Cardiovascular system

History & Examination

Cardinal symptoms Chest pain DOE, PND, orthopnea Palpitation, syncope Edema or weight gain Claudication Cyanosis

Relevant other examination Vitals- Temperature, PR, BP, RR Pallor/cyanosis Clubbing Edema Hepatomegaly and/or splenomegaly Crepitations at lung base

Cardiac examination Pulse Blood pressure Jugular venous pulse (JVP) Inspection Palpation Auscultation

Pulse

Palpable- temporal, CAROTID, brachial, RADIAL, femoral, popliteal,

posterior tibial, dorsalis pedis

Pulse Rate- normal 60-100 per minute Rhythm- regular or

irregular (atrial fibrillation, ectopics)

Volume- rough guide of pulse pressure Character Radio-femoral delay

R & R- radial, Vol. & Charac.- carotid

Character of pulse Slow rising- AS Collapsing- AR Bisferiens- AR & AS Pulsus paradoxus- heart sounds heard,

but no radial pulse- seen with cardiac tamponade or severe asthma

Pulsus alternans- alternate strong & weak beats- seen in severe LVF

Blood pressure Measured by sphygmomanometer Patient comfortable Manometer at the level of arm Cuff length- >40% arm circumference Proper cuff width- 2/3rd of arm- 12.5 cm. Korotkoff sounds heard by stethoscope Appearance- systolic BP Disappearance- diastolic BP Pulse pressure- systolic - diastolic

Classification of BP Normal- 90-119/60-79 Pre-HT- 120-139/80-89 Stage 1- 140-159/90-99 Stage 2- >160/>100 Systolic- >140/<90

AHA,2003

Jugular venous pulse

Internal jugular veinAt an angle of 45 degree

Look tangentially

JVP vs. Carotid pulse Better seen 2 upstrokes/beat Upper level Less forceful Easily obliterated Changes with

posture/respiration HJ reflux +ve

Better felt 1 upstroke/beat No upper level More forceful Not obliterated No change with

posture/respiration No change

Jugular venous pulse a wave- atrial contraction with TV open,

precedes S1 c wave- bulging of closed TV in atrium x descent- atrial relaxation with TV closed,

precedes S2 v wave- atrial f i l l ing with TV closed y descent- atrial emptying with TV open

x, v- systolic; y, a- diastolic

Abnormal JVP a absent- A-fib. a large- TS, PS, PHT a cannon- arrythmia- CHB, VT, ectopics y & x prominent- constric. pericarditis y prominent, x absent- TR y slow- TS

Inspection Proper exposure

Deformity Apex beat Scars Respiration

Palpation- apex beat Lowest & outermost point of definite cardiac

pulsation Lies just medial to MCL in 5th ICS Size- 1-2.5 cm. Caused by left ventricle Normally <50% of systole Hyperkinetic- <50% systole, forceful, dilated LV,

regurgitant lesion (MR/AR), ±S3 Sustained- >50% systole, forceful, hypertrophic LV,

stenotic lesion (AS/HOCM) or HT, ±S4

Palpation- other Parasternal impulse- enlarged LA/RV Thrill- palpable murmur (>grade 3) Other palpable sounds S1- apex, MS A2- R 2nd ICS, systemic HT P2- L 2nd ICS, pulmonary HT S3/S4- apex/L parasternal,

dilatation/hypertrophy of ventricle Aortic pulsation- chest/epigastrium,

consider aneurysm

Auscultation- normal Palpate carotid simultaneously Areas for auscultation Mitral- apex Tricuspid- L parasternal Aortic- R 2nd ICS Pulmonary- L 2nd ICS Only S1 & S2 are heard S1- closure of MV/TV, single, systole begins S2- closure of AV/PV, split (normally A2 before P2,

best heard in pulmonary area during inspiration), systole ends

Auscultation areas

Auscultation- abnormal Altered intensity (soft/loud) All soft- emphysema, pericardial effusion Soft S1/A2/P2- calcific valve Loud S1- non-calcific MS, tachycardia, ASD/Ebstein’s, high cardiac

output states like anemia, exercise, hyperthyroidism Loud A2/P2- systemic/pulmonary HT

Splitting of S2 Single- AS/PS Wide- PS, RBBB Fixed- ASD Reverse- LBBB (appears on expiration, disappears on inspiration) Syst./pulm. HT- wide, narrow or reverse split

Auscultation- other sounds Systolic- Early ejection click- AV/PV Mid/late ejection click- MVP Diastolic- Opening snap- MS S3- poor LV compliance- CHF, DCMP S4- increased LV resistance- HT, AS, HOCM

Auscultation- murmurs Due to turbulent blood flow Characteristics- Timing- systolic/diastolic, early/mid/late/pan Location- apex, LLSB, aortic/pulmonary area Radiation- AS to carotids, MR to axilla Duration/shape Grade- 1-6, grade 4 causes palpable thrill Pitch- high-regurgitant/low-stenotic Quality- blowing high-pitched- regurgitant,

harsh rough rumbling low-pitched- stenotic

Variation- with respiration, position, valsalva etc.

Auscultation- murmurs Systolic- Ejection- AS/PS, flow murmurs (non pathological) Pan- MR/TR, VSD Late- MVP, HOCM Diastolic- Early- AR/PR Mid- MS/TS Continuous- PDA

Supported by

ECG, CxR, ECHO