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CVS examination physical exMINtion-1.pptx

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1. The document provides details on performing a cardiovascular system examination, including aspects to examine related to the patient's general appearance, hands, peripheral signs, pulse, jugular venous pressure, precordium, and heart sounds and murmurs. 2. Specific physical findings are described for different cardiovascular conditions like heart failure, infective endocarditis, hyperlipidemia, and valvular abnormalities. 3. Examination techniques and how to assess different components of the cardiovascular exam like pulse, jugular venous pressure, and heart sounds are outlined.

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CVS EXAMINATION Dr . Muneer Bashoaib
GENERAL CVS EXAMINATION (AS GENERAL EXAMINATION BUT STRESS IN FOLLOWING): Look at the patient carefully: Dyspnoeic or orthopnoeic (may be found in left ventricular failure), cachexia (in severe heart failure). Squatting position in Tetralogy of Fallot Face: i. Malar flush (in MS). ii. Marfanoid face. iii. Corneal arcus and xanthelasma, which may be related to atherosclerosis in ischaemic heart disease (IHD), iv. mouth (high arch palate in Marfans syndrome). Anaemia: may be responsible for anaemic heart failure. Cyanosis: found in tetralogy of Fallot (TOF) and Eisenmengers syndrome. Oedema: pitting oedema is found in congestive cardiac failure (CCF).
IN HANDS: Clubbing. Cyanosis. Splinter haemorrhage. Oslers node (red, raised, palpable, tender nodule on pulp of finger, toes, also in thenar or hypothenar area). Janeway lesion (non-tender, red, maculopapular lesion on palm or pulp of finger). Xanthoma: Palmar or tendon (related to atherosclerosis in IHD). Tobacco stain (found in smokers, responsible for IHD).
FEATURES OF HYPERLIPIDAEMIA Xanthelasmata. Corneal arcus. tendon xanthomata
TENDON XANTHOMATA
PERIPHERAL SIGNS THAT MAY BE PRESENT IN INFECTIVE ENDOCARDITIS
CVS examination physical exMINtion-1.pptx
JANEWAY LESION VS. OSLERS NODE
FINGER CLUBBING is likely if: 1. the interphalangeal depth ratio is > 1 (that is, the digit is thicker at the level of the nail bed than the level of the distal interphalangeal joint ) 2. the nail fold angle is > 190 degrees 3. Schamroths window sign is absent
CVS examination physical exMINtion-1.pptx
FINGER CLUBBING
CVS examination physical exMINtion-1.pptx
PITTING OEDEMA SCALE (GRADES ) level ??
PERIPHERAL SIGNS OF AR
MNEMONIC FOR PERIPHERAL SIGNS OF AR --- ARATHI GOT LOW QUALITY BCG, DPT & MMR FROM PHC AR- Aortic Regurgitation G=gerhard sign L=landolfis sign, lighthouse sign Q=quinckes sign B=becker sign C=corrigans neck sign G=gerhard sign D=de mussets sign, duroziez sign P=pistol shot femorals, pulse pressure wide T=traubes sign M=muller sign M=mayne sign R=rosenbch sign P=pulsus bisferiens H=hills sign C=collapsing pulse(corrigans pulse)
PULSE Comment on : Rate , rhythm , character , volume , symmetry , radio-femeral delay , blood vessel wall , presence every where in the body
SOME ABNORMALITIES OF THE ARTERIAL PULSE AND PRESSURE WAVES
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
JUGULAR VENOUS PRESSURE AND WAVEFORM
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
Kussmauls sign is a paradoxical rise of JVP on inspiration that is seen in pericardial constriction, severe right ventricular failure and restrictive cardiomyopathy. Cannon waves (giant a waves) occur when the right atrium contracts against a closed tricuspid valve. 1. Irregular cannon waves are seen in complete heart block and are due to atrioventricular dissociation. 2. Regular cannon waves occur during junctional rhythm and with some ventricular and supraventricular tachycardias.
PRECORDIUM EXAMINATION A. Inspection B. Palpation C. Auscultation
INSPECTION 1. Precordial bulge : area of the chest overlying the heart (from the 2nd to 6th costal cartilage, from left sternal border to MCL)>> RV enlargement since early childhood. 2. Dilated veins :SVC obstruction (Filling upwards downwards),milking test ? 3. Scar (name , healing (lry intention : clean linear healing, 2ry intention : pigmentation , keloid) A. Median sternotomy scar: open heart surgery e.g. valve replacement , CABG B. Lateral thoracotomy (inframammary) scar: closed heart surgery e.g. mitral valvotomy 4. Shape of the chest . 5. Pulsations Apex ,Suprasternal pulsation, 1st aortic area , Pulmonary area , Left parasternal pulsation , epigastric pulsation.
Median sternotomy scar SVC obstruction
PACEMAKER
PALPATION
PALPATION Finger Tips for : Apex Pulmonary and aortic area Finger pads for : apex Ball of the hand for : Thrills Palpable sound Heel of the hand : for Parasternal heave
APEX 1. Site 2. Extent =area 3. Character 4. Thrill 5. Palpable S1 NB: Pulse deficit ??? HR vs. Pulse rate ?
OTHER AREA Lt parasternal heave Pulsation Thrill
AUSCULTATION
KNOW YOUR STETHOSCOPE! It is important to understand the uses of both the diaphragm and the bell. The diaphragm is better for picking up the relatively high pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs. Listen throughout the precordium with the diaphragm, pressing it firmly against the chest. The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Apply the bell lightly, with just enough pressure to produce an air seal with its full rim. Firm pressure on the bell can stretch the underlying skin and make it function more like the diaphragm. Low-pitched sounds like S3 and S4 may then disappear an observation that can help identify them.
COMMENT ON: 1. Heart sound 2. Additional heart sound 3. Murmur Auscultation of the heart Heart sound Normal ( S1, S2 ) Additional S3 , S4 , Opening snap , ejection click , midsystolic click ,tumor plop , pericardial knock ,metallic click Murmur
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
FIRST HEART SOUND (S1) The first heart sound (S1), lub, is caused by closure of the mitral and tricuspid valves at the onset of ventricular systole. It is best heard at the apex.
SECOND HEART SOUND (S2) The second heart sound (S2), dub, is caused by closure of the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge. It is louder and higher-pitched than the S1 lub, and the aortic component is normally louder than the pulmonary component.
THIRD HEART SOUND (S3) The third heart sound (S3) is a low-pitched early diastolic sound best heard with the bell at the apex. It coincides with rapid ventricular filling immediately after opening of the atrioventricular valves and is therefore heard after the second heart sound as lub-dub-dum. It is a normal physiological finding in children, young adults and febrile patients, and during pregnancy, but is usually pathological after the age of 40 years. The most common causes are left ventricular failure, when it is an early sign, and mitral regurgitation, due to volume loading of the ventricle. In heart failure, S3 occurs with a tachycardia, referred to as a gallop rhythm, and S1 and S2 are quiet (lub-da-
FOURTH HEART SOUND The fourth heart sound (S4) is less common. It is soft and low-pitched, best heard with the bell at the apex. It occurs just before S1 (da-lub-dub). It is always pathological and is caused by forceful atrial contraction against a non-compliant or stiff ventricle. An S4 is most often heard with left ventricular hypertrophy (due to hypertension, aortic stenosis or hypertrophic cardiomyopathy). It cannot occur when there is atrial fibrillation.
An opening snap is commonly heard in mitral (rarely, tricuspid) stenosis. It results from sudden opening of a stenosed valve and occurs early in diastole, just after the S2. It is best heard with the diaphragm at the apex. Ejection clicks are high-pitched sounds best heard with the diaphragm. They occur early in systole just after the S1, in patients with congenital pulmonary or aortic stenosis .
MURMUR In describing murmur, we comment upon the following: 1. Timing 2. Character 3. Site of maximal intensity 4. Grades and thrill 5. Radiation 6. Maneuvers to increase the murmur
TYPES OF MURMUR
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
CVS examination physical exMINtion-1.pptx
惡悋惠 惠悋惠 悋惺悸 忰悋惠 悋悴悋忰 悋惺悸

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CVS examination physical exMINtion-1.pptx

  • 1. CVS EXAMINATION Dr . Muneer Bashoaib
  • 2. GENERAL CVS EXAMINATION (AS GENERAL EXAMINATION BUT STRESS IN FOLLOWING): Look at the patient carefully: Dyspnoeic or orthopnoeic (may be found in left ventricular failure), cachexia (in severe heart failure). Squatting position in Tetralogy of Fallot Face: i. Malar flush (in MS). ii. Marfanoid face. iii. Corneal arcus and xanthelasma, which may be related to atherosclerosis in ischaemic heart disease (IHD), iv. mouth (high arch palate in Marfans syndrome). Anaemia: may be responsible for anaemic heart failure. Cyanosis: found in tetralogy of Fallot (TOF) and Eisenmengers syndrome. Oedema: pitting oedema is found in congestive cardiac failure (CCF).
  • 3. IN HANDS: Clubbing. Cyanosis. Splinter haemorrhage. Oslers node (red, raised, palpable, tender nodule on pulp of finger, toes, also in thenar or hypothenar area). Janeway lesion (non-tender, red, maculopapular lesion on palm or pulp of finger). Xanthoma: Palmar or tendon (related to atherosclerosis in IHD). Tobacco stain (found in smokers, responsible for IHD).
  • 6. PERIPHERAL SIGNS THAT MAY BE PRESENT IN INFECTIVE ENDOCARDITIS
  • 8. JANEWAY LESION VS. OSLERS NODE
  • 9. FINGER CLUBBING is likely if: 1. the interphalangeal depth ratio is > 1 (that is, the digit is thicker at the level of the nail bed than the level of the distal interphalangeal joint ) 2. the nail fold angle is > 190 degrees 3. Schamroths window sign is absent
  • 15. MNEMONIC FOR PERIPHERAL SIGNS OF AR --- ARATHI GOT LOW QUALITY BCG, DPT & MMR FROM PHC AR- Aortic Regurgitation G=gerhard sign L=landolfis sign, lighthouse sign Q=quinckes sign B=becker sign C=corrigans neck sign G=gerhard sign D=de mussets sign, duroziez sign P=pistol shot femorals, pulse pressure wide T=traubes sign M=muller sign M=mayne sign R=rosenbch sign P=pulsus bisferiens H=hills sign C=collapsing pulse(corrigans pulse)
  • 16. PULSE Comment on : Rate , rhythm , character , volume , symmetry , radio-femeral delay , blood vessel wall , presence every where in the body
  • 17. SOME ABNORMALITIES OF THE ARTERIAL PULSE AND PRESSURE WAVES
  • 25. Kussmauls sign is a paradoxical rise of JVP on inspiration that is seen in pericardial constriction, severe right ventricular failure and restrictive cardiomyopathy. Cannon waves (giant a waves) occur when the right atrium contracts against a closed tricuspid valve. 1. Irregular cannon waves are seen in complete heart block and are due to atrioventricular dissociation. 2. Regular cannon waves occur during junctional rhythm and with some ventricular and supraventricular tachycardias.
  • 26. PRECORDIUM EXAMINATION A. Inspection B. Palpation C. Auscultation
  • 27. INSPECTION 1. Precordial bulge : area of the chest overlying the heart (from the 2nd to 6th costal cartilage, from left sternal border to MCL)>> RV enlargement since early childhood. 2. Dilated veins :SVC obstruction (Filling upwards downwards),milking test ? 3. Scar (name , healing (lry intention : clean linear healing, 2ry intention : pigmentation , keloid) A. Median sternotomy scar: open heart surgery e.g. valve replacement , CABG B. Lateral thoracotomy (inframammary) scar: closed heart surgery e.g. mitral valvotomy 4. Shape of the chest . 5. Pulsations Apex ,Suprasternal pulsation, 1st aortic area , Pulmonary area , Left parasternal pulsation , epigastric pulsation.
  • 31. PALPATION Finger Tips for : Apex Pulmonary and aortic area Finger pads for : apex Ball of the hand for : Thrills Palpable sound Heel of the hand : for Parasternal heave
  • 32. APEX 1. Site 2. Extent =area 3. Character 4. Thrill 5. Palpable S1 NB: Pulse deficit ??? HR vs. Pulse rate ?
  • 33. OTHER AREA Lt parasternal heave Pulsation Thrill
  • 35. KNOW YOUR STETHOSCOPE! It is important to understand the uses of both the diaphragm and the bell. The diaphragm is better for picking up the relatively high pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs. Listen throughout the precordium with the diaphragm, pressing it firmly against the chest. The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Apply the bell lightly, with just enough pressure to produce an air seal with its full rim. Firm pressure on the bell can stretch the underlying skin and make it function more like the diaphragm. Low-pitched sounds like S3 and S4 may then disappear an observation that can help identify them.
  • 36. COMMENT ON: 1. Heart sound 2. Additional heart sound 3. Murmur Auscultation of the heart Heart sound Normal ( S1, S2 ) Additional S3 , S4 , Opening snap , ejection click , midsystolic click ,tumor plop , pericardial knock ,metallic click Murmur
  • 39. FIRST HEART SOUND (S1) The first heart sound (S1), lub, is caused by closure of the mitral and tricuspid valves at the onset of ventricular systole. It is best heard at the apex.
  • 40. SECOND HEART SOUND (S2) The second heart sound (S2), dub, is caused by closure of the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge. It is louder and higher-pitched than the S1 lub, and the aortic component is normally louder than the pulmonary component.
  • 41. THIRD HEART SOUND (S3) The third heart sound (S3) is a low-pitched early diastolic sound best heard with the bell at the apex. It coincides with rapid ventricular filling immediately after opening of the atrioventricular valves and is therefore heard after the second heart sound as lub-dub-dum. It is a normal physiological finding in children, young adults and febrile patients, and during pregnancy, but is usually pathological after the age of 40 years. The most common causes are left ventricular failure, when it is an early sign, and mitral regurgitation, due to volume loading of the ventricle. In heart failure, S3 occurs with a tachycardia, referred to as a gallop rhythm, and S1 and S2 are quiet (lub-da-
  • 42. FOURTH HEART SOUND The fourth heart sound (S4) is less common. It is soft and low-pitched, best heard with the bell at the apex. It occurs just before S1 (da-lub-dub). It is always pathological and is caused by forceful atrial contraction against a non-compliant or stiff ventricle. An S4 is most often heard with left ventricular hypertrophy (due to hypertension, aortic stenosis or hypertrophic cardiomyopathy). It cannot occur when there is atrial fibrillation.
  • 43. An opening snap is commonly heard in mitral (rarely, tricuspid) stenosis. It results from sudden opening of a stenosed valve and occurs early in diastole, just after the S2. It is best heard with the diaphragm at the apex. Ejection clicks are high-pitched sounds best heard with the diaphragm. They occur early in systole just after the S1, in patients with congenital pulmonary or aortic stenosis .
  • 44. MURMUR In describing murmur, we comment upon the following: 1. Timing 2. Character 3. Site of maximal intensity 4. Grades and thrill 5. Radiation 6. Maneuvers to increase the murmur
  • 55. 惡悋惠 惠悋惠 悋惺悸 忰悋惠 悋悴悋忰 悋惺悸