dawit ayele (md) internist. dyspnea an abnormally uncomfortable awareness of breathing that is...

Cardiovascular Examination

DAWIT AYELE(MD) INTERNIST

DyspneaDyspnea 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

OrthopneaDyspnea 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

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

Chest pain and discomfortNature of the pain: squeezing, crushing etc.LocationRadiation: to the jaw, left arm, hand etc.Exacerbating and Alleviating Factors

PalpitationsAn 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.

EdemaAccumulation of excessive fluid in the bodyAn ascending type of body swelling is

characteristic to cardiac problems.

Examination of the venous systemCVPExtremity veins

CVP, central venous pressurePressure of the right atriumMeasured in cm of waterUse a column of blood in the jugular veinsWe use blood to estimate this pressure

Jugular Venous pressureThe 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.

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.

CarotidPalpable pulsationsPulsations not

obliterated by pressure above the clavicle.

No effects of respiration on pulse.

No effect of positionOne pulsation per

systoleDescents not

prominent. No effect of abdominal

pressure on pulsations.

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 neckIdentify the external jugular veins on each

sideThen find the pulsations of the internal

jugular veinsObserve for a double-complex waveform

..techniqueIdentify 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

JVP pulsations

Examination of the arterial systemPulseBlood pressureThe vessel itself

Arterial PulsesThe presence and the volume of each pulse

should be compared with the other sideDetected by gently compressing the vessel

against firm structures, usually bonesThe main peripheral arterial pulses that should

be felt include: radial, brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis.

Arterial PulsesHeart 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)

..pulse, characterParvus et tarsusCollapsing pulse (water hammer)Pulsus paradoxus

Volume (amplitude): rough guide to pulse pressure and stroke volume

Delay: radio-femoral delay in coarctation of the aorta.

..characterPulsus alternans—suspect acute or chronic

reduction in left ventricular ejection fraction Anacrotic pulse, delayed upstroke, —suspect

aortic valve stenosis Pulsus paradoxus—suspect tamponade,

emphysema

Blood pressure measurementPatient should avoid smoking and caffeine for

30 minRest for at least 5 minutesThe arm should be resting and free of

clothingPosition the hand so that the brachial artery

is at the level of the heart

..BP measurementInflatable 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

…BP measurementThe level at which the Korotkoff are heard is

the systolic pressureThe disappearance point is the diastolic

pressureWait 2 or more minutes and repeat. Average

your readings.

Examination of the vesselAssess 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

Precordium-surface projections

INSPECTIONStand on patient’s rightBetter if patient is supine upper body 30o

Look for visible scar , vessel Look at precordium active/quietLook for apical impulse:+/-visible-characterizeLook for extraprecordial pulsation(epigastric..)

PALPATIONPalpate 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)

AUSCULTATIONStart 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..

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

Gallop-S3,S4Split sounds-S1,S2Extrasystole/Irregularities/Pulse deficit…