Download CARDIOVASCULAR SYSTEM EXAMINATION

Practical No : 11
CARDIOVASCULAR SYSTEM (CVS) EXAMINATION
Objectives :
At the end of the practical the student should be able to,
1. Name the main components of a physical examination
2. Perform a General Examination relevant to the system
3. Palpate the pulse and briefly explain the differences in pulse that may be
observed in a patient
4. Measure the blood pressure accurately
5. Identify the Jugular Venous Pulse and briefly explain how it is measured.
6. Name the components and perform an examination of the precordium
The components of physical examination of the CVS
Prior to any physical examination, the following must be observed,
- Consent taken from the patient with introduction of self
- Adequate privacy given to the patient
- Adequate exposure of areas that are to be examined
- Female chaperone when examining female patients
Now, the examiner can proceed to,
General
Examination
Examination of
the arterial
system
Examination of
the venous
system
Examination
of the
Precordium
General Appearance
Face
Hands
Ankles
Pulse
Blood Pressure
Jugular Venous Pressure
Inspection
Palpation
Percussion
Auscultation
The General Examination
 General Appearance
 From the time the patient walks in, eg. is the patient tired – dyspnoec?
 Look for any cannulae, bandages etc.
 Face
 Touch – forehead to check for fever (if so, measure temperature)
 Observe sclera and mucus membranes for ‘pallor’ (anaemia ) or ‘plethora’.
 Look for xanthelasma and arcus lipidus.
 Inspect tongue for central cyanosis.
 Inspect oral cavity for dental caries.
 Hands and body
 Inspect nails for clubbing, koilonychia and pallor
 Feel for the moisture and temperature of the palms
 Look for splinter haemorrhages, osler’s nodes etc.
 Feel and look for tendon xanthomata
 Examine for ankle and sacral oedema
Examination of the arterial system
Pulse
Pulse Rate
Rate
Rhythm
Volume
Character
Vessel wall
Peripheral pulses
Delays
: Commonly palpated at the wrist, over the radial artery
Three fingers are used (index, middle and ring fingers), with the index
finger placed proximally. (why three fingers?)
The pulse is counted for a full minute, or counted for 15 seconds and
multiplied by 4.
Rate is given as. X beats/min ( Normal :- 60 - 90 beats/min)
Pulse Rhythm :
This Can be
Regular
Regularly irregular
Eg. Sinus arrhythmia
Irregular
Irregularly irregular
eg. Atrial fibrillation
Pulse Volume
High volume pulse is seen in cases of hyperdynamic circulation
Eg. Anaemia
Pregnancy
Thyrotoxicosis
Low volume pulse is seen in hypovolaemic shock (‘thready’)
Eg. Massive haemorrhage
Severe Dehydration
Character
Collapsing
Slow Rising
or
Pulses Paradoxes, Alternans, Bisferians, Bigeminus
Peripheral Pulses
Temporal Arteries
Compressed against temporal bone
Carotid Arteries
Never palpate both at the same time
Compress against cervical transverse
processes
Palpate with thumb
Brachial Arteries
In the cubital fossa
Compress against bicipital
aponeurosis
Femoral Arteries
1 fingerbreadth below midinguinal
point
Popliteal Arteries
Bend the knee and palpate in the
popliteal fossa with fingertips of
both hands
Posterior Tibial Arteries
Posterior to medial malleolus
Dorsalis Pedis Arteries
At the junction of the extensor
tendons of the big toe and second toe
Delays
Examined by palpating both arteries at the same time for the same time duration
and observing for synchrony.
Radio – Radial Delay
Radio – Femoral Delay
-
Seen in Subclavian Artery Stenosis
Seen in Coarctation of the aorta
Blood Pressure
Measured using the Sphygmomanometer and Stethoscope
Two Methods
Palpatory method (only systolic)
Auscultatory method (systolic and diastolic)
Basis :
Auscultation of Korotkov Sounds
Method
- Patient should be relaxed
- Arm kept at level with the heart
- Clothing of the arm (shirt sleeves) should be removed
- Cuff should be neatly applied with no gaps
- Should choose an appropriate sized cuff
- Stethoscope should be applied to operators ears, accurately
- Manometer is kept at level with the patient’s heart, well supported and upright
-
Palpate the radial pulse and start inflating cuff until pulse is impalpable
Apply diaphragm of stethoscope to the cubital fossa over the brachial artery,
while slowly releasing air from the cuff and “LISTEN”
Korotkov I
Staccato sound, high pitched (systolic BP)
Korotkov II
Louder sustained
Korotkov III
Korotkov IV Sound becomes muffled (5 – 10 mmHg above diastolic)
Korotkov V Absence of sound (Diastolic BP)
Student exercise
 What is meant by BP?
 What is your BP
 What is your Pulse Pressure?
 What is your mean pressure?
 What factors affect BP in a normal person?
 Practise measuring each other’s BP in < 2 min.
Examination of the Venous System
Measurement of the Jugular Venous Pulse (JVP)
Method
- Ensure that the light is good (daylight preferred to artificial)
- Patient positioned at 30o - 45o to the horizontal
- Patient’s neck muscles should be completely relaxed
- Always look on both sides of the neck
- Observe the internal jugular vein (Why?) at right angles to the direction of the
wave
- Look for the upper limit of the pulsations (what are the differences from arterial
pulse?)
-
Using two rulers, measure the venous pulsation vertically from the sternal angle.
Measurement
Sternal Angle
Upper limit of
blood column
5 cm
5 cm
Distended jugular
vein
-
Right Atrium
Add 5 cm to this value (internal distance from sternal angle to right atrium) to
obtain the Jugular Venous Pulse in cmH2O
Normal value :- 4 -5 cmH2O
If pulse is low, or needs to be augmented, lower the patient – this makes the JVP
more obvious.
Q. What is the JVP waveform and its representation?
a
c
x
S1
0
0.1
v
0.2
y
S2
0.3
0.4
0.5
0.6
0.7
0.8
Seconds
Examination of the Precordium
Is the part of the chest wall overlying the heart
This follows the steps of
Inspection :
Inspection
Palpation
Percussion (not routinely performed)
Auscultation (very important)
Look for chest deformities (Pectus excavatum, pectus carinatum)or scars
(mitral valvotomy, sternotomy)
Visible apical impulse (Define ‘cardiac apex’)
Any other visible pulsations
Also look for visible neck pulsations and epigastric pulsations
Palpation
-
-
:
Begun by locating the cardiac Apex with the palm of the hand.
In normal subjects, is situated in the 5th intercostals space, just lateral to
the mid-clavicular line
The apex beat can be
MCL
o Normal
o Heaving
o Tapping
Can get an idea about cardiomegaly
and hypertrophy
Feel for a parasternal impulse/ heave
5th ICS
Use fingers in intercostals spaces
Parasternal heave is seen in right
ventricular hypertrophy.
Feel for thrills on precordium and neck
Auscultation :
- Identify the auscultatory areas of the heart
Aortic Area
2nd ICS Right
edge of sternum
Tricuspid Area
Lower left
sternal edge
-
Pulmonary Area
2nd ICS left edge
of sternum
Mitral Area
5th ICS just
lateral to MCL
In the Mitral area, listen to the 1st heart sound which is normally
prominent
In the Aortic and Pulmonary areas listen to the 2nd heart sound.
Identify the timing (systole and diastole) by simultaneously palpating the
carotid pulse
Listen for a 3rd and 4th heart sound (are they normal?)
Listen for splitting of the 2nd heart sound (Basis?)
Listen carefully for any murmers (what is a murmer?)
Time any murmers thus heard
Practise cardiovascular system examination