitation may be louder here
Tricuspid- fourth left intercostal space
Especially for tricuspid regurgitation
Mitral regurgitation and aortic stenosis are often louder here
Mitral- fifth intercostal space mid calvicular line
Mitral stenosis with bell.
To elicit mitral stenosis roll patient into left lateral and listen with bell.
Ask patient to sit up and lean forward. Listen over 2nd intercostal space and over left sternal edge with diaphragm for the murmur of aortic regurgitation.
Breathlessness
Common with some degree of heart failure
Accumulation of fluid in the alveoli occurs with left heart failure because increased left atrial end diastolic pressure leads to elevated pressure in the pulmonary veins and capillaries.
Orthopnoea
Dyspnoea when lying flat
Sign of advanced heart failure
Lying flat increases venous return to the heart and in patients with a failing left ventricle may precipitate pulmonary venous congestion and pulmonary oedema
Paroxysmal nocturnal dyspnoea
Sudden breathless which wakes the patient from sleep choking or gasping for air.
Gradual accumulation of fluid during sleep
Patients may sit on edge of bed and open windows to get some air.
Ask about
Onset and termination- abrupt or gradual
Precipitating factors- exercise, alcohol, exercise, recreational or other drugs
Frequency and duration of episodes-
Character of the rhythm- ask them to tap it out.
Syncope and dizziness
Postural hypotension
Commonly caused by hypovoleamia, antihypertensive drugs, especially diuretics and vasodilators
Neurocardiogenic syncope
Occurs in healthy people who have been forced to stand for a long time or subject to painful or emotional stimuli.
Results from abnormal autonomic reflexes and bradycardia and/or vasodilatation
Arrhythmias
SVT’s rarely cause syncope
Most common cause is bradyarrythmia due to sick sinus syndrome, or atrioventricular block
Drugs including digoxin, beta blockers and rate limiting calcium channel blockers may aggravate attacks.
Mechanical obstruction to cardiac output.
Severe aortic stenosis and cardiomyopathy can obstruct left ventricular outflow.
Angina
Precipitated by exertion
Eased by rest and/or GTN
Myocardial infarction
More severe
Persists at rest
Pericarditic pain
Sharp, raw or stabbing
Varies with movement or breathing
Aortic
Severe tearing
Sudden onset radiates to the back
Site
Angina/Myocardial Infarction
Felt in centre of chest, radiates out
Oesophageal
Retrosternal or epigastric. Can radiate out.
Aortic
Between shoulder blades and behind sternum
Onset
Sudden or gradual
Character
Crushing, gripping, like a band across my chest, dull ache
Radiation
Associated symptoms
Nausea (very common in MI)
Sweating
SOB
Syncope
Timing
Angina pain tends to be short lived
MI pain lasts fro 20 mins or more
Exacerbating or relieving factors
Rest may relive angina
Will not relieve MI
Severity