Cardiovascular Examination

1
Cardiovascular Examination

• Part 1

2
Clinical History

• Common Presenting Complaint
• Previous Medical History
• Medication
• Psychosocial Aspect

3
Presenting Complaints

• Chest Discomfort
• Breathlessness
• Dizziness
• Palpitations
• Blackouts

4
Chest Discomfort

• Classic
• Constricting chest pain radiating to the left arm
  or neck

5
Angina

• No pain at all
• Back pain
• Discomfort
• Epigastric
• Shoulder
• Isolated arm
• Jaw

6
Atypical Symptoms

• Precipitating Factors
• Relieving Factors
• Associated Symptoms
• Supporting Evidence

7
Precipitating Factors

• Effort
• Emotion

8
Relieving Factors

• Rest
• Sublingual nitrates

9
Associated Symptoms

• Breathlessness
• Autonomic Features
• Sweating
• Nausea
• Vomiting
• Pallor

10
Supporting Evidence

• EKG
• Cardiac Enzymes

11
Breathlessness

• Cardiac
• Arrhythmia
• Chronic low cardiac output
• Ischemic LV dysfunction
• Pulmonary Edema

12
Breathlessness

• Non Cardiac
• Pulmonary Edema
• Systemic Acidosis
• B-blockade
• Pulmonary Embolism
• Pneumonia

13
Differentiate

• Precipitating Factors
• Effort
• Lying flat
• Relieving Factors
• Rest
• GTN
• Sitting Up
• Associated Symptoms
• Chest Pain
• Palpitation

14
Palpitation

• Onset
• Gradual
• Rapid
• Rate of Rhythm
• Slow
• Fast
• Regular versus Irregular
• Precipitants
• Effort
• Anginal episode
• alcohol

15
Grading Symptoms - NYHA

• Fatigue
• Dyspnea
• Angina

16
Grading Symptoms - NYHA
Class Activity Limitation
I No limitation during ordinary activity
II Slight limitation during ordinary activity
III Marked limitation or normal activities without symptoms at rest
IV Unable to undertake physical activity without symptoms, symptoms may be present at rest
17
Dizziness

• Causes
• Cardiac
• Low CO
• Arrhythmia
• Drugs
• Antianginal
• Diuretics

18
Dizziness

• Causes
• Vasovagal Syndrome
• Vascular
• Carotid
• Vertebrobasilar
• Cerebrovascular

19
Dizziness

• Associated Symptoms
• Flushing
• Palpitation
• Syncope

20
Blackouts

• Cardiac
• Exertional Syncope
• Aortic Stenosis
• Outflow Obstruction
• Exercise-induced arrhythmia
• Vasovagal
• Prolonged Standing
• Emotion
• Noxious Stimuli
• Cough
• Micturition

21
Previous Medical History

• Previous MI
• Angina
• History of
• Rheumatic Fever
• Scarlet Fever
• Cardiac Surgery
• CABG
• Valve replacement

22
Previous Medical History

• Coronary Risk Factor
• Hypercholesterolemia
• Smoking
• Diabetes Mellitus
• Family History
• Hypertension
• Medication

23
Psychosocial History

• Work
• Home
• Alcohol
• Psychological problems

24
Cardiovascular Examination

• General Inspection
• Demeanor
• Color
• Pallor
• Central cyanosis
• Peripheral cyanosis
• Jaundice
• Plethora
• Malar flush

25
Cardiovascular Examination

• Build
• Obesity
• Cachexia
• Marfanoid
• Dysmorphic
• Hypertelorism PS
• Elfin facies Supravalvular AS
• Down Syndrome Endocardial cushion defect.

26
Hands and Face

• Temperature
• Sweating
• Digital clubbing
• Cutaneous features of endocarditis
• Petechiae
• Splinter haemorrhages
• Oslers modes
• Janeway lesions

27
Hands and Face

• Xanthomata
• Tendon xanthomata
• Palmar xanthomata
• xanthelesma
• Teeth
• Eyes
• Corneal arcus
• Hypertensive retinopathy
• Diabetic retinopathy
• Roth spots

28
Arterial System

• Pulses
• Rate
• Rhythm
• Volume
• Low volume
• High volume
• Character
• Pulsus alternans
• Pulsus paradoxus
• Pulsus biferiens
• Collapsing pulse
• Slow rising
• Jerky pulses

29
Arterial System

• Peripheral Pulses
• Femoral
• Volume
• Radio-femoral delay
• Duroziezs Sign
• Popliteal
• Dorsalis Pedis
• Posterior tibial

30
Arterial System

• Blood Pressure
• Check BP in both arm
• Supine upper and lower limbs
• Pulsus Paradoxus

31
Pulsus Paradoxus

• A decrease in systolic BP of greater than 10 mmHg
  or weakening of the pulse during inspiration.
• It occurs commonly in cardiac tamponade
• Occurs occasionally in constrictive pericarditis,
  severe asthma, or COPD
• Occurs rarely in restrictive cardiomyopathy,
  severe pulmonary embolism, or hypovolemic shock.

32
Jugular Venous Pressure
Systole
Diastole
a
a
c
c
v
y
x
33
Jugular Venous Pressure

• a-wave
• Rise in JVP due to atrial contraction
• c-wave
• Transmitted carotid pulse at onset of systole
• v-wave
• Rise in RA due to filling against a closed
  tricuspid valve

34
Jugular Venous Pressure

• x descent
• RA relaxation followed by descent of TV in
  systole
• y descent
• Pressure drop as TV opens at start of diastole

35
Jugular Venous Pressure

• Gives and index of RAP
• Elevated
• Recline patient at 45 degree incline
• Timed with carotid pulse

36
Jugular Venous Pressure

• Abnormal JVP
• Large a-wave
• RVH
• TS
• Cannon waves
• Atrial contraction against a closed valve
• Junctional rhythm
• Complete heart block
• Large v-wave
• TR

37
Jugular Venous Pressure

• Rapid y descent
• Myocardial dysfunction and increased CVP
• ASD
• Constrictive pericarditis
• Kussmauls sign
• Rise of JVP on inspiration
• Onstirctive pericarditis
• Tamponade
• Fixed, raised JVP
• SVC Obstruction