Cvs Inspection

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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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Cvs Inspection

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