How to Examine the Heart and Blood Vessels
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Transcript of How to Examine the Heart and Blood Vessels
© Continuing Medical Implementation …...bridging the care gap
How to Examine the Heartand Blood Vessels
How to Examine the Heartand Blood Vessels
Joel Niznick MD FRCPC
© Continuing Medical Implementation …...bridging the care gap
© Continuing Medical Implementation …...bridging the care gap
© Continuing Medical Implementation …...bridging the care gap
Look at the patientLook at the patient
• Sick/well• Comfortable/in distress• Cyanosed/plethoric• Wet/dry• Young/old• Male/Female• Establish probabilities of disease
– History will have told you what to suspect
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Common Clinical Scenarios
Common Clinical Scenarios
• Younger people– Functional murmur
vs MVP vs bicuspid AV
• Older people– Aortic sclerosis vs
aortic stenosis
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ProbabilitiesProbabilities
• Males more commonly have aortic valve disease– Young – BAV
– Elderly - Degenerative
• Females more commonly have mitral valve disease
• MVP > rheumatic heart disease
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InspectInspect
• Facies/body habitus– Cyanosis– Xanthelasma– Arcus senilis– Conjunctival hemorrhages
• Syndromes– Marfan’s– Down’s
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HandsHands
• Clubbing• Capillary return• Digital ischaemia• Splinter hemorrhages• Osler’s nodes• Janeway lesions
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Blood pressureBlood pressure
• At rest 5”
• Both arms
• Legs if young hypertensive
3
RECOMMENDED BLOOD PRESSURERECOMMENDED BLOOD PRESSUREMEASUREMENT TECHNIQUEMEASUREMENT TECHNIQUE
2.• The cuff must be level with heart.
• If arm circumference exceeds 33 cm,a large cuff must be used.
• Place stethoscope diaphragm overbrachia l artery.
2.2.•• The cuff must be level with heart.The cuff must be level with heart.
•• If arm circumference exceeds 33 cm,If arm circumference exceeds 33 cm,a large cuff must be used.a large cuff must be used.
•• Place stethoscope diaphragm overPlace stethoscope diaphragm overbrachia l artery.brachia l artery.
1.• The patient should
be relaxed and thearm must besupported.
• Ensure no tightclothing constrictsthe arm.
1.1.•• The patient shouldThe patient should
be relaxed and thebe relaxed and thearm must bearm must besupported.supported.
•• Ensure no tightEnsure no tightclothing constrictsclothing constrictsthe arm.the arm.
3.• The column of
mercury must bevertical .
• Infla te to occlude thepulse. Deflate at 2 to3 mm/s. Measuresystolic (first sound)and diastolic(disappearance) tonearest 2 mm Hg.
3.3.•• The column ofThe column of
mercury must bemercury must bevertical .vertical .
•• Infla te to occlude theInfla te to occlude thepulse. Deflate at 2 topulse. Deflate at 2 to3 mm/s. Measure3 mm/s. Measuresystolic (first sound)systolic (first sound)and diastolicand diastolic(disappearance) to(disappearance) tonearest 2 mm Hg.nearest 2 mm Hg.
StethoscopeStethoscope
MercuryMercurymachinemachine
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Look at the FundiLook at the Fundi
OSU Interactive Physical Exam Guide
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Look at the FundiLook at the Fundi
• Disc
• Vessel
• Hemorrhages
• Exudates
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PulsesPulses
• Rate
• Rhythm
• Volume– Quincke’s– Water hammer– Brachio-radial delay
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CarotidCarotid
• Upstroke-normal/brisk/delayed/anacrotic
• Volume-normal/increased/decreased
• Auscultate:– Bruit– Murmur– S2 audible ? Over carotid?
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Carotid TutorialCarotid Tutorial
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JVPJVP
• Height
• Waveform
• Specific patterns
• Response to maneuvers– Inspiration– HJR
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JVP InspectionJVP Inspection
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JVP SummaryJVP Summary
• Confirm it’s the JVP you are seeing– Compressibility
– Waveform
– Manoeuvers
• Identify the height – start at 30o
• Identify the waveform
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If unable to see JVP-lie patient flatIf still unable to see JVP-sit patient upright
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Use the hand made rulerUse the hand made ruler
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Normal JVP WaveformNormal JVP Waveform
a c v
x
xy
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JVP InspectionJVP Inspection
• Look for descents not waves
• Descents are easier to see due to greater amplitude and frequency
• Time deepest descent with systole. This is the X’ descent
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Specific JVP patternsSpecific JVP patterns
Condition PatternNormal waveform X' deeper than Y
Post CABG X' shallower, now = Y
Atrial fibrillation CV wave
Tricuspid regurgitation CV wave
Complete heart block Irregular cannon A waves
Tamponade JVP brisk X' > Y
Constriction JVP brisk X' & Y descents
X' less exaggerated than Y
RV infarction JVP –low amplitude
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PrecordiumPrecordium
• Palpate: Aortic → Pulmonary → LSB → Apex → Left decubitus
• Thrills
• Palpable HS
• Lifts
• Apex: size/position/motion
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AuscultationAuscultation
• Follow same sequence
• Aortic → Pulmonary → LSB → Apex → Left decubitus → Upright lening forward
• Diaphragm except for apex (use both here)
• Identify HS, then extra sounds, them murmurs
• Dynamic maneuvers
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Palpation - Precordium Palpation - Precordium
Parasternal:
• Palpable P2-pulmonary HTN
• Thrill– VSD/HCM
• RV lift– RVH– Severe MR
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Palpation - ApexPalpation - Apex
Apex: • Palpable in 1 of 5 adults age 40• Best felt with fingertips or finger pads
Normal Location:• No more than 10 cm from mid-sternal line in the
supine position • Left decubitus position not reliable for apical locationNormal Size:• No larger than 3 cm (about 2 finger breadths)
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Sustained Apex: • correlates with pressure overload or LVF• ( > 2/3 systole-hangs out to S2)• AS, LVH or LV systolic dysfunctionHyperdynamic Apex:• correlates with volume overload AR/MR• palpable S4 (atrial kick)• palpable S1 (MS)• palpable non-ejection click (MVP)
Apex–Dynamic AbnormalitiesApex–Dynamic Abnormalities
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Apex–Dynamic AbnormalitiesApex–Dynamic Abnormalities
Atrial kick:
• Palpable S4– Loss of LV compliance– LVH 2o Hypertension– Aortic Stenosis– Hypertrophic Cardiomyopathy
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AuscultationAuscultation
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What are we listening for?What are we listening for?
Normal First & Second Sounds
Normal First & Second Sounds 2
Splitting of the Second Sound
Timing of Cardiac Sounds
Fourth Heart Sound S4 Gallop
Third Heart Sound S3
Systolic Murmurs
Diastolic Murmurs
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Common MurmursCommon Murmurs
Systolic Murmurs• Aortic stenosis• Mitral insufficiency• Mitral valve prolapse• Tricuspid insufficiency
Diastolic Murmurs• Aortic insufficiency• Mitral stenosis
S1 S2 S1
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Grading of Murmurs:Grade 1 - only a staff man can hear
Grade 2 - audible to a resident
Grade 3 - audible to a medical student
Grade 4 - associated with a thrill or palpable heart sound
Grade 5 - audible with the stethoscope partially off the chest
Grade 6 - audible at the bed-side
AuscultationAuscultation
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Characteristics of a “functional” murmurCharacteristics of a
“functional” murmur
• Short and soft SEM
• Normal S1 and S2
• Normal cardiac impulse
• No evidence for any hemodynamic abnormality
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Functional (Innocent) MurmursCommon in asymptomatic adults
Functional (Innocent) MurmursCommon in asymptomatic adults
• Characterized by– Grade I – II @ LSB
– Systolic ejection pattern - no with Valsalva/ upright
– Normal precordium, apex, S1
– Normal intensity & splitting of second sound (S2)
– No other abnormal sounds or murmurs
– No evidence of LVH
S1 S2
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Characteristic of the NOT Innocent Murmur
Characteristic of the NOT Innocent Murmur
• Diastolic murmur• Loud murmur - grade IV or above• Regurgitant murmur• Murmurs associated with a click• Murmurs associated with other signs or
symptoms e.g. cyanosis• Abnormal 2nd heart sound – fixed split,
paradoxical split or single
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Integrating Pulse with HS and Murmurs
Integrating Pulse with HS and Murmurs
www.blaufuss.org
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Examining the PeripheralPulses
Examining the PeripheralPulses
FemoralPopliteal
Posterior Tibial
Dorsal Pedis
Radial
Ulnar
Brachial
Retinal
Carotids
Renal
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Examination of PulsesExamination of Pulses
• Grading: – Normal/Increased/Decreased/Absent– 2+/3+/1+/0 – Allen’s test
• Trophic changes/Ulceration• Perfusion
– Pallor on elevation– Rubor on dependency– Venous refill with dependency (should be less than 30
seconds)
• Bruits
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Trophic Changes Trophic Changes
Shiny, hairless skin, dystrophic nail changes and
dependent rubor associated with
peripheral arterialocclusive disease of
the patient's right foot
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Pallor on elevationPallor on elevation
Rubor on dependency
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Digital IschaemiaGangrene
Digital IschaemiaGangrene
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A Practical Guide to Clinical Medicine - UCSD
A Practical Guide to Clinical Medicine - UCSD
Acute Arterial Insufficiency:
Mottled Appearance of Skin
Chronic Arterial Insufficiencywith Ulcers
http://medicine.ucsd.edu/clinicalmed/extremities.htm
© Continuing Medical Implementation …...bridging the care gap Hiatt W. N Engl J Med 2001;344:1608-1621
Measurement of the Ankle-Brachial Index (ABI)
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Venous AbnormalitiesVarices
Venous AbnormalitiesVarices
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Spider VeinsSpider Veins
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Venous InsufficiencyVenous Insufficiency
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Stasis Dermatitis/Ulceration Stasis Dermatitis/Ulceration
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EdemaEdema
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Cellulitis vs DVTCellulitis vs DVT
Right Deep Venous Thrombosis
Cellulitis
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© Continuing Medical Implementation …...bridging the care gap