Cvs examination

Cvs examination DR.TAMILMANI: 

Cvs examination DR.TAMILMANI

Slide 2: 

Skin Color and Texture

Malar flush: long-standing MS, rash across the nose and nose in SLE. : 

Malar flush: long-standing MS, rash across the nose and nose in SLE.

Bronze skin in hemochromatosis(Cardiomyopathy): 

Bronze skin in hemochromatosis ( Cardiomyopathy )

Brown + buccal pigmentation in Addison’s disease (hypotension): 

Brown + buccal pigmentation in Addison’s disease (hypotension)

Flushing & telangiectasia in carcinoid sydrome (tricuspid & pulmonary valve disease) : 

Flushing & telangiectasia in carcinoid sydrome (tricuspid & pulmonary valve disease)

Moon face in cushing’s disease (HTN): 

Moon face in cushing’s disease (HTN)

Central cyanosis (right to left intracardiac shunt or lung disease : 

Central cyanosis (right to left intracardiac shunt or lung disease

Coarseness & dryness in myxedema (bradycardia, heart failure, PE) : 

Coarseness & dryness in myxedema ( bradycardia , heart failure, PE)

Brick red color of polycethemia (may cause HTN, thrombosis, MI) : 

Brick red color of polycethemia (may cause HTN, thrombosis, MI)

Inspection: 

Inspection Go with the probabilities Long thin people have long thin valves (MVP) Males more likely to have aortic valve disease Young-think bicuspid aortic valve Middle age-think rheumatic AV disease Elderly -think degenerative AV disease Females- think mitral valve disease MVP much more common than rheumatic MV disease

Inspection Identify specific syndromes : 

Inspection Identify specific syndromes Down syndrome trisomy 21 VSD Turner syndrome – Partial deletion or absence of X chromosome gonadal dysgenesis aortic coarctation bicuspid aortic valve aortic dissection Noonan’s syndrome Dysmophic feature-short stature,webbed neck Pulmonary stenosis Hypertrophic cardiomyopathy Marfan syndrome Myotonic Dystrophy

Marfan’s Syndrome: 

Marfan’s Syndrome Body Habitus Tall/thin/long facies Long fingers Thumb sign Wrist sign Ligamentous laxity Scoliosis/kyphosis Pectus excavatum/carinatum Ectopia lentis Narrow long facies High arched palate Aortic dissection Dilatation of the aorta affecting sinuses of valsalva MVP Mitral regurgitation LV dilatation Dilated pulmonary artery < age 40 MAC < age 40

What are the indications for checking the BP in both arms?: 

What are the indications for checking the BP in both arms? The presence of both arms R/O Atherosclerotic obstruction Scalenus anticus syndrome/cervical rib Aortic coarctation above left subclavian Anomalous origin right subclavian artery in aortic coarctation

What are the indications for checking BP in the lower extremities?: 

What are the indications for checking BP in the lower extremities? Hypertensive patient under 40 years of age. Elderly patient with suspected PVD How do you do it? Thigh cuff-auscultate over popliteal artery Large arm cuff around calf (bladder posterior) -palpate PT or DP Which is normally higher- arm or leg BP?

Ankle-brachial index: 

Ankle-brachial index Resting and post exercise SBP in ankle and arm. Normal ABI > 1 ABI < 0.9 has 95% sensitivity for angiographic PVD ABI 0.5- 0.84 correlates with claudication ABI < 0.5 indicates advanced ischaemia

Palpation-Pulses: 

Palpation-Pulses Rhythm, rate, regularity Contour Water hammer pulse-AR Brachial-radial delay AS Pulsus paradoxus Tamponade COPD Pulsus alternans LV dysfunction

Carotid Examination: 

Carotid Examination Carotid upstroke brisk, normal or delayed bisferiens or anacrotic volume: normal, increased or decreased Carotid auscultation Bruit Transmitted murmur A 2 audible in neck? Presence excludes severe AS

JVP Inspection: 

JVP Inspection Height Waveform Differentiate from carotid Descents are easier to see due to greater amplitude and frequency Specific patterns Maneuvers

Normal JVP Waveform: 

Normal JVP Waveform Consists of 3 positive waves a,c & v And 3 descents x, x ' (x prime) and y

Jugular venous pressure: 

Jugular venous pressure Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION. JVP is measured in ANY position in which top of the column is seen easily. Usually JVP is less than 8 cm water < 3 cm column above level of sternal angle.

Normal JVP Waveform: 

Normal JVP Waveform a wave - atrial systole x descent – onset of atrial relaxation c wave - small positive notch in the 'x' descent due to bulging of the AV ring into the atria in ventricular contraction. x' (prime) descent !!! occurs during systole due to RV contraction pulling down the TV valve ring “descent of the base” a measure of RV contractility v wave - after the x ' descent - slow positive wave due to right atrial filling from venous return y descent - rapid emptying of the RA into RV due to TV opening

JVP Summary: 

JVP Summary It’s easier than it looks !!! Look for descents not waves Time deepest descent with systole This is the x' (prime) descent !!! Occurs during systole due to RV contraction pulling down the TV valve ring “descent of the base” A measure of RV contractility If the dominant descent is systolic-this is the x' descent-and JVP waveform is normal

Identifying the Waveform: 

Identifying the Waveform If the dominant descent is systolic-this is the x' descent-and JVP waveform is normal The a wave is inferred as the positive wave before the dominant descent The y descent is sometimes seen but is not as deep as x' descent The c wave never seen The y descent sometimes seen Diastolic descent Shallower than X ' The v wave is inferred as the positive wave between x ' and y The x descent rarely seen visible in 1 o heart block

JVP- HJR & Kussmaul’s sign: 

JVP- HJR & Kussmaul’s sign Hepato-jugular reflux (various definitions) sustained rise 1 cm for 30 sec.  venous tone & SVR  RV compliance Positive HJR correlates with LVEDP > 15 JVP normally falls with inspiration Kussmaul’s sign inspiratory  in JVP constriction rarely tamponade RV infarction

Precordium-Palpation: 

Precordium-Palpation Parasternal Lift: RVE or severe MR Thrill: VSD, HOCM (IHSS) Palpable P2 (ULSB): pulmonary hypertension Medial retraction LVE Lateral retraction RVE

Palpation - Apex: 

Palpation - 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 location Normal Size: No larger than 3 cm (about 2 finger breadths)

Apex-Dynamic Qualities: 

Apex-Dynamic Qualities LV impulse outward movement like a ping pong ball were protruding between the ribs Apex moves outward for the first third of systole and falls away rapidly Lasts for no more than 2/3 of systole Sustained apex-hangs out to S2

Apex–Dynamic Abnormalities: 

Apex–Dynamic Abnormalities Sustained Apex: correlates with pressure overload ( > 2/3 systole-hangs out to S2) AS, LVH or LV systolic dysfunction Hyperdynamic Apex: correlates with volume overload AR/MR Palpable S4 (atrial kick) – stiff LV Palpable S1 (MS) Palpable non-ejection click (MVP)

Apex–Dynamic Abnormalities: 

Apex–Dynamic Abnormalities Atrial kick: Palpable S4 Loss of LV compliance LVH 2 o Hypertension Aortic Stenosis Hypertrophic Cardiomyopathy

Auscultation: 

Auscultation Use the diaphragm for high pitched sounds and murmurs Use the bell for low pitched sounds and murmurs Sequence of auscultation upper right sternal border (URSB) upper left sternal border (ULSB) lower left sternal border (LLSB) apex apex - left lateral decubitus position lower left sternal border (LLSB)- sitting, leaning forward, held expiration

Slide 35: 

CARDIAC CYCLE

Heart Sounds : 

Heart Sounds S1 – closure of mitral valve S2 – closure of aortic (A2) and pulmonary valves (P2) S4 – pre-systolic sound atrial contraction filling non-compliant ventricle Low pitched, bell, apex S3 – early diastolic filling of volume overloaded ventricle Low pitched, bell, apex

Auscultation: 

Auscultation Differential diagnosis of split S2: A2/P2 A2/Pericardial knock A2/OS Sometimes 3 components: A2/P2/OS A2/P2/PK Exclude S 3 Lower pitched Heard with bell At apex In left decubitus position

Use your built in heart sound simulator: 

Use your built in heart sound simulator Drum fingers on chest or table Auscultate with stethoscope Ring finger S4 Middle finger S1 Index finger S2 Thumb finger S3

Assessing Murmurs: 

Assessing Murmurs Grading of Murmurs: Grade 1 - only a staff man can hear - faint Grade 2 - audible to a resident – need to focus to hear Grade 3 - audible to a medical student –easily heard 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

Innocent Murmurs Common in asymptomatic adults: 

Innocent Murmurs Common in asymptomatic adults Characterized by Grade I – II @ LSB Systolic ejection pattern - no  with Valsalva 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 4 or above Regurgitant murmur Murmurs associated with a click Murmurs associated with other signs or symptoms e.g. cyanosis Abnormal 2 nd heart sound – fixed split, paradoxical split or single

Auscultation: 

Auscultation “Aortic area” 2nd left intercostal space (URSB) compare S1 to S2-S1 should be softer. If the same, think Mitral Stenosis identify ejection murmur-time the peak intensity in relation to systole identify ejection click if present

Auscultation: 

Auscultation “Pulmonary Area” 2nd right intercostal space (ULSB) listen for split S2 (A2/P2) identify the intensities of A2 and P2 time split S2 with respiration normally widens with inspiration, closes with expiration wide split S2-RBBB, RV volume overload,PS, RV failure wide fixed split = ASD paradoxical split = LBBB, severe AS, severe LV dysfunction, pacemaker

Auscultation: 

Auscultation Left Sternal Border Listen for early diastolic murmurs (AR/PR) Press firmly with diaphragm Listen upright with forced expiration Listen on hands and knees

Auscultation: 

Auscultation “Mitral Area” (LLSB) Listen for intensity of S1 Soft S1 -LV dysfunction, first degree heart block, pre-closure with sudden severe AR/MR Loud S1 -MS, sympathetic stimulation Variable S1 - Complete heart block with AV dissociation, Wenkebach Identify splitting of S1(differential) M1/T1, M1/EC(aortic or pulmonary) , M1/Non-EC (MVP), S4/M1

Auscultation: 

Auscultation “Mitral Area” (LLSB) Identify quality,timing and intensity of systolic murmurs ejection quality vs regurgitant quality pansystolic vs early or mid to late systolic murmer

Auscultation: 

Auscultation Apex Listen for S3 and S4 Consider differential diagnosis of S3 A2-wide P2, A2-OS, A2-PK, A2-S3 Identify diastolic rumble Determine radiation of murmur e.g.. MR to axilla

Auscultation- Timing of A2 to OS Interval : 

Auscultation- Timing of A2 to OS Interval Width of A2-OS inversely correlates with severity The more severe the MS the higher the LAP the earlier the LV pressure falls below LAP and the MV opens

Clinical Signs of LV Dysfunction: 

Clinical Signs of LV Dysfunction Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displacement Sustained apex - to S2 Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion rales

Clinical Signs of RV Dysfunction: 

Clinical Signs of RV Dysfunction With Pulmonary HPT Loud P2/palpable PR murmer RV lift Common findings Without Pulmonary HPT Soft P2 No PR +/- RV lift RV S4 TR  CV wave RV S3 murmer  JVP A wave Pulsatile liver + HJR Edema + Kussmaul’s

Common Murmurs and Timing: 

Common Murmurs and Timing Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

Aortic Stenosis: Physical Findings: 

Aortic Stenosis: Physical Findings S1 S2 S1 S2 Mild-Moderate Severe

Aortic Stenosis: Physical Findings: 

Aortic Stenosis: Physical Findings Intensity DOES NOT predict severity Presence of thrill DOES NOT predict severity “ Diamond ” shaped, harsh, systolic crescendo-decrescendo Decreased, delay & prolongation of pulse amplitude Paradoxical S2 S4 (with left ventricular hypertrophy) S3 (with left ventricular failure)

Slide 54: 

THANK YOU