© continuing medical implementation …...bridging the care gap how to examine the heart and blood...

How to Examine the Heartand Blood Vessels

Joel Niznick MD FRCPC

Look at the patientLook at the patient

• Sick/well• Comfortable/in distress• Cyanosed/plethoric• Wet/dry• Young/old• Male/Female• Establish probabilities of disease

– History will have told you what to suspect

Common Clinical Scenarios

• Younger people– Functional murmur

vs MVP vs bicuspid AV

• Older people– Aortic sclerosis vs

aortic stenosis

ProbabilitiesProbabilities

• Males more commonly have aortic valve disease– Young – BAV

– Elderly - Degenerative

• Females more commonly have mitral valve disease

• MVP > rheumatic heart disease

InspectInspect

• Facies/body habitus– Cyanosis– Xanthelasma– Arcus senilis– Conjunctival hemorrhages

• Syndromes– Marfan’s– Down’s

HandsHands

• Clubbing• Capillary return• Digital ischaemia• Splinter hemorrhages• Osler’s nodes• Janeway lesions

Blood pressureBlood pressure

• At rest 5”

• Both arms

• Legs if young hypertensive

RECOMMENDED BLOOD PRESSURERECOMMENDED BLOOD PRESSUREMEASUREMENT TECHNIQUEMEASUREMENT TECHNIQUE

2.• The cuff must be level with heart.

• If arm circumference exceeds 33 cm,a large cuff must be used.

• Place stethoscope diaphragm overbrachia l artery.

2.2.•• The cuff must be level with heart.The cuff must be level with heart.

•• If arm circumference exceeds 33 cm,If arm circumference exceeds 33 cm,a large cuff must be used.a large cuff must be used.

•• Place stethoscope diaphragm overPlace stethoscope diaphragm overbrachia l artery.brachia l artery.

1.• The patient should

be relaxed and thearm must besupported.

• Ensure no tightclothing constrictsthe arm.

1.1.•• The patient shouldThe patient should

be relaxed and thebe relaxed and thearm must bearm must besupported.supported.

•• Ensure no tightEnsure no tightclothing constrictsclothing constrictsthe arm.the arm.

3.• The column of

mercury must bevertical .

• Infla te to occlude thepulse. Deflate at 2 to3 mm/s. Measuresystolic (first sound)and diastolic(disappearance) tonearest 2 mm Hg.

3.3.•• The column ofThe column of

mercury must bemercury must bevertical .vertical .

•• Infla te to occlude theInfla te to occlude thepulse. Deflate at 2 topulse. Deflate at 2 to3 mm/s. Measure3 mm/s. Measuresystolic (first sound)systolic (first sound)and diastolicand diastolic(disappearance) to(disappearance) tonearest 2 mm Hg.nearest 2 mm Hg.

StethoscopeStethoscope

MercuryMercurymachinemachine

Look at the FundiLook at the Fundi

OSU Interactive Physical Exam Guide

Look at the FundiLook at the Fundi

• Disc

• Vessel

• Hemorrhages

• Exudates

PulsesPulses

• Rate

• Rhythm

• Volume– Quincke’s– Water hammer– Brachio-radial delay

CarotidCarotid

• Upstroke-normal/brisk/delayed/anacrotic

• Volume-normal/increased/decreased

• Auscultate:– Bruit– Murmur– S2 audible ? Over carotid?

Carotid TutorialCarotid Tutorial

JVPJVP

• Height

• Waveform

• Specific patterns

• Response to maneuvers– Inspiration– HJR

JVP InspectionJVP Inspection

JVP SummaryJVP Summary

• Confirm it’s the JVP you are seeing– Compressibility

– Waveform

– Manoeuvers

• Identify the height – start at 30o

• Identify the waveform

If unable to see JVP-lie patient flatIf still unable to see JVP-sit patient upright

Use the hand made rulerUse the hand made ruler

Normal JVP WaveformNormal JVP Waveform

JVP InspectionJVP Inspection

• Look for descents not waves

• Descents are easier to see due to greater amplitude and frequency

• Time deepest descent with systole. This is the X’ descent

Specific JVP patternsSpecific JVP patterns

Condition PatternNormal waveform X' deeper than Y

Post CABG X' shallower, now = Y

Atrial fibrillation CV wave

Tricuspid regurgitation CV wave

Complete heart block Irregular cannon A waves

Tamponade JVP brisk X' > Y

Constriction JVP brisk X' & Y descents

X' less exaggerated than Y

RV infarction JVP –low amplitude

PrecordiumPrecordium

• Palpate: Aortic → Pulmonary → LSB → Apex → Left decubitus

• Thrills

• Palpable HS

• Lifts

• Apex: size/position/motion

AuscultationAuscultation

• Follow same sequence

• Aortic → Pulmonary → LSB → Apex → Left decubitus → Upright lening forward

• Diaphragm except for apex (use both here)

• Identify HS, then extra sounds, them murmurs

• Dynamic maneuvers

Palpation - Precordium Palpation - Precordium

Parasternal:

• Palpable P2-pulmonary HTN

• Thrill– VSD/HCM

• RV lift– RVH– Severe MR

Palpation - ApexPalpation - Apex

Apex: • Palpable in 1 of 5 adults age 40• Best felt with fingertips or finger pads

Normal Location:• No more than 10 cm from mid-sternal line in the

supine position • Left decubitus position not reliable for apical locationNormal Size:• No larger than 3 cm (about 2 finger breadths)

Sustained Apex: • correlates with pressure overload or LVF• ( > 2/3 systole-hangs out to S2)• AS, LVH or LV systolic dysfunctionHyperdynamic Apex:• correlates with volume overload AR/MR• palpable S4 (atrial kick)• palpable S1 (MS)• palpable non-ejection click (MVP)

Apex–Dynamic AbnormalitiesApex–Dynamic Abnormalities

Atrial kick:

• Palpable S4– Loss of LV compliance– LVH 2o Hypertension– Aortic Stenosis– Hypertrophic Cardiomyopathy

What are we listening for?What are we listening for?

Normal First & Second Sounds

Normal First & Second Sounds 2

Splitting of the Second Sound

Timing of Cardiac Sounds

Fourth Heart Sound S4 Gallop

Third Heart Sound S3

Systolic Murmurs

Diastolic Murmurs

Common MurmursCommon Murmurs

Systolic Murmurs• Aortic stenosis• Mitral insufficiency• Mitral valve prolapse• Tricuspid insufficiency

Diastolic Murmurs• Aortic insufficiency• Mitral stenosis

S1 S2 S1

Grading of Murmurs:Grade 1 - only a staff man can hear

Grade 2 - audible to a resident

Grade 3 - audible to a medical student

Grade 4 - associated with a thrill or palpable heart sound

Grade 5 - audible with the stethoscope partially off the chest

Grade 6 - audible at the bed-side

Characteristics of a “functional” murmurCharacteristics of a

“functional” murmur

• Short and soft SEM

• Normal S1 and S2

• Normal cardiac impulse

• No evidence for any hemodynamic abnormality

Functional (Innocent) MurmursCommon in asymptomatic adults

• Characterized by– Grade I – II @ LSB

– Systolic ejection pattern - no with Valsalva/ upright

– Normal precordium, apex, S1

– Normal intensity & splitting of second sound (S2)

– No other abnormal sounds or murmurs

– No evidence of LVH

Characteristic of the NOT Innocent Murmur

• Diastolic murmur• Loud murmur - grade IV or above• Regurgitant murmur• Murmurs associated with a click• Murmurs associated with other signs or

symptoms e.g. cyanosis• Abnormal 2nd heart sound – fixed split,

paradoxical split or single

Integrating Pulse with HS and Murmurs

www.blaufuss.org

Examining the PeripheralPulses

FemoralPopliteal

Posterior Tibial

Dorsal Pedis

Radial

Brachial

Retinal

Carotids

Examination of PulsesExamination of Pulses

• Grading: – Normal/Increased/Decreased/Absent– 2+/3+/1+/0 – Allen’s test

• Trophic changes/Ulceration• Perfusion

– Pallor on elevation– Rubor on dependency– Venous refill with dependency (should be less than 30

seconds)

• Bruits

Trophic Changes Trophic Changes

Shiny, hairless skin, dystrophic nail changes and

dependent rubor associated with

peripheral arterialocclusive disease of

the patient's right foot

Pallor on elevationPallor on elevation

Rubor on dependency

Digital IschaemiaGangrene

A Practical Guide to Clinical Medicine - UCSD

Acute Arterial Insufficiency:

Mottled Appearance of Skin

Chronic Arterial Insufficiencywith Ulcers

http://medicine.ucsd.edu/clinicalmed/extremities.htm

Measurement of the Ankle-Brachial Index (ABI)

Venous AbnormalitiesVarices

Spider VeinsSpider Veins

Venous InsufficiencyVenous Insufficiency

Stasis Dermatitis/Ulceration Stasis Dermatitis/Ulceration

EdemaEdema

Cellulitis vs DVTCellulitis vs DVT

Right Deep Venous Thrombosis

Cellulitis

© continuing medical implementation …...bridging the care gap how to examine the heart and blood...

care gap precordiumpalpate

care gap auscultationfollow

care gap jvp inspectionlook

care gap jvp summaryconfirm

care gap palpation apexapex

care gap carotid tutorial

care gap specific jvp

decubitus position

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