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Cardiovascular examination


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Structured examination of the cardiovascular system

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.