How To Examine The Heart And Blood Vessels

How How to to Examine Examine the the Heart Heart and and Blood Blood Vessels Vessels Joel Niznick MD FRCPC

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Look Look at at the the patient patient • • • • • • •

Sick/well Comfortable/in distress Cyanosed/plethoric Wet/dry Young/old Male/Female Establish probabilities of disease – History will have told you what to suspect © Continuing Medical Implementation

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Common Common Clinical Clinical Scenarios Scenarios • Younger people – Functional murmur vs MVP vs bicuspid AV

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• Older people – Aortic sclerosis vs aortic stenosis

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Probabilities Probabilities • Males more commonly have aortic valve disease – Young – BAV – Elderly - Degenerative

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• Females more commonly have mitral valve disease • MVP > rheumatic heart disease

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Inspect Inspect • Facies/body habitus – Cyanosis – Xanthelasma – Arcus senilis – Conjunctival hemorrhages

• Syndromes – Marfan’s – Down’s © Continuing Medical Implementation

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Hands Hands • • • • • •

Clubbing Capillary return Digital ischaemia Splinter hemorrhages Osler’s nodes Janeway lesions

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Blood Blood pressure pressure • At rest 5” • Both arms • Legs if young hypertensive © Continuing Medical Implementation

RECOMMENDED BLOOD PRESSURE MEASUREMENT TECHNIQUE 2. 2.

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1. 1. ••The Thepatient patientshould should be berelaxed relaxedand andthe the arm st bbe e armmu must supported. supported. ••Ensure Ensureno notight tight clothing nstricts clothingco constricts the thearm. arm.

3. 3.

St ethoscope

Mercury machine

••The umn ofof Thecol column mercury mercurymust mustbe be vertical vertical. . ••Infla te to occlude Inflate to occludethe the pulse. pulse. Deflate Deflateat at22to to 33mm/s. mm/s.Measure Measure systolic systolic(first (firstsound) sound) and anddia diastolic stolic (disapp earance) toto (disappearance) nea rest nea rest 22mm mmHg. Hg.

3

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Look Look at at the the Fundi Fundi

OSU Interactive Physical Exam Guide © Continuing Medical Implementation

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Look Look at at the the Fundi Fundi

• • • •

Disc Vessel Hemorrhages Exudates

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Pulses Pulses • Rate • Rhythm • Volume – Quincke’s – Water hammer – Brachio-radial delay

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Carotid Carotid • Upstroke-normal/brisk/delayed/anacrotic • Volume-normal/increased/decreased • Auscultate: – Bruit – Murmur – S2 audible ? Over carotid?

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Carotid Carotid Tutorial Tutorial

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JVP JVP • • • •

Height Waveform Specific patterns Response to maneuvers – Inspiration – HJR

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JVP JVP Inspection Inspection

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JVP JVP Summary Summary • Confirm it’s the JVP you are seeing – Compressibility – Waveform – Manoeuvers

• Identify the height – start at 30o • Identify the waveform © Continuing Medical Implementation

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If unable to see JVP-lie patient flat If still unable to see JVP-sit patient…...bridging uprightthe care gap © Continuing Medical Implementation

Use Use the the hand hand made made ruler ruler

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Normal Normal JVP JVP Waveform Waveform

a

c

v

x x′

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y

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JVP JVP Inspection Inspection • Look for descents not waves • Descents are easier to see due to greater amplitude and frequency • Time deepest descent with systole. This is the X’ descent © Continuing Medical Implementation

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Specific Specific JVP JVP patterns patterns Condition

Pattern

Normal waveform

X' deeper than Y

Post CABG

X' shallower, now = Y

Atrial fibrillation

CV wave

Tricuspid regurgitation

CV wave

Complete heart block

Irregular cannon A waves

Tamponade

↑ JVP brisk X' > Y

Constriction

↑JVP brisk X' & Y descents X' less exaggerated than Y

RV infarction © Continuing Medical Implementation

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Precordium Precordium • Palpate: Aortic → Pulmonary → LSB → Apex → Left decubitus • Thrills • Palpable HS • Lifts • Apex: size/position/motion

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Auscultation Auscultation • Follow same sequence • Aortic → Pulmonary → LSB → Apex → Left decubitus → Upright lening forward • Diaphragm except for apex (use both here) • Identify HS, then extra sounds, them murmurs • Dynamic maneuvers © Continuing Medical Implementation

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Palpation Palpation -- Precordium Precordium Parasternal: • Palpable P2-pulmonary HTN • Thrill – VSD/HCM

• RV lift – RVH – Severe MR © Continuing Medical Implementation

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Palpation Palpation -- Apex Apex Apex: • Palpable in 1 of 5 adults age 40 • Best felt with fingertips or finger pads Normal Location: • No more than 10 cm from mid-sternal line in the supine position • Left decubitus position not reliable for apical location Normal Size: • No larger than 3 cm (about 2 finger breadths)

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Apex–Dynamic Apex–Dynamic Abnormalities Abnormalities Sustained Apex: • correlates with pressure overload or LVF • ( > 2/3 systole-hangs out to S2) • AS, LVH or LV systolic dysfunction Hyperdynamic Apex: • correlates with volume overload AR/MR • palpable S4 (atrial kick) • palpable S1 (MS) • palpable non-ejection click (MVP)

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Apex–Dynamic Apex–Dynamic Abnormalities Abnormalities Atrial kick: • Palpable S4 – – – –

Loss of LV compliance LVH 2o Hypertension Aortic Stenosis Hypertrophic Cardiomyopathy

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Auscultation Auscultation

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What What are are we we listening listening for? for?

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Normal First & Second Sounds

Normal First & Second Sounds 2

Splitting of the Second Sound

Timing of Cardiac Sounds

Fourth Heart Sound S4 Gallop

Third Heart Sound S3

Systolic Murmurs

Diastolic Murmurs

Common Common Murmurs Murmurs Systolic Murmurs • Aortic stenosis • Mitral insufficiency • Mitral valve prolapse • Tricuspid insufficiency Diastolic Murmurs • Aortic insufficiency • Mitral stenosis © Continuing Medical Implementation

S1

S2…...bridging the care gap S1

Auscultation Auscultation Grading of Murmurs: Grade 1 - only a staff man can hear Grade 2 - audible to a resident Grade 3 - audible to a medical student Grade 4 - associated with a thrill or palpable heart sound Grade 5 - audible with the stethoscope partially off the chest Grade 6 - audible at the bed-side

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Characteristics Characteristics of of aa “functional” “functional” murmur murmur • • • •

Short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for any hemodynamic abnormality

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Functional Functional (Innocent) (Innocent) Murmurs Murmurs Common Common in in asymptomatic asymptomatic adults adults

• Characterized by – Grade I – II @ LSB – Systolic ejection pattern - no ↑ with Valsalva/↓ upright

– – – –

S1 S2 Normal precordium, apex, S1 Normal intensity & splitting of second sound (S2) No other abnormal sounds or murmurs No evidence of LVH

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Characteristic Characteristic of of the the NOT NOT Innocent Innocent Murmur Murmur • • • • •

Diastolic murmur Loud murmur - grade IV or above Regurgitant murmur Murmurs associated with a click Murmurs associated with other signs or symptoms e.g. cyanosis • Abnormal 2nd heart sound – fixed split, paradoxical split or single © Continuing Medical Implementation

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Integrating Integrating Pulse Pulse with with HS HS and and Murmurs Murmurs

www.blaufuss.org

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Examining Examining the the Peripheral Peripheral Pulses Pulses

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Retinal Carotids Brachial Ulnar Radial Femoral Popliteal Posterior Tibial Dorsal Pedis

Renal

Examination Examination of of Pulses Pulses • Grading: – Normal/Increased/Decreased/Absent – 2+/3+/1+/0 – Allen’s test

• Trophic changes/Ulceration • Perfusion – Pallor on elevation – Rubor on dependency – Venous refill with dependency (should be less than 30 seconds)

• Bruits

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Trophic Trophic Changes Changes Shiny, hairless skin, dystrophic nail changes and dependent rubor associated with peripheral arterial occlusive disease of the patient's right foot

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Pallor Pallor on on elevation elevation Rubor on dependency

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Digital Digital Ischaemia Ischaemia Gangrene Gangrene

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A A Practical Practical Guide Guide to to Clinical Clinical Medicine Medicine -- UCSD UCSD Acute Arterial Insufficiency: Mottled Appearance of Skin

Chronic Arterial Insufficiency with Ulcers

http://medicine.ucsd.edu/clinicalmed/extremities.htm © Continuing Medical Implementation

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Measurement of the Ankle-Brachial Index (ABI)

Hiatt©W. N Engl JMedical Med Implementation Continuing 2001;344:1608-1621

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Venous Venous Abnormalities Abnormalities Varices Varices

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Spider Spider Veins Veins

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Venous Venous Insufficiency Insufficiency

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Stasis Stasis Dermatitis/Ulceration Dermatitis/Ulceration

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Edema Edema

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Cellulitis Cellulitis vs vs DVT DVT Cellulitis

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Right Deep Venous Thrombosis

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