Cardiovascular Examination

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Cardiovascular Examination
Deling Zou
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Anatomy
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Inspection
1 Precardial projection and excavation 2 Apical
impulse 3 Abnormal pulsations of precardium
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Inspection

• 1 Precardial projection and excavation
• 1) Precardial projection
• congenital heart disease tetralogy of Fallot
• Valvular heart disease--
  
  
  MS,PS
• pericardial effusion (large , childhood)

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• The second right intercostal space(2nd ICS-RS)
• aneurysm of aortic arch
• dilatation of ascending aorta
• 2) flat chest
• 3) pigeon chest/funnel chest

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Inspection

• 2 Apical impulse
• Normal
• positionthe fifth left intercostal
  space 0.5-1.0cm medial to the midclavicular
  line range2.0-2.5cm in diameter

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• Abnormal1) Location diaphragm
• transverse position upper,outward
• obesity ,child, pregnacy
• ascites tumor of abdominal cavity
• vertical position (thin, high, emphysema)
  inferior,inner

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mediastinum

• one side pleural effusion or pneumothoraxto the
  healthy side
  
• one side atelectesis or pleural adhesionto the
  affected

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enlargement of the heart

• right ventricular dilatation left or slightly
  upper
• left ventricular dilatationleft inferior
• LV RV dilatation left inferior (both side
  dilatation)

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Posture

• recumbent positionupper
• left lateral positionto the left 2-3cm
• right lateral positionto the right 1.0-2.5cm
• Dextrocardia 5-ICSRS

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Inspection- apical impulse - abnormal
2)Intensity and extent changes
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Inspection -apical impulse - abnormal

• 3)Inward impulse
• apex excavation in the systole
• seen adhensive pericarditis
  prominent RV hypertrophy

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Inspection

• Abnomal pulsations of
• percardium

• 1)left third-forth intercostal space lateral to
  the sternum(3,4ICS-LS)
• seen RV hypertrophy

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• 2)hypoxiphoid process
• seen
• difference deep inspiration
• RV hypertrophy ?
  abdominal aorta (aneurysm) ?

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3)basal part of the heart

• 2 ICS-LS dilatation of the pulmonary artery
  or pulmonary hypertensin, occasionally healthy
  young man
• 2 ICS-RS aneurysm of aortic arch or
  dilatation of ascending aorta

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Palpation
1 Apical impulse and pulsation of precardium 2
Thrill 3 Pericardial friction rub
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1 Apical impulse and pulsation of precardium
Palpation

• Exact position of apex
• The beginning of systole of ventricle
  first sound
• Heaving apex impulse reliable of LV hypertrophy

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2 Thrill

• One of characteristic signs of organic heart
  disease.
• Mechanism the flow of blood?narrowed
  orifice?vortices? vibration?chest wall
• thrill-high frequency
  murmurs-low frequency
• Methodposition,phase of cardiac cycle,clinical
  significance
• seen CHD or valvular stenosis ,
• occasionally insurficiency

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CHDcongenital heart disease
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3 Pericardil friction rub

• 1)Precardium-4th ICS-LS
• 2) both phases of the cardiac cycle
• 3) systolic period, sitting erect and leaning
  forward, the end of expiration
• 4)mechanism rub of the visceral and parietal
  layers of pleura
• 5)seenacute pericarditis

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Percussion

• Aimto determine the size and shape of the heart
  .
• Absolute dullness contain no gas Relative
  dullness real size

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1 murneuver of percussion

• patient in erect position the pleximeter is
  vertical with the intercostal space
• patient in the recumbent position the
  pleximeter is parallel with the intercostal space

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2 order

• leftright upwards inward
• left margin from 2-3 cm lateral to the apex
  beat up to the 2nd ICS
• right margin one intercostal space higher
  than the border of liver dullness up to the 2nd
  ICS
• size vertical distance from margin to the
  anterior midline

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Percussion
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Percussion
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• (2)The upper border the lower border of the
  anterior end of the third rib?
• (3)The basal part the second intercostal space
  upward
• left aortic node and PA
• (4)Concave part between the aorta and the left
  ventricle

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5 Changes in the area of cardiac dullness and
its significance
Percussion

• Cardiac factors
• 1)LV enlargement boot shape
  Seenaortic valvular disease ,
• hypertension heart disease

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• 2)RV enlargement slightly?--absolute
  dullness? Prominent?--relative dullness?
  to the left side prominently
  SeenPHD, MS
• 3)Two ventricle ?
• generally enlarged heart
  seenDCM , Kashan cardiomyopathy

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• 4)LA and/or pulmonary artery LAconcave
  part disappear LAPA2,3 ICS-LS outwards
• pear shape Seen MS---
  mitrial type

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• 5)pericardial effusion enlargement of both sides
  of the border
• bodys position
• recumbent positionwidening of base of the
  heart
• erect positiontriangular shape

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• 6)dilatation of the aorta /ascending aortic
  aneurysm
• widening if the dull area of first and second
  intercostal space (with systolic pulsation)

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• Extacardial factors 1)large pleural effusions
  and pneumothorax ? to the healthy
  side2)atelectasis /pleural pachynsis ?to the
  affected3)a large amount of ascites or big
  abdominal tumor diaphragm elevated?transverse
  position ?left side enlargement

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Ausclutation
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1 Ausclutatoty valve areas

• 1)ausclutatory mitral area apical
  area2)ausclutatory pulmonary area2
  ICS-LS3)ausclutatory aortic area 2
  ICS-RS4)second ausclutatory aortic area 3rd
  ICS-LSErb area5)tricuspid area 4,5 ICS-LS

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• 2 Order
• MV---PV---AV1---AV2---TV
• 3 Contents 1) rate 2)rhythm 3)heart sound
  4)extra heart sound 5)murmurs 6)pericardial
  friction sound

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• 1)heart rate
• 60100bpm FgtM
• child (lt3 years) gt 100bpm
• tachycardia normal adult gt100bpm
  child(lt3 years) gt150bpm
• bradycardia HR lt60 bpm

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Ausclutation

• heart rate60-100bmp

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• 2)cardiac rhythmsinus arrythmiaaffected by
  breathpremature beat classificationatria
  l ventricular
• junctional
• frequentlygt6 bpm
  
• occasionally lt6 bpm
• bigeminy trigeminy

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• atrial fibrillation absolute
  irregular rhythm S1 intensity
  inequality Pulse deficitseenMS,CHD,hyp
  erthyroidism,
• PHD,DCM

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Ausclutation

• atrial fibrillation

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3) cardiac sound
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Ausclutation

• content
• cardiac sound
• S1
• S2

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• 4)Abnormal cardiac sound
  Intensity
• position of the atrioventricular valve
• Ventricular contractility and output
• Valvular integrity and activity

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• S1 Accentuation
• MS
• HR?contractility?
  fever,anemia,hyperthyroidism
• complete AVB ?cannon sound

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• S1 attenuation
• MI
• P-R interval enlong
• AI
• myocarditis,myopathy,MI,HFinequality af,
  IIIAVB

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• S2---A2,P2
• S2 ? ---pressure and flow of
• blood ? A2
  hypertensin, arterisclerosis P2
  PHD,CoHD(L--R),LVF
• S2 ? ---pressure? flow ?
  Seenhypotension,AS/AL,PS/PI

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• Quality mono rhythm
• pendular rhythm---embryocardia
• Splitting of heart sound S1 splitting
• seenRBBB, right heart failure
  Ebetein malformation ,MS LA myxoma

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• S2 splitting(1)physiological splitting end of
  inspiration (2)general splitting most commonly
  seen CRBBB, PS, MS,MI ,VSD (3)fixed
  splitting ASD(4)paradoxical splitting(reversed
  splitting) pathological seen CLBBB ,AS,
  hypertension

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• 5)extra cardiac soundDiastolic period1)gallop
  rhythm --protodiastolic gallop S1S2S3 the
  third sound gallop (sign of organic heart
  disease) seen HF(AMI, severe myocarditis
  , myopathy etc.) -- late diastolic gallop
  atrial gallop S1S2S4 seen HBP ,HCM ,AS
  ,CHD -- summation gallop quadruple rhythm
• seenHF,cardiomyopathy

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• 5) extra cardiac sound Diastolic period
• 2)opening snapMS3)pericardial knock
  constrictive pericarditis4)tumor plop LA myxoma

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Ausclutation

• CONTENT
• Tumor plop

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• Systolic period(1)early systolic ejection
  sound(click) pulmonary pulmonary
  hypertension
  
  
  
  
  pulmonary artery dilatation
  PS, ASD, VSD Aortic
  hypertension, aneurysm ,
• AS, AI ,aorta
  constriction(2)mid and late systolic click
• S1----midlt0.08? lategt0.08? seen
  mitral prolapse

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• iatrogenic(1)prosthetic valvular
  sound(2)pacemaker

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6)cardiac murmurs
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• characterization of murmur and ausclutatory key
  points (1)locationL3,4 VSD L2,3PDA
  (2)transmission
• MI ---left axilla AS---neck
  (3)phase systolic murmurs
  diastolic continuous
• biphasic
• early,mid,late,whole
  murmurs

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• (4)quality blowingMI
  rumblingMS sighing--AI
  machinery--PDA
• (5)intensity Levine 6 grade classification
  shape crescendo---MS
  decrescendo---AI
  crescendo-decrescendo---AS
  continuous---PDA
  regular---MI
• 
  
  
• 
  murmurs
  
  

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• (6) others
• body position
  MS--left lateral
  positionAI--sitting erected and forward
  
  MI,TI,PVS--lie on one back
  Lie ? stand HCM
• breathexpiration--LV murmurs
  inspiration --RV murmurs
  valsalva--HCM
• exercise HR?--murmurs ?
• 
  
• 
  murmurs

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• clinical significance murmurs
  functional and organic7)pericardial
  friction sound
• both phases , unaffected by respiration .
• seen pericarditis ,
• RHD ,AMI ,renal failure, SLE

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• clinical significance of cardiac murmurs
• systolic murmurs
• MVfunctionalexercise,fever,anemia,pregnancy,
• hyperthyroidism
• relativeHBP,CHD,DCM,anemia
• organicMI(RHD),mitral prolapse

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• clinical significance of cardiac murmurs
• systolic murmurs
• Aortic areaorganicAS
• relativedilatation of
  ascending aorta

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• clinical significance of cardiac murmurs
• systolic murmurs
• pulmonary physiology
• relativeMS?ASD
• organicPS
• TVrelative RV enlarged
• organic rare

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• clinical significance of cardiac murmurs
• Diastolic murmurs
• MVorganicRHD(MS)
• relativeAI(severe)
• Austin Flint murmur
• AVAI

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• clinical significance of cardiac murmurs
• Diastolic murmurs
• PVorganic murmur is rare PI(dilatation of
  pulmonary artery)
• MSP2 ---- Graham Steell murmur
• TVrare

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• clinical significance of cardiac murmurs
• continuous murmurs
• PDA
• innocent murmur

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Vascular examination

The second clinical hospital of CMU
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pulse

• pulse rate
• pulse rhythm
• tensions and state of arterial wall
• intensity
• pulse wave

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pulse

• pulse rate
• Atrial fibrillation and frequent premature beat
  stroke volume peripheral artery no pulse
  pulse rate less than HR(pulse deficit)

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pulse

• pulse rhythm
• pulse deficit
• bigeminal pulse,trigeminal pulse
• dropped pulse

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pulse

• tensions and state of arterial wall
• Artery tension depending on blood pressure
  (mainly SBP).
• Judge state of artery wall

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pulse

• intensity
• Bownding pulse
• seenhigh fever, hyperthyroidism, AI
• Microsphygmia
• seenHF,AS and shock

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pulse

• pulse wave
• normal pulse wave
• composed of upstroke(knocking wave)?peak (tide
  wave)and downstroke(dicrotic wave)

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pulse

• pulse wave
• water hammer pulse seenAI,hyperthyroidism,PDA,
  severe anemia
• pulse tardus seenAS
• dicrotic pulse seenHCM
• pulsus alternans seenHBP,AMI,AI
• paradoxical pulse
• seencardiac tamponade,constrictive
  pericarditis
• Pulseless
• seenserious shock, arteritis

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blood pressure

• method of measurement
• direct measurement method
• indirect measurement method

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blood pressure

• standard
• definition of Bp level and classification(older
  than 18 years old)
• classification SBP(mmHg)
  DBP(mmHg)
• Ideal BP ?120
  ?80
• Normal BP ?130
  ?85
• High limit of BP 130-139
  85-89
• Grade 1(mild) 140-159
  90-99
• subgroup
• boundline hypertension 140-149
  90-94
• Grade 2(moderate) 160-179
  100-109
• Grade 3(severe) 180
  110
• Simple systolic hypertension ?140
  ?90
• subgroup
• boundline systolic hypertension 140-149
  ?90

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blood pressure

• clinical significance of BP changes
• hypertensionhigher than 140/90mmHg for 3 times
  not in the same day
• hypotensionlower than 90/60-50mmHg
• Shock,,MI,acute cardiac tamponade
• obvious difference between bilateral upper
  limbsmore than 10mmHg---arteritis,congenital
  artery malformation
• difference between upper and lower limbslower
  limb BP is 20-40mmHg higher than upper one
  normally
• pathologicalconstrictive aorta
  ,arteritis(chest-abdominal aorta)
• change of pulse BP
• ?40mmHg,wide pulse BP---hyperthyroidism,AI
• ?30mmHg,narrow pulse BP---AS,pericardial effusion

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blood pressure

• dynamic BP monitoring
• Average BP for 24h ?130/80mmHg
• bright day ?135/85mmHg
• night ?125/75mmHg
• Peak6am10am,4pm6pm

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Vessel murmur and peripheral vessel sign

• venous murmur
• jungular murmuris caused by the rapid flow of
  jungular vein into SVC (superior vena cava)

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Vessel murmur and peripheral vessel sign

• artery murmur
• Continuous murmur in the lateral lobe of thyroid
  in the patient with hyperthyroidism
• Systolic murmur in the upper abnormal region or
  lumber region caused by stenosis of renal artery.
  
• Arterio-venous fistula

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Vessel murmur and peripheral vessel sign

• peripheral vessel sign
• pistol shot sound
• SeenAI,hyperthyroidism,severe anemia
• Duroziers murmur
• capillary pulsation

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• The main symptoms and signs of common diseases of
  circulatory system

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Mitrial stenosis

• Causes
• RHDrheumatic heart disease CHDcongenital
  heart disease Other reasons senile retrograde

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• Symptoms
• cough
• hemoptysis
• dyspnea dyspnea on exertion? paroxysmal
  nocturnal dyspnea ? pneumonedema

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• Signs
• Inspection
• mitrial face Apex impulse may be displaced
  to the left
• Palpation diastolic thrill palpable over the
  apical area
• Percussion normal heart borders?pear shape
  heart

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• Auscultation 1)the first sound (S1)?
  2)diastolic murmur apical area localized mild
  and late diastolic crescendo rumbling more
  clearly when the patient is lying on his left
  side. 3) opening snap may be auscultatory
  4)accentuation of second pulmonary sound (P2?),
  splitting 5)Graham Steels murmur (PV
  diastolic) 6)Maybe atrial fibrillation(late
  stage)

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Mitral Insufficiency

• RHD / non-RHD acute/chronic
• Symptoms
• fatigue,
• palpitations,
• dyspnea on exertion,
• Left heart failure

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• Signs Inspection apex beat is displaced
  downwards and to the left

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• Palpitation
• apical impulse forceful Heaving apex impulse
• Severe systolic thrill
• Percussion
• the area of dullness to left and downwards

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• Auscultation
• 1)S1 ?(attenuation)
• 2)murmurs harsh
  pansystolic murmur blowing
  3/6 grade ?
  wide spread-transmitted to left axilla
  left
  infrascapular angle

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Aortic Stenosis

• Causes RHD Congenital
  Senile retrograde
• Symptoms
• palpitation ,dizziness, angina pectoris,
  syncope, HF-dyspnea

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• Signs
• Inspection apical impulse increase
  Displaced to left and downwards
• Palpation
• apex beat is elevated and forceful
• systolic thrill can be palpated over aortic
  auscultatory valve area
• Pulse tardus

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• Percussion
• the area of dullness is normal or to left and
  downward
• Auscultation
• 1)murmur
• aortic auscultatory valve area systolic murmur
  
• harsh ,ejection sound ,
• 3/6 grade ?(thrill)
• transmitted to neck2)A2 ?,reversed
  splitting3)S4

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Aortic Insufficiency

• Causes
• RHD Non-RHDcongenital
  prolapse syphilis aortitis
  arteriosclerosis
  endocarditis acute/chronic

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• Symptoms
• palpitation, dizziness, LHF
• SignsInspection
• apical impulse to left and downwardsPalpation
  
• apex impulse to left and downwards Heaving apex
  impulse

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• Percussion
• the area of cardiac dullness is enlarged
  downwards and to the left
• the concave part of the heart is not enlarged
  (boot shape)

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• Auscultation
• 1)specific murmur
• diastolic
• sighing
• aortic area
• heard clearly sitting erect and forward
• 2)Austin Flint murmur relative MS (rumbling
  mid-diastolic murmur)

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• Peripheral vascular signs
• head bobbing (Mussets sign)nodding motion of
  the head with each systolesigns of capillary
  pulsationwater hammer pulsepistol shot
  sounds esp. Femoral arteriesDuroziezs
  murmurVisible pulsation of carotid arteries

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Pericardial effusion

• Causes
• infective and non-infective pericarditis
• Symptoms
• pain over the pericardial region Dyspnea,
  cough, fever, lassitudeShock

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• Signs Inspection
• diminution in strength of the apex beat or
  absence of the apex beat
• jugular venous enlargement

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• Palpation
• diminution in strength of the apex beat or the
  apex beat palpated uneasily
• paradoxical pulse may be present

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• Percussion
• enlargement of the cardiac dullness bilaterally,
  changed with posture

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• Auscultation
• pericardial friction sound
  
• HR?,diminution of intensity of cardiac sound
  (S1/S2?)
• pericardial knock may be heard

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• Large effusion
• Jugular varicosity
• Liver enlargement
• Paradoxical pulse
• Pulse pressure ?

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• Kussmaul sign
• deep inspiration jugular vein distension
• Ewart sign left infrascapular region
• vocal fremitus?
• dullness -- percussion
• bronchovesicular breath sound--
  auscultation

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Heart Failure

• Causes
• myopathy ventricular load ?
• promote factors
• Symptoms
• 1 LHF fatigue, cough, frothy sputum
  dyspnea(on exertion ? orthopnea ? paroxysmal
  nocturnal )
• 2 RHF abdominal distension, oliguria, nausea,
  vomiting

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• Signs 1 LHF Inspection tachypnea ,
  cyanosis, semireclining/sitting position Acute
  pneumoedema
• frothy sputum, hyperhidrosis
  Palpation pulse alternans Percussion
  Auscultation diastolic gallop rhythm
  P2?
  Fine rales, rhonchi

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• 2 RHF Inspection Jugular distension
  Pericardial cyanosis
  Edema(pitting, pendulous)
  Palpation liver enlargement, tenderness
  Hepatojugular reflux()
  Percussion
• pleural effusion (right
  side)
• ascites Auscultation
  RV diastolic gallop rhythm
  TV systolic blowing murmurs