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1 Cardiovascular Examination Deling Zou. 2 Anatomy.

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Presentation on theme: "1 Cardiovascular Examination Deling Zou. 2 Anatomy."— Presentation transcript:

1 1 Cardiovascular Examination Deling Zou

2 2 Anatomy

3 3

4 4 Inspection 1 Precardial projection and excavation 2 Apical impulse 3 Abnormal pulsations of precardium

5 5 1 Precardial projection and excavation 1) Precardial projection congenital heart disease: tetralogy of Fallot Valvular heart disease-- MS,PS pericardial effusion (large, childhood) Inspection

6 6 The second right intercostal space(2nd ICS-RS) aneurysm of aortic arch dilatation of ascending aorta 2) flat chest 3) pigeon chest/funnel chest

7 7 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

8 8 *Abnormal 1) Location #diaphragm: “transverse position” upper,outward obesity,child, pregnacy; ascites; tumor of abdominal cavity “vertical position” (thin, high, emphysema) inferior,inner

9 9

10 10 one side pleural effusion or pneumothorax—to the healthy side one side atelectesis or pleural adhesion—to the affected #mediastinum:

11 11 #enlargement of the heart right ventricular dilatation –left or slightly upper left ventricular dilatation—left inferior LV &RV dilatation –left inferior (both side dilatation)

12 12

13 13 #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

14 14 2)Intensity and extent changes Inspection- apical impulse - abnormal

15 15 3)Inward impulse: apex excavation in the systole seen: adhensive pericarditis prominent RV hypertrophy Inspection -apical impulse - abnormal

16 16 Inspection 1)left third-forth intercostal space lateral to the sternum(3,4ICS-LS) seen: RV hypertrophy 3Abnomal pulsations of percardium

17 17 2)hypoxiphoid process seen: difference deep inspiration RV hypertrophy ↑ abdominal aorta (aneurysm) ↓

18 18 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

19 19 Palpation 1 Apical impulse and pulsation of precardium 2 Thrill 3 Pericardial friction rub

20 20 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

21 21 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

22 22 CHD:congenital heart disease

23 23 1)Precardium-4 th ICS-LS 2) both phases of the cardiac cycle 3) systolic period, sitting erect and leaning forward, the end of expiration 4)mechanism: rub of the visceral and parietal layers of pleura 5)seen:acute pericarditis 3 Pericardil friction rub

24 24 Percussion Aim:to determine the size and shape of the heart. Absolute dullness: contain no gas Relative dullness : real size

25 25 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

26 26 2 order : left—right ; upwards ; inward left margin : from 2-3 cm lateral to the apex beat up to the 2 nd ICS right margin : one intercostal space higher than the border of liver dullness up to the 2 nd ICS size: vertical distance from margin to the anterior midline

27 27

28 28 Percussion

29 29 Percussion

30 30 (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

31 31 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

32 32 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

33 33 4)LA and/or pulmonary artery: LA:concave part disappear LA+PA:2,3 ICS-LS outwards “pear shape” Seen: MS--- “mitrial type”

34 34 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”

35 35 6)dilatation of the aorta /ascending aortic aneurysm: widening if the dull area of first and second intercostal space (with systolic pulsation)

36 36 Extacardial factors : 1)large pleural effusions and pneumothorax → to the healthy side 2)atelectasis /pleural pachynsis →to the affected 3)a large amount of ascites or big abdominal tumor: diaphragm elevated→transverse position →left side enlargement

37 37 Ausclutation

38 38 1 Ausclutatoty valve areas 1)ausclutatory mitral area: apical area 2)ausclutatory pulmonary area:2 ICS- LS 3)ausclutatory aortic area: 2 ICS-RS 4)second ausclutatory aortic area: 3 rd ICS-LS—Erb area 5)tricuspid area :4,5 ICS-LS

39 39

40 40 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

41 41 1)heart rate: 60~100bpm F > M child ( < 3 years) > 100bpm tachycardia: normal adult > 100bpm child( < 3 years) > 150bpm bradycardia: HR < 60 bpm

42 42 Ausclutation heart rate:60-100bmp

43 43 2)cardiac rhythm: *sinus arrythmia—affected by breath *premature beat: classification:atrial~ ventricular ~ junctional ~ frequently: > 6 bpm occasionally: < 6 bpm bigeminy trigeminy

44 44 *atrial fibrillation: absolute irregular rhythm S1 intensity inequality Pulse deficit seen:MS,CHD,hyperthyroidism, PHD,DCM

45 45 Ausclutation atrial fibrillation

46 46 3) cardiac sound

47 47 Ausclutation content cardiac sound  S1 :  S2 :

48 48

49 49 4)Abnormal cardiac sound *Intensity: position of the atrioventricular valve Ventricular contractility and output Valvular integrity and activity

50 50 S1: Accentuation: MS HR↑contractility↑ fever,anemia,hyperthyroidism complete AVB →cannon sound

51 51

52 52 S1 attenuation : MI P-R interval enlong AI myocarditis,myopathy,MI,HF inequality: af, III°AVB

53 53

54 54 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

55 55

56 56 *Quality mono rhythm pendular rhythm---embryocardia *Splitting of heart sound S1 splitting: seen—RBBB, right heart failure Ebetein malformation,MS LA myxoma

57 57

58 58 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

59 59

60 60 5)extra cardiac sound Diastolic period 1)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

61 61

62 62

63 63 5) extra cardiac sound Diastolic period 2)opening snap:MS 3)pericardial knock: constrictive pericarditis 4)tumor plop: LA myxoma

64 64

65 65 Ausclutation CONTENT Tumor plop

66 66 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

67 67

68 68

69 69 iatrogenic (1)prosthetic valvular sound (2)pacemaker

70 70 6)cardiac murmurs

71 71

72 72 *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

73 73 (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

74 74 (6) others: body position: MS--left lateral position AI--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

75 75 clinical significance murmurs: functional and organic 7)pericardial friction sound: both phases, unaffected by respiration. seen: pericarditis, RHD,AMI,renal failure, SLE

76 76 * clinical significance of cardiac murmurs systolic murmurs MV : functional:exercise,fever,anemia,pregnancy, hyperthyroidism relative:HBP,CHD,DCM,anemia organic : MI(RHD),mitral prolapse

77 77

78 78 * clinical significance of cardiac murmurs systolic murmurs Aortic area : organic : AS relative : dilatation of ascending aorta

79 79

80 80 * clinical significance of cardiac murmurs systolic murmurs pulmonary : physiology relative : MS 、 ASD organic : PS TV : relative : RV enlarged organic : rare

81 81 * clinical significance of cardiac murmurs Diastolic murmurs MV:organic:RHD(MS) relative:AI(severe) Austin Flint murmur AV:AI

82 82

83 83

84 84 * clinical significance of cardiac murmurs Diastolic murmurs PV:organic murmur is rare PI(dilatation of pulmonary artery) MS+P2 ---- Graham Steell murmur TV:rare

85 85 * clinical significance of cardiac murmurs continuous murmurs PDA innocent murmur

86 86 Vascular examination The second clinical hospital of CMU

87 87 pulse pulse rate pulse rhythm tensions and state of arterial wall intensity pulse wave

88 88 pulse pulse rate Atrial fibrillation and frequent premature beat stroke volume peripheral artery no pulse pulse rate less than HR(pulse deficit)

89 89 pulse pulse rhythm pulse deficit ; bigeminal pulse,trigeminal pulse ; dropped pulse

90 90 pulse tensions and state of arterial wall Artery tension depending on blood pressure (mainly SBP). Judge state of artery wall

91 91 pulse intensity Bownding pulse seen:high fever, hyperthyroidism, AI Microsphygmia seen:HF,AS and shock

92 92 pulse pulse wave normal pulse wave composed of upstroke ( knocking wave )、 peak ( tide wave ) and downstroke ( dicrotic wave )

93 93 pulse pulse 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

94 94 blood pressure method of measurement  direct measurement method  indirect measurement method

95 95 blood pressure standard definition of Bp level and classification(older than 18 years old) classification SBP(mmHg) DBP(mmHg) Ideal BP  120  80 Normal BP  130  85 High limit of BP 130-139 85-89 Grade 1 ( mild ) 140-159 90-99 subgroup : boundline hypertension 140-149 90-94 Grade 2 ( moderate ) 160-179 100-109 Grade 3 ( severe ) ≥ 180 ≥110 Simple systolic hypertension  140  90 subgroup : boundline systolic hypertension 140-149  90

96 96 blood pressure clinical significance of BP changes hypertension : higher than 140/90mmHg for 3 times not in the same day hypotension : lower than 90/60-50mmHg Shock,,MI,acute cardiac tamponade obvious difference between bilateral upper limbs : more than 10mmHg---arteritis,congenital artery malformation difference between upper and lower limbs : lower limb BP is 20-40mmHg higher than upper one normally pathological:constrictive aorta,arteritis(chest-abdominal aorta) change of pulse BP :  40mmHg , wide pulse BP---hyperthyroidism,AI  30mmHg , narrow pulse BP---AS,pericardial effusion

97 97 blood pressure dynamic BP monitoring Average BP for 24h  130/80mmHg; bright day  135/85mmHg; night:  125/75mmHg Peak:6am—10am,4pm—6pm

98 98 Vessel murmur and peripheral vessel sign venous murmur jungular murmur : is caused by the rapid flow of jungular vein into SVC (superior vena cava)

99 99 Vessel murmur and peripheral vessel sign 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

100 100 peripheral vessel sign pistol shot sound Seen:AI,hyperthyroidism,severe anemia Durozier’s murmur capillary pulsation Vessel murmur and peripheral vessel sign

101 101 The main symptoms and signs of common diseases of circulatory system

102 102 Causes: RHD:rheumatic heart disease CHD:congenital heart disease Other reasons: senile retrograde Mitrial stenosis

103 103 Symptoms: cough; hemoptysis; dyspnea: dyspnea on exertion→ paroxysmal nocturnal dyspnea → pneumonedema

104 104 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

105 105 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)

106 106 Mitral Insufficiency RHD / non-RHD ; acute/chronic Symptoms: fatigue, palpitations, dyspnea on exertion, Left heart failure

107 107 Signs : Inspection : apex beat is displaced downwards and to the left

108 108 Palpitation : apical impulse forceful Heaving apex impulse Severe systolic thrill Percussion : the area of dullness to left and downwards

109 109 Auscultation : 1)S1 ↓(attenuation) 2)murmurs: harsh; pansystolic murmur; blowing; 3/6 grade ↑ wide spread-transmitted to left axilla left infrascapular angle

110 110 Aortic Stenosis Causes: RHD Congenital Senile retrograde Symptoms : palpitation,dizziness, angina pectoris, syncope, HF-dyspnea

111 111 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

112 112 Percussion: the area of dullness is normal or to left and downward Auscultation : 1)murmur: aortic auscultatory valve area systolic murmur harsh,ejection sound, 3/6 grade ↑(thrill) transmitted to neck 2)A2 ↓,reversed splitting 3)S4

113 113 Aortic Insufficiency Causes: RHD Non-RHD : congenital prolapse syphilis aortitis arteriosclerosis endocarditis acute/chronic

114 114 Symptoms : palpitation, dizziness, LHF Signs Inspection : apical impulse to left and downwards Palpation : apex impulse to left and downwards Heaving apex impulse

115 115 Percussion : the area of cardiac dullness is enlarged downwards and to the left; the concave part of the heart is not enlarged (boot shape)

116 116 Auscultation : 1)specific murmur: diastolic ; sighing ; aortic area; heard clearly sitting erect and forward 2)Austin Flint murmur : relative MS (rumbling mid-diastolic murmur)

117 117 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

118 118 Pericardial effusion Causes: infective and non-infective pericarditis Symptoms : pain over the pericardial region Dyspnea, cough, fever, lassitude Shock

119 119 Signs : Inspection : diminution in strength of the apex beat or absence of the apex beat ; jugular venous enlargement

120 120 Palpation : *diminution in strength of the apex beat or the apex beat palpated uneasily *paradoxical pulse may be present

121 121 Percussion : enlargement of the cardiac dullness bilaterally, changed with posture

122 122 Auscultation : *pericardial friction sound *HR↑,diminution of intensity of cardiac sound (S1/S2↓) *pericardial knock may be heard

123 123 * Large effusion: Jugular varicosity Liver enlargement Paradoxical pulse Pulse pressure ↓

124 124 * Kussmaul sign: deep inspiration –jugular vein distension *Ewart sign: left infrascapular region vocal fremitus↑ dullness -- percussion bronchovesicular breath sound-- auscultation

125 125 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

126 126 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

127 127 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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