How to Examine the Heart and Blood Vessels

© Continuing Medical Implementation …...bridging the care gap

How to Examine the Heartand Blood Vessels

How to Examine the Heartand Blood Vessels

Joel Niznick MD FRCPC




Look at the patientLook at the patient

• Sick/well• Comfortable/in distress• Cyanosed/plethoric• Wet/dry• Young/old• Male/Female• Establish probabilities of disease

– History will have told you what to suspect


Common Clinical Scenarios

Common Clinical Scenarios

• Younger people– Functional murmur

vs MVP vs bicuspid AV

• Older people– Aortic sclerosis vs

aortic stenosis


ProbabilitiesProbabilities

• Males more commonly have aortic valve disease– Young – BAV

– Elderly - Degenerative

• Females more commonly have mitral valve disease

• MVP > rheumatic heart disease


InspectInspect

• Facies/body habitus– Cyanosis– Xanthelasma– Arcus senilis– Conjunctival hemorrhages

• Syndromes– Marfan’s– Down’s


HandsHands

• Clubbing• Capillary return• Digital ischaemia• Splinter hemorrhages• Osler’s nodes• Janeway lesions


Blood pressureBlood pressure

• At rest 5”

• Both arms

• Legs if young hypertensive

3

RECOMMENDED BLOOD PRESSURERECOMMENDED BLOOD PRESSUREMEASUREMENT TECHNIQUEMEASUREMENT TECHNIQUE

2.• The cuff must be level with heart.

• If arm circumference exceeds 33 cm,a large cuff must be used.

• Place stethoscope diaphragm overbrachia l artery.

2.2.•• The cuff must be level with heart.The cuff must be level with heart.

•• If arm circumference exceeds 33 cm,If arm circumference exceeds 33 cm,a large cuff must be used.a large cuff must be used.

•• Place stethoscope diaphragm overPlace stethoscope diaphragm overbrachia l artery.brachia l artery.

1.• The patient should

be relaxed and thearm must besupported.

• Ensure no tightclothing constrictsthe arm.

1.1.•• The patient shouldThe patient should

be relaxed and thebe relaxed and thearm must bearm must besupported.supported.

•• Ensure no tightEnsure no tightclothing constrictsclothing constrictsthe arm.the arm.

3.• The column of

mercury must bevertical .

• Infla te to occlude thepulse. Deflate at 2 to3 mm/s. Measuresystolic (first sound)and diastolic(disappearance) tonearest 2 mm Hg.

3.3.•• The column ofThe column of

mercury must bemercury must bevertical .vertical .

•• Infla te to occlude theInfla te to occlude thepulse. Deflate at 2 topulse. Deflate at 2 to3 mm/s. Measure3 mm/s. Measuresystolic (first sound)systolic (first sound)and diastolicand diastolic(disappearance) to(disappearance) tonearest 2 mm Hg.nearest 2 mm Hg.

StethoscopeStethoscope

MercuryMercurymachinemachine


Look at the FundiLook at the Fundi

OSU Interactive Physical Exam Guide


Look at the FundiLook at the Fundi

• Disc

• Vessel

• Hemorrhages

• Exudates


PulsesPulses

• Rate

• Rhythm

• Volume– Quincke’s– Water hammer– Brachio-radial delay


CarotidCarotid

• Upstroke-normal/brisk/delayed/anacrotic

• Volume-normal/increased/decreased

• Auscultate:– Bruit– Murmur– S2 audible ? Over carotid?


Carotid TutorialCarotid Tutorial


JVPJVP

• Height

• Waveform

• Specific patterns

• Response to maneuvers– Inspiration– HJR


JVP InspectionJVP Inspection



JVP SummaryJVP Summary

• Confirm it’s the JVP you are seeing– Compressibility

– Waveform

– Manoeuvers

• Identify the height – start at 30o

• Identify the waveform


If unable to see JVP-lie patient flatIf still unable to see JVP-sit patient upright


Use the hand made rulerUse the hand made ruler


Normal JVP WaveformNormal JVP Waveform

a c v

x

xy


JVP InspectionJVP Inspection

• Look for descents not waves

• Descents are easier to see due to greater amplitude and frequency

• Time deepest descent with systole. This is the X’ descent


Specific JVP patternsSpecific JVP patterns

Condition PatternNormal waveform X' deeper than Y

Post CABG X' shallower, now = Y

Atrial fibrillation CV wave

Tricuspid regurgitation CV wave

Complete heart block Irregular cannon A waves

Tamponade JVP brisk X' > Y

Constriction JVP brisk X' & Y descents

X' less exaggerated than Y

RV infarction JVP –low amplitude


PrecordiumPrecordium

• Palpate: Aortic → Pulmonary → LSB → Apex → Left decubitus

• Thrills

• Palpable HS

• Lifts

• Apex: size/position/motion


AuscultationAuscultation

• Follow same sequence

• Aortic → Pulmonary → LSB → Apex → Left decubitus → Upright lening forward

• Diaphragm except for apex (use both here)

• Identify HS, then extra sounds, them murmurs

• Dynamic maneuvers


Palpation - Precordium Palpation - Precordium

Parasternal:

• Palpable P2-pulmonary HTN

• Thrill– VSD/HCM

• RV lift– RVH– Severe MR


Palpation - ApexPalpation - Apex

Apex: • Palpable in 1 of 5 adults age 40• Best felt with fingertips or finger pads

Normal Location:• No more than 10 cm from mid-sternal line in the

supine position • Left decubitus position not reliable for apical locationNormal Size:• No larger than 3 cm (about 2 finger breadths)


Sustained Apex: • correlates with pressure overload or LVF• ( > 2/3 systole-hangs out to S2)• AS, LVH or LV systolic dysfunctionHyperdynamic Apex:• correlates with volume overload AR/MR• palpable S4 (atrial kick)• palpable S1 (MS)• palpable non-ejection click (MVP)

Apex–Dynamic AbnormalitiesApex–Dynamic Abnormalities


Apex–Dynamic AbnormalitiesApex–Dynamic Abnormalities

Atrial kick:

• Palpable S4– Loss of LV compliance– LVH 2o Hypertension– Aortic Stenosis– Hypertrophic Cardiomyopathy




What are we listening for?What are we listening for?

Normal First & Second Sounds

Normal First & Second Sounds 2

Splitting of the Second Sound

Timing of Cardiac Sounds

Fourth Heart Sound S4 Gallop

Third Heart Sound S3

Systolic Murmurs

Diastolic Murmurs


Common MurmursCommon Murmurs

Systolic Murmurs• Aortic stenosis• Mitral insufficiency• Mitral valve prolapse• Tricuspid insufficiency

Diastolic Murmurs• Aortic insufficiency• Mitral stenosis

S1 S2 S1


Grading of Murmurs:Grade 1 - only a staff man can hear

Grade 2 - audible to a resident

Grade 3 - audible to a medical student

Grade 4 - associated with a thrill or palpable heart sound

Grade 5 - audible with the stethoscope partially off the chest

Grade 6 - audible at the bed-side



Characteristics of a “functional” murmurCharacteristics of a

“functional” murmur

• Short and soft SEM

• Normal S1 and S2

• Normal cardiac impulse

• No evidence for any hemodynamic abnormality


Functional (Innocent) MurmursCommon in asymptomatic adults

Functional (Innocent) MurmursCommon in asymptomatic adults

• Characterized by– Grade I – II @ LSB

– Systolic ejection pattern - no with Valsalva/ upright

– Normal precordium, apex, S1

– Normal intensity & splitting of second sound (S2)

– No other abnormal sounds or murmurs

– No evidence of LVH

S1 S2


Characteristic of the NOT Innocent Murmur

Characteristic of the NOT Innocent Murmur

• Diastolic murmur• Loud murmur - grade IV or above• Regurgitant murmur• Murmurs associated with a click• Murmurs associated with other signs or

symptoms e.g. cyanosis• Abnormal 2nd heart sound – fixed split,

paradoxical split or single


Integrating Pulse with HS and Murmurs

Integrating Pulse with HS and Murmurs

www.blaufuss.org


Examining the PeripheralPulses

Examining the PeripheralPulses

FemoralPopliteal

Posterior Tibial

Dorsal Pedis

Radial

Ulnar

Brachial

Retinal

Carotids

Renal


Examination of PulsesExamination of Pulses

• Grading: – Normal/Increased/Decreased/Absent– 2+/3+/1+/0 – Allen’s test

• Trophic changes/Ulceration• Perfusion

– Pallor on elevation– Rubor on dependency– Venous refill with dependency (should be less than 30

seconds)

• Bruits


Trophic Changes Trophic Changes

Shiny, hairless skin, dystrophic nail changes and

dependent rubor associated with

peripheral arterialocclusive disease of

the patient's right foot


Pallor on elevationPallor on elevation

Rubor on dependency


Digital IschaemiaGangrene

Digital IschaemiaGangrene


A Practical Guide to Clinical Medicine - UCSD

A Practical Guide to Clinical Medicine - UCSD

Acute Arterial Insufficiency:

Mottled Appearance of Skin

Chronic Arterial Insufficiencywith Ulcers

http://medicine.ucsd.edu/clinicalmed/extremities.htm

© Continuing Medical Implementation …...bridging the care gap Hiatt W. N Engl J Med 2001;344:1608-1621

Measurement of the Ankle-Brachial Index (ABI)


Venous AbnormalitiesVarices

Venous AbnormalitiesVarices


Spider VeinsSpider Veins


Venous InsufficiencyVenous Insufficiency


Stasis Dermatitis/Ulceration Stasis Dermatitis/Ulceration


EdemaEdema


Cellulitis vs DVTCellulitis vs DVT

Right Deep Venous Thrombosis

Cellulitis

© Continuing Medical Implementation …...bridging the care gap www.cvtoolbox.com



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How to Examine the Heart and Blood Vessels

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