Cardiovascular examination


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Structured examination of the cardiovascular system

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  • Cardiovascular system
    Chest pain
    Characteristics of the pain
    Where exactly
    Does it radiate
    Nature of pain....burning, stabbing, crushing, gripping?
    Precipitating factors
    Time course and relieving factors
    Associated features....nausea, vomiting, sweating, SOB....
    Lying flat (orthopnoea) many pillows do they use...LVF
    Paroxysmal nocturnal dyspnoea......Do they ever wake at night fighting for breath....LVF
    On minimal far can they walk...and what stops them....pain, breathlessness
    Ankle swelling...RVF
    Nausea and poor appetite due to bowel oedema
    Right upper quadrant discomfort due to hepatic congestion.
  • Lighting
    Seated and comfortable
    Stripped to the waist
    General Inspection
    General features
    Age, sex, general health
    Obese or skinny
    Position in they seem to need to sit up?
    Teeth....poor dental hygiene?
    Any obvious deformity
    Visible collateral veins
    Presence of scars.
  • Clubbing-
    Cardiovascular- infective endocarditis
    Respiratory- carcinoma of bronchus, fibrosing alveolitis
    Abdominal- crohns disease- unusual
    Splinter haemorrhages
    Infective endocarditis
    Oslers nodes and janeway lesions
    Infective endocarditis
  • Pulse
    Presence and symmetry
    Check both radial pulses together for asynchrony (aortic dissection, vasculitis)
    Irregularly irregular?
    Bounding pulse CO2 retention/LVF
    Small volume shock.
    Pulsus paradoxus
    Detectable increase in pulse volume is felt during expiration (cardiac tamponade or severe asthma)
    Pulsus alternans
    Alternate pulses are felt as strong or weak due to presence of bigeminy
    Requires considerable practice to feel waveforms!!
  • Due to anatomy of innominate veins best seen on right hand side

    Elevated in fluid overload
    Heart Failure
    Pulmonary embolism
    Pericardial effusion
    SVC obstruction
  • Position patient so that he is reclining comfortably until the waveform is clearly visible.
    Rest the patients head on a pillow to ensure that the neck muscles are relaxed
    Look across the neck from the right side of the patient. (due to anatomy of innominate veins)
    Identify the jugular vein pulsation
    Abdomino-jugular reflux- gently press over the abdomen for ten seconds. This increases venous return to the right side of the heart and the JVP normally rises
    Occlusion: the JVP waveform is obliterated by gently occluding the vein at the base of the neck with your fingers

    Can be raised in:
    Fluid overload- characteristically in heart failure
    Primarily a sign of right sided heart failure.
    Acute pulmonary embolism
  • Systole starts at the point of closure of the mitral valve and tricuspid valve(FIRST HEART SOUND) as the pressure in the left ventricle exceeds that in the left atrium.
    Contraction occurs before the pressure in the left ventricle exceeds that in the aorta....
    At which point the aortic valve opens and blood starts to flow into the aorta.
    Left ventricle relaxes....
    Aortic pressure exceeds that in the left ventricle and the aortic valve closes (SECOND HEART SOUND) and pulmonary valves
    The ventricle continues to relax until the pressure falls below that in the filled left atrium..
    The mitral valve opens to allow blood to flow into the left ventricle.
  • S1- ‘lub’ caused by closure of the mitral and tricuspid valves at the onset of ventricular systole and is best heard at the apex.

    S2- ‘dup’ caused by closure of the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge.
    Physiological splitting may occur at inspiration

    S3- ‘dum’ best heard with the bell. Normal in children, young adults and during pregnancy. Pathological after 40. common causes LVF and mitral regurg
  • Locate the apex beat
    Normally in the 5th left intercostal space, at or medial to the mid-clavicular line
    Normally briefly lifts the palpating fingers
    Palpate for thrills at the apex and both sides of the sternum
    Maybe absent in overweight or muscular people
    Maybe absent due to hyper-inflated chest as in asthma or emphysema.
    If you cannot feel it ask the patient to lay on his left side.
    Aortic – second right intercostal space
    Pulmonary- Second left intercostal space
    Aortic regurgitation may be louder here
    Tricuspid- fourth left intercostal space
    Especially for tricuspid regurgitation
    Mitral regurgitation and aortic stenosis are often louder here
    Mitral- fifth intercostal space mid calvicular line
    Mitral stenosis with bell.
    To elicit mitral stenosis roll patient into left lateral and listen with bell.
    Ask patient to sit up and lean forward. Listen over 2nd intercostal space and over left sternal edge with diaphragm for the murmur of aortic regurgitation.
  • Breathlessness
    Common with some degree of heart failure
    Accumulation of fluid in the alveoli occurs with left heart failure because increased left atrial end diastolic pressure leads to elevated pressure in the pulmonary veins and capillaries.
    Dyspnoea when lying flat
    Sign of advanced heart failure
    Lying flat increases venous return to the heart and in patients with a failing left ventricle may precipitate pulmonary venous congestion and pulmonary oedema
    Paroxysmal nocturnal dyspnoea
    Sudden breathless which wakes the patient from sleep choking or gasping for air.
    Gradual accumulation of fluid during sleep
    Patients may sit on edge of bed and open windows to get some air.

  • Ask about
    Onset and termination- abrupt or gradual
    Precipitating factors- exercise, alcohol, exercise, recreational or other drugs
    Frequency and duration of episodes-
    Character of the rhythm- ask them to tap it out.

  • Syncope and dizziness
    Postural hypotension
    Commonly caused by hypovoleamia, antihypertensive drugs, especially diuretics and vasodilators
    Neurocardiogenic syncope
    Occurs in healthy people who have been forced to stand for a long time or subject to painful or emotional stimuli.
    Results from abnormal autonomic reflexes and bradycardia and/or vasodilatation
    SVT’s rarely cause syncope
    Most common cause is bradyarrythmia due to sick sinus syndrome, or atrioventricular block
    Drugs including digoxin, beta blockers and rate limiting calcium channel blockers may aggravate attacks.
    Mechanical obstruction to cardiac output.
    Severe aortic stenosis and cardiomyopathy can obstruct left ventricular outflow.

  • Angina
    Precipitated by exertion
    Eased by rest and/or GTN
    Myocardial infarction
    More severe
    Persists at rest
    Pericarditic pain
    Sharp, raw or stabbing
    Varies with movement or breathing
    Severe tearing
    Sudden onset radiates to the back
  • Site
    Angina/Myocardial Infarction
    Felt in centre of chest, radiates out
    Retrosternal or epigastric. Can radiate out.
    Between shoulder blades and behind sternum
    Sudden or gradual
    Crushing, gripping, like a band across my chest, dull ache
    Associated symptoms
    Nausea (very common in MI)
    Angina pain tends to be short lived
    MI pain lasts fro 20 mins or more
    Exacerbating or relieving factors
    Rest may relive angina
    Will not relieve MI
  • Cardiovascular examination

    1. 1. Cardiovascular Examination Jonathan Downham Advanced Nurse Practitioner 2008
    2. 2. Cardiovascular Examination • Cardiovascular system – Chest pain – Breathlessness – Ankle swelling – Fatigue
    3. 3. Cardiovascular Examination • Lighting • Lying and comfortable • Stripped to the waist • General inspection – General features – Eyes – Face – Praecordium – Ankles
    4. 4. Cardiovascular Examination Clubbing Splinter Haemorrhages Oslers nodes Janeway lesions Hands
    5. 5. Cardiovascular Examination • Pulses • Carotid, radial, femoral, brachial, popliteal, posterior tibial, dorsalis pedis. – Presence and symmetry – Rate – Rhythm – Volume – Character
    6. 6. Cardiovascular Examination • Jugular venous pressure (JVP) •JVP reflects central venous or right atrial pressure. •Normally 9cmH2O •Sternal angle approx 5cm above right atrium. •Normal JVP should be about 4cm above this angle when patient is at 45 degrees
    7. 7. Cardiovascular Examination Jonathan Downham 2010
    8. 8. Cardiovascular Examination
    9. 9. Cardiovascular Examination • Systematic – Time what you hear with the patients pulse. – First heart sound (precedes peripheral pulse) – Second heart sound (after pulse is felt) – Murmers during systole – The absence of silence during diastole – Any extra sounds.
    10. 10. Cardiovascular Examination • Normal Heart Sounds
    11. 11. Cardiovascular Examination • The Precordium This is the area on the front of the chest that relates to the surface anatomy of the heart. Inspect the precordium with the patient sitting at 45 degree angle with shoulders horizontal.
    12. 12. Cardiovascular Examination Locate the apex beat
    13. 13. Cardiovascular Examination • Heave – A palpable impulse that lifts your hand noticeably • Right ventricular hypertrophy • Thrills – Feel like a ringing phone or a fly trapped in ones hand • Aortic stenosis • Palpable first heart sounds – Mitral stenosis.
    14. 14. Cardiovascular Examination Aortic Pulmonary TricuspidMitral
    15. 15. Cardiovascular Examination • Abnormal Heart Sounds – Aortic Stenosis •Timing- ejection systolic murmur •Location- loudest over 2nd right intercostal space •Character- harsh, saw like. •Thrill- often present.
    16. 16. Cardiovascular Examination • Abnormal heart sounds – Aortic Regurgitation •Timing- early diastolic •Location- left or right 2-4th intercostal space •Character- quiet, blowing •Use diaphragm with patient leaning forward.
    17. 17. Cardiovascular Examination • Abnormal heart sounds – Mitral stenosis •Timing- mid diastolic. May be preceded by opening snap. •Location- apex •Character- low pitched rumbling •Listen for mitral stenosis with lightly applied bell and patient in left lateral position
    18. 18. Cardiovascular Examination • Abnormal heart sounds – Mitral regurgitation •Timing- pansystolic •Location- loudest at the apex
    19. 19. Cardiovascular Examination
    20. 20. Cardiovascular Examination • Assess aorta for size and shape • Listen for bruits (whooshing sound) • Listen over renal arteries for the same. • Assess pulses: – Popliteal – Posterior tibial – Dorsalis pedis.
    21. 21. Cardiovascular Examination • Common Cardiovascular problems – Breathlessness • Common with some degree of heart failure • Orthopnoea – Dyspnoea when lying flat – Sign of advanced heart failure • Paroxysmal nocturnal dyspnoea – Sudden breathless which wakes the patient from sleep choking or gasping for air.
    22. 22. Cardiovascular Examination • Common Cardiovascular problems – Palpitations • An unexpected awareness of the heart beating • Most patients do not have a sustained arrhythmia • Those that do often do not experience palpitations. • Ask about – Onset and termination – Precipitating factors – Frequency and duration of episodes – Character of the rhythm
    23. 23. Cardiovascular Examination • Common Cardiovascular problems – Syncope and dizziness • Postural hypotension • Neurocardiogenic syncope • Arrhythmias • Mechanical obstruction to cardiac output.
    24. 24. Cardiovascular Examination Chest Pain •Causes •Oesophageal spasm •Pneumothorax •Musculoskeletal •Angina •Myocardial Infarction •Pericarditic Pain •Aortic Pain
    25. 25. Cardiovascular Examination Chest Pain •SOCRATES •Site •Onset •Character •Radiation •Associated symptoms •Timing •Exacerbating or relieving factors •Severity
    26. 26. Cardiovascular Examination Chest Pain Watching the patient describing the character of the pain is helpful •A clenched fist on the chest is worrying •A single pointed finger is less worrying Take time to tease out the history •Chest pain causes anxiety in patients and this may cloud genuine/significant pathology •Do not increase anxiety by performing unnecessary investigations. If in doubt: MONA.