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