1. Cardiovascular Examination Deling Zou Medical ppt http://hastaneciyiz.blogspot.com

2. Anatomy

4. Inspection 1 Precardial projection and excavation 2 Apical impulse 3 Abnormal pulsations of precardium

5. Inspection 1 Precardial projection and excavation 1) Precardial projection • congenital heart disease: tetralogy of Fallot • Valvular heart disease-- MS,PS • pericardial effusion (large , childhood)

6. The second right intercostal space(2nd ICS-RS) • aneurysm of aortic arch • dilatation of ascending aorta 2) flat chest 3) pigeon chest/funnel chest

7. Inspection 2 Apical impulse *Normal: • position—the fifth left intercostal space 0.5-1.0cm medial to the midclavicular line range—2.0-2.5cm in diameter

8. *Abnormal1) Location #diaphragm: • “transverse position” upper,outward • obesity ,child, pregnacy; • ascites; tumor of abdominal cavity • “vertical position” (thin, high, emphysema) inferior,inner

10. #mediastinum: • one side pleural effusion or pneumothorax—to the healthy side • one side atelectesis or pleural adhesion—to the affected

11. #enlargement of the heart • right ventricular dilatation –left or slightly upper • left ventricular dilatation—left inferior • LV &RV dilatation –left inferior (both side dilatation)

13. #Posture: • recumbent position—upper • left lateral position—to the left 2-3cm • right lateral position—to the right 1.0-2.5cm • Dextrocardia: 5-ICS—RS

14. Inspection- apical impulse - abnormal 2)Intensity and extent changes

15. Inspection -apical impulse - abnormal 3)Inward impulse: • apex excavation in the systole • seen: adhensive pericarditis prominent RV hypertrophy

16. Inspection • Abnomal pulsations of • percardium 1)left third-forth intercostal space lateral to the sternum(3,4ICS-LS) • seen: RV hypertrophy

17. 2)hypoxiphoid process seen: difference deep inspiration RV hypertrophy ↑ abdominal aorta (aneurysm)↓

18. 3)basal part of the heart • 2 ICS-LS: dilatation of the pulmonary artery or pulmonary hypertensin, occasionally healthy young man • 2 ICS-RS: aneurysm of aortic arch or dilatation of ascending aorta

19. Palpation 1 Apical impulse and pulsation of precardium 2 Thrill 3 Pericardial friction rub

20. Palpation 1 Apical impulse and pulsation of precardium • Exact position of apex • The beginning of systole of ventricle first sound • Heaving apex impulse: reliable of LV hypertrophy

21. 2 Thrill • One of characteristic signs of organic heart disease. • Mechanism : the flow of blood→narrowed orifice→vortices→ vibration→chest wall • thrill-high frequency murmurs-low frequency • Method:position,phase of cardiac cycle,clinical significance • seen: CHD or valvular stenosis , occasionally insurficiency

22. CHD:congenital heart disease

23. 3 Pericardil friction rub 1)Precardium-4th ICS-LS 2) both phases of the cardiac cycle 3) systolic period, sitting erect and leaning forward, the end of expiration 4)mechanism: rub of the visceral and parietal layers of pleura 5)seen:acute pericarditis

24. Percussion • Aim:to determine the size and shape of the heart . • Absolute dullness: contain no gas Relative dullness : real size

25. 1 murneuver of percussion • patient in erect position –the pleximeter is vertical with the intercostal space • patient in the recumbent position –the pleximeter is parallel with the intercostal space

26. 2 order : • left—right ; upwards ; inward • left margin : from 2-3 cm lateral to the apex beat up to the 2nd ICS • right margin : one intercostal space higher than the border of liver dullness up to the 2nd ICS • size: vertical distance from margin to the anterior midline

28. Percussion

29. Percussion

30. (2)The upper border –the lower border of the anterior end of the third rib↑ (3)The basal part —the second intercostal space upward left: aortic node and PA (4)Concave part –between the aorta and the left ventricle

31. Percussion 5 Changes in the area of cardiac dullness and its significance Cardiac factors : 1)LV enlargement: “boot shape” Seen:aortic valvular disease , hypertension heart disease

32. 2)RV enlargement :slightly↑--absolute dullness↑ Prominent↑--relative dullness↑ to the left side prominently Seen:PHD, MS 3)Two ventricle ↑: “generally enlarged heart” seen:DCM , Kashan cardiomyopathy

33. 4)LA and/or pulmonary artery:LA:concave part disappear LA+PA:2,3 ICS-LS outwards “pear shape” Seen: MS--- “mitrial type”

34. 5)pericardial effusion: enlargement of both sides of the border body’s position: • recumbent position：widening of base of the heart • erect position:“triangular shape”

35. 6)dilatation of the aorta /ascending aortic aneurysm: widening if the dull area of first and second intercostal space (with systolic pulsation)

36. Extacardial factors :1)large pleural effusions and pneumothorax → to the healthy side2)atelectasis /pleural pachynsis →to the affected3)a large amount of ascites or big abdominal tumor: diaphragm elevated→transverse position →left side enlargement

37. Ausclutation

38. 1 Ausclutatoty valve areas 1)ausclutatory mitral area: apical area2)ausclutatory pulmonary area:2 ICS-LS3)ausclutatory aortic area: 2 ICS-RS4)second ausclutatory aortic area: 3rd ICS-LS—Erb area5)tricuspid area :4,5 ICS-LS

40. 2 Order: MV---PV---AV1---AV2---TV 3 Contents:1) rate 2)rhythm 3)heart sound 4)extra heart sound 5)murmurs 6)pericardial friction sound

41. 1)heart rate: • 60~100bpm F＞M • child (＜3 years) ＞ 100bpm • tachycardia: normal adult ＞100bpm child(＜3 years) ＞150bpm • bradycardia: HR ＜60 bpm

42. Ausclutation heart rate:60-100bmp

43. 2)cardiac rhythm:*sinus arrythmia—affected by breath*premature beat: classification:atrial~ ventricular ~ • junctional ~ • frequently:＞6 bpm • occasionally: ＜6 bpm • bigeminy trigeminy

44. *atrial fibrillation: absolute irregular rhythm S1 intensity inequality Pulse deficitseen:MS,CHD,hyperthyroidism, PHD,DCM

45. Ausclutation atrial fibrillation

46. 3)cardiac sound

47. Ausclutation content cardiac sound • S1： • S2：

49. 4)Abnormal cardiac sound*Intensity: • position of the atrioventricular valve • Ventricular contractility and output • Valvular integrity and activity

50. S1: Accentuation: • MS • HR↑contractility↑ fever,anemia,hyperthyroidism • complete AVB →cannon sound