Heart/Neck Vessels

1
Heart/Neck Vessels Peripheral
Vascular/Lymphatics
2
Anatomy Review

• 4 chambers
• Right/left atrium
• Right/left ventricle
• 4 valves
• Tricuspid
• Mitral
• Pulmonic
• Aortic

3
Anatomy and Physiology
Measure Typical value Normal range
end-diastolic volume (EDV) 120 ml1 65 - 240 ml1
end-systolic volume (ESV) 50 ml1 16 - 143 ml1
stroke volume (SV) 70 ml 55 - 100 ml
ejection fraction (Ef) 58 55 to 702
heart rate (HR) 70 bpm 60 to 100 bpm3
cardiac output (CO) 4.9 L/minute 4.0 - 8.0 L/min

• Cardiac output
• (L/min) determined by
• Heart rate (beats/min)
• Stroke volume (L/beat)
• CO SV x HR

4
Health History

• Chest pain
• Do you have any chest pain or discomfort?
• OLDCART
• Do you do you use any recreational drugs?
• Do you have any increased life stress/anxiety?
• Dyspnea
• Do you have any labored or difficulty breathing
  (dyspnea)?
• OLDCART
• Related to exercise (exertional dyspnea)?
• Quantify Have far can you walk before getting
  short of breath?
• Related to position/lying supine (orthopnea)?
• How many pillows do you sleep on at night?

5
Health History

• Palpitations
• Ever have palpitations/or unpleasant awareness of
  heartbeat? (fluttering/ pounding)
• Dizziness or Syncope
• Have you felt dizzy or ever lost
  consciousness/passed out (syncope)?
• Fatigue
• Do you seem to tire easily?
• Cyanosis or pallor
• Ever noted your facial skin turn blue or ashen
  gray?

6
Health History

• Cough
• Any pink or blood tinged frothy sputum?
• Edema
• Do you have any swelling in your feet or legs?
• Nocturia
• Do you awaken at night with an urgent need to
  urinate?

7
Health History

• Past Cardiac History
• CHF, angina, MI, murmurs, rheumatic fever,
  congenital heart disease
• Assess for risk factors of coronary artery
  disease
• Hypertension, hyperlipidemia, diabetes, physical
  inactivity, obesity, smoking, stress, increasing
  age. family history of CAD (especially in 1st
  degree relatives Flt65, Mlt55)
• Additional for women Menopause or use of oral
  contraceptives

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What the History Can Tell You

• Angina (pain resulting from ischemia)
• Onset Abrupt, often precipitated by event such
  as emotion, exertion, cold or eating.
• Location Substernal or retrosternal pain.
• Duration Usually lasts a few minutes and then
  subsides.
• Characteristic Described as squeezing or heavy
  pressure
• Radiation May radiate to the neck, jaw, or arms
• Relieving Factors/Treatments Tried Often
  relieved with sublingual nitroglycerin

9
What the History Can Tell You

• Myocardial Infarction
• Onset Abrupt, often unrelated to precipitating
  event.
• Location Substernal or over precordium.
• Duration Prolonged
• Characteristic Severe, described as viselike or
  crushing
• Associated Symptoms dyspnea, dizziness, nausea,
  diaphoresis, palpitations, anxiety (sense of
  doom)
• Radiation May radiate to neck, jaw, arms or
  hands.
• Treatments Tried Sublingual nitroglycerin
  without relief

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What the History Can Tell You

• Congestive Heart Failure
• Right-sided
• Dependent Edema
• Nocturia
• Left-sided
• Coughing/Hemoptysis (pink frothy)
• Orthopnea
• Dyspnea with exertion
• Cyanosis or ashen color
• Cold, moist extremities
• Oliguria
• Restlessness/anxiety

11
Carotid Artery

• Inspect for pulsation
• Absent pulse wave with arterial occlusion
• or stenosis
• Palpate lightly one at a time for
• Contour
• Smooth with rapid upstroke
• Amplitude
• 4 Bounding
• 3 Full
• 2 Normal
• 1 Weak
• 0 Absent
• Diminished or unequal with atherosclerosis or
  other arterial disease
• Auscultate
• Over angle of jaw, mid-cervical, base of neck
  with bell
• For presence of bruit
• Blowing, swishing sound indicating turbulence
• http//www.youtube.com/watch?vyq74c6KhPuo
• Carotid arteries 2 bilaterally without bruits.

12
Jugular Venous Pressure

• Assessment of jugular veins gives estimation of
  heart function
• Ie. CHF
• Internal Jugular Vein
• Position patient supine at
• 45 degrees without a pillow
• Use Angle of Louis to read
• CVP at highest level of pulsation
• Normal-Pulsation lt2.5cm
• Abnormal- Pulsation gt2.5cm
• Indicates increased CVP associated with heart
  failure
• http//www.youtube.com/watch?vyq74c6KhPuo
• If you cannot find internal jugular veins, use
  the external and note point where look collapsed

13
Jugular Venous Pressure

• External jugular veins are lateral to
  sternomastoid muscle above the clavicles
• Assess if
• Visible (distended) _at_ 45
• External jugular veins flat _at_ 45

14
Hepatojugular Reflux

• Very sensitive in detecting right-sided heart
  failure
• Elevate to 30 degrees
• Press firmly in right upper quadrant
• Observe neck for elevation in JVP
• Rise of gt1cm is abnormal
• http//www.youtube.com/watch?vX9fKPIe6nDQ

15
Inspection Palpation

• Inspect palpate precordium for
• Lifts/Heaves
• Thrills
• Use ball of your hand firmly on the chest
• Apical impulse
• http//www.youtube.com/watch?vFkM6muqmve0feature
  related
• Apical impulse _at_ 5th intercostal space
  midclavicular line. No lifts, heaves, or thrills
  noted.
• Note location of heart may also be determined by
  percussing for borders of dullness

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Apical Impulse

• AKA Point of maximal impulse (PMI)
• Apical impulse specifically for apex beat.
• Localize apical impulse using one finger. Ask to
  exhale and hold breath may help find. May need to
  roll midway to left.
• Note location, size (1cm x 2cm), amplitude
  (short gentle tap), duration (short, occupies
  only first half of systole
• Not palpable in obese, thick chest wall
• Increased size or location with volume overload,
  hypertrophy (HTN, CAD, CHF, cardiomyopathy)
• Increased amplitude duration with high cardiac
  output states (anxiety, fever, hyperthyroidism,
  anemia

17
Auscultation

• Wth the diaphragm auscultate
  _at_ the apex of the heart for
• Rate
• Normal Adult Rate 60-100 beats/min
• Bradycardiaheart rate less than 60
• Tachycardiaheart rate greater than 100.
• Rhythm
• Regular vs. irregular
• Sinus arrythmia (rhythm varies with breathing)
• Regularly irregular, irregularly irregular
• If pulse irregular assess for pulse deficit
• Auscultate the apical beat while simultaneously
  palpating the radial pulse. Every beat hear
  should perfuse to periphery
• Apical pulse 80bpm and regular. No pulse deficit
  noted.

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Auscultation

• Proceed over precordium with bell
• Best for low pitch
• Auscultate over
• Aortic area
• Pulmonic area
• Erbs point
• Tricuspid area
• Mitral area
• Epigastric
• For
• Gallops (best with bell)
• Murmurs (depends)
• Rubs

19
Normal Heart Sounds

• S1
• Lubb
• Sound of mitral tricuspid
• valve closing simultaneously
• Start of systole
• Heard loudest at apex of heart
• Approx 5th intercostal space, midclavicular line
  on left
• S2 http//www.youtube.c
  om/watch?v2aO0HKIP3vI
• Dubb
• Sound of simultaneous closing of pulmonic and
  aortic valves
• End of systole
• Heard loudest at base of heart
• Best over 2nd intercostal space on right

20
Gallops S3 S4
Heart Sound Associated Heart Process Normal Characteristics Pathological Characteristics Cadence Word Clue
S3 Heard _at_ apex or LL sternal border with bell Early diastolic Occurs after S2 Heard more often in children and young adults Waxes and Wanes May disappear when pt sits up Higher pitch Louder More constant sound Associated with volume overload and left ventricular systolic dysfunction Ken-tu-cky. SLOSH-ing-in
S4 Heard _at_ apex with bell Late diastolic (atrial filling) Occurs before S1 No typical characteristics Seen in uncontrolled hypertension Ten-nes-see a-STIFF-wall
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Murmurs

• Swishing or blowing noises that occurs with
  turbulent blood flow in heart or great vessels.
• Categorized as
• Innocent
• Always systolic without evidence of
  physiological/structural abnormalities
• Functional
• Associated with physiological alterations such as
  high cardiac output states
• i.e. exercise, anemia, hyperthyroidism or
  increased blood volume associated with pregnancy
• Pathologic
• Caused by structural abnormalities in valves or
  chambers
• Stenosis, regurgitation, patent ductus arteriosis

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Structural Abnormalities in Valves and Chambers
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Murmur Characteristics

• Timing
• Systolic Heard during systole
• (between S1 and S2)
• If possible note early, late or mid systolic)
• Diastolic Heard during diastole (between S2 and
  S1)
• If possible note early, late or mid diastolic
• Continuous Heard in both systole and diastole
• http//www.youtube.com/watch?vXvtBpnV_lOE

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Valvular Disease Murmur Locations
Valve Systolic Murmur Diastolic Murmur
Aortic Aortic stenosis Aortic regurgitation
Pulmonic Pulmonic stenosis Pulmonic regurgitation
Mitral Mitral regurgitation Mitral stenosis
Tricuspid Tricuspid regurgitation Tricuspid stenosis
http//www.merckmanuals.com/professional/resources
/multimedia/name/audio.html
25
Murmur Characteristics

• Quality (Shape/Pattern Sound)
• Shape/Pattern
• Crescendo/Decrescendo
• AKA- Diamond shaped murmur ejection type murmur
• Primary causes Stenotic valves
• Holosystolic
• AKA- Pansystolic
• Decrescendo
• Primary causes Aortic and pulmonic
  regurgitation, Mitral and tricuspid stenosis
• http//www.merckmanuals.com/professional/resources
  /multimedia/name/audio.html

26
Murmur Characteristics

• Quality
• Sound
• Musical, blowing, harsh, or rumbling
• Pitch
• High, medium, or low Loud or soft
• Location
• Area of maximal intensity
• Radiation
• May be heard in another place on precordium or
  neck, back or axilla

27
Murmur Characteristics

• Intensity (loudness)
• 1 - Very faint, heard only after listener has
  tuned in may not be heard in all positions
• 2 - Quiet, but heard immediately after placing
  the stethoscope on the chest
• 3 - Moderately loud
• 4 Loud, with palpable thrill
• 5 - Very loud, with thrill. May be heard when
  stethoscope is partly off the chest
• 6 Very loud, with thrill. May be heard with
  stethoscope just removed from and not touching
  the skin.

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Murmur Characteristic Example

• Aortic Stenosis
• Timing Midsystolic
• Pitch Loud
• Quality Harsh
• Location Loudest _at_ 2nd right interspace
• Radiation Widely to side of neck, down left
  sternal border, or apex
• http//www.merckmanuals.com/professional/resources
  /multimedia/name/audio.html

29
Auscultation

• Pericardial friction rub
• Membranous sac surrounding heart becomes inflamed
• Differentiate pericardial from pleural friction
  rub by having patient hold breath

http//www.merckmanuals.com/professional/resources
/multimedia/name/audio.html
30
Physical Exam Findings for CHF

• Right-Sided Failure

• Left-Sided Failure

• Distended neck veins
• Dependent edema
• Ascites
• Hepatomegaly
• Nocturia

• Pulmonary Edema
• Coughing
• Hemoptysis
• Orthopnea
• Dyspnea/Tachypnea
• Crackles in lungs
• Cyanotic nail beds, ashen color
• Cold, moist extremities
• Restlessness/anxiety
• S3 gallop rhythm
• Tachycardia

http//www.youtube.com/watch?vQODCQHwSfOUfeature
related
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Peripheral Vascular Lymphatics
http//images.google.com
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Peripheral Vascular System

• Arteries
• Supply oxygenated blood to the body from the
  heart
• Veins
• Return unoxygenated blood to the heart
• Contain one-way valves that keep the blood from
  flowing backwards
• Muscles help squeeze the blood in the veins to
  the heart

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Health History

• Common or concerning symptoms
• Pain in the arms or legs
• Intermittent claudication leg or arm pain that
  is exercise induced
• Cold, numbness, pallor in the legs hair loss
• Color change in fingertips or toes in cold
  weather
• Swelling in calves, legs or feet
• Swelling with redness or tenderness
• High risk Tobacco use, diabetes, HTN,
  Hyperlipidemia, CV disease
• Severity of peripheral vascular disease closely
  parallels the risk for heart attack, stoke, and
  death from vascular causes

34
Inspection

• Inspect upper and lower extremities for
• Color
• Symmetry
• Lesions
• Clubbing
• Edema
• Capillary refill
• Pitting Edema- Apply pressure with finger for 5
  seconds.
• 1 Slight pitting, 1cm or less, disappears
  rapidly
• 2 Deeper pitting, 1.5cm, disappears 10-15 sec.
• 3 Deep pitting, 2cm, disappears more than 1
  minute
• 4 Very deep pitting, 2.5cm, disappears 2-5
  minutes
• No pitting edema noted

35
Inspection

• Inspect lower extremities for
• Hair distribution
• Varicosities
• Muscle atrophy

36
Palpation

• Palpate upper and lower extremities for
• Temperature
• Texture
• Capillary refill
• Lymph nodes
• Epitrochlear, Inguinal

37
Lymph Nodes

• Epitrochlear
• In antecubital fossa and drains
• Hand
• Lower hand
• Inguinal
• In groin and drains most of the lymph
• Lower extremities
• External genitalia
• Anterior abdominal wall

38
Palpation

• Peripheral Pulses
• Brachial, radial, femoral, popliteal, posterior
  tibial, dorsalis pedis
• Assess for symmetry in limbs
• Force
• 4 Bounding
• 3 Full, increased
• 2 Normal
• 1 Weak
• 0 Absent
• If pulse is difficult to palpate use a Doppler
  (ultrasound stethoscope) to amplify sound of
  pulse wave

39
Peripheral Pulses- Brachial

• Located medial to biceps tendon
• Grade force bilaterally

40
Peripheral Pulses-Radial

• Note
• Rate
• Rhythm
• Force

41
Peripheral Pulses-Ulnar

• Modified Allen Test
• Evaluate adequacy of collateral circulation prior
  to cannulating radial artery
• Firmly occlude both ulnar and radial arteries
• Release pressure on ulnar artery
• Normal- return of color in 2-5 seconds

42
Peripheral Pulses-Femoral

• Located just below inguinal ligament halfway
  between the pubis and anterior superior iliac
  spine.
• Grade force bilaterally
• If weak auscultate for bruit

43
Peripheral Pulses-Popliteal

• Located just lateral to medial tendon
• Grade force bilaterally

44
Peripheral Pulses-Posterior Tibial

• Located behind the groove between the malleolus
  and Achilles tendon
• Grade force bilaterally

45
Peripheral Pulses-Dorsalis Pedis

• Located just lateral to parallel with the
  extensor tendon of the big toe.
• Force should be symmetrical

46
Assess for Deep Vein Thrombosis

• Assess for
• Erythema
• Calf Edema
• Increased warmth
• No calf erythema, edema, warmth
• No longer widely practiced
• Tenderness with palpation
• Homans sign
• No calf erythema, edema, or warmth.

47
Venous vs. Arterial Insufficiency
Assessment Criterion Venous Arterial
Color Normal or cyanotic Pale worsened by elevation dusky red when extremity is lowered
Temperature Normal Cool (blood flow blocked to extremity)
Pulse Normal Decreased or absent
Edema Often marked Absent or mild
Skin Changes Brown pigment around ankles Thin, shiny skin decreased hair growth thickened nails.
48
Arterial
Venous
49
Is that all? ?
MIDTERM 40 points all multiple choice
GOOD LUCK!!!!