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Cardiovascular Examination. DAWIT AYELE (MD) INTERNIST. Dyspnea. Dyspnea an abnormally uncomfortable awareness of breathing that is easily differentiated from normal, quiet, unnoticed breathing heart failure, pulmonary edema, obstructive airway disease, and pulmonary embolism.

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cardiovascular examination

Cardiovascular Examination

DAWIT AYELE(MD) INTERNIST

dyspnea
Dyspnea

Dyspnea

  • an abnormally uncomfortable awareness of breathing that is easily differentiated from normal, quiet, unnoticed breathing
  • heart failure, pulmonary edema, obstructive airway disease, and pulmonary embolism.
  • Onset, precipitating factors, paroxysmal nature
orthopnea
Orthopnea
  • Dyspnea that occurs when the patient is lying down and improves upon sitting.
  • It is quantified according to the number of pillows on which the patient sleeps
paroxysmal nocturnal dyspnea
Paroxysmal Nocturnal Dyspnea
  • Describes episodes of sudden dyspnea and orthopnea that awakens the patient from sleep, usually 1 or 2 hours after going to bed. The patient typically sits up, or goes to a window for air. Wheezing and coughing may be associated
chest pain and discomfort
Chest pain and discomfort
  • Nature of the pain: squeezing, crushing etc.
  • Location
  • Radiation: to the jaw, left arm, hand etc.
  • Exacerbating and Alleviating Factors
palpitations
Palpitations
  • An unpleasant awareness of the heart beats.
  • Patients report it as: skipping beat, bounding beat, racing beat, stopping of the heart.
  • It may result from: irregularities, tachycardia, forceful beat, bradycardia, extra beats.
edema
Edema
  • Accumulation of excessive fluid in the body
  • An ascending type of body swelling is characteristic to cardiac problems.
cvp central venous pressure
CVP, central venous pressure
  • Pressure of the right atrium
  • Measured in cm of water
  • Use a column of blood in the jugular veins
  • We use blood to estimate this pressure
jugular venous pressure
Jugular Venous pressure
  • The internal jugular communicates directly with the right atrium
  • No venous or cardiac valves intervene
  • Act as a manometer of right atrial pressure
  • The external jugular vein is usually more readily visible as it passes over the sternomastoid muscle towards the mid-clavicle. It is easily kinked as it passes through the fascia of the neck and may give a false impression of right atrial pressure.
distinguishing the internal jugular from the carotid artery pulsation
Distinguishing the internal jugular from the carotid artery pulsation

JVP

  • No pulsations palpable
  • Pulsations obliterated by pressure above the clavicle
  • Level of pulse wave decreased on inspiration; increased on expiration.
  • Pulsation of the jugular vein will vary with position
  • Usually two pulsations per systole (x and y descents).
  • Prominent descents
  • Pulsations sometimes more prominent with abdominal pressure.

Carotid

  • Palpable pulsations
  • Pulsations not obliterated by pressure above the clavicle.
  • No effects of respiration on pulse.
  • No effect of position
  • One pulsation per systole
  • Descents not prominent.
  • No effect of abdominal pressure on pulsations.
technique for examination for cvp
Technique for examination for CVP
  • Position the patient reclining at an angle of 45°
  • Turn the head to the left, Neck should not be sharply flexed
  • Observe neck with a light falling obliquely across the neck
  • Identify the external jugular veins on each side
  • Then find the pulsations of the internal jugular veins
  • Observe for a double-complex waveform
technique
..technique
  • Identify the highest point of pulsation
  • With a centimeter ruler measure the vertical distance between this point and the sternal angle.
  • Measurements greater than 3 is abnormal
examination of the arterial system
Examination of the arterial system
  • Pulse
  • Blood pressure
  • The vessel itself
arterial pulses
Arterial Pulses

The presence and the volume of each pulse should be compared with the other side

Detected by gently compressing the vessel against firm structures, usually bones

The main peripheral arterial pulses that should be felt include: radial, brachial, carotid, femoral, popliteal, posterior tibial and dorsalis pedis.

arterial pulses1
Arterial Pulses
  • Heart rate: use the radial artery, count for 60 seconds, if the rhythm is irregular, auscultate
  • Rhythm: regular Vs irregular
    • If irregular: regularly irregular, irregularly irregular
  • Character: form of the wave (speed of upstroke and downstroke and summit)
pulse character
..pulse, character
    • Parvus et tarsus
    • Collapsing pulse (water hammer)
    • Pulsus paradoxus
  • Volume (amplitude): rough guide to pulse pressure and stroke volume
  • Delay: radio-femoral delay in coarctation of the aorta.
character
..character
  • Pulsus alternans—suspect acute or chronic reduction in left ventricular ejection fraction
  • Anacrotic pulse, delayed upstroke, —suspect aortic valve stenosis
  • Pulsus paradoxus—suspect tamponade, emphysema
blood pressure measurement
Blood pressure measurement
  • Patient should avoid smoking and caffeine for 30 min
  • Rest for at least 5 minutes
  • The arm should be resting and free of clothing
  • Position the hand so that the brachial artery is at the level of the heart
bp measurement
..BP measurement
  • Inflatable bladder over the arm. The lower border of the cuff should be 2.5cm above the antecubital crease
  • Inflate the cuff 30mmHg above the point at which radial pulse disappears
  • Put your stethoscope over the antecubital fossa and deflate the cuff slowly at a rate of 2-3 mmHg/sec
bp measurement1
…BP measurement
  • The level at which the Korotkoff are heard is the systolic pressure
  • The disappearance point is the diastolic pressure
  • Wait 2 or more minutes and repeat. Average your readings.
examination of the vessel
Examination of the vessel
  • Assess the rigidity and elasticity of the arteries
  • The thickness and firmness of the arterial walls are examined by rolling the vessel, usually the radial artery
  • Osler’s maneuver: elevate the cuff pressure to obliterate the radial pulse; if, after obliteration of the pulse, the radial artery is easily palpable and appears rigid then it is a positive Osler’s sign
inspection
INSPECTION
  • Stand on patient’s right
  • Better if patient is supine upper body 30o
  • Look for visible scar , vessel
  • Look at precordium active/quiet
  • Look for apical impulse:+/-visible-characterize
  • Look for extraprecordial pulsation(epigastric..)
palpation
PALPATION

Palpate heart sounds(valves):-press ball of the hand firmly on the chest

S1-Mitral-apex

-Tricuspid-left parasternal 4th INTERCOSTAL

S2-Aortic-rt parasternal 2nd INTERCOSTAL

-Pulmonic-lt parasternal 2nd INTERCOSTAL

  • Characterize apical impulse- may use finger tips& positioning- Location , diameter,amplitude , duration
  • Check for thrill(palpable m)/heave(hypertrophy)
auscultation
AUSCULTATION
  • Start at apex or base: Rt 2nd,lt 2nd 3rd,4th,5th
  • Use diaphragm-for high pitched S1 & S2(MR,AR),pericardial friction rub
  • Use bell-for low pitched-S3,S4,MS-(apex & along the lower sternal border)-apply it lightly
  • You may use maneuvers-sit pt. up, standing , squatting,exercise,lean forward, exhale completely, stop breathing or inhale deeply..
slide35

Characterize added sounds:

Murmur-Timing-systole/diastole/early, late, holo

-Shape-crescendo , decrescendo, plateau

-Location

-Radiation

-Transmission

-Intensity-grade 1-6

-Pitch-high,medium,low

-Quality-blowin,harsh,rumblin,musical

slide36

Gallop-S3,S4

  • Split sounds-S1,S2
  • Extrasystole/Irregularities/Pulse deficit…