cardiovascular examination
TRANSCRIPT
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Cardiovascular examination
Professor Salwa Ibrahim
Cairo university
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General examination
• General appearance : unwell, breathless, distressed
• Signs of hyperlipidemia : tendon xanthoma, corneal arcus
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Signs of infective endocarditis
• Splinter hemorrhages : multiple linear, reddish brown marks along the axis of fingernails and toe nails
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• Purpura: many petichiae are seen in the extremities and soft palate.
• Janeway lesions: painless, erythematousmaculopapules on the palms and soles that do not blanche. They are caused by thrombi in small vessels, without vasculitis
• Osler's nodules: painful, red papulo-nodules with a pale center. They are found on the fingertips, and last days to weeks. Caused by microabscesses in the dermis, they may even contain gram-positive cocci.
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Finger clubbing
• Clubbing may be present in one of four stages:
1. Fluctuation and softening of the nail bed (increased ballotability)
2. Loss of the normal <165° angle between the nailbed and the fold
3. Increased convexity of the nail fold
4. Thickening of the whole distal (end part of the) finger (resembling a drumstick)
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Causes of clubbing
• Cardiac: infective endocarditis, cyanotic heart disease
• Respiratory: suppurative lung disease, bronchogenic carcinoma, interstitial lung disease
• Gastrointestinal : IBD, primary liver cirrhosis
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Arterial pulse
• As ventricles eject blood, a pressure wave (pulse) is transmitted and can be felt
• Rate : 60-100/minute
• Rhythm : regular/irregular
• Volume : Large artery (femoral, carotid, brachial ) pulses are used to assess pulse volume and character
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Radial pulse
• Place the pads of your three middle fingers over the right radial artery
• To detect collapsing pulse, feel the pulse with the base of your fingers, then raise the patient arm above
• Palpate both radial pulses simultaneously
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Brachial pulse
• Artery is located medial to the biceps tendon
• Use the thumb to palpate it
• Character and volume
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Carotid pulse
• Never assess both carotid pulses
• Place the thumb between larynx and the anterior border of sternomastoid
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Large pulse volume
• Large pulse pressure : AR, anemia, thyrotoxicosis, pregnancy
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Pulsus paradoxus
• Exaggeration of normal decrease in pulse volume during inspiration
• Acute severe asthma, pericardial effusion
• Decrease in SBP > 15 mmhg with inspiration
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Pulsus alternans
• Beat to beat variation in pulse volume
• Advanced heart failure
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Slow rising pulse
• Aortic stenosis : gradual upstroke with decreased peak occurring late in systole
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Pulsus bisferiens
• Two systolic beats separated by a distinct mid-systolic dip
• Mixed aortic stenosis and regurgitation
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Jugular venous pulsation
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Carotid pulsation
• Medial to sternomastoid
• One peak
• Unaffected by posture
• Unaffected by respiration
• Better felt than seen
JVP
• Lateral to sternomastoid
• Wavy pulsation
• Prominent on lying down
• Decrease by inspiration
• Seen and not palpable
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EXAMINATION
• Position patient to lie down 45 degrees
• Identify JVP on the right side
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Inspection
1 Precordial bulge, funnel chest,
sterntomy scar
2 Apical impulse
3 Abnormal pulsations of precordium
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Apical impulse
*Normal:
• Position—the fifth left intercostal space midclavicular line range—2.0-2.5cm in diameter
• The most lateral and inferior palpable impulse
Inspection
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EPIGASTRIC PULSATION
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LEFT PARATERNAL PULSATION
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CARDIAC BASE PULSATION
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Palpation
1 Apical impulse and pulsation of precordium
2 Thrill
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APICAL PULSE
• Outermost lower most palpable impulse
• Located while patient lie flat
• If not felt. Turn patient to left side
• Count spaces starting from angle of Lewis
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Left Ventricular Hypertrophy
• APEX IN PLACE, FORCEFUL SUSTAINED (HEAVING APEX)
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Left Ventricular Dilatation
• APEX DISPLACED DOWN AND OUT
• FORCFUL NON SUSTAINED (HYPERDYNAMIC APEX)
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Right Ventricular Hypertrophy
• LEFT PARATERNAL PULSATION
• HEAVING
• LEFT PARASTERNAL UPLEFT
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TAPPING APEX
• OCCURS WITH MITRAL STENOSIS
• PALPABLE FIRST HEART SOUND
• APEX IN PLACE
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Epigastric pulsation
• RV
• Aortic
• Hepatic
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Cardiac base
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Thrill
• PALPABLE MURMUR
• SIMILAR TO MOBILE PHONE VIBRATING
• SAME AREAS LIKE VALVE
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Ausclutation
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Auscultation
• Heart sounds
• Murmurs
• Additional sounds
• Pericardial rub
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HEART SOUNDS
• FIRST HEART SOUND: CLOSURE OF MITRAL AND TRICUSPED VALVE
• ATTENUATED IN MR
• ACCENTUATED IN MS
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SECOND HEART SOUND
• CLOSURE OF AORTIC AND PULMONARY VALVE
• ACCENTUATED IN TACHCARDIA
• MUFFELED IN AR, AS
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MURMUR
• ABNORMAL SOUND CAUSED BY TURBULENT BLOOD FLOW ACROSS ABNORMAL VALVE
• TIMING (SYSTOLE/DIASTOLE) INTENSITY, RADIATION, THRILL, CHARCTER
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Mitral stenosis
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Mitral Regurge
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AORTIC STENOSIS
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AORTIC INCOMPETENCE