Physical examination of cvs

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Physical examination of cvs

  1. 1. APPROCH TO CARDIOVASCULAREXAMINATION04/03/2011 menbit@ymail.com 1
  2. 2. LEARNING OBJECTIVESOn completion of the course students will be ableto: explain common symptoms of cardiac disease conduct a step -wise approach in cardiovascularexamination identify the normal and abnormal cardiac findings interpret cardiac findings04/03/2011 menbit@ymail.com 2
  3. 3. INTRODUCTION: OVER VIEW OF CARDIACANATOMYThe right ventricle occupies most of the anteriorcardiac surface.The inferior border of the right ventricle lies belowthe junction of the sternum and the xiphoidprocess.The right ventricle narrows superiorly and meetsthe pulmonary artery at the level of the base of theheart.The left ventricle, behind the right ventricle and tothe left, forms the left lateral margin of the heart.04/03/2011 menbit@ymail.com 3
  4. 4. Point of maximum impulse is located in the leftborder of the heart. is usually found in the 5th interspaces 7 cm to 9cm lateral to the midsternal line. it is about 1 to 2.5 cm in diameter.right atrium of the heart is found anteriorly andaccessible for physical examination.The left atrium of the heart is mostly posteriorand cannot be examined directly.Circulation through the heart includes the cardiacchambers, valves, blood, blood vessels.04/03/2011 menbit@ymail.com 4
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  7. 7. Because of their positions, the tricuspid and mitralvalves are called atrioventricular valves.The aortic and pulmonic valves are called semilunarvalves because each of their leaflets is shaped like ahalf moon.As the heart valves close, the heart sounds arisefrom vibrations emanating from the leaflets, theadjacent cardiac structures, and the flow of blood.Systole is the period of ventricular contraction.During systole Pressure in the left ventricle risesfrom less than 5 mm Hg in its resting state to anormal peak of 120 mm Hg.04/03/2011 menbit@ymail.com 7
  8. 8. Diastole is the period of ventricular relaxation.During diastole ventricular pressure falls further tobelow 5 mm Hg, and blood flows from atrium toventricle.The mitral valve is closed, preventing blood fromregurgitating back into the left atrium.during diastole the aortic valve is closed, preventingregurgitation of blood from the aorta back into theleft ventricle.Closure of the atrioventricular valves produce thefirst heart sound, S1.Closure of the semilunar valves produce the secondheart sound, S2.04/03/2011 menbit@ymail.com 8
  9. 9. SPLITTING OF HEART SOUNDSRight ventricular and pulmonary arterial pressuresare significantly lower than corresponding pressureson the left side.right-sided events usually occur slightly later thanthose on the left.So instead of a single heart sound, you may heartwo discernible components, the first from left-sided aortic valve closure, or A2, and the secondfrom right-sided closure of the plutonic valve, or P2.Consider the second heart sound and its twocomponents, A2 and P2, which come from closureof the aortic and pulmonic valves respectively.04/03/2011 menbit@ymail.com 9
  10. 10. During expiration, these two components arefused into a single sound, S2. During inspiration, however, A2 and P2 separateslightly, and S2 may split into its two audiblecomponents.Current explanations of inspiratory splitting citeincreased capacitance in the pulmonary vascularbed during inspiration, which prolongs ejection ofblood from the right ventricle, delaying closure ofthe pulmonic valve, or P2.04/03/2011 menbit@ymail.com 10
  11. 11. SPLITING OF HEART SOUNDS04/03/2011 menbit@ymail.com 11
  12. 12. Of the two components of the second heartsound, A2 is normally louder, reflecting the highpressure in the aorta.It is heard throughout the precordium.P2, in contrast, is relatively soft, reflecting the lowerpressure in the pulmonary artery. It is heard best in its own area—the 2nd and 3rdleft interspaces close to the sternum. It is here thatyou should search for splitting of the second heartsound.04/03/2011 menbit@ymail.com 12
  13. 13. CON…S1 also has two components, an earlier mitral anda later tricuspid sound.The mitral sound, its principal component, is muchlouder, again reflecting the high pressures on the leftside of the heart.It can be heard throughout the precordium and isloudest at the cardiac apex.The softer tricuspid component is heard best at thelower left sternal border, and it is here that you mayhear a split S1.The earlier louder mitral component may mask thetricuspid sound, however, and splitting is not alwaysdetectable. Splitting of S1 does not vary withrespiration.04/03/2011 menbit@ymail.com 13
  14. 14. SPECIFIC SITES OF HEART SOUNDS04/03/2011 menbit@ymail.com 14
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  18. 18. Common symptomsDyspnea:is a state of shortness of breath on exertion and /or restis graded based on the New York Heart AssociationClass (NHAC):Class I: No limitation of physical activity .No symptomswith ordinary exertionClass II: Slight limitation of physical activity Ordinaryactivity causes symptomsClass III: Marked limitation of physical activity less thanordinary activity causes symptoms . Asymptomatic atrest.Class IV: Inability to carry out any physical activitywithout discomfort .Symptomatic at rest.04/03/2011 menbit@ymail.com 18
  19. 19. Paroxysmal Nocturnal Dyspneashortness of breath that occurs during sleepOrthopneaShortness of breath that occurs during recumbentpositionPalpitationsubjective unpleasant perception of one’s own heartbeat.SyncopeSudden episode of faintingChest painBody swellingCough04/03/2011 menbit@ymail.com 19
  20. 20. Peripheral symptoms1. Symptoms of Arterial occlusion: pain, loss of function, altered cutaneoussensation, gangrene, pain around calf muscle onwalking which gets relieved with rest2. Symptoms of Venous insufficiency:Swelling and pain of the affected body area.04/03/2011 menbit@ymail.com 20
  21. 21. PHYSICAL EXAMINATIONComponents:PERIPHERAL MANIFESTATIONARTERIAL PULSESBLOOD PRESSURE JUGULAR VENOUS PRESSURETHE CAROTID PULSE FIRST AND SECOND HEART SOUNDS, S1 AND S2OTHER EXTRA HEART SOUNDS SUCH AS S3 OR S4.CARDIAC MURMURS.04/03/2011 menbit@ymail.com 21
  22. 22. 1. Peripheral manifestationObserve the following general conditions :I. FaceMalar flush (thin face, purple cheeks) may be foundin mitral stenosis. Lips for (cyanosis).II. EyesPallor of the conjunctiva ,palms and nail bed indicatesanemia.04/03/2011 menbit@ymail.com 22
  23. 23. III. HandsClubbing of fingers : Cyanotic congenital heartdisease, Infective endocarditisPeripheral cyanosisSplinter hemorrhages: - vertical linear hemorrhagesbeneath the nails.Oslers nodes: - Tender lumps in pulp of fingertips whichmay be found in endocarditisJane way lesions:- are painless red macules on the wristand palm which may be seen in patients with acuteinfective endocarditis.04/03/2011 menbit@ymail.com 23
  24. 24. 2. JUGULAR VENOUS PRESSURE (JVP):-Systemic venous pressure is much lower than arterialpressure because: much of the force of ventricular contraction is dissipated asblood passes through the arterial tree and the capillary bed. Walls of veins contain less smooth muscle, which reducesvenous vascular tone and makes veins more distensible. blood volume and the capacity of the right heart to ejectblood into the pulmonary arterial system.Cardiac disease may alter these variables, producingabnormalities in central venous pressure. For example, venous pressure falls when left ventricularoutput or blood volume is significantly reduced it rises when the right heart fails or when increased pressurein the pericardial sac impedes the return of blood to the rightatrium.04/03/2011 menbit@ymail.com 24
  25. 25. • These venous pressure changes are reflected in theheight of the venous column of blood in the internaljugular veins, termed the jugular venous pressure.• Pressure in the jugular veins reflects right atrialpressure, giving clinicians an important clinical indicatorof cardiac function and right heart hemodynamics.• The JVP is best estimated from the internal jugular vein,usually on the right side, since the right internal jugularvein has a more direct anatomic channel into the rightatrium.• The internal jugular veins lie deep to the sternomastoidmuscles in the neck and are not directly visible.• carefully distinguish these venous pulsations frompulsations of the carotid artery.04/03/2011 menbit@ymail.com 25
  26. 26. INTERNAL JAGULAR VEIN04/03/2011 menbit@ymail.com 26
  27. 27. STEPSRaise the head of the bed or examining table toabout 30°.Raise the head slightly on a pillow to relax thesternomastoid muscles.Turn the patient’s head slightly away from the sideyou are inspecting.Use tangential lighting and examine both sides ofthe neck and find the internal jugular venouspulsations.04/03/2011 menbit@ymail.com 27
  28. 28. Look for pulsations in the suprasternalnotch, between the attachments of thesternomastoid muscle on the sternum andclavicle, or just posterior to the sternomastoid.Identify the highest point of pulsation in the rightinternal jugular vein.Extend a long rectangular object or cardhorizontally from this point and a centimeter rulervertically from the sternal angle, making an exactright angle.Measure the vertical distance in centimeters abovethe sternal angle where the horizontal objectcrosses the ruler.04/03/2011 menbit@ymail.com 28
  29. 29. JVP INSPECTION04/03/2011 menbit@ymail.com 29
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  32. 32. This distance, measured in centimeters above thesternal angle or the atrium, is the JVP.normally Level of sternal angle is about 5 cm abovethe level of mid right atrium and JVP is less than 8 cmabove right atrium.Venous pressure measured at greater than 3 cmabove the sternal angle, or more than 8 cm in totaldistance above the right atrium, is consideredelevated above normal. Increased pressure suggests right sided heart failure, constrictive pericarditis, tricuspid stenosis, orsuperior vena cava obstruction.Unilateral distention of the external jugular vein isusually due to local kinking or obstruction.Occasionally, even bilateral distention has a localcause.04/03/2011 menbit@ymail.com 32
  33. 33. IJV VS CAROTID ARTERY PULSATIONINTERNAL JUGULAR VEINPULSATIONSRarely palpableSoft, rapid,Pulsations eliminated by lightpressureLevel of the pulsationschanges withposition, dropping as thepatient becomes moreupright.Level of the pulsations usuallydescends with inspiration.CAROTID ARTERY PULSATIONSPalpableA more vigorous thrust with asingle outward componentPulsations not eliminated bypressureLevel of the pulsationsunchanged by positionLevel of the pulsations notaffected by inspiration04/03/2011 menbit@ymail.com 33
  34. 34. 3. THE CAROTID PULSEprovides valuable info.useful for detecting stenosis or insufficiency of theaortic valve.pt. lay down with the head of the bed still elevatedto about 30°.Then place your left index and middle fingers on theright carotid artery in the lower third of theneck, press posteriorly, and feel for pulsation.Never press both carotids at the same time. Thismay decrease blood flow to the brain and inducesyncope.04/03/2011 menbit@ymail.com 34
  35. 35. CAROTID ARTERY PALPATION04/03/2011 menbit@ymail.com 35
  36. 36.  ASSESS:I. amplitudeThis correlate reasonably well with the pulsepressure.Small, thready, or weak pulse in cardiogenic shock;bounding pulse in aortic insufficiency.II. contour of the pulse wave, namely the speed of theupstroke, the duration of its summit, and the speedof the down stroke.The normal upstroke is smooth, rapid, and followsS1 almost immediately.The down stroke is less abrupt than the upstroke.Delayed carotid upstroke occurs in aortic stenosis04/03/2011 menbit@ymail.com 36
  37. 37. III. BRUITS.Detect thrills, that feel like the throat of a purring cat. in the presence of a thrill, you should listen over bothcarotid arteries with the diaphragm of yourstethoscope for a bruit, a murmur-like sound ofvascular rather than cardiac origin.Ask the patient to hold breathing for a moment so thatbreath sounds do not obscure the vascular sound.A carotid bruit with or without a thrill in a middle-agedor older person suggests but does not prove arterialnarrowing.Note: An aortic murmur may radiate to the carotidartery and sound like a bruit04/03/2011 menbit@ymail.com 37
  38. 38. 4. HERATPositions used:1. Supine, with the head elevated 30°Inspect and palpate the precordium:the 2nd interspaces; the right ventricle; the left ventricle,the apical impulse (diameter, location, amplitude,duration).2. Left lateral decubitusPalpate the apical impulse if not previously detected.Listen at the apex with the bell of the stethoscope.Used for Low-pitched extra sounds (S 3, opening snap,diastolic rumble of mitral stenosis)04/03/2011 menbit@ymail.com 38
  39. 39. Con…3. Sitting, leaning forward, after full exhalationListen along the left sternal border and at theapex.Soft decrescendo diastolic murmur of aorticinsufficiency.04/03/2011 menbit@ymail.com 39
  40. 40. INSPECTION AND PALPATIONLook at PMI. , aortic area , pulmonic area, and leftventricular area. the ventricular movements of a left-sided S3 or S4.Then Palpate all the above areas .Begin with general palpation of the chest wall.First palpate for impulses using your fingerpads.Hold them flat on the body surface, using lightpressure for an S3 or S4, and firmer pressure for S1and S2.Ventricular impulses may heave or lift your fingers.04/03/2011 menbit@ymail.com 40
  41. 41. PALPATION TECHNIQUE04/03/2011 menbit@ymail.com 41
  42. 42. Thrills may accompany loud, harsh, or echoingmurmurs as in:aortic stenosispatent ductus arteriosusventricular septal defect, andless commonly, mitral stenosis.They are palpated more easily in patient positionsthat accentuate the murmur.at normal sized individual, s2,s3,s4,opening snap ,systolic ejection click are not appreciated throughinspection and palpationA palpable S2 suggests systemic hypertension.04/03/2011 menbit@ymail.com 42
  43. 43. AREAS OF PALPATION AND INSPECTION04/03/2011 menbit@ymail.com 43
  44. 44. Apical impulse characteristicsI. LOCATION.Located usually in 5th interspaces 7-9 cm from the mid sternallinethe apical impulse may be displaced upward and to the left bypregnancy or a high left diaphragm.Lateral displacement from cardiac enlargement in congestiveheart failure, cardiomyopathy, and ischemic heart disease.Displacement in deformities of the thorax and mediastinalshift.II. DIAMETER.In the supine patient, it usually measures less than 2.5 cm andoccupies only one interspace.Note: In the left lateral decubitus position, a diameter greaterthan 3 cm indicates left ventricular enlargement04/03/2011 menbit@ymail.com 44
  45. 45. III. AMPLITUDE. Estimate the amplitude of the impulse.It is usually small and feels brisk and tapping.Increased amplitude may also reflect hyperthyroidism, severeanemia, pressure overload of the left ventricle (e.g., aorticstenosis), or volume overload of the left ventricle (e.g., mitralregurgitation)IV. DURATION.To assess duration, listen to the heart sounds as you feel theapical impulse.Normally it lasts through the first two thirds of systole, andoften less.NOTE: A sustained, high-amplitude impulse that is normallylocated suggests left ventricular hypertrophy from pressureoverload (as in hypertension).A sustained low-amplitude (hypokinetic) impulse may indicatedilated cardiomyopathy.04/03/2011 menbit@ymail.com 45
  46. 46. AMPLITUDE AND DURATIONNORMAL VS HYPERKINETIC NORMAL VS SUSTAINED04/03/2011 menbit@ymail.com 46
  47. 47. PERCUSSIONIn most cases, palpation has replaced percussion inthe estimation of cardiac size.But When you cannot feel the apicalimpulse, percussion may suggest where to searchfor it.percuss from resonance toward cardiac dullness inthe 3rd, 4th, 5th, and possibly 6th interspaces.NOTE:A markedly dilated failing heart may have ahypokinetic apical impulse that is displaced far tothe left. A large pericardial effusion may make the impulseundetectable04/03/2011 menbit@ymail.com 47
  48. 48. AUSCULTATIONAUSCULTTATION TIPSThe diaphragm is better for picking up the relativelyhigh-pitched sounds of S1 and S2, the murmurs ofaortic and mitral regurgitation, and pericardial frictionrubs.Listen throughout the precordium with the diaphragm,pressing it firmly against the chest. The bell is more sensitive to the low-pitched sounds ofS3 and S4 and the murmur of mitral stenosis.Apply the bell lightly, with just enough pressure toproduce an air seal with its full rim.Low-pitched sounds such as S3 and S4 may disappearwith high pressure.04/03/2011 menbit@ymail.com 48
  49. 49. Ask the patient to roll partly onto the left side intothe left lateral decubitus position, bringing the leftventricle close to the chest wallThis position accentuates or brings out a left-sidedS3 and S4 and mitral murmurs, especially mitralstenosis. You may otherwise miss them.04/03/2011 menbit@ymail.com 49
  50. 50. Ask the patient to sit up, lean forward, exhalecompletely, and stop breathing in expiration.This position accentuates or brings out aorticmurmurs resulted from aortic regurgitation.04/03/2011 menbit@ymail.com 50
  51. 51. HEART MURMURS.Are abnormal heart soundsare longer than heart sounds created by :Restricted forward flow Of blood through stenoticvalve.Backward Flow of blood through regurgitant valveAbnormal opening in heart chambersOver flow of blood through normal valves innocently with any detectable cardiac structureabnormality.04/03/2011 menbit@ymail.com 51
  52. 52. GENERAL CLASSIFICATIONI. INNOCENT murmur with no detectable physiologic disorderII. PHYSIOLOGICrelated to demand supply disharmonization (overflow) e.g. anemia, pregnancy ,fever etc.III. PATHOLOGIC as aresult of tangible cardiac disorder .e.g. valvularlesions04/03/2011 menbit@ymail.com 52
  53. 53. CHARACTERISTIC OF MUMURSALL MURMURS ARE DESCRIBED AS FOLLOWS:TIMINGSHAPEQUALITYLOCATIONRADIATIONPITCH04/03/2011 menbit@ymail.com 53
  54. 54. 1. TIMINGa systolic murmur, falling between S1 and S2, or adiastolic murmur, falling between S2 and S1.Murmurs that coincide with the carotid upstrokeare systolic.Classified as:systolic,diastolic,continuous04/03/2011 menbit@ymail.com 54
  55. 55. SYSTOLIC MURMURSI. A midsystolic murmurBegins after S1 and stops before S2.most often related to blood flow across the stenoticsemilunar (aortic and pulmonic) valves.II. A pansystolic (holosystolic) murmurStarts with S1 and stops at S2, without a gap betweenmurmur and heart sounds.often occur with regurgitant (backward) flow across theatrioventricular valves.III. A late systolic murmurStarts in mid- or late systole and persists up to S2This is the murmur of mitral valve prolapse.04/03/2011 menbit@ymail.com 55
  56. 56. DIASTOLIC MURMURSI. An early diastolic murmurStarts right after S2, without a discernible gap, andthen usually fades into silence before the next S1.related to incompetent semilunar valves.II. A middiastolic murmurStarts a short time after S2.Related to turbulent flow of blood across theatrioventricular valves.III. A late diastolic (presystolic) murmurStarts late in diastole and typically continues up to S1.Related to turbulent flow of blood across theatrioventricular valves.04/03/2011 menbit@ymail.com 56
  57. 57. CONTINUOUS MURMUR.have both systolic and diastolic components.starts in systole and continues without pausethrough S2 into but not necessarily throughoutdiastole.related to patent ductus arteriosus , ventricvularseptal defect.Note: like cardiac murmurs pericardial friction rubscontinues through both phases .04/03/2011 menbit@ymail.com 57
  58. 58. 2. SHAPE.The shape or configuration of a murmur is determinedby its intensity over time.I. crescendo (grows louder) The presystolic murmur of mitral stenosisII. decrescendo(grows softer)-The early diastolic murmur of aortic regurgitationIII. crescendo-decrescendo(first rises in intensity, thenfalls).The midsystolic murmur of aortic stenosis and innocentflow murmursIV. plateau(has the same intensity throughout).The pansystolic murmur of mitral regurgitation04/03/2011 menbit@ymail.com 58
  59. 59. 3. LOCATION OF MAXIMAL INTENSITY.This is determined by the site where the murmuroriginates.For example, a murmur best heard in the 2nd rightinterspace usually originates at or near the aorticvalve.4. RADIATIONThis reflects the intensity of the murmur.Explore the area around a murmur and determinewhere else you can hear it.A loud murmur of aortic stenosis often radiates intothe neck (in the direction of arterial flow).04/03/2011 menbit@ymail.com 59
  60. 60. 5. INTENSITY.This is usually graded on a 6-point scale and expressedas a fraction.The numerator describes the intensity of the murmurwherever it is loudest, and the denominator indicatesthe scale you are using.Intensity is influenced by the thickness of the chest walland the presence of intervening tissue.An identical degree of turbulence would cause a loudermurmur in a thin person than in a very muscular orobese one. Emphysematous lungs may diminish the intensity ofmurmurs.04/03/2011 menbit@ymail.com 60
  61. 61. GRADING OF MURMURSGrade 1 = Very faint, heard only after listener has“tuned in”; may not be heard in all positionsGrade 2 = Quiet, but heard immediately after placingthe stethoscope on the chestGrade 3 = moderately loudGrade 4 = Loud, with palpable thrillGrade 5 = Very loud, with thrill. May be heard whenthe stethoscope is partly off the chestGrade 6 = Very loud, with thrill. May be heard withstethoscope entirely off the chest04/03/2011 menbit@ymail.com 61
  62. 62. 6. PITCHThis is categorized as high, medium, or low.7. QUALITY.This is described in terms such as blowing, harsh,echoing, and musical.04/03/2011 menbit@ymail.com 62
  63. 63. AssignmentNUTRITIONAL ASSESSMENT(presentation)Define Food and nutritionDescribe all relevant Methods of nutritionalassessment.04/03/2011 menbit@ymail.com 63
  64. 64. THANK YOU04/03/2011 menbit@ymail.com 64
  65. 65. ኩኩኩኩኩኩ!!! ኩኩኩ ኩኩኩኩኩ??menbit@ymail.com 65

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