Cardiovascular Examination Deling Zou

Anatomy

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

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

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

Inspection 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

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

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

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

#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

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

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

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

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

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

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

1 Apical impulse and pulsation of precardium Palpation 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

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

CHD:congenital heart disease

3 Pericardil friction rub 1)Precardium-4th 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

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

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

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

Percussion

Percussion

(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

5 Changes in the area of cardiac dullness and its significance Percussion 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

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

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

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”

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

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

Ausclutation

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: 3rd ICS-LS—Erb area 5)tricuspid area :4,5 ICS-LS

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

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

Ausclutation heart rate:60-100bmp

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

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

Ausclutation atrial fibrillation

3) cardiac sound

Ausclutation content cardiac sound S1： S2：

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

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

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

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

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

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

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

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

Ausclutation CONTENT Tumor plop

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

iatrogenic (1)prosthetic valvular sound (2)pacemaker

6)cardiac murmurs

*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

(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

(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

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

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

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

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

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

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

* clinical significance of cardiac murmurs continuous murmurs PDA innocent murmur

Vascular examination The second clinical hospital of CMU

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

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

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

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

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

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

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

blood pressure method of measurement direct measurement method indirect measurement method

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 boundline systolic hypertension 140-149 90

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

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

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

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

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

The main symptoms and signs of common diseases of circulatory system

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

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

Palpation :diastolic thrill palpable over the apical area 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

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)

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

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

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

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

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

Inspection : apical impulse increase Displaced to left and downwards 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

Percussion: Auscultation : 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

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

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

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

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

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

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

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

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

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

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

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

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

Causes : Symptoms: Heart Failure 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

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

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