Cardiovascular Examination

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Cardiovascular Examination

Deling Zou

Medical pptMedical ppt http://hastaneciyiz.blogspot.com

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Anatomy

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Inspection

1 Precardial projection and excavation

2 Apical impulse

3 Abnormal pulsations of precardium

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1 Precardial projection and excavation

1) Precardial projection • congenital heart disease: tetralogy of Fallo

t • Valvular heart disease--

MS,PS

• pericardial effusion (large , childhood)

Inspection

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• The second right intercostal space(2nd ICS-RS)

• aneurysm of aortic arch

• dilatation of ascending aorta

2) flat chest

3) pigeon chest/funnel chest

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2 Apical impulse

*Normal: • position—the fifth left intercostal

space 0.5-1.0cm medial to the midclavicular line range—2.0-2.5cm in diameter

Inspection

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*Abnormal1) Location #diaphragm:

• “transverse position” upper,outward• obesity ,child, pregnacy;• ascites; tumor of abdominal cavity• • “vertical position” (thin, high, emphys

ema) inferior,inner

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• one side pleural effusion or pneumothorax—to the healthy side

• one side atelectesis or pleural adhesion—to the affected

#mediastinum:

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#enlargement of the heart

• right ventricular dilatation –left or slightly upper

• left ventricular dilatation—left inferior

• LV &RV dilatation –left inferior (both side dilatation)

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#Posture:• recumbent position—upper

• left lateral position—to the left 2-3cm

• right lateral position—to the right 1.0-2.5cm

• Dextrocardia: 5-ICS—RS

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Decrease Increase Physiological Chest wall pachynsis

Narrow intercostol space Thin chest wall Broaden intercostol space exercise,euphoric mood

Pathological . myopathy(AMI,DCM) . pericardial effusion . emphysema .constrictive pericarditis . left side massive pleural effusion or pneumothroax

.LV hypertrophy

.hyperthyroidism

. fever .anemia

2)Intensity and extent changes

Inspection- apical impulse - abnormal

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3)Inward impulse:

• apex excavation in the systole

• seen: adhensive pericarditis prominent RV hypertrophy

Inspection

-apical impulse - abnormal

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Inspection

1)left third-forth intercostal space lateral to the sternum(3,4ICS-LS)

• seen: RV hypertrophy

3 Abnomal pulsations of percardium

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2)hypoxiphoid process

seen:

difference deep inspiration

RV hypertrophy ↑ abdominal aorta (aneurysm) ↓

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3)basal part of the heart

• 2 ICS-LS: dilatation of the pulmonary artery or pulmonary hypertensin, occasionally healthy young man

• 2 ICS-RS: aneurysm of aortic arch or dilatation of ascending aorta

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Palpation

1 Apical impulse and pulsation of precardium

2 Thrill

3 Pericardial friction rub

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1 Apical impulse and pulsation of precardium

• Exact position of apex

• The beginning of systole of ventricle first sound

• Heaving apex impulse: reliable of LV hypertrophy

Palpation

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2 Thrill

• One of characteristic signs of organic heart disease.

• Mechanism : the flow of blood→narrowed orifice→vortices→ vibration→chest wall

• thrill-high frequency murmurs-low frequency

• Method:position,phase of cardiac cycle,clinical significance

• seen: CHD or valvular stenosis ,

occasionally insurficiency

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Clinical significance of thrillLocation phase Disease2 ICS-RS Systole AS (RHD,CHD,senile)2 ICS-LS Systole PS (CHD)3,4 ICS-LS Systole VSD (CHD)Apex Systole MI (severe)Apex Diastole MS (RHD)2 ICS-LS Continous PDA

CHD:congenital heart disease

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1)Precardium-4th ICS-LS2) both phases of the cardiac cycle3) systolic period, sitting erect and leaning

forward, the end of expiration4)mechanism: rub of the visceral and pari

etal layers of pleura5)seen:acute pericarditis

3 Pericardil friction rub

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Percussion

• Aim:to determine the size and shape of the heart .

• Absolute dullness: contain no gas Relative dullness : real size

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1 murneuver of percussion

• patient in erect position –the pleximeter is vertical with the intercostal space

• patient in the recumbent position –the pleximeter is parallel with the intercostal space

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2 order :• left—right ; upwards ; inward• left margin : from 2-3 cm lateral to

the apex beat up to the 2nd ICS• right margin : one intercostal space

higher than the border of liver dullness up to the 2nd ICS

• size: vertical distance from margin to the anterior midline

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3 Normal heart borders (area of relative dullness)

Right(cm) ICS Left(cm) 2~3 Ⅱ 2~3 2~3 III 3.5~4.5 3~4 Ⅳ 5~6

Ⅴ 7~9

(LMCL—ML:8~10cm)

Percussion

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4 The composition of various parts of the border of the heart (1)

Right ICS Left

SVC,SA II PA

RA III LA

RA Ⅳ LV

Ⅴ LV

Percussion

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(2)The upper border –the lower border of the anterior end of the third rib↑

(3)The basal part —the second intercostal space upward

left: aortic node and PA(4)Concave part –between the aorta

and the left ventricle

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5 Changes in the area of cardiac dullness and its significance

Cardiac factors :

1)LV enlargement: “boot shape” Seen:aortic valvular disease ,

hypertension heart disease

Percussion

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2)RV enlargement : slightly↑--absolute dullness↑ Prominent↑--relative dullness↑ to the left side prominently Seen:PHD, MS

3)Two ventricle ↑:

“generally enlarged heart” seen:DCM , Kashan cardiomyopathy

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4)LA and/or pulmonary artery:

LA:concave part disappear LA+PA:2,3 ICS-LS outwards

“pear shape” Seen: MS--- “mitrial type”

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5)pericardial effusion: enlargement of both sides of the border

body’s position: • recumbent position ： widening of base

of the heart

• erect position:“triangular shape”

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6)dilatation of the aorta /ascending aortic aneurysm:

widening if the dull area of first and second intercostal space (with systolic pulsation)

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Extacardial factors :1)large pleural effusions and pneumothorax → to the healthy side2)atelectasis /pleural pachynsis →to the affected3)a large amount of ascites or big abdominal tumor: diaphragm elevated→transverse position →left side enlargement

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Ausclutation

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1 Ausclutatoty valve areas

1)ausclutatory mitral area: apical area2)ausclutatory pulmonary area:2 ICS-LS3)ausclutatory aortic area: 2 ICS-RS4)second ausclutatory aortic area: 3rd ICS-LS—Erb area5)tricuspid area :4,5 ICS-LS

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2 Order:

MV---PV---AV1---AV2---TV

3 Contents : 1) rate 2)rhythm 3)heart sound 4)extra heart sound 5)murmurs 6)pericardial friction sound

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1)heart rate:

• 60~100bpm F ＞ M

• child ( ＜ 3 years) ＞ 100bpm

• tachycardia: normal adult ＞ 100bpm child( ＜ 3 years) ＞ 150bpm

• bradycardia: HR ＜ 60 bpm

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Ausclutation

heart rate:60-100bmp

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2)cardiac rhythm:*sinus arrythmia—affected by breath*premature beat: classification:atrial~ ventricular ~

• junctional ~

• frequently: ＞ 6 bpm

• occasionally: ＜ 6 bpm

• bigeminy trigeminy

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*atrial fibrillation: absolute irregular rhythm S1 intensity inequality Pulse deficitseen:MS,CHD,hyperthyroidism,

PHD,DCM

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Ausclutationatrial fibrillation•

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Cycle Nature Duration Site Mechanism

S1 Isovolumetric contraction phase

Blunt 0.1″ Apical area

Closure of the MV and TV

S2 Isovolumetric relaxation phase

Distinct 0.08″ Basal part

Closure of the AV and PV

S3 The end of ventricular rapid filling phase

Weak Blunt

0. 04″ after S2 0.12~0.18″

Apex (inner-upper)

Ventricular vibration

S4 The end of ventricular diastolic phase

Weak 0. 1″ forward S1

Apex Atrium contraction

3) cardiac sound

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Ausclutationcontentcardiac sound S1 ：

S2 ：

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4)Abnormal cardiac sound *Intensity:

• position of the atrioventricular valve

• Ventricular contractility and output

• Valvular integrity and activity

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S1: Accentuation:

• MS

• HR↑contractility↑ fever,anemia,hyperthyroidism

• complete AVB →cannon sound

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S1 attenuation :

• MI

• P-R interval enlong

• AI

• myocarditis,myopathy,MI,HFinequality: af, III°AVB

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S2---A2,P2

S2 ↑ ---pressure and flow of

blood ↑ A2 : hypertensin, arterisclerosis P2 : PHD,CoHD(L--R),LVF

S2 ↓ ---pressure↓ flow ↓ Seen:hypotension,AS/AL,PS/PI

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*Quality mono rhythm

pendular rhythm---embryocardia

*Splitting of heart sound S1 splitting:

seen—RBBB, right heart failure Ebetein malformation ,MS LA myxoma

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• S2 splitting:(1)physiological splitting :end of inspiration (2)general splitting : most commonly seen: CRBBB, PS, MS,MI ,VSD (3)fixed splitting :ASD(4)paradoxical splitting(reversed splitting) :pathological seen: CLBBB ,AS, hypertension

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• 5)extra cardiac soundDiastolic period1)gallop rhythm: --protodiastolic gallop: S1+S2+S3 the third sound gallop (sign of organic heart disease) seen : HF （ AMI, severe myocarditis , myopathy etc. ） -- late diastolic gallop: atrial gallop S1+S2+S4 seen : HBP ,HCM ,AS ,CHD -- summation gallop: quadruple rhythm

seen:HF,cardiomyopathy

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• 5) extra cardiac sound Diastolic period

2)opening snap:MS3)pericardial knock: constrictive pericarditis4)tumor plop: LA myxoma

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AusclutationCONTENT

Tumor plop

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• Systolic period(1)early systolic ejection sound(click) pulmonary :pulmonary hypertension; pulmonary artery dilatation PS, ASD, VSD Aortic: hypertension, aneurysm ,

AS, AI ,aorta constriction(2)mid and late systolic click:

S1----mid ＜ 0.08″ late ＞ 0.08″ seen: mitral prolapse

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• iatrogenic(1)prosthetic valvular sound(2)pacemaker

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6)cardiac murmurs*Mechanism: acceleration of blood flow

stenosis of valvular orifice or great vessles turbulent flowvalvular insufficiency vortices

abnormal passage foreign body dilatation of vessles(aneurysm)

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• *characterization of murmur and ausclutatory key points (1)location:L3,4 –VSD L2,3—PDA (2)transmission:

MI ---left axilla AS---neck (3)phase: systolic murmurs diastolic ~ continuous ~

biphasic ~• early,mid,late,whole

murmurs

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(4)quality: blowing—MI

rumbling—MS sighing--AI machinery--PDA

(5)intensity :Levine 6 grade classification shape: crescendo---MS decrescendo---AI crescendo-decrescendo---AS continuous---PDA regular---MI

murmurs

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(6) others: • body position: M

S--left lateral positionAI--sitting erected and forward MI,TI,PVS--lie on one’ back

Lie → stand: HCM • breath:expiration--LV murmurs

inspiration --RV murmurs valsalva--HCM

• exercise: HR↑--murmurs ↑ murmurs

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• clinical significance murmurs:

functional and organic

7)pericardial friction sound:• both phases , unaffected by respirati

on .

• seen: pericarditis ,

RHD ,AMI ,renal failure, SLE

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* clinical significance of cardiac murmurs

systolic murmursMV ： functional:exercise,fever,anemia,pregnancy,

hyperthyroidism

relative:HBP,CHD,DCM,anemia

organic ： MI(RHD),mitral prolapse

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systolic murmursAortic area ： organic ： AS

relative ： dilatation of ascending aorta

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* clinical significance of cardiac murmurssystolic murmurs

pulmonary ： physiology relative ： MS 、 ASD organic ： PS TV ： relative ： RV enlarged organic ： rare

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Diastolic murmurs MV:organic:RHD(MS)

relative:AI(severe)

Austin Flint murmur

AV:AI

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* clinical significance of cardiac murmursDiastolic murmurs

PV:organic murmur is rare PI(dilatation of pulmonary artery)

MS+P2 ---- Graham Steell murmur

TV:rare

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* clinical significance of cardiac murmurscontinuous murmurs

PDA

innocent murmur

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Vascular examination

The second clinical hospital of CMU

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pulse

pulse rate pulse rhythm tensions and state of arterial wall intensity pulse wave

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pulse

pulse rate

Atrial fibrillation and frequent premature beat stroke volume peripheral artery no pulse pulse rate less than HR(pulse deficit)

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pulse

pulse rhythm

pulse deficit ； bigeminal pulse,trigeminal pulse ； dropped pulse

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pulse

tensions and state of arterial wall Artery tension depending on blood

pressure (mainly SBP).

Judge state of artery wall

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pulse

intensity

Bownding pulse

seen:high fever, hyperthyroidism, AI

Microsphygmia

seen:HF,AS and shock

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pulse

pulse wave• normal pulse wave

composed of upstroke （ knocking wave ）、peak （ tide wave ） and downstroke （ dicrotic wave ）

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pulsepulse wave

• water hammer pulse seen:AI,hyperthyroidism,PDA, severe anemia

• pulse tardus seen:AS• dicrotic pulse seen:HCM• pulsus alternans seen:HBP,AMI,AI • paradoxical pulse seen:cardiac tamponade,constrictive pericarditis• Pulseless seen:serious shock, arteritis

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blood pressure

• method of measurement

direct measurement method

indirect measurement method

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blood pressure• standard

definition of Bp level and classification(older than 18 years old) classification SBP(mmHg) DBP(mmHg)Ideal BP 120 80Normal BP 130 85High limit of BP 130-139 85-89Grade 1 （ mild ） 140-159 90-99 subgroup ： boundline hypertension 140-149 90-94Grade 2 （ moderate ） 160-179 100-109Grade 3 （ severe ） ≥ 180 ≥110Simple systolic hypertension 140 90 subgroup ：boundline systolic hypertension 140-149 90

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blood pressure• clinical significance of BP changes hypertension ： higher than 140/90mmHg for 3 times not in th

e same day hypotension ： lower than 90/60-50mmHgShock,,MI,acute cardiac tamponadeobvious difference between bilateral upper limbs ： more than 1

0mmHg---arteritis,congenital artery malformationdifference between upper and lower limbs ： lower limb BP is 2

0-40mmHg higher than upper one normally pathological:constrictive aorta ,arteritis(chest-abdominal aorta)change of pulse BP ：40mmHg ， wide pulse BP---hyperthyroidism,AI30mmHg ， narrow pulse BP---AS,pericardial effusion

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blood pressure

• dynamic BP monitoring

Average BP for 24h 130/80mmHg;

bright day 135/85mmHg;

night: 125/75mmHg

Peak:6am—10am,4pm—6pm

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Vessel murmur and peripheral vessel sign

• venous murmur

jungular murmur ： is caused by the rapid flow of jungular vein into SVC (superior vena cava)

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• artery murmur

Continuous murmur in the lateral lobe of thyroid in the patient with hyperthyroidism

Systolic murmur in the upper abnormal region or lumber region caused by stenosis of renal artery.

Arterio-venous fistula

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• peripheral vessel sign

pistol shot sound

Seen:AI,hyperthyroidism,severe anemia

Durozier’s murmur

capillary pulsation


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• The main symptoms and signs of common diseases of circulatory system

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• Causes:• RHD:rheumatic heart disease

CHD:congenital heart disease Other reasons: senile retrograde

Mitrial stenosis

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• Symptoms:• cough;

• hemoptysis;

• dyspnea: dyspnea on exertion→ paroxysmal nocturnal dyspnea → pneumonedema

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• Signs:

• Inspection : mitrial face

Apex impulse may be displaced to the left

• Palpation :diastolic thrill palpable over the apical area

• Percussion :normal heart borders→pear shape heart

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• Auscultation : 1)the first sound (S1)↑ 2)diastolic murmur :apical area; localized; mild and late diastolic ;crescendo ;rumbling; more clearly when the patient is lying on his left side. 3) opening snap may be auscultatory 4)accentuation of second pulmonary sound (P2↑), splitting 5)Graham Steel’s murmur (PV diastolic) 6)Maybe atrial fibrillation(late stage)

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Mitral Insufficiency• RHD / non-RHD ; acute/chronic

• Symptoms:• fatigue,• palpitations, • dyspnea on exertion, • Left heart failure

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• Signs :

Inspection : apex beat is displaced downwards and to the left

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• Palpitation : apical impulse forceful

Heaving apex impulse

Severe systolic thrill

• Percussion : the area of dullness to left and

downwards

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• Auscultation :

1)S1 ↓(attenuation)

2)murmurs: harsh; pansystolic murmur; blowing; 3/6 grade ↑ wide spread-transmitted to left axilla left infrascapular angle

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Aortic Stenosis

• Causes: RHD Congenital Senile retrograde

• Symptoms :

palpitation ,dizziness, angina pectoris, syncope, HF-dyspnea

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• Signs :• Inspection : apical impulse increase

Displaced to left and downwards

• Palpation :apex beat is elevated and forceful

systolic thrill can be palpated over aortic auscultatory valve area

Pulse tardus

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• Percussion: the area of dullness is normal or to left and downwar

d

• Auscultation : 1)murmur: aortic auscultatory valve area systolic murmur harsh ,ejection sound , 3/6 grade ↑(thrill) transmitted to neck

2)A2 ↓,reversed splitting3)S4

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Aortic Insufficiency• Causes:

• RHD Non-RHD ： congenital prolapse syphilis aortitis arteriosclerosis endocarditis

acute/chronic

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• Symptoms : palpitation, dizziness, LHF

• SignsInspection :

apical impulse to left and downwards

Palpation :

apex impulse to left and downwards Heaving apex impulse

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• Percussion :

the area of cardiac dullness is enlarged downwards and to the left;

the concave part of the heart is not enlarged (boot shape)

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• Auscultation :

1)specific murmur:diastolic ;

sighing ;

aortic area;

heard clearly sitting erect and forward

2)Austin Flint murmur :relative MS (rumbling mid-diastolic murmur)

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• Peripheral vascular signs

*head bobbing (Musset’s sign):nodding motion of the head with each systole;*signs of capillary pulsation;*water hammer pulse;*pistol shot sounds : esp. Femoral arteries;*Duroziez’s murmur;*Visible pulsation of carotid arteries

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Pericardial effusion

• Causes: infective and non-infective pericarditis

• Symptoms : pain over the pericardial region Dyspne

a, cough, fever, lassitudeShock

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• Signs : Inspection :

diminution in strength of the apex beat or absence of the apex beat ;

jugular venous enlargement

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• Palpation :

*diminution in strength of the apex beat or the apex beat palpated uneasily

*paradoxical pulse may be present

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• Percussion : enlargement of the cardiac dullness

bilaterally, changed with posture

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• Auscultation :

*pericardial friction sound

*HR↑,diminution of intensity of cardiac sound (S1/S2↓)

*pericardial knock may be heard

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*Large effusion:

• Jugular varicosity

• Liver enlargement

• Paradoxical pulse

• Pulse pressure ↓

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* Kussmaul sign:

deep inspiration –jugular vein distension

*Ewart sign: left infrascapular region

vocal fremitus↑

dullness -- percussion

bronchovesicular breath sound-- auscultation

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Heart Failure• Causes :

myopathy ; ventricular load ↑

promote factors

• Symptoms: 1 LHF: fatigue, cough, frothy sputum

dyspnea(on exertion → orthopnea → paroxysmal nocturnal ~)

2 RHF: abdominal distension, oliguria, nausea, vomiting

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• Signs :1 LHF: *Inspection : tachypnea , cyanosis, semireclining/sitting position Acute pneumoedema:

frothy sputum, hyperhidrosis *Palpation :pulse alternans *Percussion : *Auscultation :diastolic gallop rhythm P2↑ Fine rales, rhonchi

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• 2 RHF: *Inspection :Jugular distension Pericardial cyanosis Edema(pitting, pendulous) *Palpation : liver enlargement, tenderness Hepatojugular reflux(+) *Percussion :

pleural effusion (right side) ascites

*Auscultation : RV diastolic gallop rhythm TV systolic blowing murmurs

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Cardiovascular Examination

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