Cardiovascular examination introduction Dr. Rasheed Ibdah For me, the only things of interest are those linked to the heart”

GENERAL EXAMINATION GUIDELINES

The patient: Should have their shirt(s) off, or wear an examination gown Females nine years old and older should wear a gown with the opening in the front Should be calm and quiet

The stethoscope: Should be your own!!! Should have a separate bell and diaphragm

The environment: Should be quiet (patient, family, clinic attendants, exam room, surrounding areas) May briefly disconnect ventilator or occlude suction devices

Physical Examination General Hands Pulse Blood pressure Face Neck Jugular venous pressure Precordium Inspection Palpation Percussion Auscultation Back Abdomen Lower limbs Other

Examination - General Position patient at 45 degrees Respiratory rate Cachexia Marfan’s syndrome Down’s syndrome

Examination - Hands Clubbing Splinter haemorrhages (infective endocarditis) Osler’s nodes (tender) Janeway lesions (non-tender) Xanthomata (Hyperlipidaemia)

Splinter Haemorrhages Clubbing

Examination – Face and Neck Jaundice Xanthelasmata Corneal arcus Malar flush (mitral stenosis) High arched palate (Marfan’s syndrome) Dental caries (infective endocarditis) Central cyanosis Carotid pulse character Slow rising (AS) Bisferiens (AS + AR) Collapsing (AR) Alternans (LVF) Jerky (HOCM) Carotid bruit

Precordium - Inspection Scars Median sternotomy CABG Valve replacement Lateral thoracotomy Infraclavicular (pacemaker) Pectus excavatum Pacemaker box Apex beat Sternotomy scar Pectus excavatum

Precordium - Palpation Apex beat Location Character Heaving Thrusting Double Tapping Paradoxical Left parasternal heave Thrills (palpable murmurs) Systolic Diastolic Palpable P2 (pulmonary hypertension) Pacemaker box

Precordium – Auscultation Murmurs Pitch Radiation Dynamic manoeuvres Respiration Left-sided  on exp. Right-sided  on insp. Valsalva Squatting Timing of murmur Systolic Diastolic Continuous Site of maximal intensity Loudness Grades I-VI Thrill

Where to listen: Apex/5LICS (mitral area) Left lower sternal border/4LICS (tricuspid and secondary aortic area) Right middle sternal border/2RICS (aortic area) Left middle sternal border/2LICS (pulmonary area)

AO PU TR MI

How to listen: Listen systematically: S1, S2, systolic sounds, systolic murmurs, diastolic sounds, diastolic murmurs

Normal heart sounds LUB DUP

Heart Murmurs Diastolic Systolic Continuous Pericardial friction rub Early diastolic Aortic regurgitation Pulmonary regurgitation Mid-diastolic Mitral stenosis Tricuspid stenosis Atrial myxoma Continuous Patent ductus arteriosus Arteriovenous fistula Pericardial friction rub Systolic Pansystolic Mitral regurgitation Tricuspid regurgitation Ventricular septal defect Ejection systolic Aortic stenosis Pulmonary stenosis HOCM Atrial septal defect Late systolic Mitral valve prolapse

S1 AV VALVES CLOSING (MITRAL AND TRICUSPID) START OF SYSTOLE LOUDEST AT APEX

S2 SEMILUNAR VALVES CLOSING: AORTIC AND PULMONIC A2 BEFORE P2 SPLITS WITH INSPIRATION AT PULMONIC AREA (LUSB) LOUDEST AT BASE (TOP OF HEART)

S1 vs S2: Differentiate S1 from S2 by palpating carotid pulse: S1 comes before and S2 comes after carotid upstroke

Extra heart sounds

S3 (gallop): Usually physiologic Low pitched sound, occurs with rapid filling of ventricles in early diastole Due to sudden intrinsic limitation of longitudinal expansion of ventricular wall Makes Ken-tuck-y rhythm on auscultation

S3 (cont.): Best heard with patient supine or in left lateral decubitus Increased by exercise, abdominal pressure, or lifting legs LV S3 heard at apex and RV S3 heard at LLSB

S4 (gallop): Nearly always pathologic Can be normal in elderly or athletes Low pitched sound in late diastole Due to elevated LVEDP (poor compliance) causing vibrations in stiff ventricular myocardium as it fills Makes “Ten-nes-see” rhythm

S4 (cont.): Better heard at the apex or LLSB in the supine or left lateral decubitus position Occurs separate from S3 or as summation gallop (single intense diastolic sound) with S3

S4 Associations: CHF!!! HCM severe systemic HTN pulmonary HTN Ebstein’s anomaly myocarditis

Friction rub: Creaking sound heard with pericardial inflammation Classically has 3 components; can have fewer than 3 components Changes with position, louder with inspiration

Examination - Pulse Radial artery Rate (normal = 60-100) Bradycardia (<60) Tachycardia (>100) Rhythm Regular Irregular Radiofemoral delay (coarctation of the aorta) Character and volume assessed from carotid artery Collapsing pulse (aortic regurgitation) Pulsus alternans (left ventricular failure) Pulse deficit (atrial fibrillation)

Rate: Bradycardic (conditioning, heart block, digoxin toxicity) Normal Tachycardic (CHF, excitement, fever, anemia, arrhythmia)

Rhythm: Regular Irregular (can be sinus arrhythmia with respiratory variation or PAC/PVC’s) Regularly irregular Irregularly irregular (arrhythmia)

Volume: Bounding/water hammer (pulse pressure >30 mmHg in infant, >50 mmHg in child) Full Normal Thready low output states: shock, severe CHF, large VSD or PDA L sided obstruction: AS, aortic atresia, HLHS Absent

Character: Normal Alternans Bisferiens Paradoxus

Jugular venous pulse WHAT: VISIBLE PRESSURE CHANGES IN RIGHT ATRIUM WHERE: UNDER STERNOCLEIDOMASTOID MUSCLE WHY: DIAGNOSE HEART FAILURE, FLUID OVERLOAD, AV BLOCK

JUGULAR VENOUS PULSE x y c a v