THE

CARDIOVASCULAR

SYSTEM

University of TEESSIDE

Nurse Practitioner Course

Dr. Phil Jennings. James Cook University Hospital

Introduction

• History Taking– Features of common symptoms– Presentation of common problems

• Examination Routine– What do to– Important physical signs

• Investigations – A quick look at X rays and ECGs

Symptoms: Chest Pain

• Important points to establish– Site– Radiation– Character– Exacerbating and

Relieving factors– Duration– Associated

symptoms

Symptoms: Chest Pain

CARDIAC

Angina

Myocardial Infarct

Pericarditis

Aortic dissection

PULMONARY

Pleurisy

Pulmonary Embolus

Pneumothorax GASTRO

Ulcer or Reflux

Gallstones

Pancreatitis

MUSCULOSKELETAL

Chostochondritis

Trauma

NON ORGANIC

Anxiety

Chest Pain: Angina

Angina pains are typically central crushing chest pains.

Patients describe angina as feeling like a heavy weight in the middle of the chest

Angina can present in unusual positions

Chest Pain: Angina

Angina pains commonly radiate to the arms, neck and jaw

Typically angina lasts for several minutes

Chest Pain: Angina

Angina pains normally occur during periods of physical exertion. This is the single most important factor to consider when deciding if a patient has angina or not

The term ‘unstable angina’ is used to describe pains which occur at rest and signifies severe coronary disease

Chest Pain: MI

• Features suggesting MI– The pains are usually more severe– There are more associated symptoms

such as sweating, nausea or vomiting– Duration is > 30 minutes– Usual relieving factors such as rest or

GTN spray do not help

Chest Pain: Pericarditis

• Pericarditis– Similar distribution to angina / MI– Often sharper or stabbing– Helped by sitting forward– Typically has a long duration– Often seen in otherwise well, young patients

without coronary disease– May be a history of a viral illness of fever

Chest Pain: Dissection

• Features of Dissection

– Pains are described as tearing and can be excruciating

– Often radiates through to the back

Symptoms: Palpitations

Important points to establish

Onset

Rate

Rhythm

Duration

Termination

Associated symptoms

Symptoms: Palpitations

Supraventricular

Atrial Fibrillation

Atrial Flutter

Atrial Tachycardia

Reentrant TachycardiaVentricular

Ventricular Ectopics

Ventricular Tachycardia

Symptoms: Palpitations

• Features of Atrial Fibrillation– Common. Especially elderly or IHD– Pulse is irregularly irregular in other words

unpredictable from one beat to the next– Can be an incidental finding or presents

with palpitations, fatigue, chest pain or breathlessness

– The mainstay of treatment is rate control and anticoagulation

– Electrical cardioversion may be used in some patients

Symptoms: Breathlessness

• Breathlessness or dyspnoea can have a number of causes– Heart Failure– Valve disease– Myocardial Ischaemia– Pericardial disease

There are also non cardiac causes of dyspnoea

- Pulmonary disease

- Anaemia, Obesity or being unfit

Symptoms: Breathlessness

• Important points to establish– Occurrence of symptoms:

• All the time• Woken from sleep• During exertion

– Assess normal exercise tolerance– Associated symptoms

• Chest pain, palpitations• Cough, wheeze, sputum,

haemoptysis• Ankle oedema

Symptoms: The End

Any Questions So Far ???

Examination

• Suggested CVS Exam routine– General Inspection– Hands– Pulse– BP– Head & Neck

• JVP, Carotids, Anaeimia, Cyanosis

– Praecordium– Auscultation– Extras

Examination

What is the most important start to any exam ??

Introduce yourself to the patient and let them know what you are about to do …

Exam: General Inspection

• If the patient is not exposed then ask if you may expose them

• The patient should be reclined at a 45º angle• Look for obvious

– Breathlessness– Pallor– Sweating– Scars– Props: Oxygen pipes, Inhalers, GTN spray

• Make some comments

Exam: Hands

• Start with the nails and look for clubbing

– Increased Curvature

– Loss of nail bed angle

– Fluctuant nail Beds

• Examine BOTH hands at eye level

Exam: Hands

• Cardiovascular causes of clubbing can be

– Congenital Cyanotic Heart Disease

– Atrial Myxoma– Endocarditis

Exam: Hands

• Next look for Splinter Haemorrhages

– A sign of systemic vasculitis which may indicate Infective Endocarditis.

– They can also be caused by trauma so remember to bear in mind the patient’s occupation

Exam: Hands

• Other points to note– Temperature– Perfusion– Pallor– Nicotine staining– Extensor tendon swellings

(xanthomas)

Exam: Pulse

• Start by palpating the radial pulse

• At this site asses– Rate– Rhythm

• You should not asses volume at the radial artery

Exam: Pulse

• Next move to the brachial artery to assess

– Volume– Character

Exam: Blood Pressure

• You may now want to measure the blood pressure

• A single measurement is acceptable unless the history suggests dissection

Exam: Head & Neck: FACE

Jaundice

Exam: Head & Neck: FACE

Anaemia

Exam: Head & Neck: FACE

Xanthelasma Arcus

Exam: Head & Neck: FACE

Cyanosis

Exam: Head & Neck: JVP

The JVP is best examined by looking across the neck.

A double waveform should be seen for each cardiac cycle

Exam: Head & Neck: JVP

Sternal Angle

Sternal Angle

Top of venous pulsation

Top of venous pulsation

Height

Of

JVP

In

cms

Exam: Head & Neck: JVP

• Carotid Pulsation– 1 per cardiac

cycle– Palpable– Position

independent– Does not enhance

with hepatojugualr– reflex

• JVP Pulsation– 2 per cardiac

cycle– Not palpable– Varies depending

on position– Enhances with

hepatojugular reflex

Exam: Praecordium

Look

For

Obvious

Deformity

Pigeon Chest Funnel Chest

Exam: Praecordium

Look

For

Obvious

Scars

Median Sternotomy

CABG, Valve, Tx

Lateral Thoracotomy

Coarct Repair

Exam: Praecordium

Locate Apex Examine for heave

Exam: Praecordium

1 2 3

1. Mid Clavicular Line

2. Anterior Axillary Line

3. Mid Axillary Line

2nd

3rd 4th 5th

Intercostal Spaces

Exam: Auscultation

Bell

Low pitched murmurs eg. Mitral Stenosis

Press hard enough only to make a seal with the skin

The ‘hole’ must be rotated to the bell in order for it to work

Exam: Auscultation

DiaphragmNormal / High pitched murmurs.

Use for general purpose auscultation

Exam: Auscultation

Earpiece

Angled to provide a better fit into the auditory cannal.

During use point forward unless you have an abnormal shaped head !

Exam: auscultation

1. Apex: Mitral Valve

2. Sternal Edge: Tricuspid Valve

3. L 2nd Space: Pulmonary Valve

4. R 2nd Space: Aortic Valve

BELL

&

DIAPHRAGM

Exam: auscultation

Heart Sounds:

Lub

Dub

First Second

Mitral Valve

Tricuspid Valve

Aortic Valve

Pulmonary Valve

Exam: auscultation

Heart Murmurs: Systolic

First Second

Pan Systolic Murmur

Mitral Regurgitation

Tricuspid Regurgitation

Exam: auscultation

Heart Murmurs: Systolic

First Second

Ejection Systolic Murmur

Aortic

StenosisPulmonary

Stenosis

VSD

Exam: auscultation

Heart Murmurs: Diastolic

First Second

Early Diastolic Murmur

Aortic Regurgitation

Exam: auscultation

Heart Murmurs: Diastolic

First Second

Mid Diastolic Murmur

Mitral

Stenosis

Exam: auscultation

Heart Murmurs: Extras

Mitral MurmursMitral Area

Patient in Left Lateral

Radiate to Axilla

Exam: auscultation

Heart Murmurs: Extras

Aortic MurmursAortic Area

Sit Patient Forward

Breath Held in Expiration

Radiates to Carotids

Exam: Extras

• Is there anything else you wish to do ?– Examine the peripheral pulses– Check for radio – radial or radio – femoral

delay– Listen at the lung bases– Check for sacral oedema– Check for peripheral oedema– Measure the BP if not already done

Investigations: CXRName Marker

Projection

Investigations: CXR

Cardiac

Silhouette

Lung

Fields

Investigations: CXR

Right

Hemidiaphragm

Left

Hemidiaphragm

Trachea

Right

HilumLeft

Ventricle

Left Atrial Appendage

Aortic

Knuckle

Investigations: CXR

Cardiac Thoracic

Normal Cardio – Thoracic Ratio (CTR) is up to 0.5

Investigations: ECG

Investigations: ECG

Calculating the Heart Rate

Divide 300 by the number of large squares inbetween R waves

300 / 2 = 150 bpm

300 / 6 = 60 bpm

Investigations: ECG

Rhythm

In sinus Rhythm

1 P wave for each QRS complex

Rate lies between 60 – 100 beats per minute

Investigations: ECGNormal ECG

Thankyou for your attention