cvs inspection
TRANSCRIPT
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INSPECTIONOF
CARDIOVASCULAR
SYSTEMDr. Ch.VIJAY
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Patient must be stripped to waist.
Examined in good light.
Examined in both upright and in lying down
position.
Examiner should sit or stand directly facing thepatient.
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The examination includes 2 parts :-
A) INSPECTION OF NECK
B ) INSPECTION OF CHEST
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VENOUS PRESSURE
ARTERIAL PULSE
ENGORGEMENT OF LEFT EXTERNAL
JUGULAR VEIN
DETECTION OF GOITRE
WEBBING OF NECK
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Venous pressure measured >3 cm above the sternal angle is consideredelevated
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NORMAL JUGULAR VENOUS WAVES
a wave - atrial systolex descent onset of atrial relaxationc wave - small positive notch in the'x' descent due to bulging of the AVring into the atria in isovolumetricventricular contraction.
v wave - after the x' descent - slowpositive wave due to right atrial fillingfrom venous returny descent- rapid emptying of the RAinto RV due to TV opening
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VENOUS PULSATIONS ARTERIAL PULSATIONS
b/w SCM 2 heads &clavicleSuperficial ,widespreadVisibility>>>palpabilityObliterable
Multiple pulsationsChanges with -respiration -position -abd.pressureUpper limit visible 2 peaks/heart beat2 descents,rapid
Medial to SCM
Deeper,localised
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CAROTID PULSATIONS Carotid shudder A coarse vibration at the height of carotid
pulse said to be diagnostic of combined AS+AR. Dancing carotids(Corrigans Sign) Massive pulsation of
neck carotid arteries observed in AR. These pulsations are
severe enough to cause visible movement of ears or headwith each beat of heart(Alfred de Mussets sign). Pulsating carotids are usually indicative of wide arterial
pulse pressure. Kinked carotid artery
Males suggestive of coarctation of aorta.Females have a small pulsatile oval swelling in persons
with hypertension, atheroma, and kyphoscoliosis. Prominent pulsation on right side of neck, in hypertension,
is referred to as Rowntrees sign. contd
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EPIGASTRIC PULSATIONS
Epigastric pulsation may be cardiac, aortic, or hepatic
in origin.
Character Cardiac pulsations Aortic pulsations Hepatic pulsations
Relation to apical
thrust
Synchronus with
apex
Soon after apex Soon after apex
Thrust orretraction
More of retraction More of thrust More of thrust
Location High up inepigastrium
Low down inepigastrium
Right of themidline
Causes MSLt sided pleuraleffusion
NervousnessTransmittedpulsations byabdominal lumpAneurysm ofabdominal aorta
Enlarged pulsatingliver in TR or TS
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DISTENDED SUBCUTANEOUS ARTERIES :-
Dilated and tortuos superficial arteries under the skin
of the chest and back are a characteristic feature ofcoarctation of the aorta.
Suzmans sign?
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Size, shape and type of chest
Shape of the precordium
Apical thrust
Other pulsations of the precordium
Other pulsations of the chest wall
Suprasternal or episternal pulsation
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They have a direct bearing on presence of atypical orabnormal physical signs in the chest as in funnelchest, rachitic chest, and scoliosis, or the straight backsyndrome.
It is also responsible for diseasedcondition of the heart, as inemphysema and severe
kyphoscoliosis.
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Bulging or retraction of the precordium may be dueto diseases outside the heart; they should be ruledout first, before implicating heart as the cause.
PRECORDIAL BULGING :- A good sign forrecognizing bulge in male is lateral displacementand elevation of left nipple in comparison withright.
Causes :
1) Skeletal deformities2) Diseases of lung and pleura
3) Diseases of heart or precordium
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BACKWARD BULGE :-
1) Pectus excavatum
2) Shield chest
PRECORDIAL FLATTENING :-
1) Old pericarditis or adherent pericardium
2)
Fibrosis or collapse of lung3) Scoliosis or kyphoscoliosis
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APEX BEAT v/s PMI :
The term PMI is often used as a synonym for an apex beat. It actually meanspoint of maximum impulse i.e. the site of the
loudest murmur.
The maximal precordial pulsations
may be due to
Dilated pulmonary artery
Large RV
Ventricular aneurysm
Aortic aneurysm
Hence THE DEFINITION OF APEX BEAT is thelowermost and outermost point of definite cardiacimpulse, which can be appreciated.
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NORMAL VARIATIONS :-
A. Infancy or childhood, apex is in 4th intercostal space.
B. In thin, narrow chested, and elderly subjects, seen in6th intercostal space.
C. In obesity, abdominal distension and during
pregnancy, it may be displaced slightly outward andupward by the raised diaphragm.
D. Apical thrust is normally invisible in few persons dueto
1) Heart being situated behind a rib2) Thick chest wall
3) Pendulous breast
4) Emphysematous chest
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POSTURAL SHIFT :-
A. Mere shifting in bed from left lateral to the rightlateral position may shift the apex as much as 11/2 to2 inches.
B. A change from recumbent to the upright position oreven taking a deep breath may alter the position ofthe thrust.
C. Failure of apical thrust to shift in this manner(with
change in posture or on inspiration) is a sign ofadherent pericardium.
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APICAL THRUST MUST BE OBSERVED FOR :
Presence or absence
Location, whether normal or displaced
Extent, whether localized or diffuse
Direction of movement during systole, whetheroutward or inward (thrust or retraction)
Lack of mobility or fixation Other characteristics
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Displacement of apical thrust:- Due toA) Extrinsic or Extra cardiac causes
I) Extra thoracic scoliosis, straight back syndromeII) Intra thoracic Displaced
i. sideways pleural effusion, pneumothoraxii. downwards aortic aneurysm, mediastinal
new growthIII) Intra abdominal ascites, meteorism, massive
abdominal tumour or advanced pregnancy.B) Intrinsic or cardiac causes
I) Congenital dextrocardiaII)Acquired hypertension, aortic and mitral valve
disease
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Extent of apical thrust:- Diffuseness of thrust is
seen inA) Thin chest wallB) Hyperdynamic heart conditionsC) Severe valvular regurgitationD) Left to right shuntsE) Complete AV blockF) Hypertrophic obstructive cardiomyopathyG) Retraction of lung from fibrosis or collapse
A double systolic outward thrust is characteristic ofHOCM. It is also seen in mitral valve prolapse and LV
dyskinesia as in acute MI.
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Force of apex thrust:- force is visibly increased inA) Thin chest wallB) Retracted lungC) Hyperdynamic heartD) LV hypertrophy as in hypertension or AR
Cardiac causes of invisible apex :-A) Weak action of heart as in MI or acute myocarditisB) Pericardial effusionC) Dilation of heartD) Dextrocardia
Skodas sign :- (Negative cardiac impulse)It is sucking in or retraction during systole of the apical region. It may be due
toA) Hyperdynamic heart with apex situated behind a ribB) Hypertrophied right ventricle, with forward thrust in the midprecordial
area and retraction of apexC) Adhesive pericarditis, a diagnosis justified only when retraction involves
both ribs and interspaces (BROADBENTS SIGN)
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Best observed by tangential inspection of precordial area, preferablywith patient recumbent with lowering his eyes level to anteriorwall of patients chest.
Physiological diffuse pulsation (wavy or peristaltic cardiacimpulse) : Seen in
Thin chest individuals Hyperdynamic hearts During fever or after exercise Retracted lungs
Physiological para-apical retraction : A systolic retraction ofchest wall between the apical region and sternum, due to thesucking in effect of RV systole
It may be mistaken for abnormal apex.It is however situated medial to true apex and is a retraction rather
than a outward movement. Contd
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Left parasternal pulsation : A systolic heaving of the mid precordial area, maximal
between 3rd and 6th ribs is characteristic of massive RV
hypertrophy. A central lift may be due to systolic expansion of left
atrium from mitral regurgitation. A heave in the left parasternal region may be due to LV
hypertrophy.
Rocking or see saw movements : seen in massivehypertrophy of right or left ventricle.
In RV hypertrophy, an inward movement of the apex is
associated with an outward movement of the midprecordium
during systole
In LV hypertrophy, the phenomenon is reversed
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Diffuse systolic retraction : A diffuse retraction of
precordial area, involving ribs and interspaces is due tothe
Tricuspid regurgitation
Adhesive pricarditis
Aortic regurgitation
Lateral retraction in lateral decubitus position due to Large RV or severe TR (with initial outward
movement)
Constrictive pericarditis: systolic retraction (with initialoutward movement), followed by diastolic thrust
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High thoracic pulsations : Observed in 2nd rightintercostal space or behind the upper part of thesternum indicative of
Aneurysm of the ascending or transverse part of aortic
arch Dilatation of the aorta
AR
Pulsations involving the 2nd or 3rd left interspace due to :
Dilatation of pulmonary artery as in PDA or septaldefects,MS or aneurysmal dilatation of P.artery.
Retraction of left lung from fibrosis or collapse.
Aneurysm of descending thoracic aorta
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Pulsations of sternoclavicular joint: Due to Right side suggests right sided aortic arch
Either side occurs in aortic dissection or aneurysm
Systolic outward pulsation of upper half of sternum is dueto aneurysm of ascending aorta
Pulsation to right of sternum is due to dilated and unfolded
ascending thoracic aorta and rarely due to large right atrium
Pulsations in atypical situations
CAUSE LOCATION
Empyema necessitates Pulsatile swelling in lateral aspect of chest wallLymphosarcoma Highly vascular tumour in mid sternum
Descending thoracic aorta aneurysm Back
Innominate artery aneurysm Supraclavicular region or upper part of thorax
Coactation of aorta Interscapular and intercostal regions
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It may be seen in
Hyperdynamic heart.
Anemia.
Aneurysm of aorta. Dilatation of aorta as in atheroma or syphilitic
aortitis.
Raised or uncoiled aorta as in hypertension.
Elongation and flexion of the innominate artery.
Anomalous right subclavian artery.
Thyroidea ima artery.
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