Physical Examination of Cardiovascular

Dr.Ira Andaningsih SpJP Cardiovascular Block 2008

Learning Objective
1. Examine the important surface topographic landmarks of the heart (inspection, palpation, percussion and auscultation). 2. Assessment of the blood pressure and its variation about the cardiovascular disease (orthotastic hypotension, coarct aorta, cardiac tamponade). 3. Assessment of the arterial pulse (a. radialis, a. brachialis, aorta abdominalis, a. femoralis, a. poplitea, a. carotis, a. dorsalis pedis).

Learning Objective
4. Assessment of the JVP and hepatojugular reflux. 5. Assessment of the peripheral edema (tibial). 6. Students should be able to identify the normal heart sound (S1, S2). 7. Students should be able to identify the abnormal heart sound (S1, S2, S3, S4, systolic clicks, diastolic opening snaps, murmurs).

Procedure

1. 2. 3. 4. 5. 6. 7. 8.

Inspection Measurement of blood pressure Arterial pulsation examination JVP examination and hepatojugular reflux Edema examination Percussion Palpation Auscultation

General Inspection
Clues for cardiac diagnosis: Is the patient in acute distress? What is the patients breathing like? Are accesory muscles being used? Are the patient pale? Is the patient cyanosis?

Inspection

Inspect the head and face Inspect the skin Inspect the eyes Inspect the mouth Inspect the neck Inspect the chest configuration Inspect the nails and extremities

Head and face

-

An earlobe crease in a relatively young person (CAD) A cyanotic lips, and slight jaundice due to hepatic congestion(RHD) Bobbing of the head coincident with each heart beat (severe aortic regurgitation)

Earlobe Creases

Head and face

Down syndrome is associated with congenital heart disease. Another diseases are associated with heart disease is : Marfans syndrome, Systemic Lupus Erythematosus, Cushing syndrome have characteristic that can be present in general appearance. High arched palate (MVP) Palatal ptechiae (infective endocarditis)

Skin

Cyanosis (central/peripheral?) Pallor Temperature: warmer(severe anemia, thyrotoxicosis),coolness and pain (claudicatio,occlusion) Xanthomata(tendon,eruptive) Rash(erythema marginatum) Ptechiae (infective endocarditis)

Xanthomata

Xanthomata

Eyes
1.
2.

3.

4.
5.

Xanthelasma ( CAD) Embolic retinal occlusions (rheumatic heart disease, atheroslerosis of the aorta or arch vessels). Papilledema ( malignant hypertension, cor pulmonale with severe hypoxia,patients with cyanosis and polycythemia). Arcus senilis (CAD) Hypertelorism(Pulmonary Stenosis,supravalvar aortic stenosis

Xanthelasma

Arcus Senilis

Papilledema

Neck and chest configuration

Webbing of the neck(Turners syndrome /coarctatio aorta or Noonans syndrome/ pulmonary stenosis) Distended Jugular veins (CHF) Visible cardiac motion ? Pectus Excavatum (Marfans syndr,MVP) Pectus carinatum (Marfans syndr)

Pectus Excavatum

Pectus Carinatum

Chest Configuration

Extremities
Nicotine staining of the fingers(CHD) Oslers nodes(infective endocarditis) Splinter hemorrhages(infective endocarditis) Abnormalities finger/toe:extra phalanges/toe (ASD)

Splinter Hemorrhages

Extremities
Long,slender fingers(Marfans syndrome/Aortic regurgitation). Quinckes sign:systolic flushing of the nailbeds, which can be readily detected by pressing a flashlight against the terminal digits( Aortic regurgitation).

Extremities

Clubbing of the fingers and toes(central cyanosis/congenital).It may also appear within a few weeks of the development of infective endocarditis. Edema of the extremities (CHF) Edema in only one leg(obstructive venous or lymphatic disease than to heart failure) Pain and cool in the extremities with cyanotic(arterial occlusion).

Clubbing Finger

Measurement of Blood Pressure

The principles: Direct (intra arterial catheter) Indirect (Sphigmomanometer) Korotkoff sounds 1-5. Determinant BP by palpation Determinant BP by auscultation

Assess BP by Palpation

Assess BP by Auscultation

Blood pressure

Rule out orthostatic hypotension Rule out Supravalvar Aortic Stenosis Rule out Coarctation of Aorta Rule out Cardiac Tamponade

Rule out Orthostatic Hypotension

1. Patient recumbent for at least 5 minute, measure the baseline BP and pulse 2. Patient standing and measure the BP and pulse 3. Orthostatic hypotension if: Systolic BP drop 20 mm Hg or more with development of symptom such as dizzyness or syncope(in most patients,also increase HR)

Rule out Supravalvular Aortic Stenosis

If BP in the right arm high, measure BP in the left arm (auscultatory ) Supravalvar Aortic Stenosis if: Hypertension in the right arm and Hypotension in the left arm

Rule out Coarctation of the Aorta

If the BP is elevated in the arm, measure BP in the lower extremities. Patient lie down on the abdomen ,the cuff is placed around the posterior aspect of the midthigh The stethoscope is placed over the popliteal fossa If wide cuff not available,place the reg.cuff in the distal border maleoli and stethoscope is placed over posterior tibial or dorsalis pedis artery. Coarc Aorta if BP in the leg is lower than in the arm

Rule out Cardiac Tamponade

Paradoxical pulse (pulsus paradoxus) Patient breathe as normal as possible Inflate cuff until no sounds are heard. Gradually deflate until soundsare heard in expiration only.Note this pressure. Continue deflate slowly untilsounds are heard during inspiration.Note this pressure AbN if difference 10 mmHg,N if 5 mmHg

Arterial Pulsation Examination

Determinant the cardiac rate Determinant the cardiac rhythm Palpation Carotid artery Palpation Radialis/Brachialis pulse Palpation Abdominal Aorta pulse Palpation Femoralis/Popliteal pulse Palpation Posterior Tibial/Dors.Pedis pulse

Determinant Cardiac Rate

Assessed by the radial pulse. The examiner stand in the front of the patient Grasp both radial arteries with the 2nd,3rd and 4th fingers. Count the pulse for 30 seconds x 2. If patient in irregular rhythm(AF) presents,patient has pulse deficit. Only assessment by auscultation on the heart can count the cardiac rate.

Technique evaluating Radial Pulse

Determinant cardiac rhythm

The ECG is the best method for diagnosing cardiac rhythm. Regular rhythm: regular on palpation Regularly irregular:irregularity in a definite pattern(premature beats, bigeminy) Irregularly irregular:has no pattern (Atrial Fibrillation).

Palpation Carotid Artery

Patient in the supine position,examiner in the right side Auscultate carotid artery for bruits first. If bruits presents do not palpate the artery,if the cholesterol plaque is present it can produce an embolus Place 2nd and 3rd fingers on the thyroid cartilage and slip them laterally between trachea and m.sternocleidomastoid

Technique Auscultation Carotid Artery

Technique Evaluating Carotid Artery Pulse

Technique Evaluating Carotid Artery Pulse

Palpation Carotid Artery

Palpation should be performed low in the neck to avoid pressure on carotid sinus (can cause drop in BP and HR) Each carotid artery is evaluated separately. Never press on both carotid artery in the same time.

Palpation Carotid Artery

Normal :Smooth, upstroke stepper more rapid than downstroke Diminished : Small, weak pulse (anacrotic) Increased:Large,strong,hiperkinetic (waterhammer) Double peaked pulse :Prominent percussion and dicrotic wave (bisferiens)

The Arterial Pulse

Palpation Brachialis pulse

The examiner use the thumbs to palpate. Can be felt medially under the tendon of the biceps muscle. Examiner standing in front of the patient simultaneously can be felt both brachial arteries.

Technique Palpation Brachialis Pulse

Palpation Abdominal Aorta

Performed by palpating deeply but gently into the mid abdomen. Presence of mass with laterally pulsatile suggest abdominal aneurysm. In thin individual normal pulsatile can be palpated.

Technique Auscultation Abdominal Aorta

Palpation Femoral Pulse

Patient in the supine position and examiner in the right side. The lateral corners of the pubic hair triangle are observed and palpated. Both femoral artery may be compared simultaneously. If one of the artery is diminished or absent auscultation for bruits is necessary. If presence indicate obstructive aortoiliofemoral disease.

Technique Palpation Femoral Pulse

Palpation Popliteal Pulse

Often difficult to assess. Each artery is evaluated separately. Patient in supine position Examiner hold the leg in a mild degree of flexion and places the thumbs on the patella and presses the remaining fingers of both hands in the fossa poplitea medial to lateral biceps femoris tendon Firm pressure is usually required to feel pulsation

Technique Palpation Popliteal Pulse

Palpation Dorsalis Pedis Pulse

Is best felt by dorsoflexion of the foot. Easily palpated in the grove between the extensor digitoum longus and hallucis longus tendon. May be felt simultaneously

Technique Palpation Dorsalis Pedis Pulse

Technique Palpation Posterior Tibial Pulse

Grading of Pulses

0 1 2 3 4

Absent Diminished Normal Increased Bounding

Jugular Venous Pulse

Provide information about the wave forms and the right atrial pressure. Pulsation internal jugular vein are beneath the sternocleidomastoid muscle. Only the right internal jugular vein is evaluated because its straighter than left. External jugular vein is easier to visualize but less accurate and should be not used.

Jugular Wave Forms

Patient lie flat without pillow so that the neck will not be flexed. The patients trunk at approximately 25 to the horizontal. The higher the venous pressure,the greater elevation will be required.The lower the venous pressure, the lower the elevation needed. Patients head turned slightly to the right and slightly down to relax the right sternocl.mastoid. With small flashlight shine the light to the neck.

Technique Evaluating Jugular Wave Forms

Jugular Wave Pressure Examination

The standard reference is manubriosterno angle/ angulus ludovici Determine the height of venous distension by noting the top of the wave forms in the int jug.venous pulsation. Imaginary horizontal line from this height to the sternal angle Measure the distance The angle of elevation of the head of the bed is also estimated.

Neck Vein Distention

JVP

At 45elevation,Jug.pulse is 7 cm above the sternal angle. At 45,upper limit of normal 4-5 cm above the sternal angle. At 30,upper limit of normal 6 cm. At supine position,normal if equal or lower than the sternal angle. At 90 when neck vein distended up to the jaw margin that the RA pressure is high(>15 mmHg)

Hepato Jugular Reflux Examination

Abdominal Compression Assessing high jugular venous pressure. Pressure over the liver can grossly assess RV function. Patient in supine position,mouth open and breathing normally Places the right hand over the liver (right upper quadran),apply a firm,progressive prssure. Compression is maintained for 10 seconds.

Hepato Jugular Reflux

Normal response: transient increase in distension during the first few cardiac cycles,followed by a fall to baseline level. RV failure : remained distended during the compression and falls rapidly(at least 4 cm) on sudden release. If test incorrect (patients mouth closed),a valsava maneuver will result inaccurate.

Edema Examination

Fingers are pressed into dependent area for 2-3 seconds. If pitting edema is present,the fingers will sink into the tissue and when removed,the impression of the fingers will remain. Usually quantified from 1+ to 4+ If 4+ is usually to the sacrum(bedridden patient)

Technique Evaluating Pitting Edema

Technique Evaluating Pitting Edema

Pitting Edema over the Sacrum

Landsmark of the Chest

Landsmark of the chest

Technique Percussion

Technique Percussion

Percussion of the heart

Performed at the 3rd ,4th ,and 5th intercostal space from the left anterior axillary line to the right anterior axillary line. Normal : A change in the percussion from resonance to dullness 6 cm lateral to the left of sternum.

Palpation

To evaluate the apical impuls For assessing localized motion For assessing generalized motion For assessing presence or absence of thrills

Point of Maximum Impulse

Most easily performed with sitting position Only the fingertips should be applied in the 5th intercostal space,midclavicular line If not felt,move in the area of cardiac apex. PMI usually within 10 cm of the midsternal line and no larger than 2-3 cm in diameter. If laterally or felt in 2 interspaces it is cardiomegaly.

Technique Assessing PMI

Assessing Localized Motion

Patient in supine position Use the fingertips to assess any localized motion The presence of a systolic impulse in 2nd intercostal space to the left of sternum is suspect Pulmonary Hypertension

Technique Assessing Localized Motion

Assessing Generalized Motion

Use the proximal portion of the hand to palpate for any large area motion,called heave or lift Palpates each of the 4 main cardiac area The 2nd impuls in the area of PMI is usually felt in association with S3. The use of an aplicator stick can be helpful to reinforce visually what has been palpated

Technique Assessing Generalized Motion

Technique Assessing Genaralized Motion

Assessing Thrills

The presence of thrills indicates a loud murmur. Use the head of metacarpal and applying very gentle pressure on the skin If too much pressure thrills will not be felt

Auscultation of the Heart

The bell of the stetoscope should be applied slightly to the skin For:low-pitched sounds (gallop, murmur of atrioventricular stenosis) The diaphragm of the stetoscope should be pressed tightly to the skin For: high-pitched sounds (valve closure,systolic event, regurgitant murmur)

Standard Auscultation Position

Supine Left lateral decubitus Upright Upright, leaning forward

Auscultation Position

Auscultation Cardiac Area