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- 1. Clinical skills II:Cardiovascular Examination Dr Leopold Bitunga Physician Internal Medicine/CHUK Lecturer of Medicine–UR /CMHS /Internal Medicine
- 2. Cardio vascular examination (CVS) CVShistory review Breathlessness • on exertion only (noting degree of exertion), at rest, if wakes at night (eg paroxysmal nocturnal dyspnoea, PND) • Duration, severity, precipitating factors, • orthopnoea, number of pillows used Pain in chest • onset - on exertion or at rest, or associated with activity, such as breathing or change in posture • character - sharp, crushing or “tight”
- 3. Cardio vascular examination (CVS) •Site • Radiation • Duration • Exacerbating and relieving factors (e.g. drugs such as GTN) • Accompanying sensations (e.g. breathlessness, vomiting, cold sweats, pallor, reflux, heartburn) • Precipitating factors - cold, heavy meal, emotion Oedema • Ankle swelling - time of day • Abdominal swelling - tightness of trousers or skirt
- 4. Cardio vascular examination (CVS) Palpitation •Patient conscious of irregularity or forcefulness of heart beat • Character of palpitation – patients may tap out the rhythm Dizziness • whether associated with change in posture, or palpitation • whether true vertigo • whether associated with collapse or loss of consciousness • Faints
- 5. Cardio vascular examination (CVS) Peripheralvascular symptoms • Intermittent claudication – pain in the calves or buttocks on exertion, relieved by rest. • Exercise limit, on flat ground and stairs • cold feet or hands – association with temperature, associated cyanosis, pain or dysasthesia (Raynaud’s phenomenon). • Rest pain – pain in muscles or feet
- 6. Cardio vascular examination (CVS) •PSH • REVIEW
- 7. Cardio vascular examination (CVS) CVSsequence EXAMINATION -Hand : color, nail( clubbing, splinter hemorrages),cyanosis - Pulse This refers to the radial pulse. Rate : count over 15 seconds period • Increased rate : tachycardia >100 • Decreased rate< 60/min : bradycardia • Normal : 60 -100 wide range of rate • Irregularity ( count in 30 seconds or 1 hour) radial pulse, heart rate at apex counted with stethoscope for 30 sec , the difference between the figure and radial pulse called pulse deficit
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- 9. Cardio vascular examination (CVS) Rhythm •Regular or irregular? • An increase in the pulse rate during inspiration and decrease during expiration is physiological and is called “sinus arrhythmia”, most marked in childhood. • Irregular ?? extra beats ( systole) • ECG : tachy , brady cardia
- 10. Cardio vascular examination (CVS) Volume •Depends on the output of the heart, on the state of the vessel walls and on the amount of peripheral vasoconstriction. It may be described as large, normal or small volume. Character • The pulse is “quick rising” when there is increased peripheral vasodilatation, e.g. in hyperthyroidism, fever, anaemia and after exercise. • most marked in severe aortic incompetence where the quick rise and fall give a rough indication of the degree of incompetence. The pulse in this condition is also called “waterhammer”, “collapsing” or “Corrigan” (after the physician who first described it). • It is of large volume and is best recognized by holding the anterior aspect of the patient’s wrist in the palm and elevating the patient’s arm. • In aortic stenosis the pulse is of small volume and is slow rising, sustained and slow falling.
- 11. Cardio vascular examination (CVS) Conditionof vessel wall • The vessel should be compressed to empty it of blood and rolled under the fingers. • It should be described as palpable or impalpable, hard or soft. This sign is difficult to ellicit and interpret. Blood Pressure • measured by a sphygmomanometer. Air should be released from the cuff slowly and steadily. • The tactile method of estimating systolic BP may be used to determine the level to which the cuff should be inflated, i.e. the level of BP at which the radial pulse disappears. • On auscultation over the brachial artery at the antecubital fossa, the first sound to be heard gives the systolic BP. • Further lowering elicits sounds becoming increasingly loud and this is followed by a sudden muffling (Phase 4), and disappearance (Phase 5). • The latter is taken to represent the diastolic level.
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- 13. Cardio vascular examination (CVS) Peripheralarteries • Palpate the main vessels - radial, brachial, carotid, femoral, popliteal, dorsalis pedis and posterior tibial - to get some idea of the integrity of the peripheral arterial tree. • The pulse should be readily palpable at all these sites in normal individuals. • Compare the volume of the radial and femoral pulses, especially in the investigation of hypertension (“radio-femoral delay”). • Auscultation over the carotid arteries, to identify a bruit, is indicated when the patient presents with symptoms suggestive of cerebral ischaemia.
- 14. Cardio vascular examination (CVS) Veins •The veins in the legs are examined to detect varicosities or for evidence of thrombosis. By far the most important sign involving the veins is the determination of the venous pressure in the neck. • Venous pressure • Inspection of neck veins is used to obtain evidence of raised venous pressure. • Seen on right internal jugular vein is used >>>direct continuation of the superior vena cava, and no valves. • The patient sitting in a semi- reclining position and the vein looked for along a line joining the angle of the jaw and the sternoclavicular joint. The neck must be positioned to relax the appropriate sternomastoid muscle. • During cvs disease details
- 15. Cardio vascular examination (CVS) •The internal jugular venous pressure is seen as a soft undulation and a double peak can often be identified. It is easily obliterated by finger pressure, unlike the carotid artery.. • Increased venous pressure is usually evidence of right-sided heart failure. Pressure over the abdomen may increase the degree of venous filling (hepatojugular reflux). Giant systolic (“V”) waves may be seen in tricuspid incompetence. Venous overfilling in the neck without pulsation occurs in superior vena cava obstruction.
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- 17. Cardio vascular examination (CVS) Oedema Cardiacoedema develops first in the dependent parts of the body. At lumbosacral area if the patient is in bed and at the ankles if the patient is ambulant. ‘pitting edema
- 18. Cardio vascular examination (CVS) EXAMOH HEART Consider the signs already Inspection • Deformity which might affect the position of the heart or affect its function e.g. pigeon chest, funnel chest, kyphoscoliosis. • Cardiac impulse is localised to a small area just inside the mid- clavicular line ,in the 4th or 5th intercostal spaces • Observe whether the impulse is localized or diffuse • Observe any abnormal movement of the chest wall, or of the sternum, coinciding with the heartbeat. • Observe any pulsation at the base of the heart • Pulsation in epigastrium due to right ventricle
- 19. Cardiovascular examination (CVS) Palpation Definethe apex beat the point on the chest wall furthest outwards and downwards where the cardiac impulse can be distinctly appreciated • Measure from midline – 4th or 5th space 3½” (7 cm) or less from the mid-line in adults with patient upright • The position of the apex moves with change of posture. • In disease the apex beat may be displaced by increase in size of the heart or by change in the lungs (collapse, pleural effusion, pneumothorax, fibrosis of lungs). -
- 20. Cardio vascular examination(CVS) Place the flat of the hand over the apex and then over the base. • The character of the impulse may be “localized” or “diffuse”, or no impulse may be detected; it may he “heaving”, “slapping” or accompanied by a series of vibrations (thrill). • Assessment of the trachea is essential to determine whether any deviation of the apex beat from its normal position is due to mediastinal shift. • Finally, with the flat of the hand, palpate also the left parasternal area in expiration to detect presence of right ventricular ‘heave”, which occurs in right ventricular hypertrophy
- 21. Cardio vascular examination(CVS) Percussion • The position and character of the apex beat is the best way of assessing cardiac size clinically. • Cardiac percussion is not performed. • Complete cvs , on lung bases
- 22. Cardio vascular examination(CVS) Auscultation Describe four standard areas for auscultation. 1. Mitral area - the apex of the heart; 2. Aortic area - the second right intercostal space; 3. Pulmonary area - the second left intercostal space; 4. Tricuspid area- the left lower sternal border.
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- 24. Cardio vascular examination(CVS) Auscultation: - Heart sounds - Murmurs - Frictions
- 25. Cardio vascular examination(CVS) Heart Sounds • Identify first and second heart sounds • Relating them to the carotid pulse or to the cardiac impulse at the apex. • Quality and intensity • Softened of 1st sound >>> impaired contractility of the heart • Loud and sharp in mitral stenosis • Second sound is accentuated at the aortic area in systemic hypertension and at the pulmonary area in pulmonary hypertension. • Both sounds may be muffled in the presence of obesity, emphysema or pericardial effusion. • 3rd sound is physiological for children and young adults and pathological in case of heart disease • 4TH sound • Details in cardiology including prosthetic sounds
- 26. Cardio vascular examination(CVS) Murmurs Additional to the heart sounds and result from turbulent blood flow. May arise where blood is forced through a narrowed valve orifice or regurgitates through a valve which is incompetent. Abnormal communications between the chambers of the heart or great arteries may also give rise to murmurs. In listening to and describing a murmur the following points must be noted: a) Timing: Systolic or diastolic. It is this which gives most trouble to students. Murmurs are best timed by placing their position with respect to the heart sounds: 1. Systole being the period between the first and second sound, 2. Diastole between second and first sound.
- 27. b) Position ofmaximum intensity – e.g. mitral or aortic area. c) Conduction or radiation: the direction in which the murmur is heard clearly – for example, to the carotids in aortic stenosis, to the axilla for mitral regurgitation. d) Intensity: faint, moderate, loud or very loud and may be graded in intensity. e) Quality or character: high-pitched or lowpitched, “rumbling”, “harsh” or “rough”, “blowing”, or “musical f) Change of murmur with posture and during the phases of respiration.
- 28. Cardio vascular examination (CVS) DiastolicMurmurs Diastolic heart murmurs are always pathological. At the apex • Mid diastolic murmur of mitral stenosis. Aortic area and left border of sternum • early diastolic murmur of aortic incompetence
- 29. Cardio vascular examination (CVS) SystolicMurmurs Mitral area • mitral incompetence or VSD • mid-systolic - aortic or pulmonary valve stenosis. Pulmonary area • A loud rough mid-systolic murmur accompanied by a thrill may indicate congenital pulmonary stenosis (rare0
- 31. References • GUIDE TOHISTORY TAKING AND EXAMINATION , www.ucl.ac.uk/pcph/undergrad/cbt/year4/history-a • Macleod's Clinical Examination 12th Edition. • Oxford American Handbook of Clinical Examination and Practical Skills • www.gla.ac.uk/media/media_363722_en.pdf
Editor's Notes
- #11 Note any variation in Systolic pressure between alternate beats (pulsus alternans)
- #14 This is a difficult sign to detect – essentially one is looking for the effect of changes in the diameter of a large vessel on the overlying tissues.
- #15 The vertical height of the venous column above the sternal angle (junction of the manubrium sterni with the sternal body at the level of the second costal cartilage) is measured and normally this is not greater than 3 cm
- #17 Heart Failure As well as increased venous pressure, other signs of heart failure should be looked for. In right heart failure an enlarged liver and dependent oedema may be found and if tricuspid regurgitation is present the liver may pulsate. Crepitations in the lungs are found in left heart failure and are often accompanied by dyspnoea. A gallop rhythm may be present.
- #18 Note also pulsation in epigastrium due to right ventricle, aorta, or rarely, pulsating liver. The presence and site of any surgical thoracotomy scars should be noted
- #19 It should lie within a vertical line drawn downwards from the centre of the clavicle (the mid-clavicular line)
- #22 Their names do not represent the surface markings of valves but indicate the areas on the chest wall at which sounds arising in the respective valves are best heard
- #25 Either sound may be split, for example in the presence of bundle-branch block. Splitting of the second sound at the pulmonary area normally increases during inspiration and is easily heard in children and young adults. Also in children and young adults, a third heart sound is often present and is physiological occurs during the early diastolic filling of the ventricles and is separated from the second sound by a definite gap A fourth heart sound coinciding with atrial systole is also a common cause of gallop rhythm and is often heard when the left ventricle is under strain as in hypertension or recent myocardial infarction. It occurs shortly before the first sound and is to be distinguished Pathological 3rd sound :. In the presence of heart disease a third heart sound may have pathological significance. It is a common finding in heart failure. Here the combination of an increased heart rate and a loud third sound gives rise to one form of “gallop rhythm
- #26 Sometimes murmurs, always systolic in time, may occur in the absence of any demonstrable structural lesion of the heart and are termed “functional”, “innocent” or “benign
- #27 The more inconstant a murmur, the less likely is it to be significant of structural damage. Sometimes murmurs of pathological importance may only be heard after exercise. Murmurs must be studied at the bed- side and the following incomplete account deals in summary form only with those which the student should aim to recognise early in his career
- #30 . Most systolic murmurs here and down the left side of the sternum are benign. • At the aortic area A loud, low-pitched, rough systolic murmur conducted into the neck (and sometimes accompanied by a thrill) suggests aortic stenosis. It is characteristically mid-systolic (ejection systolic). The second sound is often faint or absent. The pulse is of poor volume and slow rising character to an extent determined by the degree of stenosis. The same murmur is commonly heard in elderly patients who have aortic valve sclerosis without narrowing. This is not accompanied by narrow pulse pressure, low volume pulse or radiation of the murmur. • Friction Pericardial friction is distinguished by its superficial quality i.e. it sounds as if it were nearer to the ear than the heart sounds. It is to and fro and has a coarse “shuffling” quality. The patient should be asked to hold his breath – pericardial friction will not disappear but pleura-pericardial friction may disappear.