MG Cardiovascular System

8/4/2019 MG Cardiovascular System

1/30

Cardiovascular System

Joel M. Felner ( http://www.ncbi.nlm.nih.gov/books/NBK393/ )

The evaluation of the cardiovascular system includes a thoroughmedical history, a detailed examination of the heart and theperipheral arterial and venous circulations, and appropriatelaboratory studies. In addition to the electrocardiogram andchest x-ray, the availability of sophisticated noninvasivetechniques (e.g., echocardiography and nuclear cardiology) andthe continued improvement of cardiac catheterization andangiography have significantly enhanced the clinical work-up ofthe patient with a cardiovascular problem. A careful assessment

will enable the clinician to identify the etiologic, anatomic, andphysiologic components of a specific cardiovascular disorder, aswell as to determine overall cardiac function.

History

The medical history in a patient with a cardiac problem is usuallycentered on symptoms due to myocardial ischemia,dysrhythmias, and reduction in ventricular function. The majority

of these individuals will consult a physician because of chestpain, dyspnea, palpitations, ankle edema, or syncope. Any or allof these symptoms may also have extra-cardiac causes.Because symptoms of heart disease may be absent at rest andappear only during stress, the medical history has uniquediagnostic importance. The patient's daily activities should beassessed for their role in precipitating the symptoms and inidentifying these symptoms as cardiac in origin. A purelysymptom-based classification of heart disease has major

limitations, however, since functional abnormalities are oftenmore extensive than those represented by symptoms alone. Inaddition, the anatomic and physiologic disturbances maydevelop to advanced stages before symptoms appear. Examplesof the manner in which the principal symptoms of heart diseasemay serve as a guide to diagnosis will be highlighted.

Chest pain or discomfort(Chapter 9) has numerous cardiaccauses (e.g., myocardial ischemia, pericarditis, pulmonaryembolism, aortic dissection) as well as noncardiac etiologies(e.g., anxiety, cholecystitis, pneumonia). The pain of myocardial

Cardiovascular System Page 1 of 30
http://www.ncbi.nlm.nih.gov/books/NBK393/http://www.ncbi.nlm.nih.gov/books/n/cm/A427/http://www.ncbi.nlm.nih.gov/books/NBK393/http://www.ncbi.nlm.nih.gov/books/n/cm/A427/


2/30

ischemia, characterized by a squeezing, strangling, or burningsensation, must be differentiated from pleuritic pain, which issharp, stabbing, intensified by inspiration, and relieved by sittingup. Among the causes of myocardial ischemia are anginapectoris and myocardial infarction. Pleuritic pain usually

accompanies pericarditis and pulmonary embolism.

Dyspnea (shortness of breath) (Chapter 11) of cardiac originmust be distinguished from dyspnea due to pulmonary disease.Cardiac dyspnea, including paroxysmal nocturnal dyspnea(breathlessness at night) and orthopnea (dyspnea precipitatedby assuming the recumbent position), is characteristicallyrelated to effort until the advanced stages of heart disease whenit may become present at rest. Rapid progression of an episode

of respiratory distress may result in a very severe form ofdyspnea, acute pulmonary edema, i.e., "asthmatic" wheezes anda pink, frothy sputum.

Palpitations (Chapter 10) describe an awareness of theheartbeat. Although the underlying disturbance usually requireselectrocardiographic confirmation, occasionally the cadence ofthe palpitations may be ascertained at the bedside. Palpitationsmay often be of no consequence.

Syncope of cardiac origin (Chapter 12) may be due either to aninability of the heart to maintain adequate cardiac output for agiven level of activity or to a dysrhythmia that results in suddenloss of cardiac output. Left ventricular outflow tract obstruction(e.g., aortic stenosis or hypertrophic cardiomyopathy) commonlycauses effort syncope, whereas syncopal episodes due todysrhythmias can occur either at rest or during activity.

Edema (Chapter 29), a detectable excess of fluid in theinterstitial spaces, is most commonly located in the ankles andfeet and is referred to as peripheral or ankle edema. When dueto cardiac disease, it is usually a late sign of congestive heartfailure, specifically, right heart failure.

Additional symptoms that may herald a cardiovascular probleminclude claudication (extertional cramping of the muscles)(Chapter 13), most often of the lower extremities, fatigue, andhemoptysis (Table 7.1).

http://www.ncbi.nlm.nih.gov/books/n/cm/A454/http://www.ncbi.nlm.nih.gov/books/n/cm/A445/http://www.ncbi.nlm.nih.gov/books/n/cm/A469/http://www.ncbi.nlm.nih.gov/books/n/cm/A863/http://www.ncbi.nlm.nih.gov/books/n/cm/A499/http://www.ncbi.nlm.nih.gov/books/NBK393/table/A386/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A454/http://www.ncbi.nlm.nih.gov/books/n/cm/A445/http://www.ncbi.nlm.nih.gov/books/n/cm/A469/http://www.ncbi.nlm.nih.gov/books/n/cm/A863/http://www.ncbi.nlm.nih.gov/books/n/cm/A499/http://www.ncbi.nlm.nih.gov/books/NBK393/table/A386/?report=objectonly


3/30

Symptoms of Cardiovascular Diseases

SymptomChapter

Chest pain ordiscomfort

9

Dyspnea 11

Palpitations 10

Syncope 12

Peripheral edema 29

Claudication 13

Table 7.1

Physical Examination

Instruments needed for the cardiovascular examination arelisted inTable 7.2. The examination involves inspection,palpation, and auscultation of the heart, arteries, and veins. Thecardiac examination consists of evaluation of (1) the carotidarterial pulse and auscultation for carotid bruits; (2) the jugularvenous pulse and auscultation for cervical venous hums; (3) the

precordial impulses and palpation for heart sounds andmurmurs; and (4) auscultation of the heart. The evaluation oftheperipheral arteries, the aortic pulsation, elicitation of pulsusalternans, and a search for thrombophlebitis completes thecardiovascular examination (Table 7.3).

Table 7.2Instruments Needed for CardiovascularExamination

Stethoscope

Penlight

Centimeter ruler and tapemeasure

Sphygmomanometer

Table 7.3 Most Frequently Used ExaminationSequence of the Cardiovascular System

http://www.ncbi.nlm.nih.gov/books/n/cm/A427/http://www.ncbi.nlm.nih.gov/books/n/cm/A454/http://www.ncbi.nlm.nih.gov/books/n/cm/A445/http://www.ncbi.nlm.nih.gov/books/n/cm/A469/http://www.ncbi.nlm.nih.gov/books/n/cm/A863/http://www.ncbi.nlm.nih.gov/books/n/cm/A499/http://www.ncbi.nlm.nih.gov/books/NBK393/table/A386/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/table/A388/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/table/A389/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A427/http://www.ncbi.nlm.nih.gov/books/n/cm/A454/http://www.ncbi.nlm.nih.gov/books/n/cm/A445/http://www.ncbi.nlm.nih.gov/books/n/cm/A469/http://www.ncbi.nlm.nih.gov/books/n/cm/A863/http://www.ncbi.nlm.nih.gov/books/n/cm/A499/http://www.ncbi.nlm.nih.gov/books/NBK393/table/A386/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/table/A388/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/table/A389/?report=objectonly


4/30

Anatomicstructure Patient position

Chapter

Carotid pulse Supine, 1530 trunk elevation 20

Jugular venouspulse

Supine, 1545 trunk elevation(occasionally 4590)

19

Precordialpulsations

Supine (occasionally left lateral) 21

Auscultation Supine, left lateral and sitting(occasionally standing and squatting)

2228

Peripheralarterial pulses

Supine 30

Peripheralvenous pulses

Supine

Most Frequently Used Examination Sequence of theCardiovascular System.

Special attention should be given to the patient's generalappearance, since it can reflect the state of the circulation aswell as noncardiac diseases that may involve the heart. Thepatient's color (pale, flushed, or cyanotic), facial features, bodybuild, and obvious pulsations should be noted. The bloodpressure and heart rate and rhythm are obtained with the vitalsigns, but must be integrated with the findings of thecardiovascular examination to arrive at the proper diagnosis.

Examination of the Heart

Carotid Arteries

Begin the cardiovascular examination by assessing the carotid

arterial pulses (Chapter 20). They are ordinarily examined whilethe patient is breathing normally and reclining with the trunk ofthe body elevated about 15 to 30 degrees (Figure 7.1). In orderto examine the carotid arteries, the sternocleidomastoid (SCM)muscle should be relaxed and the head rotated slightly towardthe examiner. The examiner places the forefinger or thumb,depending on individual preference, slightly over the artery inthe groove just lateral to the trachea. Care should be takenalways to palpate in the lower half of the neck in order to avoid

the area of the carotid bulb, lest a hypersensitive carotid sinus

http://www.ncbi.nlm.nih.gov/books/n/cm/A642/http://www.ncbi.nlm.nih.gov/books/n/cm/A622/http://www.ncbi.nlm.nih.gov/books/n/cm/A653/http://www.ncbi.nlm.nih.gov/books/n/cm/A678/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/n/cm/A642/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A392/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A642/http://www.ncbi.nlm.nih.gov/books/n/cm/A622/http://www.ncbi.nlm.nih.gov/books/n/cm/A653/http://www.ncbi.nlm.nih.gov/books/n/cm/A678/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/n/cm/A642/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A392/?report=objectonly


5/30

reflex be evoked with resultant bradycardia and hypotension. Itis important that the carotid pulses be palpated using lightpressure, one side at a time, since bilateral carotid compressionmay produce cerebral ischemia and syncope; extreme cautionshould be exercised in patients who have a history of syncope or

transient neurologic symptoms.

Figure 7.1Examination of the carotid arterial pulse

Place the patient in the supine position with the trunk elevatedapproximately 30 degrees, the head turned slightly toward theside being examined and the chin elevated. Palpate the carotidartery by gently pressing with the fingertips of the index, middle,and third fingers at, or hooked around, the medial aspect of the

sternocleidomastoid muscle in the lower half of the neck. Gentle,but firm pressure is necessary with the fingers placed directly onthe summit of the vessel. Palpating pressure should be varied toobtain maximal information by first pressing down, then slowlydecreasing the pressure until the pulse contour and amplitudeare best felt. This often occurs with surprisingly light pressureonce direct contact with the blood vessel has been established;firm pressure often reduces the tactile sensation.

Listen to the heart with the stethoscope in order to identify thefirst (S1) and second (S2) heart sounds while simultaneouslypalpating the carotid artery. The heart sounds are used asreference points for the cardiac examination in order todetermine which events occur in systole (between S1 and S2) andwhich in diastole (between S2 and S1). While listening to theheart sounds, the examiner carefully and slowly applies moreand more pressure to the carotid artery until the maximumpulse is felt; palpation should be continued for 5 to 8 seconds.

The examiner should then slowly release the pressure on theartery while attempting to form a mental image of the pulsewave. It may be possible to detect an anacrotic notch (halt onthe upstroke) or a bisferiens pulse (bifid or double peak) moreeasily with light pressure than with heavy pressure. In patientswith evidence of carotid arterial disease, palpation of the vesselsobviously should be gentle.



6/30

Divide the carotid pulse wave into three parts: (1) ascendinglimb or upstroke; (2) peak; and (3) descending limb. Initiallyconcentrate on the amplitude (size) of the carotid pulse and notewhether it is normal, decreased, or increased. If necessary, useyour own carotid pulse as a control. Next, direct attention to

analysis of the pulse contourand note if there is a single ordouble peak, a shudder or thrill, and the location of the peakwithin systole (i.e., early, mid, or late). Then concentrate on theupstroke and note whether it is normal, rapid, or slow. Finally,concentrate on the down-stroke of the pulse, which is difficult topalpate reliably. If there is a rapid fall-off, for instance, themajority of the clownstroke will be completed during systole.

The normal carotid arterial pulse wave is illustrated in Figure 7.2

together with the heart sounds. The upstroke of the carotidtracing is moderately rapid and smooth, and begins just afterthe initial component of the first heart sound. The summit of thecarotid pulse is smooth and dome shaped, and occursapproximately in the middle of systole. The descending limbfrom the systolic peak is usually less steep than the ascendinglimb. In most normal individuals, the carotid incisura or dicroticnotch is not palpable; however, one can usually sense a changeto a less steep down-slope.

http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A393/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/figure/A393/?report=objectonly


7/30

Figure 7.2

These graphics represent the normal cardiac pulsations andheart sounds. Thejugular venous pulsation normally has 3positive wavesthe a, c, and v waves and 2 negative troughsx

and y troughs. The "a" wave is approximately synchronous withthe first heart sound and just precedes the carotid upstroke. The"v" wave coincides approximately with the second heart sound.

The normal carotid artery pulsation has a single positive waveduring systole, followed by the dicrotic notch (about the time ofthe second heart sound). The apex impulse represents thenormal brief, palpable systolic impulse occurring at the time ofthe first heart sound. In young normal individuals there may be apalpable early diastolic filling wave representing the rapid filling

phase of ventricular diastole and corresponding to the normalthird heart sound.Auscultation at the aortic area reveals anormal first heart sound (S1) and second heart sound (S2). S2 isnormally louder than S1 in this area. At the pulmonary area thereis normal inspiratory (physiologic) splitting of the second sounddue to asynchronous aortic and pulmonic closure. The aorticcomponent of the second heart sound (A2) normally precedesthe pulmonic component (P2). At the tricuspid area there isnormal splitting of the first heart sound due to asynchronous

mitral and tricuspid closure. The mitral component of the firstsound (M1) normally precedes the tricuspid component (T1). Atthis area, physiologic splitting of the second sound may also beappreciated. At the mitral area, the first and second heartsounds are normal. The first sound is normally louder than thesecond heart sound and only the aortic component of the secondheart sound is normally appreciated. Occasionally a third heartsound is normal, reflecting deceleration of blood into the leftventricle during the rapid filling phase of early diastole. Children

and young adults often have normal or physiologic third heartsounds.

There are a variety of abnormal arterial pulses including thehypokinetic pulse commonly seen with left ventricular failure;the hyper kinetic pulse commonly seen with mitral or aorticregurgitation; and the bisferiens pulse seen with aorticregurgitation or hypertrophic cardiomyopathy. During routinepalpation of the carotid pulse, pay particular attention to the

amplitude of the pulse following any premature beat, A



8/30

diminished pulse amplitude following a premature beat issuggestive of hypertrophic cardiomyopathy.

Auscultation should be performed along the course of the carotidartery in order to detect any bruits. (See Figure 7.3 and Chapter

18). The location of maximum intensity of the bruit should benoted, as well as the pitch and duration of the sound. It isnecessary for the patient to stop breathing during auscultationto eliminate the harsh sounds of tracheal breathing that couldmask a low-pitched carotid bruit.

Figure 7.3Auscultation of the carotid artery

Auscultation of the carotid artery. Lightly apply the bell of thestethoscope over the course of the carotid artery, from the baseof the neck to angle of the jaw, during full expiration.

Jugular Veins

Thejugular venous pulse (Chapter 19) is usually examined next.It includes observation of venous wave form, assessment of theresponse of the venous pressure to abdominal compression,estimation of the central venous pressure (CVP), andauscultation for cervical venous hums. Venous pulsations areexamined by inspection of either the external or internal jugular

http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A394/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A593/http://www.ncbi.nlm.nih.gov/books/n/cm/A593/http://www.ncbi.nlm.nih.gov/books/n/cm/A622/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A394/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A593/http://www.ncbi.nlm.nih.gov/books/n/cm/A593/http://www.ncbi.nlm.nih.gov/books/n/cm/A622/


9/30

veins, although the latter are generally more reliable becausethey more directly reflect right atrial hemodynamics.

The position of the patient is extremely important for theexamination of the jugular veins (Figure 7.4). Relax the neck

muscles by placing a small pillow behind the neck. The headshould not be rotated more than a few degrees, since rotationmay tense the SCM muscle and obscure the transmission ofvenous pulsations. The trunk of the body should be elevateduntil maximal venous pulsations are noted. The degree of trunkelevation varies from subject to subject and must be establishedfor each person. In most normal individuals, the maximumpulsation of the internal jugular vein is usually observed whenthe trunk is inclined to about 15 to 30 degrees. In patients with

elevated venous pressure, it may be necessary to elevate thetrunk more than 45 degrees to visualize the maximum venouspulsation. At times there is venous distention without visiblewaves and the pulsations are only seen with the patient uprightat 90 degrees.

Figure 7.4Anatomy of the blood vessels in the neck

Evaluation of the jugular venous pulse and the carotid artery arebest accomplished with the patient supine, the neck musclesrelaxed by placing a small pillow under the head and the trunkelevated until the maximal internal jugular venous pulsations



10/30

are visible. Venous pulsations are usually most prominent in thesuprasternal notch, the supraclavicular fossa or just below theear lobes.

The common carotid artery is located deep to thesternocleidomastoid muscle at the root of the neck. It divides

into external and internal branches. The terminal portion of thecommon carotid and the root of the internal carotid arterybecome dilated at the level of the carotid sinus. The internalcarotid artery continues to the base of the skull where it entersthe cranium.

The internal jugular vein ends below and behind thesternoclavicular. Throughout its course, the internal jugular veinlies at the side of the carotid artery and crosses the artery as itpasses behind the slernocleidomastoid muscle. Since this vein

lies deep to the muscle usually only pulsations transmitted tothe surrounding soft tissues are visible. Superiorly, the internal

jugular vein is posterolateral to the common carotid artery, as itdescends, the vein becomes lateral to the artery and at the rootof the neck it lies anterior to the artery. The external jugular veinis a superficial vessel that crosses the sternocleidomastoidmuscle perpendicularly as it descends towards the middle of theclavicle.

Look forpulsations of the internal jugular vein by standing justbehind the patient and looking down alongside the SCM muscleor by bending over in front of the patient and looking directlyalong the SCM muscles. Direct your study of the wave form towhichever internal jugular pulse is easier to see. For mostpatients, the right internal jugular vein is superior for accurateevaluation of the venous wave form. The internal jugular venouspulsations may be highlighted by shining a beam of light from apenlight tangentially across the skin overlying the left internal

jugular vein. This technique may amplify the wave form bycasting a shadow of its pulsations on the pillow or bed sheetbehind the neck.

The normal jugular venous pulse consists of intermittentincreases in the volume of blood in the veins caused by slowingor halting of blood flow in the right atrium. Because they arelow-pressure impulses, venous pulsations are not palpable andtherefore are interpreted by inspection rather than by palpation,in contrast to the carotid arterial pulse. Generally, internal andexternal jugular venous pulsations may be eliminated by



11/30

applying gentle pressure below the point of observation. Thisprocedure also may produce increased distention of the vein byblocking the flow of blood to the heart. The visible venouspulsations in the neck are slower and more undulating than thebrisk, forceful arterial pulse waves. Respiration may produce

marked changes in venous pulsations, whereas arterial pulsesnormally change relatively little. Under normal circumstances,inspiration decreases intrathoracic pressure and increases returnof blood to the heart from the peripheral veins. The result is toreduce the mean level of venous pulsation and distention; theopposite occurs during expiration.

Abdominal pressure may also be used to distinguish venousfrom arterial neck pulsations. This test is best performed with

the patient lying comfortably in bed at the optimal angle forobserving the internal jugular venous pulsations. The patient isinstructed to continue normal breathing in order to avoidperformance of a Valsalva maneuver. Moderately firm pressureis then slowly applied for about 30 seconds with the palm of thehand pressing on the abdomen, usually on the right side (overthe liver). Normally this maneuver produces no visible change inthe arterial pulse, but a slight increase in the prominence of the

jugular venous pulsations. In the presence of heart failure the

jugular venous pulsations may be markedly increased. Theresponse of jugular venous pulse to abdominal compression isknown as the hepato-jugular reflux test. It is useful not only fordistinguishing venous from arterial pulsations but also inunmasking occult abnormalities of circulatory function.

The normally visible jugular venous pulsations consist of twooutward pulsations or positive waves ("a" and "v") and twodescents or collapses or negative waves ("x" and "y") as shown

in Figure 7.2. The "c" wave, a positive wave that follows the "a"wave, may be recorded, but is seldom seen at the bedside. Thecarotid pulse may be used to time venous pulsations, but theheart sounds generally are preferable at the bedside. The "a"wave, the larger of the two visible positive waves, begins beforeS1 and precedes the upstroke of the carotid pulse. The negative"x" and "y" waves occupy systole and diastole, respectively. The"v" wave occurs in late systole virtually synchronous with S2.Frequently, it is easier to visualize jugular descents becausethey are the largest and fastest movements.



12/30

The internal jugular veins are also used to estimate centralvenous pressure. The technique is similar to that for evaluationof the internal jugular venous wave form (Figure 7.5). Thepatient is examined at the optimum degree of trunk elevationfor inspection of the venous pulse. While the patient is breathing

gently or preferably at the end of a normal expiration, thehighest point of visible pulsation of the internal jugular vein isdetermined (Figure 7.5). The CVP can then be estimated bymeasuring the vertical distance between the midright atriumand the top of the column of venous blood in relation to a fixedreference point, the sternal angle (of Louis). The verticaldistance between the top of the column of venous blood and thelevel of the sternal angle is normally 2 cm. For convenience atthe bedside, the sternal angle is chosen as a reference point

because it has a relatively constant relationship, in all positions,to the midpoint of the right atrium (i.e., 5 cm above the mid-right atrium).

Figure 7.5Estimation of the central venous pressure(CVP)

Place the patient in the supine position with the head slightlyelevated on a pillow to relax the sternocleidomastoid muscle.Elevate the trunk by adjusting the head of the bed so as tomaximize the internal jugular venous pulsations and make them

visible above the clavicles. Since the internal jugular vein lies

http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A397/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/figure/A397/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/figure/A397/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/figure/A397/?report=objectonly


13/30

deep to the sternocleidomastoid muscle, the vein itself is notseen, but watch instead for the pulsations transmitted throughthe surrounding soft tissue.With the patient breathing quietly or preferably at the end ofnormal expiration, identify the highest point at which pulsations

of the internal jugular vein can be seen. With a centimeter rulerpositioned at the sternal angle of Louis (felt as a transverseridge formed by the angulation of the sternum at the articulationof the second ribs) measure the verticle distance using a cottonswab between this point and the venous pulsations. The sternalangle bears a constant relation to the mean CVP with the patientin a supine, upright or any intermediate position and is 5 cmabove the mid right atrium. If the highest point of the venouspulsation is below the sternal angle, hold the centimeter ruler at

the neck rather than at the sternal angle and use the cottonswab to establish the horizontal and verticle relationships thatunderlie this measurement. Record the distance in centimeters,above or below the sternal angle, together with angle at whichthe patient is lying

The normal CVP is less than or equal to 7 cm H2O (i.e., 5 + 2cm). The most common cause of an elevated CVP is failure ofthe right ventricle secondary to failure of the left ventricle.

Earlobe and rarely eyeball pulsations are evidence of markedlyelevated venous pressure.

Central venous pressure may also be estimated by examiningthe veins of the dorsum of the hand. To perform thisdetermination, the patient should be in either a sitting or lyingposition at a 30-degree elevation or greater, and the handshould be kept below the level of the heart long enough for theveins of the dorsum of the hand to become distended. The arm

is then slowly and passively raised while the physician observesthe veins. Care should be taken that the arm is not flexedexcessively at either the shoulder or the elbow and that theupper arm is not constricted by-clothing. Normally, the veins willbe seen to collapse when the level of the dorsum of the handreaches the sternal angle or the level of the suprasternal notch.

The vertical distance above the sternal angle at which the veinscollapse should be recorded as well as the position of the patientduring the test.



14/30

Auscultation at the base of the neck, just above the clavicle andlateral to the clavicular attachment of the SCM muscle, with thepatient sitting, enables one to determine if a cervical venoushum is present (Chapter 18). The cervical venous hum is acontinuous whining or roaring noise throughout systole and

diastole produced by the flow of blood through the internaljugular veins. It occurs more frequently on the right than on theleft, but may be present bilaterally. It is loudest with the patientsitting, during inspiration, and in diastole. It may be increased byturning the head away from the side being auscultated. It isobliterated by applying light pressure directly above the point ofauscultation, the Valsalva maneuver, compression of the internal

jugular vein, or lying down. An arterial bruit, in contrast, isloudest in systole, unaffected by light pressure, the Valsalva

maneuver, and the patient's changing position. The venous humis a frequent finding in normal individuals, but may also be aclue to high-output states (e.g., thyrotoxicosis).

Precordial Movements and Thrills

The precordial examination, performed next, consists ofinspection and palpation of the anterior chest wall. Precordialmovements (Chapter 21) should be evaluated at the apex (left

ventricle), lower left parasternal edge (right ventricle), upper left(pulmonary artery) and upper right (aorta) parasternal edges,and epigastric and sternoclavicular areas (Figure 7.6). It is bestto examine the precordium with the patient supine because ifthe patient is turned on the left side, the apical region of theheart is displaced against the lateral chest wall, distorting thechest movements. Inspect the chest wall by positioning yourselfon the patient's right side and looking tangentially across thefourth, fifth, and sixth intercostal spaces. Ask the patient to take

a deep breath and then to exhale slowly as you look for adiscrete area of apical movement. The following are the factorsto be considered about any precordial movement that can beseen or felt: (1) location; (2) amplitude; (3) duration; (4) time ofthe impulse in the cardiac cycle; and (5) contour.

http://www.ncbi.nlm.nih.gov/books/n/cm/A593/http://www.ncbi.nlm.nih.gov/books/n/cm/A653/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A399/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A593/http://www.ncbi.nlm.nih.gov/books/n/cm/A653/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A399/?report=objectonly


15/30

Figure 7.6Anteroposterior view of the chestindicating the major precordial areas to beexamined

Try to detect by both inspection and palpation any abnormalpulsations that the underlying cardiac chambers and greatvessels may produce. Auscultation is routinely performed overeach of these five areas. The aortic area is the secondintercostal space to the right of the sternum. The pulmonary

area is the second left intercostal space to the left of thesternum. The parasternal or right ventricular area is the lowerhalf of the sternum on the left. The apical or left ventricular areais the fifth intercostal space at the mid clavicular line. Theepigastric area is just below the xiphisternum (subxyphoid area)

Locate the apex impulse by placing the palm and fingers of yourright hand over the left precordium in the fourth, fifth, and sixthintercostal spaces near the midclavicular line (Figure 7.7). If

unable to palpate an impulse, move your hand laterally to theanterior axillary line. If still unable to locate the impulse, ask thepatient to roll onto the left side and attempt to palpate the apexas just described (Figure 7.8). Always state in which patientposition the apex impulse was identified because the left lateraldecubitus position distorts a normal apex and makes it appearor feel unduly sustained. If still unable to locate the apeximpulse, inspect the right precordium in a manner similar to thatused for the left precordium. On rare occasions the impulse may

http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A400/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/figure/A401/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/figure/A400/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/NBK393/figure/A401/?report=objectonly


16/30

be visible in the right chest, providing the initial clue to thepresence of dextrocardia.

Figure 7.7Examination of the apex impulse in thesupine position

Place the patient in the supine position elevating the trunkapproximately 3045 degrees. Position yourself on the patient's

right side and place the flat part of your right hand over the leftprecordium in the fourth, fifth, and sixth intercostal spaces nearthe mid clavicular line. First locate the apex impulse with thedistal half of the palm of your hand and its adjacent proximalphalanges. The full extent of a broad apex impulse is bestappreciated with the palm. Use the tips of the first and secondfingers placed directly on the impulse to make detailedobservations of the impulse. Assess the location, diameter andduration of the impulse



17/30

Figure 7.8 Examination of the apex impulse withthe patient in the left lateral decubitus position

If the apex impulse cannot be located with the patient supine,ask the patient to roll to his left side and attempt to palpate theapex with the fingers of your right hand placed over the leftprecordium in the fourth, fifth, and sixth intercostal spaces nearthe mid clavicular line. This maneuver helps find the apicalimpulse, but since it displaces the impulse laterally, it should not

be used to identify its true location. When the impulse ispalpable, access its quality by making finer observations withyour fingertips; this position, however, also occasionally distortsa normal apex into feeling unduly sustained

Record the location of the apex impulse by noting its distancefrom either the midsternal or midclavicular line and theintercostal space in which it is felt. Also record the approximatediameter (cm) of the apex. The amplitude and duration of theapical pulsation may be more important than its location andsize; therefore, state whether the impulse is of normal,increased, or diminished force and whether it occupies half ormore than half of systole. If necessary, palpate your own apeximpulse for comparison. In addition, if a single pulsation ispalpated, determine whether its force is uniform throughoutsystole or whether there is a late systolic accentuation or bulge.

In a normal individual the apex impulse is a tapping, earlysystolic outward thrust that occurs in the fifth intercostal space

in the midclavicular line. It is localized to a small area not more



18/30

than 1 to 2 cm (dime-sized) in diameter. The outward thrust isbrief, lasting about one-half of systole, and is of minimalamplitude. Normally, diastolic pulsations are not palpable. Leftventricular hypertrophy, for instance, results in exaggeration ofthe normal left ventricular thrust both in amplitude and duration.

It is nondisplaced, sustained (occupying more than one-half ofsystole), and 2 to3 cm (quarter-sized). Left ventricular dilation,in contrast, results in downward and lateral displacement of theapex below the fifth interspace.

The lower left parasternal region of the chest is best evaluatedby looking at the chest from the side and by placing the heel ofthe hand over or just to the left of the sternum (Figure 7.9). If aleft parasternal impulse or lift is appreciated, determine if the

impulse is sustained throughout systole, vigorous or slight, andbegins with or after the onset of the apex impulse. Determine itsonset by placing your right hand over the apex impulse and yourleft palm over the left parasternal impulse. The right ventricle isreally an anterior structure, and when enlarged, it may lift theanterior portion of the chest including the sternum. In normalindividuals the parasternal region usually retracts (movesinward) during ejection and is not palpable.

Figure 7.9Palpation of the left parasternal impulse



19/30

Place the patient in the supine position with the trunk elevated3045 degrees. Place the heel of your right hand, with the handslightly cocked up, together with downward pressure (arrow) ofyour left hand over the lower left sternal area to best feel theslight left parasternal upward movement that usually reflects

right ventricular action. If no movement is felt, ask the patient totake a deep breath, exhale slowly and then hold the breathduring expiration, before repeating the hand maneuvers.

Right ventricular hypertrophy and/or dilation results in asustained systolic lift of the lower parasternal region of thechest. This lift is present in patients with high right ventricularpressure (pulmonary arterial hypertension or pulmonic stenosis)or volume overload (tricuspid regurgitation or atrial septal

defect), but is infrequently seen in chronic lung disease if right-sided heart failure is not present. The pulsations of the mainpulmonary artery are also often visible and palpable, especiallyin patients with parasternal pulsations.

Patients with acute myocardial infarction or with angina pectorismay have an outward paradoxical precordial movement thatoften can be seen or palpated at the apex, the anteriorprecordium, or in an "ectopic" area. The impulse is usually

sustained throughout systole, frequently with a second systolicbulge, and is often difficult to distinguish from that of leftventricular hypertrophy by palpation alone if the bulge occurs inthe region of the apex. In order to time systolic and diastoliccardiac movements accurately, it is essential to inspect andpalpate the precordium while actually listening to the heartsounds.

The early diastolic and late diastolic (presystolic) precordialmovements are the visible and palpable counterparts of thethird (S3) and fourth (S4) heart sounds, respectively. They maybe felt at the cardiac apex with the patient in the left lateraldecubitus position. Careful inspection of the precordium with thenaked eye or observing the motions of a wooden stick tapedover the cardiac apex best demonstrates any precordialimpulses that correlate with audible S3 and S4 sounds. The right-sided S4, seen and felt at the lower left sternal edge, occursslightly earlier in diastole than the left-sided S4. It oftencorrelates with a very prominent jugular "a" wave and a



20/30

sustained outward movement (lift) in the lower left parasternalarea.

Heart murmurs that can be palpated are referred to as thrills(Chapters 26 and 27). The diastolic rumble of mitral stenosis and

the systolic murmur of mitral regurgitation may be palpated atthe cardiac apex. The harsh systolic murmur of aortic stenosismay cut across the palm of the hand toward the right side of theneck, while the thrill of pulmonic stenosis cuts across the palmof the hand to the left side of the neck. The thrill due toventricular septal defect is usually located in the third and fourthintercostal spaces near the left sternal border. Heart soundsmay also be palpable. For instance, the loud S1 of mitral stenosismay be palpated at the apex.

Heart Sounds and Murmurs

Auscultation (Chapters 2228) of the heart is performed afterexamining the jugular venous pulse, carotid pulse, andprecordial movements because acoustic events can best beinterpreted after the other components of the cardiacexamination have been evaluated. Auscultation of the heartshould, therefore, not be performed as an isolated event

because heart sounds, murmurs and pulse tracings must all beintegrated in order to understand normal and altered cardiacphysiology and anatomy. Attempt to study two and occasionallythree aspects of the cardiac examination simultaneously. Thenpictorially display the heart sounds and correlate them, by useof a diagram, with any murmurs heard, the jugular venous waveform, the carotid pulse, and the apex impulse to bestunderstand the patient's cardiac problem (Figure 7.2).

Proper use of a quality stethoscope is essential for an accurateauscultatory examination. The important parts of thestethoscope are the ear pieces, the tubing, and the chest pieces.

The ear pieces must fit the ear canal snugly without going to anuncomfortable depth. The tubing should be as short as possible,but long enough to be comfortable and convenient for the user;10 to 12 inches is an ideal length. The chest pieces, the bell, andthe diaphragm should be combined into one housing. Adiaphragm pressed firmly on the chest filters out low-frequencyvibrations and amplifies high-frequency vibrations. It is routinely

used to hear the first and second heart sounds, systolic

http://www.ncbi.nlm.nih.gov/books/n/cm/A746/http://www.ncbi.nlm.nih.gov/books/n/cm/A805/http://www.ncbi.nlm.nih.gov/books/n/cm/A678/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A393/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A746/http://www.ncbi.nlm.nih.gov/books/n/cm/A805/http://www.ncbi.nlm.nih.gov/books/n/cm/A678/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A393/?report=objectonly


21/30

murmurs, and the diastolic murmur of aortic regurgitation. Thebell should be applied to the chest with very light pressure,barely creating an air seal, so low-frequency sounds andmurmurs are appreciated. It is used to hear the third and fourthheart sounds and the diastolic murmur (rumble) of mitral

stenosis. A trumpet-shaped bell is much better than a shallowone.

Auscultation usually begins at the aortic area (upper rightsternal edge). The stethoscope is then moved sequentially to thepulmonary (upper left sternal edge), tricuspid (lower left sternaledge), and mitral (apex) areas. It is helpful to palpate the carotidpulse or apex impulse simultaneously to time the acousticevents as systolic or diastolic. A finger on the carotid artery will

sense the systolic thrust that is virtually coincident with S1. Useof a more distant artery for this purpose leads to error becauseof the time it takes the pulse wave to reach the periphery.

The heart sounds are usually the first auscultatory eventsidentified. They are brief, discrete, auditory vibrations of varyingintensity (loudness) and frequency (pitch). The first heart sound(Chapter 22) identifies the onset of systole. It is normally splitinto mitral (M1) and tricuspid (T1) components that are

temporally related to closure of the respective atrioventricular(A-V) valves. The second heart sound(Chapter 23) identifies theend of systole and the onset of diastole. It is normally split intoaortic (A2) and pulmonic (P2) components that are temporallyrelated to closure of the respective semilunar valves. Thesecond sound is louder than S1 in the aortic listening area; S1 islouder at the apex.

In the aortic area, listen for the first and second heart sounds,the aortic ejection sound, and the murmurs of aortic stenosisand aortic regurgitation with the stethoscope diaphragm. Thenmove the diaphragm to the second and third left intercostalspaces in order to appreciate the aortic and pulmoniccomponents of S2, the pulmonary ejection sound, and themurmurs of pulmonic stenosis and pulmonary and aorticregurgitation. Continue to the fourth and fifth intercostal spacesalong the left sternal border and listen for the murmurs oftricuspid regurgitation and tricuspid stenosis and the murmurproduced by ventricular septal defect. Right ventricular S3 and S4sounds (gallops) can best be heard in this area with the

http://www.ncbi.nlm.nih.gov/books/n/cm/A678/http://www.ncbi.nlm.nih.gov/books/n/cm/A696/http://www.ncbi.nlm.nih.gov/books/n/cm/A678/http://www.ncbi.nlm.nih.gov/books/n/cm/A696/


22/30

stethoscope bell. The diaphragm should be moved to the thirdand fourth intercostal spaces to the right of the sternum to judgewhether a murmur of aortic regurgitation is louder along the leftor right sternal border.

The diaphragm should then be positioned at the cardiac apexwhere S1 and S2 should again be studied. An aortic ejectionsound, a mid to late systolic click, the opening snap of mitralstenosis, the systolic murmur of mitral regurgitation, andoccasionally the high-pitched murmur of aortic regurgitation arealso heard in this area with the diaphragm.

The bell of the stethoscope should then be positioned over theapical impulse with the patient turned to the left lateral position

to listen for low-frequency diastolic sounds and murmurs.

Have the patient exercise (5 to 10 sit-ups), or cough ifmyocardial infarction is suspected, to "bring out" the murmur ofmitral stenosis and the S3 and S4 gallop sounds. The third andfourth heart sounds (Chapters 24 and 25) are low pitched andmay be audible as well as palpable. They are best heard at thecardiac apex when generated from the left ventricle and at thelower left sternal edge when generated from the right ventricle.

The technique known as inching may help determine whetherextra cardiac sounds are systolic or diastolic. The examinermoves the stethoscope inch by inch from the aortic area to theapex while focusing attention on S2. Determine whether theextra sound precedes (systolic) or follows (diastolic) S2. Theacoustic events can best be appreciated by a careful review ofthe hemodynamic curves of the cardiac cycle.

Several additional areas should be ausculted (Figure 7.10),

including (1) the inferior edge of the sternum and epigastrium,especially in patients with chronic obstructive lung disease, inwhom heart sounds and murmurs are difficult to hear in themore conventional listening areas; (2) the first and secondintercostal spaces below the left midclavicular area for thecontinuous (systolic and diastolic) murmur of patent ductusarteriosus; (3) the interscapular area of the back for the systolicmurmur of coarctation of the aorta; (4) over the lung areas; (5)over the head, eyes, liver, sacrum, abdomen, as well as over

http://www.ncbi.nlm.nih.gov/books/n/cm/A714/http://www.ncbi.nlm.nih.gov/books/n/cm/A733/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A404/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A714/http://www.ncbi.nlm.nih.gov/books/n/cm/A733/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A404/?report=objectonly


23/30

tumors or bony overgrowths; and (6) over all scars to identifythe continuous murmur of a peripheral A-V Fistula.

Figure 7.10

Anteroposterior view of the chest showing some additional areasshaded for auscultation. The first and second left intercostalspaces at the mid clavicular line (MCL). The fifth intercostalspace to the right of the sternum. The epigastric area just below

the xiphisternum

Murmurs (Chapters 26 and 27) are prolonged series of auditoryvibrations that should be characterized according to (1) timing inthe cardiac cycle (systolic, diastolic, continuous); (2) intensity(loudness); (3) frequency (pitch); (4) configuration (shape); (5)duration (long or short); (6) radiation (to other auscultatoryareas); and (7) variation, if any, with respiration or othermaneuvers (position change, Valsalva, etc.).

The classic way to time murmurs and heart sounds is with afinger on the carotid arterial pulse. The heart sound virtuallycoinciding with the carotid upstroke (pulse) is Sl and the heartsound just after the carotid pulse is S2. The intensity of amurmur is graded I to VI with I faint, III loud, IV palpable, and VIloud enough to be heard with the stethoscope just off the chest.

The frequency of a murmur varies from low (rumbling) to mid(harsh) to high (blowing). The configuration is described ascrescendo (increases progressively in intensity), decrescendo

(decreases progressively in intensity), crescendo-decrescendo

http://www.ncbi.nlm.nih.gov/books/n/cm/A746/http://www.ncbi.nlm.nih.gov/books/n/cm/A805/http://www.ncbi.nlm.nih.gov/books/n/cm/A746/http://www.ncbi.nlm.nih.gov/books/n/cm/A805/


24/30

(diamond-shaped), or plateau (even). Of all the parameters bywhich a murmur is analyzed, its time of occurrence in thecardiac cycle and the precordial area of maximal intensity areeasiest to learn and thus are most reliable.

The influence of respiration on the second sound is extremelyimportant. The examiner will wish to note respiratory variationboth during quiet breathing and at times during exaggeratedbreathing. The interval between the two audible components ofS2 normally increases on inspiration and virtually disappears onexpiration. The Valsalva maneuver may be used to exaggeratethe effects of respiration. Variation in the cardiac cycle, as withatrial fibrillation or heart block, may also exert profoundinfluences on S2 and on S1. When S2 is split, determine the

relative loudness of each component (A2 and P2).

Examination of the Peripheral Arteries

The evaluation of theperipheral arterial pulses (Chapter 30) isan integral part of the cardiovascular examination. Palpation ofthe peripheral arteries may yield the following information: (1)frequency and regularity of the pulsations; (2) condition andpatency of the peripheral arteries; and (3) characteristics of the

arterial pulse wave. All of the following pulses should beexamined thoroughly by palpation: temporals, brachials, radials,aortic, femorals, popliteals, posterior tibials, and the dorsalispedii (Figure 7.11). When applicable, pulses should be examinedbilaterally and graded as to quality of the impulse on a scale of 0to 3 with 2 being normal, 0 absent, 1 decreased, and 3increased. In addition, hair distribution should be checked on thetoes and feet.

http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A406/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/NBK393/figure/A406/?report=objectonly


25/30

Figure 7.11Location of the arteries that areroutinely examined

The temporalis artery is located in front of the ear where it isvery superficial and readily palpated. Pulses in the upperextremities can be identified at the brachial artery, just medialto the biceps muscle above the elbow, and the radial artery,

along the radial-volar aspect of the forearm at the wrist. Pulsesin the lower extremities can be identified in the followinglocations: the femoral artery, below the inguinal ligament; thepopliteal artery behind the knee; the dorsalis pedis artery on thedorsum, near the center of the long axis of the foot; and theposterior tibial artery just behind the medial malleolus. Theexamination of the femoral pulse may be facilitated by the useof two hands, one on top of the other, especially in obesepatients. It is important to concentrate on the palpatorysensation in simultaneous comparison of bilateral vessels. Theradial and femoral arteries must also be palpated simultaneouslyto exclude coarctation of the aorta.

The abdominal aorta is a retroperitoneal structure and should beexamined with the abdominal muscles completely relaxed byflexion of the hips. Palpate the abdominal aortic pulse byapplying firm pressure with the flattened fingers of both hands,one on top of the other, to indent the epigastrium toward thevertebral column. Care should be used in patients withsuspected aneurysms



26/30

To examine the brachial artery, palpate along the course of theartery just medial to the biceps tendon and lateral to the medialepicondyle of the humerus. To examine the radial artery,palpate along the radialvolar aspect of the subject's forearm atthe wrist.

The abdominal aorta is an upper abdominal, retroperitonealstructure that is best palpated by applying firm pressure withthe flattened fingers of both hands to indent the epigastriumtoward the vertebral column. The normal aortic pulse should beless than 6 cm in diameter. Auscultation should be performedover the aorta and along both iliac arteries into the lowerabdominal quadrants to detect bruits.

The femoral artery is best palpated with the fingertips of theexamining hand pressed firmly into the groin. Auscultationshould be performed in this area as well.

The popliteal artery passes vertically through the deep portion ofthe popliteal space. It may be difficult or impossible to palpate inobese or very muscular individuals. The pulse is detected bypressing deeply into the popliteal space with the supportingfingertips.

The posterior tibial artery lies just posterior to the medialmalleolus and is felt most readily by curling the fingers of theexamining hand around the ankle.

The dorsalis pedis artery usually lies near the center of the longaxis of the foot. Place the fingertips transversely across thedorsum of the forefoot near the ankle. This pulse often requiressome searching and is congenitally absent in approximately 10%of normal individuals.

Information should be obtained by simultaneously palpating theradial and femoral arteries and noting the relative time of onsetof the pulse at the two locations. Normally, the pulse wavearrives in these locations virtually simultaneously. In a patientwith coarctation of the aorta, both onset and peak of the weakfemoral pulses are delayed. Compared to the carotid pulse, thepulse wave in these more peripheral vessels arrives later and ischaracterized by a steeper initial wave that reaches a higher



27/30

systolic peak, whereas the diastolic and the mean arterialpressures are lower.

Palpating peripheral arteries is the most important singlemaneuver in establishing whether or not chronic occlusive

arterial disease is present. One may obtain an impression ofthickness and hardness of the walls of the brachial, radial, anddorsalis pedis arteries by "rolling" the compressed vesselagainst the underlying tissue. Auscultation of the peripheralarteries is also very important. A systolic bruit over theabdominal aorta, iliac, or femoral arteries when the patient hasbeen supine for more than 10 minutes usually signifies intimaldisease, but not necessarily significant occlusion.

Pulsus alternans refers to a characteristic pulse pattern in whichthe beats occur at regular intervals, but with an alternation ofthe height of the pulse. This valuable sign should be searchedfor by palpating the femoral artery; less often, the radial arterymay disclose that alternate pulses vary in amplitude. Have thepatient hold his or her breath while you feel the pulse to makecertain that the alternation of pulse volume is independent ofrespiration. The pulse rhythm should be regular, sincealternation of the strength of cardiac beats commonly results

from bigeminal rhythm. Rarely, pulsus alternans may feelirregular because of a slight delay in sensing the weaker beat.

When pulsus alternans is prominent, it may be confirmed andquantified by use of a sphygmomanometer. As the pressure islowered in the sphygmomanometer, the examiner shouldroutinely observe whether every Korotkoff sound is heard withequal intensity. As the cuff pressure is lowered further, thefrequency of the sounds may suddenly double as the weakerbeats also become audible. In most instances, the weak pulsesare only slightly weaker than the strong beats. On rareoccasions, a weak beat may be so small that no palpable pulseis detected at the periphery, so-called total alternans. Pulsusalternans is produced by an alternation in left ventricularcontractile force associated with an alternation of left ventricularfiber length; it is a very valuable sign of left ventriculardysfunction. In most instances, it is found in association with athird heart sound.

Examination for Thrombophlebitis



28/30

The presence or absence ofthrombophlebitis (Chapter 30) is anintegral part of the cardiovascular database. Thrombophlebitisrefers to venous inflammation with secondary thrombosis of theinvolved vein. It is most commonly noted in the deep veins ofthe leg and superficial veins of the arm. Superficial

thrombophlebitis can be seen and felt, making the diagnosiseasy in most cases. Most deep vein thromboses are clinicallysilent and cannot be detected by routine examination. Whenthrombophlebitis is confined to small venous channels beneaththe subcutaneous tissue or in the pelvis, the lesions are neithervisible nor palpable. Mild pain in the calf may be the onlysymptom, and tenderness may be the only sign.

The examiner should also compare the skin temperature in the

two calves, since active phlebitis may create local warmth. Calfcircumference should also be determined in all suspected cases.Pain is a prominent feature of muscular, synovial, or vascular legdiseases, and various tests have been used to identify thespecific etiology. Homans's test (dorsiflexion sign) is used todetect irritability of the posterior leg muscles through whichinflamed or thrombosed veins course. The Lowenberg cuff test isanother helpful clinical maneuver for detection of calf veinthrombosis.

A summary of only the most common conditions associated withan abnormality on the cardiovascular examination is shown in

Table 7.4.

Table 7.4Common Conditions Associated with anAbnormality on the Cardiovascular Examination

Abnormality Condition

Chap

terCarotid pulse

Bisferiens Aortic regurgitation 20

Hypertrophiccardiomyopathy

Aortic stenosis

Hypokinetic Left ventricular failure

Jugular venous pulse

Giant "a" wave Tricuspid stenosis 19

Pulmonary arterial

http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/NBK393/table/A408/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A642/http://www.ncbi.nlm.nih.gov/books/n/cm/A622/http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/NBK393/table/A408/?report=objectonlyhttp://www.ncbi.nlm.nih.gov/books/n/cm/A642/http://www.ncbi.nlm.nih.gov/books/n/cm/A622/


29/30

Abnormality ConditionChapter

hypertension

Regurgitant ("cv") wave Tricuspid regurgitation

Deep "x" and "y" descents Constrictive pericarditisApex impulse

Displaced inferolaterally (leftventricular dilatation)

Left ventricular failure 21

Mitral regurgitation

Aortic regurgitation

Non displaced, sustained (leftventricular hypertrophy)

Systemic arterialhypertension

Aortic stenosis

Hvpertrophiccardiomyopathy

Auscultation

Abnormal S 1 Mitral stenosis 22


Abnormal S 2 Atrial septal defect 23

Aortic stenosis

Pulmonary arterial

hypertensionAbnormal S 3 Left ventricular failure 24

Mitral regurgitation

Aortic regurgilalion

Abnormal S 4 Systemic arterialhypertension

25

Aortic stenosis

Hypertrophiccardiomyopathy

Other abnormal heart sounds Mitral stenosis (openingsnap)

27

Mitral valve prolapse(systolic click)

28

Bicuspid aortic valve(ejection sound)

28

Pulmonic stenosis(ejection sound)

28

Systolic murmurs Mitral regurgitation 26

Aortic stenosis

http://www.ncbi.nlm.nih.gov/books/n/cm/A653/http://www.ncbi.nlm.nih.gov/books/n/cm/A678/http://www.ncbi.nlm.nih.gov/books/n/cm/A696/http://www.ncbi.nlm.nih.gov/books/n/cm/A714/http://www.ncbi.nlm.nih.gov/books/n/cm/A733/http://www.ncbi.nlm.nih.gov/books/n/cm/A805/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/n/cm/A746/http://www.ncbi.nlm.nih.gov/books/n/cm/A653/http://www.ncbi.nlm.nih.gov/books/n/cm/A678/http://www.ncbi.nlm.nih.gov/books/n/cm/A696/http://www.ncbi.nlm.nih.gov/books/n/cm/A714/http://www.ncbi.nlm.nih.gov/books/n/cm/A733/http://www.ncbi.nlm.nih.gov/books/n/cm/A805/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/n/cm/A846/http://www.ncbi.nlm.nih.gov/books/n/cm/A746/


30/30

Abnormality ConditionChapter

Tricuspid regurgitation

Pulmonic stenosis

Ventricular septal defectDiastolic murmurs Mitral stenosis


Tricuspid stenosis

Pulmonic regurgitation

Other murmurs Patent ductus arteriosis

Pericardial friction rub

Peripheral arterial pulses

Hypokinetic

Occlusive arterial

disease

30

Bilaterally asymmetricDissecting aorticaneurysm

Local obstruction

Upper to lower extremity delay Coarctation of aorta

Pulsus alternansLeft ventriculardysfunction

Bruit

Occlusive arterial

disease

18, 30

Peripheral venous pulses

Palpable and tender segment("cord")

Thrombophlebitis 30

Common Conditions Associated with an Abnormality on theCardiovascular Examination.

ConclusionAn orderly process of history taking and physical examinationtogether with selective application of modern laboratorytechnology should enable the clinician to arrive at an accuratediagnosis, estimate the degree ofseverity, formulate a logicalplan oftreatment, and better understand the pathophysiologicabnormalities in the patient with a cardiovascular problem.

Cardiovascular System Page 30 f 30
http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/n/cm/A593/http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/n/cm/A593/http://www.ncbi.nlm.nih.gov/books/n/cm/A915/http://www.ncbi.nlm.nih.gov/books/n/cm/A915/

Date post:	07-Apr-2018
Category:	Documents
Upload:	shah-alam
View:	216 times
Download:	0 times

MG Cardiovascular System

Documents