Cv physical exam - Gabriel

1. P A O L O G A B R I E L , M D
C A R D I O L O G Y
O C T O B E R 2 0 1 8
Cardiovascular
Physical Examination
1

2. CV Exam
 Not meant to be comprehensive
 Focus on things you will see on the wards and in clinic
 not rare diseases
 brief overview of murmurs
 Review of anatomy
 Practical clinical pearls
 Echo
2

3. CV Exam
 Vital Signs
 Blood pressure
 Pulse: rate, rhythm, volume
 Pulmonary Exam
 Vasculature
 Lower extremities, carotids
 Components
 Observation, Palpation, Auscultation
 Percussion
3

4. Observation
 General appearance
 Shortness of breath
 at rest
 walking
 sitting upright
 able to speak
 chest wall impulse
 Chest pain
4

5. Heart Failure
5

6. Heart Failure
6

7. Myocardial Ischemia
7

8. Anatomy
8

9. Angle of Louis
9

10. Areas of Auscultation
10

11. Palpation
 Your hand = bedside echo
 Right Ventricle
 Vigor of contractility
 Use heel of hand
 Assess for lift or heave
 Palpable P2
 Tap of pulmonic valve closure
 Pulmonary hypertension
11

12. Palpation
 Left Ventricle
 Fingers across chest, under
breast
 PMI: apex of ventricle that
pin-points with finger tip
 If not palpable, try left
lateral position
 Increased PMI: shifted to L
of mid-clavicular line
 Vigor of contraction
12

13. Auscultation
 Normal valve closure creates sound
 1st heart sound:
 S1: closure of mitral and tricuspid valves
 2nd heart sound:
 S2: closure of aortic and pulmonic valves
13

14. Auscultation
14

15. Auscultation
15

16. Auscultation
 Murmurs: Sound created by turbulent flow across valves:
 Leakage (regurgitation) when valve closed
 Obstruction (stenosis) to flow when normally open
 Systolic Murmurs:
 Aortic stenosis, Mitral regurgitation (Pulmonary stenosis, Tricuspid
regurgitation), VSD
 Diastolic Murmurs:
 Aortic regurgitation, Mitral stenosis (Pulmonary regurgitation,
Tricuspid stenosis)
 Some murmurs best appreciated in certain positions:
 Mitral: patient on L side; Aortic: sitting up and leaning forward
16

17. Extra Heart Sounds
 Extra Heart Sounds – S3 & S4
 Ventricular sounds, occur during
diastole – can be normal in young
patient
 • S3follows S2
 caused by blood from LA colliding
w/ “left over” blood in LV
 Heart failure
 • S4precedes S1
 caused during atrial systole
 blood squeezed into non-compliant
LV
 Hypertension
17

18. Carotid Arteries
 Palpate
 Listen for bruits
18

19. Jugular Venous Pressure
 Practice, practice,
practice
 Hepatojugular
reflux
 abdominal pressure
 Have patient sit
upright at edge of
bed
 If above clavicle,
>10 cm = 7.4 mmHg
19

20. Jugular Venous Pressure
20

21. Edema
21

22. Edema
22

23. Echo – Noninvasive Hemodynamics
 IVC assessment is not reliable in ventilated patients
 Estimated CVP reported in mmHg
 Based on size and collapsibility
 Right heart catheterization (gold standard)
 Mitral Valve E/e’ correlates with left atrial pressure
 PCWP
 PAD
 Right versus left sided filling pressures
 Grade I diastolic dysfunction ≠ HFpEF
23

24. Post-cath Patients
 Vascular access complications
 Arterial access – hematomas, AVF, pseudoaneurysms
 IJ access
 Check distal pulses
 If femoral access and patient is hypotensive, complains of new groin,
abdominal, flank/back pain, think about retroperitoneal hemorrhage
 For arteriotomy bleeds, hold firm pressure proximal to needle stick site
 Not directly over the hole in the skin
 Please call for assistance, if necessary
 cardiology, vascular surgery
 Bleeding: anticoagulants, antiplatelets
24

25. References
 Netter’s Cardiology
 http://www.blaufuss.org/tutorial/indexTut.html
 http://pie.med.utoronto.ca/PIE/PIE_whatWeDo_va
lves.html
 https://meded.ucsd.edu/clinicalmed/heart.htm
25

26. 26