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Examination of cvs

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Examination of cvs

  1. 1. Examination of CVS *General examination regarding CVS 1.Anaemia-Angina 2.Breathlessness 3.Clubbing with cyanosis-Right to left shunt 4.HyperlipidaemiaXanthroleshma Archus cornea-Creamy yellow discoloration at the boundary of iris due to cholesterol precipitation 5.Splinter hemorrhage-(SBE)-Small linear hemorrhage under nail 6.Ostler’s nodes-Painful erythematous swelling in finger pulp(SBE)
  2. 2. Examination of CVS *Arterial pulsation examination 1.Radial pulse(RRV_CC) Rate , rhythm , volume , condition of vessel wall , character ,radio radial delay , radio femoral delay(Coarctation of aorta) **Volume and character better by carotid pulse 2.Brachial pulse-Medial to biceps at antecubital fossa 3.Carotid pulse-Angle of jaw just anterior to sternocleidomastoid muscle 4.Popliteal-Popliteal fossa 5.Posterior tibial-2cm below and behind the medial malleolus between flexor digitorum and flexor hallucics longus 6.Dorsalis pedis-Just lateral to extensor hallucis longus in 1st inter metatarsal space most proximally
  3. 3. Pulse rate 1.Bardycardia(Heart rate below 60 beats/min) Sinus bradycardia: When SA node produces impulse <60 beats/min 2.Tachycardia(Heart rate >100beats/min) Sinus tachycardia: When SA node produces impulse 100 beats/min **Causes of sinus bradycardia Physiologic—Athlets ,sleep Pathologic—MI ,hypothermia , hypothyroidism **Causes of sinus tachycardia Physiologic—Exercise , emotion , excitement Pathologic—CCF ,anaemia , hyperthermia ,hyperthyroidism **Causes of tachycardia AF ,VF ,VT , VF +Flutter **Causes of hyperdynamic circulation/increased pulse volume Exercise , fever , pregnency , hyperthyroidism , anemia **Irregular pulse AFF ,heart block
  4. 4. Character of pulse 1.Normal/catacrotic 2.Low volume pulse Shock ,pericardial effusion , aortic stenosis 3.High volume pulse 4.Collapsing pulse/water hammer pulse AR ,PDA ,Hyperdynamic circulation 5.Pulsus bisferiens(Double peak) Combined AR and AS 6.Pulsus alternans(Altered strong and weak pulse) LVF 7.Pulsus paradoxas(Decreased volume in inspiration) Constrictive pericarditis , pericardial effusions , severe asthma 8.Pulsus deficit(Difference in H.R and P.R) AF 9.Dicrotic pulse: Fever 10.Plateau: AS
  5. 5. Examination of CVS *Examination of BP *JVP examination a.45 degree lying b.Opposite sided face c.Relaxed neck muscle d.Observe along medial border of sternocleidomastoid muscle e.If not found , then do abdomino jugular reflux to confirm highest limit of pulse f.Measure from sternal angle which is normally 4cm indicating 6mmHg pressure of right atrium. In Kussmaul’s sign there is paradoxical rise in JVP in inspiration indicating constrictive pericarditis due to less accommodation of increased venous return during inspiration--1.a wave peak: Right Atrial contraction(Giant in TS , absent in AF) 2.x descent: Tricuspid ring descent/fall in g atrial pressure during ventricular systole(Rapid descent in Constrictive peri.) 3.c wave peak: Tricuspid closure 4.v wave peak: Atrial filling/ventricular contraction(Giant in TR) 5.y descent: Opening of tricuspid(Rapid descent in Pericardial effusion) **Raised JVP: CCF , TR ,constrictive pericarditis , pericardial temponade , sup.venacaval obstruction
  6. 6. Impalpable apex beat Obese Athletes Asthma Emphysema CCF Dextrocardia Pericardial effusion
  7. 7. Examination of CVS *Precordium examination Area of heart that lies on the anterior chest wall is precordium Inspection: 1.Shape of the chest/precordium 2.Visible pulse 3.Engorged vein 4.Scar marks Palpation: 1.Loacte apex and measure from left sternal edge along midclavicular line(Minorly check for any swelling/tenderness) If not found/obese person make left lateral position to confirm(Normal , Thrusting in right ventricular hypertrophy , Tapping in MS , Thrilling in VSD) 2.Check for thrill(Palpable vibration on chest wall) by flat of the fingers at apex(mitral area) , 3 rd/4th space(tricuspid area) , aortic and pulmonary area , below the clavicle(PDA) ,above tricuspid area(VSD) 3.Left parasternal heave( Systolic thrust in right ventricular hypertrophy) by heel of the hand with fingertips right angle to sternum 4.Pulmonary component of 2nd heart sound(Palpable P2) at left 2nd space with finger tips(Use index , middle , ring finger tips) Percussion: 1.Locate apex and upper border liver dullness and join the line which is inferior border of heart 2.Draw clinical base of heart ;RnL 2nd space 1.25cm from each sternal edge ,on left space along upper border of 3rd rib and on right space along lower border of 2nd rib 3.Mark multiple point along right and left margin of heart where dullness is found by percussing from shoulders ,lateral chest wall ,and join the point to indicate the borders/margin of heart
  8. 8. Examination of CVS Auscultation 1.Locate apex and at apex with diaphragm 2.On left lateral position then with diaphragm at apex and bell at apex in breath holding expiration and radiation to axilla(Maneuver for MS) 3.Return to 45 degree angle 4.At tricuspid , pulmonary , aortic area with diaphragm 5.Sit and Lean a bit forward and auscultate with diaphragm at left parasternal edge(Think Tricuspid area but never say it) with breath holding inspiration(Maneuver for AR) and at pulmonary-aortic area in breath holding expiration 6.Over carotid arteries by diaphragm and radiation in neck **During auscultation of CVS always check coincidation with carotid artery with thumb and during thrill palpation do only if murmur found
  9. 9. Apex beat 1.Position 2.Character Normal Tapping(MS) Heaving(LVH) Double apical(Hypertrophic cardiomyopathy) Diffuse (Dilated cardiomyopathy) Thrills PS ,AS-Systolic TS ,MS-Diastolic Left parasternal heave RVH
  10. 10. About murmurs Systolic murmurs Diastolic murmurs Continuous murmurs PASs+ASD (Mid systolic/ejection systolic) PARd (Early diastolic) PDA Arteriovenous shunt TMR+VSD (Pansystolic) TMS (Mid diastolic) MP (Late systolic)
  11. 11. About heart sounds Heart sounds Reasons of producing S1 TM(Closure)---TMSS is only one(S1) medical college in BD S2 (Single in expiration and splits in inspiration) AP(Closure)---Many (S2) students PASS in TMSS medical college S3 Abrupt cessation of ventricular filling S4 Stiff ventricle Systolic click PASS Opening snap Opening of stenosed mitral valve
  12. 12. About different murmurs MS: Low pitched localised , rough rumbling , mid diastolic murmur in mitral area best heard with bell of stethoscope in left lateral position with breath hold after expiration with presystolic accentuation Cause: Chronic rheumatic fever MR: S1 soft Pansystolic murmur radiating towards left axilla MP: Mid systolic click Late systolic murmur VSD: Pansystolic murmur Normal S1 and S2 ASD: Fixed splitting S2 Mid systolic murmur Mid diastolic murmur
  13. 13. AR: 3 pulses: 1.High volume pulse(Collapsing pulse/Water hammer pulse) 2.Carotid dense pulse 3.Capillary pulse: Pressure on nail tips initiates blood column flickering under nail Slide on tongue to see capillary pulse 3BP: 1.High systolic 2.Low diastolic 3.Wide pulse pressure 3 murmurs: 1.Early diastolic(Classical murmur) 2.Mid systolic 3.Soft mid diastolic(Austin flint murmur)
  14. 14. TR: Pansystolic murmur Normal S1 and S2 TS: Mid diastolic murmur PR: Early diastolic/Graham steel murmur PS: Ejection systolic murmur PDA: Continuous murmur(Both in systolic and diastolic phase , Ruptured sinus valsalva)
  15. 15. AS: Ejection systolic click Ejection systolic murmur radiating towards neck
  16. 16. Symptoms analysis Chest pain(SOCRATES ;any pain) Breathlessness Palpitation Syncope Oedema
  17. 17. Symptoms analysis Chest pain Pericardium ,heart ,pleura ,lung ,trachea ,larynx,oesophagus ,musculoskeletal causes
  18. 18. Traits Angina MI Oesophageal pain Site Retrosternal Same Retrosternal or epigastric Radiation Arm ,neck ,epigastrium Same Arm ,back Precipitated by Exercise Spontaneous Often present Relieved by Rapidly by rest /nitrates Not by rest/nitrates Relieved by rest/nitrates but not rapidly Wakes from sleep No No Often Hurt burn No No Sometimes Vomit/nausea No Common No
  19. 19. Symptoms analysis Palpitation Awareness of heart beat Syncope Loss of consciousness due to inadequate cerebral perfusion Causes—Postural hypotension(HANDI) hypovolaemia hypopituitarism addison’s disease neuropathy drugs(vasodilators and anti HTN drugs)